Alcohol Abuse and Family in the Latinx Community

Articles:

• Resources for Friends and Family with an Addicted Loved One
• Support Groups for Families
• Family Involvement in Teen Addiction Treatment
• How to Tell Loved Ones You’re Struggling With Substance Abuse

Webinars:

• Creative Ways to Help Families Heal Through Recovery
• Family Case Management: Healing Families from Addiction

Link to Genesis’s Presentation

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Hi, my name is Genesis Games. Thank you for joining me in this webinar — another webinar from the Community Education Series at The Recovery village and Advanced Recovery Systems. My presentation today is called “The Bottle Looks Familiar: Alcohol Abuse and the Role of the Family in the Latinx Community.”

I am passionate about working with the Latinx community. I am Latinx myself, and I am excited to be able to share my experience working in substance abuse and working specifically in substance abuse within the Latinx community. A little bit more about myself — I was a primary therapist for a drug court program in Central Florida. I had the opportunity to work with clients, specifically minority clients, that were in this drug court program throughout several months. I also worked as a primary therapist at a substance abuse residential facility here in South Florida. I was a clinician at a shelter for unaccompanied minors, mainly Latinx unaccompanied minors, about 30 minutes south of Miami.

Currently, I work at a private practice with individuals and their families in early recovery. I also have training in couples therapy and emotionally focused couples therapy. I say this because you’ll see throughout this presentation, I really come from a relational point of view. So, we’re not going to be talking about couples. We’re not going to be talking about family. We’re going to be talking about addiction within the Latinx community. But I do come from a very relational point of view, and that’s definitely something that you’re going to pick up on very quickly in the presentation.

So, objectives for today’s presentation. This is not an Addictions 101 class. This is not teaching you a new reality or a new approach, or asking you to change your theoretical orientation. This presentation is geared for addictions professionals who are already practicing, have a theoretical background, have techniques they use that they feel comfortable with and understand addiction. More so, this is to help these clinicians learn how to tailor what they do already for the Latinx community, helping them gain more understanding of the nuances of working within the Latinx community and, again, how they can adapt what they are already doing to best serve this specific problem.

We’re going to talk about the role of cultural norms, including messages around drinking, gender differences and religious beliefs. The goal of mental health and trauma and alcohol use disorder, including connotation, immigration, acculturation, multigenerational trauma and stigma around seeking help. The role that the family plays in enabling alcohol use versus serving as a protective factor, providing culturally sensitive assessments and determining appropriate approaches based on cultural understanding and medical necessity.

So, we’re going to start with the role of culture. Cultural diversity is important. The Latinx community is the largest ethnic minority group in the U.S. Latinx in the U.S. are a generous group, including people born in Spanish-speaking, Latin American countries — the Caribbean included — and also people born in the U.S. with a Latin American ancestry. So, we’re talking about pretty much an entire continent. Each country has their own cultural differences, history, dialects and political landscapes. Differences in immigration and how they arrived in the U.S. Why they decided to come to the U.S., and even your immigration status or process of obtaining an immigration status can be vastly different.

Understanding that diversity is essential. You might live in an area where you mainly have people from Central America, and so their experience in Central America — their experience of immigrating to the U.S. — is going to be significantly different than if you were in a place like South Florida, where we have people from the Caribbean. It’s a different culture or subculture within the bigger culture. Understanding this is important because if you are working with Latinx clients from different places, we can’t go in with the assumption from a specific client that we once worked with that was from Dominican Republic. Their experiences, their issues or concerns are not going to be similar to the kind that’s now sitting in front of me, who might be from Mexico. Their experiences are going to be, for the most part, very, very different.

It’s important to take into account colonization. There were genocides and destruction of indigenous cultures. Basically, these whole cultures were lost — if not entirely, a lot of it was lost.
It really depends where you’re looking at. So, if you look at places in the Caribbean, those indigenous cultures were totally lost. If you look at places like Mexico and Central American countries, there’s still big populations within the country that are indigenous that practice indigenous cultures. But it really, again, depends on geography to be able to determine how acceptable and how present are these indigenous influences today. There was this ideology that Native Americans were savages without soul, who needed to be taught true civilization. This still permeates today — especially in the therapy office — when it comes to relationship styles.

We have this idea of individualism and then “you do you,” and you make the decisions that are best for yourself. You make your decisions on your own, and that’s very different from a collectivistic community where we think about everyone. We think about the whole, and we make decisions based on the common good. We often pathologize this idea of collectivism. We see it as something abnormal, something unhealthy, something wrong, something that needs to be changed, values that need to be shifted. This is a way, again, of thinking their way is wrong because of our way. The dominant way — the American way — is to be more individualistic. So this is definitely a way that these ideals still show up in the therapy room, and we have to be mindful of that — because our idea of relationships doesn’t mean that that’s the only version of healthy relationships.

To better understand the Latinx community, we need to understand some of their cultural values. The idea of familismo is a dedication and commitment to one’s family. Family is extremely important — again, we’re thinking collectivistically. Family is extremely important. We’re very committed. We’re very dedicated to everyone in the family. You think about family when making big decisions. La familia supersedes financial or professional achievements. And again, when we’re making big decisions, we’re going to think about how these decisions affect every single member in our family. So, I may not take a job or I might not take a promotion if this means that I can’t be present for my family or that I need to move away. I may give up on studying abroad or going off to college to a different state because this was too distant from my family. I wouldn’t be able to be present. I wouldn’t be able to be as helpful and as engaged as I would like.

So, the support of family is going to be important in supporting decisions in my life, and lacking that support is going to create a lot of stress and a lot of discomfort. La familia is multigenerational and includes extended family members, so it’s not uncommon to see — at birthday parties or family gatherings, or even living under one same roof — multiple generations. Grandparents, parents, children, even great-grandchildren at times. It’s also not uncommon to have close family friends as cousins or aunts and label them as family members, although they’re not blood-related. The idea of respeto, or respect, means that respect is owed to everyone. You don’t earn my respect; you automatically have my respect. I think this is really important in a way that Latinx folks conduct themselves.

So, now is the importance of cultivating interpersonal relationships in diverse social settings. Personalismo is the importance of cultivating meaningful interpersonal relationships in diverse social settings. It’s really important, and the most important relationship is the relationship I have with my family members. But the relationship that I form with other people in social settings are also very important. I’m not going to be the person that just kind of sits in the corner, keeps to myself — that wouldn’t be respectful and that wouldn’t be seen as okay in the Latinx community. I am going to try and cultivate meaningful relationships, whether it’s in school, it’s at my work, it’s at church — any form of community organization that I’m a part of.

I am going to make sure I make some meaningful interpersonal relationships in these different settings, that I get to know people, that people get to know me. The idea of collectivism is important in evaluating which one action impacts the common good. Machismo, the Latinx domineering towards women, the idea of patriarchy, women having the typical gender role of caretakers. This last term, positive machismo, is new to the literature, and it’s basically this movement motivating men to establish that your personal relationships are characterized by emotional openness, gender equality and family commitment. Moving away from the traditional gender role of machismo and patriarchy.

So, what are the messages around drinking? Again, there’s a lot of diversity, but within the diversity, these are some of the general statements that — among Latinx — they believe to be true or they hold to be true about drinking. Across Latinx subgroups, beer is preferred over wine and hard liquors. Celebrations revolve around alcohol. It’s acceptable for men to drink as a reward for a day’s work. Women tend to have a more conservative attitude. Latinx who identify as protestants adhere to abstinence. So basically, alcohol is a big part of celebrations; it’s a big part of even day-to-day life if you’re a man. Women do tend to have a little bit more of a conservative attitude as far as how much they drink or when they drink, how often.

So, we’re going to talk about mental health and trauma associated with immigration. And this is really important because we know that a big part of addiction is a history of mental health issues or an issue of trauma. We know that people tend to fall to addiction as a way to cope with unresolved trauma or mental health concerns that are not being addressed. So, really understanding a lot of the mental health background of your potential trauma you’ve experienced is essential to really understand the function that their substance abuse is serving in their lives. We can’t really provide proper addiction treatment without understanding mental health and trauma.

There’s a lot of mental health and trauma that’s associated with immigration. Like, why would you leave your home country where all of your family lives, where your childhood friends live, where you know most people, know the laws, you know the culture, you know the language. You have a school that you like, or you may have a job you like, and you have a life that you know and that you can navigate, and it’s not new to you. To move to a completely different country to start from zero — to have to learn a language, learn loss, learn culture, find friends, find a community and do all of that. Well, usually for traumatic reasons. Not necessarily in every case, but usually for traumatic reasons. So, it’s really important to understand the mental health and trauma component.

So, these are questions that I always want to know when I’m working with a Latinx client. Whether addiction is the problem for sure, whether suspected addiction might be a problem, or maybe they’re just having anxiety and have no history of addiction, have never touched alcohol or a substance in their life. I still want to know these questions. These questions are really important, again, to understand the possible mental health concerns present, possible history of trauma as well. I want to ask why they left their home country. People leave their home country for a lot of different reasons, but those reasons are very important and very telling of their story. Some people might leave because of economic hardship in hopes of having a better future for themselves and for their families, but it doesn’t mean that they’re incredibly poor. It doesn’t mean they don’t have enough money to put food on the table; it might just mean that they feel like they reached, like, a glass ceiling in their home country and they want to do better.

So, they want to move to a country that provides them more opportunity, maybe for themselves, maybe for their children. That’s going to be very different than someone who is escaping extreme poverty and scarcity, who is coming here with the hopes of, yes, having some more money, but being able to fulfill their basic needs. So, they’re not necessarily looking to go to college or live here so that they can have this very prosperous business and live in a wealthy affluent neighborhood. Their hope is that they’re going to make it here so they can have enough money to take care of themselves and then have enough money to take care of their family in their home country. Still in survival mode, not necessarily going above and beyond, but really just survival mode and trying to be helpful to their family still back in home country, dealing with poverty — without that, they might not make it. Sometimes, people flee their home country because they are fleeing from violence of gangs or the political scene of their country. Sometimes, you’re escaping intimate partner violence. Other times, it might be that their basic needs and rights are being denied by the government in their home country, and they’re coming here seeking the ability to have those rights. Whether it’s freedom of speech or freedom of religion, maybe because of their sexuality, their sexual orientation — it’s not safe for them to live in their home country. So these reasons, again, can tell you a lot about the trauma history that they probably may or may not have, and also their expectations for what life in the U.S. was going to look like.

The second question that I always ask is, what was the journey to the U.S. like? And that is also really important because in that journey, a lot of times, trauma happens. So, we might be coming to the U.S. because of trauma in our home country. We might experience trauma in the journey as well. There’s many ways of entering the U.S., both legally and illegally. People might enter via airports, land and sea. Human trafficking is definitely one of the main ways how people enter via land. Crossing the border, a lot of times, there are rapes; there is violence that they see. They see people getting murdered, getting killed, being sexually assaulted, whether it happened to them or they saw it happened to someone else. These are things that they may have experienced.

There’s also that piece that you make it to the other side, a lot of times, they owe money to the people that cross them over, often known as coyotes. So, they’re not only coming with no money and no legal status, but they’re also coming with a huge debt that they have to pay. If they don’t pay that debt, there’s usually negative consequences involving the safety of their families in home country. Again, a lot of the trauma may happen in the journey, and so we really want to know what the journey was like for them. The political state is also really important. Different policies, different laws change. Someone that maybe came 10 years ago would be very different than someone that came nine months ago, because our political climate has changed and our policies around immigration have changed significantly. So, understanding not just what happened but why it happened helps us kind of get a better idea of what the person’s experienced and may continue to experience.

What is it like to live in the U.S.? This is very important because, again, most people when they decide to come have a certain expectation of what life in the U.S. is going to be like; they have a purpose of coming here. So we want to know, have they been able to meet that goal? Have they been able to fulfill that purpose? And if so, what has that been like for them? Their specific experience: Are they living in a community where they’re experiencing racism and they don’t feel safe — they feel targeted? Do they have health care? They have insurance? Can they afford health care? Are they able to go to a hospital or clinic or urgent care where their staff speaks their language or their dialects and they’re able to easily communicate? Are they able to find any resources in Spanish, whether it’s education, it’s health, it’s safety? Are they able to find these resources in their language? Are they able to receive government assistance, or did they receive government assistance when they first came?

Was that something that helped them kind of start fresh, or did they have to scramble on their own from the get-go? Did they come to unite with family that was already living in the United States, or were they here totally unknown? Did they travel with a significant other or with a family member? Are they employed right now? Are they making any income in their employment? Are they able to pursue any degree, like a technical degree or certification, or even enroll in further education in college? Is this still a possibility of something that they want to do? Is this accessible? These are things that we want to know because at this point, it gives us a better idea of what their day-to-day life is. What their expectations were like or not. In some of those struggles that they may be facing, whether it’s safety issues or just being excluded because there’s nothing which I really understand — what’s going on around me? Or just not being able to make money, and really struggling to survive from a financial standpoint.

What is their immigration status — this is the next question that I always want to ask — what was the immigration status when they first arrived to the U.S.? Did they come legally? Did they come illegally and then had to go through an entire process? What was that process like? How long did that process take? Was it an easy process? Even if they came legally, some people wait years in their home before they’re able to get a visa to enter the country legally. So, what was that like in their home country, waiting several years to be able to enter the country legally? What was, again, the legal process like? How long did it take? Were they able to work in the meantime? That’s a big one — a lot of times, people are not able to legally work if they don’t have a legal status. They have to do other kinds of jobs. So, what was that like for them?

What was the instability in that period of time? What is your status now? Is your visa still pending? Do they have a mixed-status family? That means that some people are legally here, some people are not. Are they in a mixed-status relationship where maybe they are legally here — they’ve gone through the process — but your significant isn’t? That leads to a lot of anxiety because at any point, we can be torn apart, whether it’s a family unit or it’s a significant other. At any point, we can be torn apart. So, this takes us to deportation. Were they ever deported in the process? Have they ever had a family member or significant other be deported? Do they live with fear of deportation? Have they had close calls? Again, these are points that give us a lot of information of what their life is like in the U.S. and potential traumas that they might be experiencing or have experienced in the U.S. So, we’re looking for trauma in the country, we’re looking for trauma in their journey to the U.S., and we’re looking for trauma living in the U.S.

Overall, Latinx immigrants historically have been tolerated at best and, at worst, they have been persecuted. This is, again, is going to depend on the political climate at any given point in the country. They’re often seen as a threat to the cultural and political integrity of the U.S. They are welcomed whenever there’s a shortage of labor, but they also become a convenient scapegoat when things are going well.

Acculturation: The definition of acculturation is conforming to a different culture, usually the dominant one. Acculturation happens gradually and on a spectrum. You don’t become acculturated to the dominant culture from one day to the next. It includes shifts in attitudes, values, beliefs and behaviors. It impacts our social and psychological well-being. Basically, I am letting go of why I believed my values, my costumes, my traditions, to take on those of the dominant culture. Kind of stripping away what was what I believed in, what I did, my perspective of life, my world view, to take on the world of the dominant culture.

This creates a lot of stress, and continuously trying to balance it — that’s a man’s place by their culture of origin. And then the dominating culture, which is the culture they’re trying to adjust to, creates a lot of what we call acculturative stress. It’s kinda like this tug of war. I want it to be accepted. I want to make friends. I want to meet people. I want to be successful. I want to be able to accomplish the goals and the expectations that I had for my life in the U.S., so I am really trying to fit in and do whatever I need to do to be accepted. But then I have demands from my family of origin, my culture of origin, telling me like I am forgetting my roots. I am not being true to my roots. I’m not being true to my culture. I’m leaving my family behind. I’m being selfish. And so, again, this all creates what we call acculturative stress. This also brings a family tension.

Intergenerational gap increases acculturative stress. Brings a family tension. The intergenerational gap refers to younger generations, children and teenagers, even young adults, adapting to the dominant culture. A lot easier, with less stress, with less tension. It’s just a lot more easy than older generations. This creates tensions between children and parents, children and grandparents. And if, again, you’re living in a multigenerational household, this tension is going to be very present. We know based on research that acculturative stress is associated with alcohol use disorder, depression and psychosomatic symptoms. So it’s not only trauma we’re also looking at; we’re also looking at their mental health concerns, and these are mental health concerns that are associated with an acculturative stress.

So, what does acculturation do to alcohol abuse? We know that Euro-Americans tend to drink more, but we also know that Latinx consume more drinks per sitting. So, Euro-Americans might drink more days out of the week. The Latinx are going to drink more, even if it’s less days out of the week. The rate of drinking among Latinx increases as acculturation stress increases, no surprise there. Acculturated Latinx drink more and are more likely to engage in binge drinking than not-acculturated Latinx. So, if we think about a few slides ago, we talked about how Latinx women tend to be more conservative about drinking overall. What we know is that as they become more infiltrated, they’re more likely to drink more.

Bicultural. So, this is what we want to really promote in our offices, in our centers with our clients. This is the healthiest and most functional approach. We want to integrate elements from the native culture and the dominant culture together. We want them not forced to choose. We want to look at our native culture. What are things for my native culture that fit into my life in the U.S.? Then what are things about the American culture that I want to adopt? And then we want a merge of the two. We don’t want to totally let go of our native culture because, again, this creates a lot of stress, a lot of guilt, a lot of family tension. It’s not authentic to the person. So we don’t want to force someone to strip away from the art. We want them to be able to choose things from who they are that they want to bring into this new life, and you’re creating this new identity they’re developing. We want them to look at the dominant culture and choose things that they like from it, things that are functional for them, and begin to implement these as well. Again, we’re not forcing people to choose one or the other, and this reduces some of that acculturative stress and everything that comes with acculturative stress.

Stigma around seeking help. So, it’s important to understand the mental health aspects, and it’s important to understand the trauma aspects. It’s important to understand the views on seeking help. This is really important. There’s this saying in Spanish called “terapia es cosa de locos,” or therapy is for crazy people. It’s basically crazy people are the ones that go to therapy. I’m not crazy, you’re not crazy — why would you go to therapy, right? So, when we suggest that someone goes to therapy that has a Latinx background, they might have that idea that only people that are crazy are the ones that go to therapy. So, they might be insulted by us suggesting therapy. We’re telling them that they’re crazy, and so we want to be mindful about that belief system. There’s also the idea that “la ropa sucia se lava en casa,” or dirty laundry is washed at home. Basically, we discuss our personal problems with our family. You don’t go outside of our family to discuss our personal problems. This can create what might seem like resistance in the therapy room, where the person is not exposing and staying at surface level at all times, and not really going deep. It’s not necessarily because they want to be resisting, or to aggravate you. It’s more so because you’re not comfortable with that.

They have this deep-rooted belief that those intimate issues are only discussed with family members. A lot of times, people also have this perspective that religion and therapy don’t make sense. If you have enough faith and you believe enough and you truly believe in what you say you believe, whatever your religious background is, then you don’t need therapy. If you’re going to therapy, it’s because you lack faith; it’s because you’re not really a believer of whatever religious beliefs you have. So, we also want to be mindful of how we bring religion into the therapy room and how we try to really bring those together so that someone can feel comfortable talking about your religious beliefs, talking about your spirituality. Understanding that there’s some place for both and that both can be discussed in our therapy office, and that their religious beliefs can be helpful in their recovery process and can be integrated in their recovery process. There’s also this idea that certain emotions — or, this actually unspoken rule that certain emotions are not welcomed. So, you’re not allowed to be angry at your mom because she’s your mom. You’re not allowed to hold resentments towards your dad because it’s your dad. Certain emotions based on, again, the high regards that there is to family that are not acceptable.

It’s not acceptable for you to express that; it’s not acceptable for you to say that. So really, giving them a lot of psychoeducation on emotions — that we’re meant to have a wide range of emotions, have conflicting emotions, all of these, you know, all of this good stuff about emotions. Lack of education is a problem about mental health and addiction overall. Lack of education about therapy and treatment, so they generally need to be — most of them, not everyone that’s a Latinx person, but a lot of clients are going to need to be walked through the whole process, to understand mental health, to understand the addiction, breaking it down for them, helping them understand what therapy treatment might typically look like. You know, how to navigate insurance if they have insurance, how to navigate just the whole system. Also, a lack of presentation, as most therapists are not people of color. So, most of the time when a Latinx person is seeking therapy, the therapist that might be assigned to them at a community treatment facility is not going to look like them.

If they’re going the private practice route, then they have a little bit more of a say on who their therapist is and they might select someone that looks like them that’s bilingual, but even then, they may have some limitations. So there’s just not a lot of — they’re missing people of color, and not enough identify as a Latinx, which is a factor. It’s also going to be geography, but just keeping that in mind, it can be intimidating going into sessions and talking about things that you feel like you shouldn’t be talking about, because you only discussed that with your religious leader and your family. You kind of feel like you’re crazy because you’re going to therapy and really don’t understand mental health or addiction. You really don’t understand therapy or how the systems work, and then you’re going to share all of this with someone that doesn’t look like you and made the assumption that because they don’t look like you, they can’t understand you. Now, we know that that’s not necessarily true. That’s why we have cultural awareness and cultural diversity training, but just know that that might be the preconceived notion that they might be walking in with.

The role of the family. So, we talked about family a lot throughout this presentation. Family most definitely plays a huge role in anyone’s life, especially in the life of Latinx. Family is seen as a protective factor in literature. Families are highly connected. Extended families play a huge role and provide social support. There are multigenerational households, and this closeness of family is a protective factor. Again, it’s outside stressors and it helps improve the house. So family, again, it’s a positive thing if there’s no dysfunction, but we’re not looking at family as negative; we’re not looking at family as, “Oh, they’re too close.” That, again, would be through our Eurocentric perspective, our Eurocentric glasses, and not really looking at it from a multicultural perspective.

Now, like in any family, there can be dysfunction. And what we often see in Latinx families is — we see this in addiction as well — we see it a lot in addiction, and we see it a lot in Latinx families. So, there’s definitely an overlap there of high incidents of addiction in families that haven’t been mentioned yet. Latinx families expect that members turn towards family for satisfaction and support rather than turning to the larger world. So, they expect that all the needs, wants, desires and hopes that a family member — that a person — can have can be satisfied within the family. No one is supposed to make you happier than your family. All your hopes and aspirations should be fulfilled through your family. Your family is anything that you do, when the outside world is really to kind of fit in your family at the end of the day.

Again, it’s not in every Latinx family — this is not the belief in every Latinx family. It’s the belief in the Latinx family where enmeshment is present. This stunts the individual growth because we know that our families cannot provide us with every single wish and desire that we may have. It creates guilt and shame stemming from a sense of obligation. So, as I decided I want to pursue one of my personal goals and that isn’t to my family, then I’m going to feel guilty and ashamed for feeling like I am not fulfilling my obligation to my family. If I decide to not do it and I decide I’m going to choose my family over my goals, then I am going to deal with feeling unfulfilled and probably generate some form resentment towards my family. But it’s a resentment I can’t really speak of because it’s not accepted for me to have those kinds of emotions towards my family.

I may then feel ashamed that I am not able to find satisfaction and fulfillment within my family. That there must be something totally wrong with me because I want to go outside of my family to find that satisfaction. So, it takes us back to guilt and shame, essentially. And it’s not uncommon for alliances between family members to arise, family members choosing sides — you know, it’s mom and dad or it’s mom and sister against dad and brother, or grandparent and grandchild against dad or whatever the case may be. There’s often alliances that are formed that further complicate and make the relationship dynamic between family members dysfunctional.

So, usually within management, there also comes enabling. Enabling is very much present in every dysfunctional dynamic, and it’s definitely prevalent in substance abuse or addiction. So, enabling shields people from experiencing the full impact and consequences from their behaviors. It’s a protection, right? I don’t ever have to deal with the consequences of my behavior, so I don’t really learn my lesson ‘cause I don’t ever have to suffer. I don’t ever have to fix a problem. It always gets fixed for me. Someone always jumps in and saves the day, so I get to do what I like without any negative consequences. Enabling looks like keeping secrets to keep peace. You know, we’re not going to tell dad that this happened, or we’re not going to tell so-and-so that this happened because that would be a conflict. That we want to keep peace. It makes excuses for inappropriate behavior. So, we’ll make excuses for things that are not acceptable, bails out of trouble, blames others, seeks control.

So, if I enable you, if I keep secrets and I make excuses for your needs, If I’m going to get you out of trouble, then I’m going to be in the know, right? Like, you’re not going to push me away. You’re going to be transparent with me and tell me what’s going on. I’m going to know what you’re doing, and that’s going to give me a sense of control over the situation. Now, is that control real or is that an illusion? Most of the time, it’s an illusion because the person is going to continue — they’re going to continue to do whatever it is that they’re doing. You are in the know, but just because you’re in the know doesn’t mean that you’re going to influence what they do, or you think you’re going to be able to change your mind about what they do. The person that enables usually care-takes. So again, they’re very caring and accommodating and just doing everything to make that other person’s life easy and they can shield them from the impact of their conditions.

Enabling also means avoiding facts, avoiding the truth of what’s going on in front of them, what’s going on with your loved one, the long-term consequences. The person that enables — when they get upset, they often make threats. Like, I’m not going to give you money ever again. I’m going to kick you out of the house. But it’s empty because situations happen, boundaries get violated and there’s never that acceptance. It’s just talk. A lot of times, enabling can also mean you don’t make money out of the problem. So, I don’t know how to help you. I don’t know how to make you feel better, so I am just going to give you money. I’m going to give him money. You know, I’m gonna try and bribe you. Like, if you stop using, stop hanging out with these people, then I might get you a car, or I’m gonna pay for that trip you want to take, or I’m just going to keep giving you money to bail you out. Or giving you money to pay for your detox treatment, but I’m just not gonna engage and try to see how I can help you get out of a problem. I am just going to throw the money at you. It’s another way of avoiding the reality of the severity of the situation.

So, now we’re going to talk about, I think, the most important piece of this presentation, which is how can we provide assessments or conduct assessments and provide treatment in a way that is culturally sensitive. A lot of what we’ve covered — everything that we’ve covered to this point is really to give you a background, to create awareness of the questions you should be asking, the things that you should be wanting to mentally highlight as a client is sharing their story with you. Assumptions that we may have that we want to let go of. Just more awareness, not just of culture but the immigration system and the political landscape of their country, their home country, but also our country. All of these things are important, and we had to go through all of these things in detail in the presentation so that we are able to discuss culturally sensitive assessments and treatment approaches.

Like I said before, I’m not teaching you anything new. I’m not suggesting that you let go of whatever strategies you use with your clients or whatever theoretical approach you adhere to. But what I am suggesting is that you take on this information and you think about how this information can help you modify what you already use with your clients, specifically when working with Latinx clients. I really enjoy his work. I think he has phenomenal information. I have a resource list at the end of this presentation.

“Addiction is an unhealthy response to a traumatic childhood event.” So, addiction is a way for us to cope with a traumatic event that happened most likely in childhood. It may be one traumatic event; it may be multiple traumatic events. It might be one childhood traumatic event coupled with traumatic events experienced as adults, but the importance here is that addiction is a coping mechanism for trauma.

He defines addiction as any repetitive behavior that satisfies a craving and provides both pleasure and release in the short term while having long-term negative consequences. So, I want you to underline mentally craving, pleasure and release in the short term. So, I have a craving; I satisfy that craving in the short term by engaging in that behavior that is repetitive. Because the craving keeps coming back, I have to be able to be engaged in that behavior continuously to satisfy that craving. But that is only satisfying in the short term. That’s why it’s repetitive and it does have long-term negative consequences. However, those long-term negative consequences don’t stop me from continuing engaging in that behavior.

Addiction as a disorder from an attachment perspective, right? Addiction as an attachment disorder — we’re going to talk about attachment styles in a second. This is where I said, you know, I have come from a relational point of view. So, someone that has a secure attachment. They had a secure attachment to their caregivers, and the child feels like they have a secure attachment to friends, close friends, close family members and significant others. They have a positive view of the world. They give people the benefit of doubt, they have this mentality of abundance — you know, if I don’t get along with someone, doesn’t mean that the world hates me. It means I just don’t get along with that person. There’s plenty of other people in the world that I can get along with and build healthy relationships in any kind of way. So, they have a very positive view of themselves, view of those around them and view of the world. This is the only healthy attachment style of all four.

Someone with an anxious attachment style, they want that connection with people, as anyone wants. All the attachment styles want connection; that’s something we are hardwired to need and to want. But they have this fear that they’re not going to be able to either create that connection with someone or be able to sustain that connection with someone over the long run. They’re in constant fear that people are going to abandon them. They don’t feel like they can be safe with someone without the concern that they may not be there the next day. So, there’s a lot of anxiety around relationships. We want to create these meaningful relationships with people, but we don’t think that we’re deserving of these relationships. We don’t think we’re good enough; we think that we’re maybe defective and people will eventually find out. This is a negative perception of myself, a negative perception — not necessarily a negative perception that people around me are bad, but a negative perception that people around me won’t accept me for who I am. An overall more negative perception of the world.

There’s not an abundance mindset; there’s more of a scarcity mindset. If I can’t establish a relationship with someone that is, they’re proof that there is something totally wrong with me. The avoidant attachment style — again, they create that connection with other people, but they’re often afraid of being engulfed, of being controlled, losing their independence when they’re in tight connections with other people. So, they want that connection, but when they feel the connection is too tight, they freak out and they want space and they act out, oftentimes, to create that space. They’ll self-sabotage, or sabotage that relationship so that they can create distance from themselves and the other person. Their views, again, are negatives about myself. Like, they’re negative about other people. A lot of times, a negative view about themselves comes when they have a string of relationships that end or friendships, and they find that they don’t have long-lasting, solid relationships in their life. So, they can begin to internalize this and get to think, “Well, maybe there is something wrong with me. Maybe I am defective. Maybe I’m not meant to be in relationships with people. Maybe I’m not meant to have friends.”

It’s a negative view of others because they see others as people that want to be enmeshed with them, be clingy, basically absorb all of their energy, deplete them from their energy, from their resources, and take their freedom. Overall, there’s kind of this negative view of the world in general; there’s not an idea of abundance. Again, there’s ideas of scarcity — they tend to really idealize the person they want to enter a relationship with. Maybe they idealize an ex; they may idealize just this avatar, so to speak, of a person they want to be in a relationship with, and you have a very narrow focus. This is true in romantic relationships, but this is all still true for friendship and even for family relationships.

The last attachment style is highly associated with emotional neglect and severe trauma; this is organized attachment. It’s a mixture of anxious and avoidant attachment. So again, like every human being, they crave that emotional connection. They crave to be in relationships with other people — meaningful relationships with other people. So, they pursue these relationships, but they pursue those relationships from a place of anxiety. And once they find themselves in these relationships and the other person is engaged in their connections and things are becoming more serious, more permanent, more committed, they feel like, “Oh my God, they’re getting too close to me. They’re going to recognize who I truly am. I’m not good enough. I’m not lovable. It’s not going to be good. You’re going to leave me, so I’m going to create space. I’m going to push them away so that I don’t further hurt myself.” Relationships where there’s a disorganized attachment — where one of the members of a relationship has a disorganized attachment — can feel like a push or pull, right? I really pull you in and want to be with you, but push you away when I feel like you’re too close. When you are at a distance, I feel too far away from you, so I pull you back in. And it can definitely be very confusing and can create a lot of trauma for the person with a disorganized attachment, but also for the other person in the relationship.

So, bringing this back to addiction, right? Bringing the idea of attachment — the science behind attachment — back to the idea of addiction. The consequence and dysfunctional solution to the absence of satisfying close relationships — that’s addiction. When we think about addiction from an attachment disorder perspective, it’s the consequence and dysfunctional solution to the absence of satisfying close relationships. If someone has satisfying relationships, they would find the comfort and security they need in those relationships. They wouldn’t need to go to substances for that, right? Basically, the substances — and this is what is seen in true addiction when addiction has progressed — the substance becomes that person’s best friend. It becomes that person’s significant other; it becomes that person’s emotional confidant. If that person was able to turn to the people in their life and really invest in those relationships with the people in their life, they wouldn’t need any substances to be able to meet those needs. Securely attached individuals engage in self-protective behaviors, healthy behaviors.

So, like we talked about, securely attached individuals have a positive perspective of themselves, with other people and of the world in general. Because of this positive perspective — especially the positive perspective of themselves — they’re more likely to engage in self-protective behaviors like eating well, sleeping well, exercising, going to regular doctor’s checkups, not engaging in high-risk behaviors. They care about themselves, they value themselves and they value the people in their lives as well. They just — they protect themselves. Like, when you care about something, you protect it, and the same thing happens with ourselves. Higher levels of attachment anxiety and avoidance and close relationships results in decreased emotion regulation. So, we learn emotion regulations from our attachment to people in our lives, right? From our relationship with the people in our life, starting with our caretakers in childhood, but also any other significant relationships that we’ve had throughout our lifetime, including our significant others.

So, when we have high anxiety and high avoidance, we tend to not have these close relationships or these close relationships are not healthy. Therefore, we are unable to regulate with people in our lives. Addiction is associated with negative and shameful views of the self. We see each other as inadequate or undeserving of happiness, of love, of support of good things. This is going to drive the decisions that we make and how we relate to others in our lives. This all leads to alcohol or any substance, but in this case, alcohol becomes the safe haven and the secure base. We all need a safe haven and we all need a secure base. For some people, it’s going to be alcohol; for some people, it might be other substances. For some people, it might be someone or it might be a belief system that they have, but we all need a safe haven — a secure base.

So, what’s the role of the therapist? Like, we have all these fake facts and all these fake understandings, but really, you might be asking yourself, “What can I do as a therapist to better serve Latinx clients that are struggling with alcohol use or might be struggling with alcohol use?” The therapeutic alliance is the best predictor of treatment success — we know that from research. So, we really want to focus on the relationships that we’re building with the client. We want to focus on really being nonjudgmental and being present, having unconditional positive regard, entering the therapeutic relationship with an honest stance and really being there for the client, taking in everything that the client has to give us, meeting them where they’re at. Moving on the client’s pace, not at our pace. Not imposing our values or our beliefs onto the client. That is a fast way to create and sustain a strong therapeutic alliance.

Again, this is the best predictor that treatment will be successful. The rupture repair is important. At some point, your relationship with the client is going to suffer a rupture. All relationships suffer ruptures, even therapeutic relationships. The key, though, is that we’re able to repair that relationship, that we’re able to ask clarifying questions, that we’re able to take accountability and ownership for mistakes or assumptions that we’ve made. That we’re able to apologize, that we’re able to talk about any misunderstandings or uncomfortable feelings that came up for either party. This models healthy relationships. This is the perfect model of a healthy relationship. It might be the only model this client has of a healthy relationship. They might not feel comfortable providing you with feedback. They might not feel comfortable hearing feedback from people in their lives. They might not feel comfortable sharing their emotions, how the behavior of someone impacted them at an emotional level. You open that conversation. Again, coming from a nonjudgmental, accepting stance really models healthy relationships. Healthy relationships are a combination of rupture and repair. We want to be in the moment with the client and for the client. We want to invite the client to move along the therapeutic process. Again, we don’t want to impose, we don’t want to impose our ideas or our values, but we don’t also don’t want to impose our beliefs. Certainly we want to find a balance between being directive and not directive, and I think this is really important.

You know, therapists try and classify themselves as directive versus non-directive. The reality is that regardless of what you prefer, most Latinx clients have never been to therapy before, and therapy is something that is rarely talked about within the Latinx community, like we’ve talked about before. We don’t understand how the process works. They don’t know a lot about mental health and addictions. They don’t know what to expect, so they really need to be provided with a lot of cycle education and a lot of directions throughout this process. If you don’t provide that, they’re going to drop off or they’re not going to move along in the process and make the progress that you would hope for them to make. They need that direction. So, this could be a challenge for clinicians that really identify as non-directive. We really need to find a balance if we want to truly serve this population.

Dr. Dan Siegel came up with this idea of COAL, which is an acronym for the type of mindfulness that we want to have on the couch. We want to be present. We want to be there for the client. We want to absorb everything that the client is sharing, and we want to be mindful of details in their story that might indicate trauma, might indicate mental health concerns, might even indicate alcohol abuse — because most likely, the clients are not gonna come and tell you, “Hey, I have alcoholic abuse, I suspect I have alcohol abuse.” We want to really have an open ear for those things, but we also just want to be able to have that therapeutic alliance and we really want to meet with Latinx and foster trust. Create that trust, build that trust, let them know that we are committed to walking with them through this process.

The C stands for being curious. So again, we want to have this curious stance. We don’t want to come in with assumptions. We don’t want to think that, well, because I’ve worked with Latinx clients before and this has been the situation; this might be the situation with this client just because you’re also Latinx, right? I want to come from a place of curiosity. I want to ask questions. I want to wonder. I really want them to help me understand what their life experiences have been and why you’re struggling with whatever they’re coming to you saying that they’re struggling with. I want to be open — open to different ideas, to different values, to different belief systems, to different spiritual beliefs, religious beliefs, and I want to welcome those in my office. Even if these are things I’ve never heard of before, even if these are things that are new to me, I will go and study and do my own research after I’m done with that client. But in that moment that I’m with the client, I want to be open and welcoming. It’s all of that. I want to be a stepping stone, right? I’m not trying to change the client; we’re going to eventually try to change the dysfunctional behaviors and dysfunctional patterns in the client’s life because that is part of therapy, but we need to accept the client for who they are as you’re showing up on our couch.

We want to be loving. We want to be gentle. So, we want to communicate to the client that we are here for them. We’re not here to be against them. And depending on the setting that you’re working in, a lot of times, clients don’t come to us voluntarily. They come to us because they’re court-mandated or some sort of legal trouble, and they kind of have to be there — where it’s the best option for them to be there from a legal standpoint, but not necessarily because they want to genuinely be there. So, we want to reinforce that we’re coming from enough and we’re not the court system and we’re not a judge. That we’re there to really help them — help them in that legal process, but also help them have a better life. Help them deal with whatever other issues they think they have, they believe they have. So, we just want to remember that as curious, open, accepting, and loving mindfulness you want to practice on the couch.

The assessment process. So, we want to have a clear history of the immigration experience and the cultural identity of the client, how they identify themselves and how they describe their immigration experience. Again, we’re looking for trauma in their home country. We’re looking for trauma in the journey. We’re looking for trauma living in the U.S. Does it mean that we’re going to have trauma all across? Not necessarily, but we want to look through that. The relationship between their cultural values and their alcohol use. So, what does your particular culture and values within your culture say about alcohol use? Explore gender narratives and expressions of emotion. So, what emotions are acceptable, which emotions are not? And how does gender play a role in that? Listen to the client’s story and recognize attachment styles. So, are they secure, anxious, avoidant or disorganized? Try to recognize that in their story. Ask about childhood, ask about their relationship with their parents, their grandparents, their siblings, and their romantic relationships, relationships with friends.

Clarify the perception problems — so, why are they coming to therapy? Why do they think they should be in therapy? Why do they think they should be completing this assessment? Again, is it a court situation? Is it a family member tracking therapy? Is it them themselves recognizing that they have some sort of problem? They may recognize that alcohol is part of the problem. They may be in denial about alcohol being part of the problem and they just simply think they have anxiety, right? So, you want to hear from them, their perception of the presenting problem. You might be already diagnosing them in your mind, and you might already — you know, your wheels might be turning and you may be thinking this is totally a classic presentation of alcohol use disorder. And that’s cool — let me see, I diagnose. You want to know from the client’s perspective what that presenting problem is, ‘cause that’s really where you want to get started and that’s the language you want to use. Then, somehow, go tie that back to alcohol, but you really want to use the motivation. Whatever the client tells you, their presenting problem — that’s your motivation for therapy.

If I’m telling you I’m having problems with my husband, then that’s my motivation, I don’t want to have problems with my husband, so I came to therapy to make him happy. So, let’s talk about the problems I have with my husband, and then we can tie that back into addiction. Discuss motivation for treatment and potential obstacles. So, how motivated are they from treatment and what might be some obstacles that may come along the way? Whether it’s finances, insurance, working, it’s family not approving of treatment — whatever that may be, we definitely want to discuss that. We want to identify the support system and your perspective on the presenting problem and treatment. So, support system — close friends, family, significant others — do they see the problem? The client has a problem; are they supportive of the client seeking treatment? If possible, would we want to include the main support person or persons in the assessment process? So, if we can have a parent, if you can have a grandparent, if we can have a sibling, if we can have a significant other, if we can have a close friend or cousin, someone that is identified as a support person for the client present in a portion of the assessment.

It would be helpful. Even if it’s a conversation over the phone, it would be helpful because it will give you a wider perspective of what the client is going through, what treatment might look for the client and that support that they’re going to receive. It’s also going to give you more insight to the dysfunctionality within the family. Like, how dysfunctional is a family? Is this family dysfunctional at all? Is there a measurement? Assess utilizing formal assessments. We want to do this with caution. We also can go through the criteria and type for alcohol use. We want to do both with caution. DSM-5 was basically created in studies of middle-class white men, and so were most of the formal assessments, right? Middle-class white men were usually the ones used in the research, and women. So, we want to be mindful of the assessments that we are using. If we can find an assessment that is more culturally sensitive, then we would obviously prefer to use that one. If we can’t, then we can sell you assessments that we have, where we can go down the list of the DSM-5 criteria, which is usually what I prefer to do. But we wanted to do that within the context of their culture.

We want to be mindful of that — that we’re not just blindly seeing these assessments or going through the criteria of the DSM-5. That we’re doing this from the lens of their culture. We want to collaboratively create goals for therapy, create a treatment plan. If we get an understanding of, you know, what are we expecting to get out of therapy and how are we going to get to that? This format? And like I said, before therapy and treatment, these are all new things for most Latinx clients, so they don’t understand a lot of this — a lot of the verbiage that we may use. So, we really want to break it down, and breaking it down and doing it together is going to really strengthen that therapeutic alliance and your ability to trust us and to kind of buy into the process.

Appropriate approach to treatment. So, we want to determine the appropriate level of care and provide education about why this is the appropriate level of care. As we are considering what the appropriate level of care is, we have to take into account certain factors. We want the least restrictive level of care that would meet that client’s needs. We want the family to be involved — again, family is a huge part of the Latinx community, and if the family is not able to be involved in the treatment process, chances are the moment they go back to their family and they stop seeing us for treatment or they leave our treatment center, they’re going to relapse because the dynamics would have not changed. Their family is going to continue to enable them, and they’re going to just allow that dynamic back. The enmeshment is going to continue to be there. A lot of the intense emotions that come up when they’re around their family — they’re going to come back again and they’re not gonna know how to manage those. So, we really want to have the family as involved as possible.

I love the idea where family can come in for family sessions in person and have a handful of those before a client is discharged. When I think of a better residential facility or even a PhD type of facility, that is obviously not always possible because a lot of times, people come from out of state or from different cities, and families may not have the ability to travel. That’s something that you also want to take into consideration, which then takes me to the next point, which is the location. You know, do they have to drive? How far do they have to drive? Is it out of state? Will the family be able to be involved? Did they even agree to leaving the state so far from their family? We really want to take into account location for financial concerns, but also for the ability of this family to be involved. Financial constraints — are they the primary breadwinner in the family? What’s going to happen if we’re trying to assign them 60 days to a treatment facility and they can’t work. I mean, it’s your job — you’re supposed to sustain themselves. Are they going to be able to pay for outpatient services? So, all of these financial constraints have to be taken into account. If they’re doing outpatient, they might need a babysitter. Are they going to be able to pay for the outpatient services and also pay for the babysitter? That’s an added expense.

Occupational obligations kind of also tie into financial constraints. You know, they may run a small business where they are the primary breadwinners. What is that going to look like? You know, are they going to just abandon their business? Are they qualified for things like FMLA? Are they going to lose their job? Like, what are their obligations, occupation, which tied back to financial constraints. Child care, again, is important. Are they going to have child care? Is there someone that they feel comfortable with leaving their children with? Are they going to have to pay for that? Because that would be an additional cost. Religious affiliation — so, are their religious spiritual beliefs an important part of who they are? It’s a source of strength for them, and it’s a protective factor in their life. We would want to find a facility or a therapist that includes spirituality into logistical needs in their therapy. They’re comfortable talking about religious and spiritual beliefs, and if they are of the same religious or spiritual belief, then that may be even better.

If selecting detox, residential, PHP or IOP, you want to ensure that the program is truly in Spanish and is culturally sensitive. This sounds like a no-brainer; like, obviously if the client is Spanish speaking and I’m trying to send them to a residential facility, I’m going to pick a Spanish facility that has a Spanish program. But you really want to make sure because a lot of these addiction treatment centers — they want clients, they’re really good at their marketing. They will say that they have a Spanish program, but in reality, they have one Spanish-speaking therapist in the whole facility. They don’t really have a Spanish program and they’re not culturally sensitive. Not with some facilities, but they usually aren’t. So, one of my peeves is that I don’t ever refer a client to a facility that I haven’t toured myself and that I don’t have a close connection to either the clinical director or one of the therapists there. If I don’t have a close connection with them and I haven’t toured the place, I haven’t sent many clients there. I’m very skeptical just because I want to make sure that my clients are having the best care possible.

Again, for a lot of Latinx clients, this might be the first time they’ve ever explored treatment or therapy in any capacity. So, I don’t want them to be scarred and never want to seek any help again because they have a negative experience. What a lot of these treatment centers do, like I said, they’ll promote that they have a Spanish program when, in reality, they have one Spanish-speaking therapist in the whole facility. So, those clients can’t participate in group. They can’t. They don’t have textbooks, workbooks, handouts or any source of literature in Spanish, so they can’t read and consume that. They can’t really socialize with other people because probably most of the other people are going to be monolingual as well. And they only have that one therapist that can provide therapy for them in Spanish. That is not the experience of going through detox or residential, or PHP or even IOP. That’s not really what it’s meant to be. That’s not the format and that’s not the real experience.

So, we want to make sure that the program actually has a Spanish track, meaning they have groups in Spanish. They have, you know, nurses and health professionals that speak Spanish. They have therapists that speak Spanish and they have literature that’s available to the clients in Spanish. The clients are able to have family sessions, couple sessions in Spanish as well. They’re able to attend AA meetings or whatever support group type of meetings like they do, also in Spanish. We want them to be culturally sensitive. So, it’s not just about, “I speak Spanish and I’m a therapist so come send me your clients.” It’s about the fact that I understand the culture that makes Latinx culture. I did a webinar like this that helped me have an understanding of working with the Latinx community, understanding immigration, understanding cultural differences, understanding all of these things that we’ve talked about in this webinar. So, we want to make sure that the therapists there, if they’re not a Latinx themselves, and even if they are Latinx, they have this cultural sensitivity. Because, again, being Latinx doesn’t mean that I am culturally sensitive to all other Latinx. I may be very focused on what my experience as a Latinx has been and assume that that is the same experience that other Latinx folks have, which is a very, very wrong assumption.

So, these are the references that I use for this presentation. I used a lot of Dr. Gabor Mate for addictions, Dr. Dan Siegel when it comes to mindfulness and being present with their clients. Dr. Sue Johnson when it comes to things related to attachment. Dr. Dan Siegel also has attachment information, attachment psychics. Hazel Betty Ford Foundation, more so in regards to statistics and information regarding substance use, as well as the National Institute of Alcohol Abuse and Alcoholism, more so for statistics in that kind of information.

Well, thank you all for participating and being part of this webinar and taking some time from your busy schedules to join me and to really, you know, have that thirst for understanding and gaining more knowledge of how to work within the Latinx community. I think it’s very important that we continue to grow. I think that as therapists, we are constantly learning and forever students. The clients you’ve worked with in the population, age group — these things may change throughout our career as therapists, and we really want to make sure that we’re constantly pushing ourselves to be able to help the populations out there that we’re currently working with. So, I am really excited that you guys joined me, and I’d be interested in learning more about how alcohol abuse presents in the Latinx community and the role that family plays in it as well. I hope that this information was helpful and made you feel confident when you work with the Latinx clients, when you’re assessing Latinx clients and when you’re deciding how to proceed when it comes to treatment. Thank you.

Thank you for watching this video. We hope you enjoyed the presentation.