ART THERAPY GROUP CURRICLUM: YOUTH SUD

Art Therapy Group Curriculum For Youth Experiencing Substance Use Disorder
Receiving Treatment in a Residential Facility

Hailey Kivler
Department of Counseling
PennWest University
Dr. Carolyn Brown Treadon

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ART THERAPY GROUP CURRICLUM: YOUTH SUD
Abstract
This paper will explore how art therapy is effective at treating substance use disorder in youth
ages 12-17 years old through a group curriculum delivered in a residential setting. The creative
process offers youth an alternative to traditional talk therapy, allowing for expression and nonverbal communication that goes beyond what words could offer. Based on elements from
Adlerian theory and the Socio-ecological Model of Substance Use Disorder, the curriculum
treats substance use disorder in a holistic way, considering the many areas of life that influences
drug use. This paper will provide evidence to support the effectiveness of art therapy with this
population and propose a group curriculum that can transform the type of residential treatment
offered for youth with substance use disorder.

Keywords: Youth, substance use disorder, substance use, art therapy, Adlerian, socioecological model of substance use disorder

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Table of Contents
Title Page ..................................................................................................................................................... 1
Abstract ....................................................................................................................................................... 2
Table of Contents ........................................................................................................................................ 3
Section I: Introduction ............................................................................................................................... 4
Problem to be Investigated.................................................................................................................... 6
Purpose Statement................................................................................................................................. 6
Justification ........................................................................................................................................... 6
Definition of Terms .............................................................................................................................. 7
Section II: Review of Literature .............................................................................................................. 10
Theoretical Orientations...................................................................................................................... 10
Adlerian ......................................................................................................................................... 10
Socio-ecological model of substance use disorder ........................................................................ 12
Substance Use & Substance Use Disorder (SUD) .............................................................................. 13
Withdrawal and Relapse ................................................................................................................ 15
Overdose ........................................................................................................................................ 15
Co-Occurring Disorders ................................................................................................................. 17
Substance Use Disorder in Youth ....................................................................................................... 18
Risk Factors ................................................................................................................................... 19
Recovery and Abstinence in Youth ............................................................................................... 20
Residential Treatment for Youth SUD........................................................................................... 20
Barriers to Treatment ..................................................................................................................... 21
Vulnerable Youth Systems and SUD ............................................................................................. 22
SUD in Youth since COVID-19 .................................................................................................... 23
Art Therapy ......................................................................................................................................... 24
Art Therapy & SUD ....................................................................................................................... 24
Section III: Methodology .......................................................................................................................... 26
Who Will Benefit ................................................................................................................................ 27
Curriculum Structure .......................................................................................................................... 27
Curriculum Outline ............................................................................................................................. 28
Section IV: Curriculum ............................................................................................................................ 29
Section V: Discussion ................................................................................................................................ 30
References .................................................................................................................................................. 34
Appendix A ................................................................................................................................................ 42

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Section I: Introduction
As technology has advanced over time, so has illicit substances and methods of use,
particularly in the youth population of the United States. Adding the stress of the COVID-19
pandemic mixed with the emotional and hormonal changes of adolescents, more youth than ever
have taken to using substances to cope. Chaffee (2022) looked at youth substance use data from
1991 compared to 2017, finding marijuana use doubled amongst youth and that nicotine usage
went from 13% to 33% since the creation of electronic cigarettes (e-cigarettes). Many nicotine,
tobacco, and alcohol companies today are marketing their products to the younger generations
who are more technologically inclined and interested, creating a demand and increase in use
among youth under the age of 18. While there is a lot of effort pushed into selling these products,
there is not enough going into prevention or treating the substance use in youth.
There are many barriers that can prevent individuals from receiving treatment for
substance use. Stigma associated with drug use among adolescents can cause those around the
youth to judge rather than offer help. Substance use treatment is one of the most expensive types
of care in the United States, limiting the availability of treatment depending on economic status
and insurance coverages (Farhoudian et al, 2022). Substance use treatment for youth should be
able easily accessible and effective for the population. This research paper introduces an art
therapy-based curriculum designed for youth under the age of 18 years old that aims to treat both
SUD and co-occurring mental illnesses. The curriculum is based off aspects of Adlerian theory
and structure inspired by the socio-ecological model of substance use disorder, facilitated
through the art therapy modality. This curriculum engages with youth through art making and
provides an effective treatment plan for a group of youth experiencing SUD.
Problem to be Investigated

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Substance use can be difficult to treat due to the evasiveness of the deeper issues that
contribute to the use of the substance. People use substances for a wide variety of reasons, from
using them to cope with trauma to using them to escape their thoughts and feelings. This is
further complicated when the client is a youth and potentially experiencing co-occurring mental
disorders. A study done on the effectiveness of treatment for youth with substance use and a cooccurring mental health disorder found that at time of aftercare check in one year after residential
treatment, “47 percent of the youth with mental health issues used marijuana weekly compared
to 39 percent of the other youth, 32 percent used hallucinogens compared to 18 percent of others,
and 17 percent had suicidal thoughts compared to 12 percent of the others” (Foxhall, 2001, para.
6). From this data, it is apparent that youth with additional mental health disorders are more
likely to engage in substance use even after receiving treatment. There is a lack of effective
treatment that tackles both the substance use and potentially occurring mental health disorders
that also contribute to substance use among youth.
Purpose Statement
The purpose of this curriculum is to develop an art therapy-based curriculum for youth
with substance use disorder in an effective residential group therapy setting that addresses both
the substance use and mental health concerns.
Justification
Youth substance use is a prevalent problem today, with 1 in 8 youth reporting use of an
illicit substance in the past year (“Drug Use Among Youth: Facts and Statistics”, 2023).
Substance use has become so common for youth that by 12th grade, two-thirds of students had
tried alcohol while two out of ten students admitted to using prescription medication illegally
(Johnson et al, 2014). While using a substance once may not initially indicate a SUD, using a

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substance once with no adverse consequences only builds confidence that nothing bad will
happen again. Recurrent use of substances often turns into SUD, causing problems at school,
work, or home while also exposing youth to dangerous situations where impaired decision
making can lead to situations such as impaired driving or engaging unsafe sex (“Substance
Use/Misuse”, 2023). Youth today are exposed to substances at younger and younger ages, at a
time when they do not have a fully developed body and brain. It can be hard for anyone, let alone
an adolescent who is still developing, to come to the realization that their substance use has
become a problem with short- and long-term consequences to life.
Data reported by the annual National Survey on Drug Use and Health showed nearly 1
million youths (ages 12 to 17) needed treatment for SUD in 2018, although only 83,000 of them
received services in a treatment center (“Key Substance Use and Mental Health Indicators”,
2019). There are youth who are in desperate need of effective treatment but are prevented from
being able to get the help they need due to internal and external barriers. Barriers to treatment
include racial bias, economic cost of care, and the stigma associated with SUD (Alegria et al.,
2010; Earnshaw, 2020; Farhoudian et al., 2022). The process of getting treatment for SUD can
become overwhelming and in turn create additional stress for youth and their family.
Traditional treatment methods have been found to be ineffective at treating substance use
in adolescents. According to Marlatt & Witkiewitz (2002), “programs for adolescents using a
pure abstinence-based approach (the “just say no” approach) are ineffective in reducing
substance use and abuse” (p. 2). Telling youth to strictly refuse substances without giving them
the knowledge to make these choices on their own only serves to add to the negative stigma
behind substance use. Lack of effective treatment the first time around can leave a negative
impression on the adolescent’s idea of recovery and can cause aversion to future treatment.

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Letting youth go with ineffective treatment can lead the youth into a cycle of
incarceration as they age. Research collected shows that continued use can “contribute to an
elevated risk of recidivism, which leads to further, and oftentimes more serious, involvement
with the juvenile justice system” (Fisher et al, 2018, p. 3). There is a lack of published research
on the use of art therapy with youth substance use, creating a need for this gap to be filled in the
field. Current treatment methods for youth are not available or effective enough to target SUD as
mentioned previously. Art therapy can help to address this by providing non-judgmental,
creative, and collaborative approach that traditional talk therapy may lack.
Definition of Terms
The following terms will be used throughout the study.
Adlerian “Individual” Psychology
An approach to psychology that emphasizes a “holistic and phenomenological
understanding to human behavior”, stressing the importance of viewing all aspects of an
individual including lifestyle and social context (Carlson & Johnson, 2016). Human behavior is
goal-oriented and is often influenced by external factors such as birth order, the family
constellation, personal lifestyles, and social interest.
Art therapy
“An integrative mental health and human services profession that enriches the lives of
individuals, families, and communities through active art-making, creative process, applied
psychological theory, and human experience within a psychotherapeutic relationship.” (“About
Art Therapy”, 2022, para.1)
Recovery

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“A process of change through which individuals improve their health and wellness, live a
self-directed life, and strive to reach their full potential” (“SAMHSA’s Working Definition of
Recovery”, 2012, p. 3).
Relapse
Refers to an individual “losing control over a behavior and reverting to earlier patterns of
behavior after a period of abstinence” (Fernandez et al, 2020, para. 3).
Residential Treatment
“Are licensed, community-based facilities that provide 24-hour inpatient care for people
with mental health and/or chemical dependency disorders in a residential treatment setting”
(“Residential Treatment Facilities”, 2022, para. 1)
Socio-Ecological Model of Substance Use Disorder
A dynamic model of SUD that “recognizes the mosaic of interactions that play a role in
addiction, including society and public policy (laws and regulations); communities;
organizations and personal networks; and our own individual biological, genetic, and
psychological makeup” (“Understanding the Crisis of Addiction”, 2022, para. 8).
Substance
“This is material abused (e.g. Cocaine, alcohol, marijuana), a medicine (sedative, for
example) or toxin” (“What is SUBSTANCE? Definition of SUBSTANCE”, 2013, para. 1)
Substance Use Disorder (SUD)
“Characterized by recurrent use of alcohol or drugs (or both) that results in problems
such as being unable to control use of the substance; failing to meet obligations at work, home,
or school; having poor health; and spending an increased amount of time getting, using, or
recovering from the effects of using the substance.” (Lipari & Van Horn, 2017, para 1).

ART THERAPY GROUP CURRICLUM: YOUTH SUD
Overdose
“Injury to the body (poisoning) that happens when a drug is taken in excessive amounts.
An overdose can be fatal or nonfatal.” (“Commonly Used Terms”, 2021, para. 24)
Withdrawal
A “physiological response to the sudden quitting or slowing of use of a substance to
which the body has grown dependent on” (Sharp, 2022, para. 3).

Conclusion
In this section, the purpose of this study was defined as creating an effective group art
therapy curriculum for youth experiencing SUD in residential treatment. As described
previously, there are many reasons that there is a need for this research, including ineffective
treatments for youth and lack of available research on how art therapy can address SUD. The
next section addresses the current state of substance use disorder among youth and examines
how a group curriculum based in Adlerian theory in combination with the socio-ecological
model of substance use disorder facilitated through the art therapy modality can be an effective
treatment for youth experiencing symptoms of SUD.

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Section II: Review of Literature
This section will examine past literature that describes the problem of substance use
amongst youth and provide support behind the elements of the developed art therapy curriculum.
The socio-ecological model of substance use disorder will be identified and validated as a core
concept of the developed curriculum structure. The Adlerian theoretical orientation will be
explained and its explanation of SUD and other psychopathology will be examined.
Additionally, past research on art therapy and its effectiveness with youth SUD will be provided
to validate the curriculum.
Theoretical Orientations
To create an effective art therapy curriculum for youth that addresses SUD and any cooccurring disorders, a holistic treatment that addresses the youth and all the factors influencing
them is needed. Adlerian theory is integrative and goal-oriented, identifying the individual’s
specific needs while also considering the individual’s family system and social context. The
socio-ecological model of substance use disorder will be examined for the purpose of reasons
behind substance use and integrates well with Adlerian theory’s dynamic approach.
Adlerian with Youth SUD
Developed by Alfred Adler, Adlerian or “Individual” psychology came about as an
alternative to Freud’s psychoanalysis and is notable for emphasizing the holistic, social, and
goal-oriented nature of humans while promoting the idea of looking at individuals as a whole,
indivisible from all of their parts (Fong et al, 2015). This differed from Freud’s Psychoanalytic
theory, that viewed different parts of an individual functioning separately, such as with the id,
ego, and superego. Adler believed that all psychopathology comes from difficulty in navigating
the five major tasks of life, in which he identified as the following: coping with problems of

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social relationships, coping with problems of work, coping with problems of love, coping with
the self, coping with existence (Fong et al, 2015). SUD and other co-occurring disorders result
from being unable to cope with one or more of these tasks of life. Rather than mental illnesses
being innate or life long, psychopathology can be alleviated through learning a different way to
navigate life.
Lifestyle.
The way in which an individual lives their life is unique and indicative of their internal
processes. Adler defined the term lifestyle as the “holistic pattern of beliefs and goals that the
person uses for interacting with others and for measuring self-worth” (Fong et al, 2015, p. 210).
Lifestyle develops through early experiences in childhood but goes on to influence the present
and future choices. In times of stress or emotional pressure, lifestyle will become evident in how
an individual reacts. Awareness through therapy or significant life events allow for change in
lifestyle to occur (Fong et al, 2015). To overcome psychopathology such as depression or SUD,
gaining insight into these life patterns through effective therapy can help to develop healthy
lifestyle changes.
Birth Order and the Family Constellation.
Adlerian focuses on the importance of family, birth order and how the order of birth
between siblings can predict later life outcomes. The family constellation is described as “the
family atmosphere and emotional tone of the home, presence of siblings, their age differences
and birth order, parental influences and expectations, parenting styles and family values,
neighbors, and peers” (Fong et al, 2015). Early experiences gained with the family unit are
essential for emotional development and how an individual reacts in their present and future.
Adler theorized that the order in which an individual is born in the family influences their

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personality and lifestyle. There is evidence that birth order can be applied to SUD outcomes and
found that being a first born male or female was a protective factor against SUD while being the
youngest put the youth more at risk of developing SUD (Horner et al, 2012). Family not only
plays an important part in an individual’s childhood, but also the rest of their lives.
Social Interest.
In addition to an individual’s lifestyle and family being important influences, Adlerian
theory also stresses the importance of the feeling of connection even outside of the family. Adler
described this connection as social interest, “an internal feeling of connectedness to others and
their well-being, to the well-being of the individual” and the desire to need and belong (Fong
Chang et al, 2015, p. 207). Adler theorized that substance use specifically is driven from a lack
of social interest and used as a “means to evade the tasks of life, including love, friendship,
work, and self” (Giordano et al, 2014, p. 116). In Adler’s view, SUD comes from the inability to
cope with the five major tasks of life with the addition of lacking the feeling of connection with
others.
Socio-Ecological Model of Substance Use Disorder
A modernized model of addiction, the socio-ecological model of substance use disorder
examines addiction through the different influencing factors in an individual’s life. The model
“recognizes the mosaic of interactions that play a role in addiction, including society and public
policy (laws and regulations); communities; organizations and personal networks; and our own
individual biological, genetic, and psychological makeup” (“Understanding the Crisis of
Addiction”, 2022, para. 8). Bringing attention to Figure 1, it is evident through this lens that there
are various factors in a person’s life that can sum together and overlap to affect their perception
of substances and contribute to the engagement of the use of substances.

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Figure 1
Socio-Ecological Model of Substance Use Disorder

Note: This model portrays the different factors that influence SUD. From “Understanding the
Crisis: Addictions” by Indiana University, 2022. (IndianaUniversity.edu). Copyright 2023 by
The Trustees of Indiana University.
Identifying these factors and their interactions, the socio-ecological model of substance
use disorder allows for professionals to be able to address these underlying issues with clients by
allowing them to make their own connections and insights into their addictive tendencies.
Additionally, addressing the underlying factors has proven successful in reducing addiction and
substance use (Understanding the Crisis: Addictions, 2022). The socio-ecological model of
substance use helps to create a roadmap to recovery, identifying areas to work on for each unique
individual.
Substance & Substance Use Disorder
Mind altering substances, what are commonly known as drugs, have been around since
the beginning of humanity. Many cultures utilized their own medicinal practices that included
certain plants and rituals. In fact, the English word Drug was taken from French word Drogue
which means Dry Herb and suggests that earliest drugs were taken and developed from plant

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sources (Wadud et al, 2007). The word Drug can have different contexts based on the use of the
substance. Drugs that are used for medicinal purposes are considered fine for use but at the same
time, could be considered bad when they are misused for the purpose of “getting high” or
achieving an altered state of mind. This appears contradictory, that the same substance being
used at similar doses can be perceived in completely opposite lights depending on the intent of
the user.
The Substance Abuse and Mental Health Services Administration (SAMHSA) describes
substance use disorder (SUD) as “the recurrent use of alcohol and/or drugs causes clinically
significant impairment, including health problems, disability, and failure to meet major
responsibilities at work, school, or home.” (“SAMHSA’s Working Definition of Recovery”, 2012,
para. 1). The use of substances alone does not necessarily meet criteria for the disorder unless it
becomes disruptive and impairing to everyday life. SUD does not discriminate based on age and
can affect both youth and adults. There are many reasons that an individual may be tempted to
use or try drugs for the first time, however using once does not always indicate a substance abuse
problem. A SUD may be diagnosed more specifically based on the type of drug dependence,
such as cannabis use disorder or alcohol use disorder. Additionally, an individual with SUD can
struggle with multiple substances, which is classified as polysubstance use disorder.
Moralization is a human function that involves a “shift in focus to the individual as the
problem, not the phenomenon itself, nor the social context” (Frank & Nagel, 2017, p. 3).
America has gone through major events that exemplify how morality has impacted the
perception of substance use, from the Prohibition Era that outlawed alcohol due to religious
beliefs to Nixon’s politically fueled “War on Drugs” that continues to this present day. The
culture has become one that invokes “blame, shame, and the wholesale rejection of addicts as

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people who have deep character flaws, while ignoring the complex biological and social context
of addiction” (Frank & Nagel, 2017, p. 1). This has led to the stigmatization of substance users
and added a social barrier for users to receive treatment for SUD, despite the research supporting
the biological influences on SUD. Substance users not only face the intensity of the disorder
firsthand themselves; they also face discrimination and judgment from others when attempting to
reach out for help.
Withdrawal & Relapse
SUD can impact the lives of individuals in other areas of life as well. Prioritizing
substances can affect a person financially and lead to neglect for themselves and/or children in
housing, food, clothing, etc. Using substances around others can show a different side of a
person that strains relationships and family ties, severing sources of support. When it comes to
one’s physical state, stopping substances suddenly can result in withdrawal, a “physiological
response to the sudden quitting or slowing of use of a substance to which the body has grown
dependent on” (Sharp, 2022, para. 3). Once an individual feels like they are ready to stop using,
some will experience the unpleasant symptoms of withdrawal that discourage stopping, resulting
in relapse. Relapse refers to an individual “losing control over a behavior and reverting to earlier
patterns of behavior after a period of abstinence” (Fernandez et al, 2020, para. 3). In terms of
SUD, relapse would occur when an individual goes back to using after not using the particular
substance(s) for a period of time. The lack of support and the negative reaction from the body
can incite a cycle of addiction that is extremely difficult to break.
Overdose
Left untreated, SUD can lead to unpredictable and untimely consequences. The most
severe being death, whether momentarily after use of too much of a substance or after prolonged

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use. Overdose (OD) is “a biological response to when the human body receives too much of a
substance or mix of substances” that can result in fatality depending on the type of substance and
if medical treatment was provided or not (Smith, 2018, para. 1). Any kind of substance, from
caffeine to alcohol, can be over consumed and result in symptoms of an overdose. Common
substances that often result in death from overdose are opioids, depressants, and alcohol (Smith,
2018).
Figure 2
Number of drug overdose deaths and deaths involving illicitly manufactured fentanyl among
persons aged 10–19 years (2019-2021)

Note: The figure displays the number of overdose among youth ages 10-19 years old over the
course of July 2019 to Dec 2021. IMF stands for illicitly manufactured fentanyl. From “Drug
Overdose Deaths Among Persons Aged 10–19 Years — United States, July 2019–December

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2021” by CDC, 2022. (https://www.cdc.gov/mmwr/volumes/71/wr/mm7150a2.htm). Copyright
2022 by CDC.
An opioid known as fentanyl has become a huge concern due to the large number of
overdoses that have occurred in the past couple of years. Looking at Figure 2, illicitly
manufactured fentanyl, or fentanyl not made for medical purposes, makes up most of the
overdoses from all drugs among youth in 2019-2021. Overdoses can happen accidentally or
intentionally to end one’s life. Many accidental overdoses occur when substances are laced,
when one drug is added to another whether done to enhance the effects or done secretly by
dealers to lessen their costs or make more addictive (“How Dangerous Marijuana is When Mixed
With Another Drug”, 2022). In most cases, it is hard to tell whether substances have been laced
just by looking, making it dangerous for anyone, let alone youth, to take a substance when they
have no idea what is truly in it. No matter the type of drug, use of substances can result in serious
injury or even death when consumed in large amounts or mixed with other substances.
Co-Occurring Disorders
In addition to physical and social symptoms of SUD, there are also mental and emotional
components that occur, often in the form of another mental disorder. There are different theories
as to why SUD and other mental health disorders commonly co-occur, including that there are
common risk factors for SUDs and other mental disorders, that mental disorders can contribute
to SUD, and that SUD can contribute to development of other mental disorders (“Substance Use
and Co-Occurring Mental Disorders”, 2021). Anxiety, depression, attention-deficit
hyperactivity disorder (ADHD), bipolar are just a few mental disorders that can occur alongside
SUD. In 2019, a study found that 2.7% of youth had a SUD but no Major Depressive Episode
(MDE); 1.7% of youth had both a SUD and a MDE (SAMHSA, 2020). That means that in total,

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4.4% of youth had at least a substance use disorder with 39% of those youth also having a major
depressive episode.
Treating the SUD and co-occurring disorder simultaneously has been shown to be most
effective, as symptoms often overlap between both disorders (“Substance Use and Co-Occurring
Mental Disorders”, 2021). However, often times SUD and co-occurring mental health disorders
are treated separately. SAMHSA (2020) found that treatment for major depressive episodes has
increased over the years for youth, treatment for SUD & co-occurring disorders has been lacking
with only 1.3% of youth with SUD & MDE receiving both SUD & mental health services
together. Every person is unique and will have their own specific needs, making it important to
take consideration of all symptoms and possible treatment routes. SUD is a mental health
concern and youth should receive both treatment for SUD and mental health services in order to
receive the most effective treatment.
Substance Use Disorder in Youth
Surveys administered to students during school in an academic setting are a common type
of research method that has been utilized over the years to accurately track youth substance use
and trends. In the past couple of years, the modality of vaping substances with the use of an
electronic device has become overwhelmingly popular and a prevalent problem among youth.
Monitoring the Future (MTF) is a long-term survey administered to adolescents in the US that
discovered vaping (marijuana, nicotine, and/or flavored liquid) resulted in one of the “largest
absolute increases MTF has ever tracked for any substance” (Johnson et al, 2014, p.1). The
modernization of the way that substances are consumed has captivated the youth of this
generation, popularized use and distracted from the dangers of the substances themselves.

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The MTF study found that youth substance use rates for other drugs including marijuana,
alcohol, cigarettes, and ever certain illicit drugs such as LSD, MDMA, cocaine, crack, and heroin
remained steady in 2020 (Johnson et al, 2014). Substance use among adolescents has been
consistent in past years and even on the rise for substances used with electronic vaporizers. Drug
use is especially dangerous to adolescents because of their developing brains, particularly the
decision-making part of the brain known as the prefrontal cortex (“Drugs and Young People”,
2019). Taking substances that alter the brain before it is fully developed can cause youth to act in
ways not typical to their normal selves. In fact, drug use can influence youth to engage in risky
behaviors such as unsafe sex and dangerous driving (“Drugs and Young People”, 2019). While
the use of substances can alter the thinking of adults and adolescents alike, adolescents risk more
damage in terms of their development and ability to function as an adult in the future.
Risk Factors
Certain risk factors may contribute and influence a young person’s engagement in the use
of substances. Considering the socio-ecological model of substance from Figure 1, there are
individual, interpersonal, community, and societal influences in a youth’s life that may make
them more likely to engage in taking drugs. Individual factors include the youth’s biological
predisposition to developing SUD and personality/temperament factors (“Risk and Protective
Factors”, 2022). Interpersonal refers to risk factors related to relationships in a youth’s life, such
as an unsupportive family or peer pressure to fit in with other youth. In fact, youth growing up
with a parent with SUD are more likely to develop it SUD themselves, a high proportion of
“approximately 1 in 8 children in the US were living in a household with at least one parent with
SUD” (Lipari & Van Horn, 2017, para. 15). SUD does not only affect youth indirectly through
their parents but can impact them directly later in life by influencing them to use.

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Community risk factors are localized and might include a youth’s neighborhood or
middle and high schools. Societal factors refer to the larger area of a state or nation.
Overwhelmed schools can lack the mental health resources needed to support youth despite the
status of their drug use. Furthermore, societal factors on the state, national, and worldwide levels
can impact how youth view and perceive drug use. Laws and norms that are favorable towards
substances, such as the more recent nicotine vaping marketing advertisements towards teenagers,
can impact a youth’s perception about the dangers of drug use (“Risk and Protective Factors”,
2022). While there are many different forms of factors that implement further risk, there are also
protective factors that can help to prevent youth substance use. Having a supportive family, a
friendly personality, a school with prevention programs are all factors that help to protect youth
from considering using drugs (“Risk and Protective Factors”, 2022). Understanding the risk
factors that contribute to youth SUD can help to identify potential protective factors to
implement and develop a plan of treatment.
Recovery & Abstinence in Youth
In 2011, SAMHSA broadened their definition of recovery by removing the mention of
abstinence as a criterion for recovery: “a process of self-directed change through which
individuals improve their health and wellness, live self-directed lives, and strive to reach their
full potential.” (Finch et al, 2020, p. 2). While this offers a more holistic view of recovery for
adults, recovery in youth differs because substances can further impact their developing minds
and bodies. For youth with SUD, “developmental, legal, and familial context fundamentally
differs in ways that render adult based conceptualizations of recovery insufficient”. (Finch et al,
2020, p. 3). While its been found that strictly abstinence-based programs have been ineffective
with youth, abstinence from substances should be highly encouraged for youth until legal age

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(for recreational substances) along with the knowledge of the dangers of substances, so that
youth can have the autonomy to abstain from substances on their own (Marlatt & Witkiewitz,
2002). Looking at reduction of symptoms & abstinence from substances can be a means of
measuring effectiveness of treatment without focusing solely on abstinence.
Residential Treatment for Youth with SUD
When youth display symptoms of SUD and it has begun to impact their lives in
noticeable ways, treatment becomes essential for the safety and wellbeing of the youth. There are
many different routes of treatment, such as counseling and psychiatric medication management,
and can be through outpatient visits or long-term care such as inpatient care. Inpatient care is
intensive care and when done full time, is considered residential treatment because clients are
living there for a period to receive the fullest and most effective care. SUD in youth is serious,
especially due to the dangerous and unpredictable nature of the substances, and often requires
residential care over a few months’ time to help stabilize the individual and address both SUD
and any co-occurring disorders. What is unique about SUD is that it is characterized by
“alternating periods of abstinence and use, or recovery and relapse” (Farhoudian et al, 2022, p.
1). Often, it can take multiple attempts at residential care to get the client’s intended results and
can occur not only in youth but over the lifetime, making early prevention and treatment
increasingly important.
Barriers to SUD Treatment
Not only do individuals with SUD go through the negative symptoms associated with the
disorder, but there are additionally many barriers to recovery that individuals with SUD face. A
study by Farhoudian (2022) found that there are individual barriers that include fear about what
treatment is like and low self-esteem, social barriers revolve around the bias of substance use and

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family factors, and structural barriers that refer to the availability of treatment centers and
insurance companies. There have also been racial and economic disparities discovered in the
quality of residential care received. According to Alegria et al (2010), “black adolescents with
SUD reported receiving less specialty and informal care, and Latinos with SUD reported less
informal services”. The current established services are not effective or suitable for all youth
based on cultural and economic factors, failing to provide quality care to certain populations.
Earnshaw (2020) found that the moralization of substance use and the developed stigma “leads to
the development of substance use disorders (SUDs), undermines SUD treatment efforts, and
drives persistent disparities within these crises (p. 1300). The fact of the matter is that substance
users are discouraged from seeking treatment due to the many different types of barriers they
face getting the effective treatment they deserve.
Vulnerable Youth Systems and SUD
Foster Care.
Systems designed to protect and rehabilitate youth often end up increasing youths’ risk of
using substances. The foster care system in America does its best to place youth in relatives or
available foster family homes, however, defers to congregate care (groups homes, facilities)
when family placements are not available. Research has shown that children do best when placed
in family settings and that “congregate care should not be used as a default placement setting due
to a lack of appropriate family-based care” (Watson, 2016, p. 9). Lacking family-based care and
attention can increase risk factors such as feelings of isolation and connection.
Juvenile Justice System.
To understand the full scope of the challenges for a youth experiencing SUD, the
Juvenile Justice System in America must be mentioned, particularly for its lack of support for

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youth offenders with SUD. It has been found that less than 3% of youth in the juvenile justice
system who need treatment actually receive it (“Criminal Neglect: Substance Abuse, Juvenile
Justice and the Children Left Behind”, 2004). SUD can cause individuals to engage in risky
behaviors that may not have been engaged in normally were they not under the influence of
substances. Risky behavior for youth can sometimes include crime and involvement with police
and if convicted, the Juvenile Justice System. Cooper (2009) speculates the failure in the system
to effectively address SUD is the:
Low reliance on adolescent self-reporting utilized by most of the research, the failure of
justice and other systems to routinely assess youth for either current drug use or indicia of
drug use (e.g., “resiliency” or “protective” factors), and confidentiality and other
restrictions pertaining to access to juvenile justice system information. (p. 2)
With an ineffective corrections system for youth in the US, youth with SUD who have offended
are further failed by the system condemning them by not providing them tools and pathways to
treatment.
Substance Use Disorder in Youth Since COVID-19
With the onset of the COVID-19 pandemic beginning in late 2019-early 2020,
government lockdowns and the fear of the unknown virus caused widespread panic across the
globe. Conflicting data has come out regarding substance use in youth during the early and late
pandemic. According to an article by Lundalh and Cannoy (2021), the pandemic increased risk
factors for youth substance use, such as isolation and depression, but also reduced youth’s access
to substances during the lockdown periods. While it may have seemed that COVID-19 reduced
substance use rates among youth in the lockdown stage, it consequentially caused overdoses
from opioids to skyrocket due to lack of access to in-person treatment and social supports

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(Richter, 2022). The pandemic era and lockdowns initially reduced youth access to substances
but inadvertently prevented access to treatment for those with access and increased opioid related
deaths.
COVID-19 suspended social activities for youth, including in-person school, sports,
clubs, etc. Considering that many of these were social protective factors for youth, such as
positive friend groups and positive social activities, it can be understood that adolescents faced
these additional challenges during the pandemic. In the absence of these protective factors and
with the newfound increase in isolation of social distancing, it was found that youth reported
increased rates in anxiety, depression, and loneliness and had higher rates of nicotine and
prescription use (Das, 2022). While only observed with nicotine and prescription drugs, the
increased use of these substances show how the type of preferred substance among youth can be
influenced by societal factors as well as show the relationship between increase in negative
feelings and increase in substance use.
Art Therapy
The term art therapy was originally coined by an artist named Adrian Hill in 1941 to
describe the therapeutic effects of art but was implemented in the 1960’s by pioneers such as
Margaret Naumburg, Hanna Kwaitkowska, and Edith Kramer (“Art Therapy”, 2016). Though
relatively new in terms of counselor professions, the field has expanded since the 60’s and now
is taught at the master’s level in many graduate schools across the nation. According to the
American Art Therapy Association (AATA),
“Art therapy is an integrative mental health and human services profession that enriches
the lives of individuals, families, and communities through active art-making, creative

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process, applied psychological theory, and human experience within a psychotherapeutic
relationship” (“About Art Therapy”, 2022, para 1).
Art therapy is adaptable and integrative, able to incorporate Adlerian theory and the socioecological model of substance use disorder into its framework, including art interventions and
talk-based discussions.
Art Therapy with Youth SUD
Using art as a means of expression can take away the pressures of having to verbalize
problems out loud, especially the often-stigmatized thoughts and feelings that come with SUD.
Looking at how art therapy has been utilized in residential treatment, it has been found that the
benefits art therapy brings in SUD treatment include decrease in denial, reducing opposition
towards treatment, providing an outlet for communication and lessening shame (Aletraris et al,
2014). Art therapy provides a creative means of therapeutic communication that can access the
deeper issues surrounding SUD and address through healing creative expression. Literature
collected from as early as the 1950’s suggest that art therapy helps to target rigid defenses and
denial, fostering insight and awareness, encouraging emotional expression, enhances self-esteem
and promotes creativity and problem solving in SUD clients (Hanes & Rojas, 2022). Art therapy
offers a non-judgmental means of expression that explores the deeper issues behind substance
use in an alternative manner than traditional talk therapy.
Conclusion
Substance Use Disorder is a pervasive mental health disorder that can be hard to treat and
is often stigmatized by the public in a negative manner. In youth under the age of 18, the disorder
can be increasingly more dangerous and difficult to treat, especially due to the nature of the
illness and the lack of effective and available treatment out there. The provided literature review

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provides important information that points to the need for this curriculum utilizing the art therapy
modality with influences from Adlerian theory and the socio-ecological model of substance use
disorder.

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Section III: Methodology
This section will introduce the methodology behind the structure curriculum, including
the targeted audience that will benefit from the curriculum, a summary of the structure of the
curriculum, and a brief outlined overview of the topics and art interventions that will be used in
the curriculum. The curriculum is designed to occur over ten weeks, with each session aimed at
addressing factors identified in the socio-ecological model of substance use. The curriculum is
expansive in that it aims to address co-occurring disorders that contribute or occur
simultaneously to prevent relapse. Trauma is another topic that will be touched upon in the
sessions due to its implications on substance use in youth, however, is not intended to treat those
with traumatic experiences alone. Individual therapy is required at least once weekly in addition
to this group curriculum with the addition of psychoeducational classes on mental health and
substances in order to provide effective treatment of co-occurring disorders.
Who Will Benefit from This Curriculum
The purpose of the design of this curriculum is to provide effective treatment for youth
ages 12-17 years old that are temporarily residing in a residential substance use treatment
program by utilizing art therapy in a group setting. The curriculum is designed to target
substance using youth who may lack healthy coping skills, personal supports, and self-esteem by
offering the therapeutic process through the creative and relatable means of art therapy. This
group curriculum portion of the youth’s treatment is intended to be administered and facilitated
only by a master’s level, licensed art therapist. An art therapist is a master’s level clinician that is
not only trained in traditional therapy, but additionally specializes in art therapy interventions
like those included in the curriculum.
Curricular Structure

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The curriculum and interventions within are intended to address substance use disorders
and any co-occurring disorders in youth over the course of ten sessions. Each session will be
over the duration of an hour and a half once a week in addition to any other treatment that the
facility provides. Ideally, youth should be receiving individual therapy and psychoeducation
sessions on mental health, substance use and the effects of substances to be able to get the most
out of the art therapy group curriculum and their time at the residential facility. Over the course
of ten weeks, the curriculum will address aspects of substance use in youth in conjunction with
art therapy interventions. The goal of the curriculum is to reduce substance use in youth by
viewing substance use as a failure at navigating major task in life and lacking social interest,
targeting the deeper issues behind the substance use.
This curriculum utilizes the socio-ecological model of substance use disorder to examine
the four different aspects of life that contribute to the risk of using substances: Individual,
Interpersonal (Family/Friends), Community/Peers, and Society. These factors are the bases of the
different phases of the curriculum, with two sessions each dedicated to exploring individual and
interpersonal factors and two sessions each for community/peers and society factors.
Additionally, aspects from Adlerian theoretical orientation will be intertwined into the
curriculum within both the topics discussed and the art therapy interventions chosen.
Curricular Outline
Week 1: Introduction)
Forging Direction – The Road Drawing
Week 2: Individual
Looking Back – Timeline of My Life
Week 3: Individual

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Processing Trauma – Body Map
Week 4: Interpersonal
Family of Origin – Genogram
Week 5: Interpersonal
Birth Order – Kinetic Family Drawing/Sculpture
Week 6: Community/Peers
Exploring Supports - The Tree of Life
Week 7: Community/Peers
Recovery Groups – Group Mural
Week 8: Society
Self-Concept vs Social Identity – Dual Self-Portrait Collage
Week 9: Society
Overcoming the Stigma of Addiction – Group Mandala
Week 10: Termination
Letting Go of Addiction - Torn Paper Transformations
Conclusion
In this section, a summary of the structure of the curriculum, a description of individuals
who could benefit from the curriculum, and an outline of the intended topics and interventions to
be discussed. Additionally, this section clarified the need for additional individual therapy
alongside the facilitation of this group therapy curriculum. An explanation of how the theoretical
orientations connected with topics and interventions was provided. The socio-ecological model
of substance use was highlighted as the influencing model towards the overall structure of the
topics of the course. The following section presents the curriculum in its entirety.

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Section IV: Curriculum
This section will explore the curriculum in detail. The curriculum is blended in Adlerian
theory with the addition of the structural tenants of the socio-ecological model of substance use
disorder delivered through art therapy interventions. The curriculum will occur over ten weeks
with an hour and a half session occurring once each week, focusing on one art intervention every
week that touches on a part of the structure of the socio-ecological model of substance use
disorder. Beginning with an introduction and ending with a termination intervention, the eight
weeks in-between will be based on each of the four stages of the model (Individual,
Interpersonal, Community/Peers, and Society). Starting with the individual realm, the
interventions will become broader, moving outwards into the interpersonal, community/peers,
and society realms. This is purposeful as the individual must understand themselves first before
being able to understand the impact of their social connections. See Appendix A for full
curriculum.
Conclusion
Delivered as intended, this curriculum can impact the lives of youth struggling with
substance use disorder. Utilizing art as a non-verbal means of communication to deliver the
theoretical underpinnings, the curriculum offers youth the chance to construct their own version
of recovery that is unique to their individual needs and struggles. This section presented the
curriculum in full. The next section will discuss the benefits of the curriculum while also
exploring limitations and future research.

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Section V: Discussion
This section will explore discussion on the importance of this curriculum, the
significance of being deployed by the art therapy modality, and its development routed in
Adlerian and socio-ecological model of substance use disorder. The following will also address
any limitations and areas for future research regarding the curriculum and presented research.
Summary of Research
Substance use among youth can be challenging to address because of the many factors
that influence a youth’s decision to engage in the use of substances. Substance use is a negative
coping skill that results from lack of social interest and failure at navigating the five major task
of life, as identified by Adler (Fong et al, 2015). Traditional modalities of residential treatment
are not always effective with substance use among youth, especially when focusing on only
abstinence (Marlatt & Witkiewitz, 2002). The negative societal stigma associated with drug use
and getting help and the racial and economic barriers that prevent youth from receiving effective
treatment (Farhoudian, 2022; Earnshaw, 2020). The pervasive nature of SUD and barriers to
treatment for youth provide the need for a new type of treatment.
Art therapy is an expressive modality that allows participants to engage in the therapeutic
process without the need for verbal words. The curriculum was developed using art therapy in a
non-threatening manner as a foundation to allow for youth to have choice and autonomy in their
lives and their recovery. Adlerian and the socio-ecological theory of substance use disorder are
holistic approaches that examine both internal and external factors that influence substance use.
Combing both with art therapy is a natural combination and able to connect with youth in ways
beyond traditional talk therapy.
Discussion

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This curriculum uses the lens of Adlerian theory combined with the socio-ecological
model of substance use disorder to examine these factors, while utilizing the non-verbal power of
art therapy to help youth express their thoughts and feelings. Substance use disorder runs in my
family and I’ve seen many people that I love struggle as adults, particularly my father who
struggled with alcoholism. When I was 16 years old, he went to rehab and has been in recovery
and abstinent from alcohol ever since. I’ve personally seen recovery in my father and know that
it exists for everyone, even if it may look different from person to person. My first mental health
job was working with adolescent youth in a substance misuse residential. Seeing youth younger
than myself struggle with substance use and being able to use therapeutic art with them inspired
this curriculum. I more recently discovered Adlerian theory and have utilized it as my
foundational theoretical orientation, as it aligns well with art therapy and working with youth.
This curriculum was inspired by issues I’ve personally seen and experienced, motivating a
solution for a population some may find challenging to work with.
Limitations
The curriculum proposed does have limitations that should be considered. While
fundamentally grounded in theory, this curriculum has not been officially tested with clients or
evaluated for success rates. Reliability and validity values are currently unknown. The
therapeutic value of the curriculum has not yet been established or evaluated and there may be
confounding variables and unforeseen risks. Not all participants may connect with art therapy
modality and may prefer more traditional talk therapy and interventions. Screening prior to the
start of the group may indicate youth that are a good fit for the art-based content of this
curriculum.

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Facilitation of this curriculum is intended to be done within a residential setting, where it
is assumed that youth are receiving additional services such as individual therapy and
psychoeducational information on substances and mental health. This curriculum is reliant on the
residential setting and may produce different results in other settings, such as outpatient or
private practice. The curriculum was created with a group therapy format, involving
collaboration and creation between at least two or more participants. While some interventions
can be used in an individual setting, a few are reliant on the social aspect of the group.
Future Research
Further research into the effectiveness of art therapy with youth substance use disorder
would be beneficial in identifying successful interventions and preferred medium and material
types within the population. Clarifying how the socio-ecological model of substance use disorder
applies to the youth population and differs from the adult population would be beneficial in
informing the approach taken with youth. Further insight into Adlerian theory and substance use
could make for more targeted interventions. While the curriculum is intended for youth ages 1217 years old, it may also be effective with adults with further research. Putting the curriculum in
practice and gathering research would lead to insight on its effectiveness and provide evidence of
the success of art therapy with the youth substance use disorder population.
Conclusion
Substance use among youth has become a growing concern, with youth death by
overdose increasing “109% from July–December 2019 to July–December 2021” (Tanz et al,
2022, para. 2). While substance use rates have stayed the same among youth from 2021 to 2022,
the rise in overdose related deaths to illicit substances such as opioids, particularly fentanyl, has
become an epidemic and reveals a need for effective substance use services that reach youth

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(“Most reported substance use among adolescents held steady”, 2022). The research presented
offers an alternative approach to therapy, providing an art therapy group curriculum grounded in
Adlerian theory and structured by the socio-ecological model of substance use disorder. Through
the non-verbal means of art therapy and utilization of Adlerian theory and the socio-ecological
model of substance use disorder, youth are encouraged to learn about themselves, examine
factors in their lives, and are empowered to create a version of recovery that feels right to them.

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