Considering the theoretical background of research about substance abuse among immigrant and refugee populations within the United States is an important part of understanding the current literature; however, there are some difficulties in the conceptualization of theory for these populations within the context of substance abuse. In the existing literature, there are several theories that are used to frame substance abuse within immigrant communities, thus adding to the difficulties as well. It would be unreasonable to expect all authors to subscribe to only one theory, however the variety of theories found increases the difficulty of a comprehensive discussion. It is beyond the scope of this chapter to mention all of the theories that have been identified to conceptualize this area of literature; instead a few theoretical frameworks and societal factors that have been used repeatedly in relation to substance abuse and which might be useful in providing additional clarity to these extant complexities will be discussed.
One approach that has been frequently utilized in the literature is ecodevelopmental theory (Szapocznik & Coatsworth, 1999). This theory takes tenets of ecological systems (Bronfenbrenner, 1977) and developmental theories such as stages highlighted in the expanded family life cycle model (Carter & McGoldrick, 2005) in an attempt to explain the complexities of substance abuse within immigrant and refugee populations. This enables a discussion of surrounding systems that influence the individual, while also taking into account the stages of life many individuals and families experience. For example, Bronfrenbrenner (1977) discussed development as a series of systems that mimicked concentric circles. The circle closest to the individual is the micro-system, which consists of people and environments that influence the individual on a regular basis (i.e., family members, friends, colleagues, work environment, etc.). Each of these micro-systems interacts with each other, and this interaction creates the meso-system. The next two systems are the exo- and macro-systems. The exo-system consists of the larger influences of economics, politics, education, government, and religion, while the macro-system consists of overarching values and beliefs that a person has. This whole system then moves through time and this element of time is termed the chronosystem. Immigrants and refugees may have similar types of micro-systems, however their interaction with their macro-system may be a bit different due to experiences during displacement or migration, language, culture, and law.
The second piece of ecodevelopmental theory is the Family Lifecycle Model. The Family Lifecycle Model describes the normative stages that a family goes through (i.e., initial coupling, marriage/commitment, transitioning to parenthood, etc.). Combining each of these concepts into one theory allows for an understanding of both external and internal influences. Ecological systems theory focuses more on the outside systems with which an individual interacts (i.e., peer and familial influence and work and/or school environment) and the family lifecycle provides an understanding of important internal influences such as stages of life (i.e., childhood, adolescents, coupling, etc.).
Assimilation (or Acculturation) Model
One model that focuses more on the population (i.e., immigrants and refugees) than on the problem (i.e., substance abuse) is the assimilation (or acculturation) model. This model describes new comers (i.e., immigrants and refugees) as adopting the host country’s customs and patterns of substance use. This means that immigrants and refugees may likely adopt substance use habits that are more reflective of their current surroundings rather than their country of origin. This is not definitive however, and the literature is mixed. Both D’Avanzo (1997) and Rebhun (1998) reported that people might simply continue the substance abuse patterns that they participated in while living in their country of origin. This may explain the immigrant paradox discussed previously; the longer that immigrants and refugees and their families stay in the United States, the higher their risk for substance abuse. This would make sense as first-generation migrant peoples would have a foreign country of origin, but second-generation would be living in their country of origin and thus only have their current location (with all of its influences, culture, etc.) as a frame of reference.
While the assimilation (or acculturation model) focuses more on the population rather than the problem, the biopsychosocial theory takes another angle. This theory integrates aspects of psychology and sociality to expand the explanation and understanding of biological factors (Engel, 1977), and in utilizing this theory, the problem (substance abuse) is placed as the primary focus. Marlatt (1992) first used this theory to describe substance abuse in an effort to explain the influence of substance abuse on the entirety of a person. According to Marlatt (1992) addictive behaviors are influenced by the combination of biological, psychological, and sociocultural factors. Biological determinants may include genetic predispositions to addiction (Palmer et al., 2015) and the way in which the substance physically affects the body. The biological portion of the experience of substance abuse greatly influences the psychological and social experiences (Marlatt, 1992). Psychological risk may include beliefs or values, mental health, exposure of psychological trauma, and expectations of substance effects. The sociocultural influences include both the influence received from and given to others. Each of these determinants interact with and influence each other, and provide a complex picture of how substance abuse might be experienced.
Socially disadvantaged populations, such as racial or ethnic minorities, face health disparities. They are more likely to have health problems, less likely to have access to health care, and more likely to receive substandard care (Institute of Medicine, 2002). These disparities result partially from differences in socioeconomic status, education, employment and housing stability. In terms of substance abuse, ethnic minorities are less likely to use or to complete substance abuse treatment (Chartier & Caetano, 2011). This theory suggests that as a disadvantaged population, immigrants and refugees face disparities in access to and use of substance abuse treatment. Consequently, the outcomes of substance use in these populations would be more severe.
A historical trauma perspective reminds us that traumatic experiences can lead to wounds that extend across generations (Sotero, 2006). When a community experiences systematic trauma, such as genocide and forced removal from community, the community as a whole suffers substantial loss and social disadvantages. For example, displacement can lead to reduced socioeconomic status as possessions are left behind and displaced persons must look for employment in a new location. For the individuals in the community, exposure to trauma often leads to psychological symptoms such as PTSD, depression, or anxiety. These trauma-impacted individuals must find a way to cope, and they are likely to turn to substance abuse or other self-destructive behaviors to numb pain. Their parenting and family functioning are likely to be negatively impacted, and their families are likely to be alienated from external supports. These effects will impact their children in turn. Among children of Holocaust survivors, for example, those children who perceived greater parental burden (i.e., the extent to which parents required care from their children due to the parent’s distress from traumatic exposure) had greater symptoms of PTSD (Letzter-Pouw, Shrira, Ben-Ezra, & Palgi, 2014). The children see the ongoing effects of the original trauma.
This framework can be very useful in understanding substance abuse in refugee and other trauma-impacted communities. A refugee community, for example, suffers substantial losses, which impact their ability to function as parents and family members and which increase their chances of turning to substance use to cope with ongoing losses. Children in these families may experience a powerful combination of ineffective parenting, family norms of substance use, socioeconomic disadvantages, and a sense of loss or disconnection related to the original traumatic events and stressors. These children are at risk to turn to substances.
Each of these theories could be helpful in explaining the immigrant or refugee experience of substance abuse. While it is not necessary for a professional to consider using all of these in guiding his/her work, examining each more closely would be beneficial. Each has something to add and to enable consideration of immigrants’ and refugees’ needs regarding substance abuse.