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Public Health Program Purpose:
There is an unmet need in the United States for substance abuse treatment programs that
address co-morbid mental health disorders in a manner that successfully reaches and treats
pregnant or postpartum Latinas. First there is the challenge of co-morbidity, which is quite
common for substance abuse and mental health disorders.1 Then there are the barriers to
successfully treating the Latino population, which require a bicultural and bilingual approach.2
Finally, pregnant and postnatal women struggling with substance abuse requires additional
resources and services.3 Entre Familia is a long-term residential treatment center located in
Mattapan, MA and run by the Boston Public Health Commission (BPHC). It is designed to treat
pregnant and postnatal Latinas from metropolitan Boston who struggle with substance abuse and
have co-occurring mental health disorders.4
Literature Review:
In the United States, substance abuse in Latinos is comparable to that in Whites, and
slightly higher than that in Blacks.5 However, co-occurring mood and anxiety disorders are more
common among substance-abusing Latinos than they are for the rest of the population in the
United States. These rates are even higher for women and U.S. born Latinos.1 Within the last
year, approximately 1 out 8 Blacks, 1 out of 7 Whites, and 1 out of 6 Latinos living in
Massachusetts have experienced a mental health disorder.2 Furthermore, there is a relationship
between exposure to traumatic events (such as intimate partner violence) and substance abuse for
Latinos.1,6 In the United States, intimate partner violence among pregnant women is estimated to
be at 5.2% for the general population, and 6.2% for pregnant Latinas.6 Additionally, unlike in the
rest of the country, Latinos in MA have higher rates of depression and lower self-reported mental
health compared to other races and ethnicities.2 Despite the higher lifetime prevalence of mental
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illness, Latinos are less likely to receive mental health care: under 30% of Latinos with mental
illness are receiving mental health care, compared to just over 50% of Whites.7,8 In MA, the
completion rate for illicit drug treatment among Latinos is significantly lower than that for
Whites and Blacks.2
Because Latinos use fewer health care services and are less likely to enter the health care
system, it is important to have targeted programs so that when they do enroll in a treatment
program they are successful.5,8 Many Latinos have specific issues (e.g. acculturation, stress
related to immigration) that must be addressed in order to maintain adherence. Other issues that
are common barriers to successful entrance and treatment for the Latino population are stigma
(which is associated with physical abuse, sexual abuse, marital infidelity, and addiction, to name
a few), language and culture barriers, and issues concerning residency documentation, insurance
coverage, and financial stability.5
A 2014 issue brief published by the Massachusetts Health Policy Forum made five
recommendations to reduce the racial/ethnic disparities in behavioral health and health care in
MA: increase early identification of behavioral health problems, increased qualified mental
health providers, build community coalitions, reduce disparities that arise from interactions
within the health care system, and expand access to behavioral health service regardless of
insurance coverage, documentation status, or ability to pay. The report concluded that MA must
make “significant outreach efforts to the Latino community” in order to reduce these disparities.2
Three strategies have been found to be particularly successful with the Latino population.
When offered ethnicity-specific programs, Mexican Americans were 11 times more likely to
return for a second treatment session than when they attended a mainstream program.9 Familybased therapy, which involves incorporating family members into therapy session, was also
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found to be beneficial and increased engagement of all parties.10 Another strategy, Motivational
Interviewing, increased retention of Latino clients seeking treatment.11 An important aspect in
treating substance abuse in Latinos is ethnic matching between therapist and client. Latinos
matched with Latino therapists showed greater decreases in substance use than Latinos matched
with Anglo therapists. Ethnic matching did not influence treatment outcome for Anglo clients.12
Gender-specific programs have been shown to be more successful than mixed-gender
programs. Women in women-only programs were more than twice more likely to successfully
complete the program than women in mixed-gender programs, regardless of severity of
substance abuse or co-occurring mental disorders. This also allows for targeted services for
women, such as addressing the psychosocial correlates of their drug use, lack of social support,
and pregnancy. Pregnant or parenting women benefit from programs such as prenatal referrals,
parenting education, family support services, child care, and legal services.3 Studies have
indicated that compared to women who are separated from their children during substance abuse
treatment, women who are able to keep their children with them have higher retention and
completion rates, reduced psychological distress, and improved skill acquisition.13,14
Program Description:
Entre Familia, which is run by the Boston Public Health Commission, is a 6 to 12 month
residential treatment program for substance abuse with co-occurring mental health disorders.
Entre Familia is both gender- and culture-specific; the target population is pregnant and
postpartum Latina women and their children from metropolitan Boston.4 The program can house
up to 21 women and 40 children.15 Entre Familia provides bilingual and bicultural clinical
treatment and support services. The program uses a family-centered model of care with services
based on a “bio-psycho-social trauma-informed model for the treatment of addiction.”15
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There are many inputs into Entre Familia. There is the target population: pregnant or
postpartum Latina women (and their children). The staff includes case managers, therapists,
counselors, and housing staff, and is primarily Latino. Staff also includes program coordinators
and BPHC employees, who oversee the program. Most of the staff works 40 hour work weeks,
but there is also 24 hour residential staff. Money comes from the BPHC, as well as through
federally funded programs.4 The program is partially funded by payment from the clients as well,
which is based on a sliding scale (going as far as to offer free services) and accepts Medicaid and
MassHealth.16 Physical inputs include the building itself, beds, food, and a child care area.
Entre Familia outputs include residential services and program management. Remaining
outputs can be divided into three categories. First there are the core clinical treatment services:
screening, assessment, referrals to medical and mental health services, residential care,
comprehensive case management, childcare services, and referrals for specialized services to
address developmental and behavioral difficulties and early intervention. Second are the clinical
support services: enhanced case management, individual family treatment planning, and case
coordination of services for children. Finally, through the federally funded Boston Consortium of
Services for Latino Families in Recovery (BCSLFR), there are activities designed to increase
family functioning and build social support networks by engaging the fathers of the children, the
partners of the women, and extended family members in treatment.4
Short-term outcomes for Entre Familia are program completion; improvement of mental
health; self-confidence; learning skills required to live independently (budgeting, employment
skills, etc.); strengthening social and family connections; awareness of available resources.
Medium-term outcomes include ongoing enrollment in case management to help with the
transition from the residential program; adherence to psychotherapy and/or substance abuse
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treatment strategies; management of mental health via continued counseling and/or group
therapy; applying, adopting, and sustaining life skills; maintaining strengthened family and
social networks; evaluation of residential services and program. Long-term impact includes
abstinence from substance use; positive lifestyle; strong relationship with children and family
members; policy changes to increase access to treatment programs for women and Latinos.
The first assumption made is that the clients want to be in treatment and that clients and
their children are able and willing to relocate. It also assumes that relationships among family
members and partners should be repaired and that the treatments are culturally appropriate and
meaningful. External factors include the influence of family members and partners; cultural and
linguistic factors; ability of women to abstain from substance abuse; continued care for mental
health; immigration status; child health and legal status; continued BPHC/federal funding.
Program Critique:
Entre Familia has many strengths. First, the program is targeting a population that is both
underserved and at risk.1,2 Additionally, it is gender-specific and catering specifically to the
Latino population by providing bilingual and bicultural services, both of which have been shown
to result in more successful outcomes.3,9,12 Finally, Entre Familia uses a family-based model and
allows children to live with their mothers, strategies which have led to improve substance abuse
treatment outcomes in women and among the Latino population in general.10,13
There are two major weaknesses to the program. There is no mention of outreach to the
Latino community, which is listed as a recommendation for successfully reducing racial and
ethnic health disparities.2 Second, despite many good therapy strategies, the program makes no
mention of using Motivational Interviewing, which has been useful in treating the Latino
population in other settings.11
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Bibliography:
1. Alvarez J, Jason LA, Olson BD, Ferrari JR, Davis MI. Substance abuse prevalence and
treatment among latinos and Latinas<br />. Journal of Ethnicity in Substance Abuse.
2007;6(2):115-115-141.
2. Alegria M, Cook B, Loder S, Doonan M. The time is now: Tackling racial and ethnic
disparities in mental and behavioral health services in massachusetts. . 2014.
3. Grella CE. Women in residential drug treatment: Differences by program type and pregnancy.
J Health Care Poor Underserved. 1999;10(2):216-229.
4. Boston Public Health Commission. Residential services.
http://www.bphc.org/whatwedo/Addiction-Services/treatment-and-recovery-supportservices/residential-services/Pages/Moms-Project.aspx. Accessed Feb/06, 2015.
5. Amaro H, Cortes D. Drug abuse among hispanics: A brief evidence-based guide for providers.
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6. Rodriguez MA, Heilemann MV, Fielder E, Ang A, Nevarez F, Mangione CM. Intimate
partner violence, depression, and PTSD among pregnant latina women. Ann Fam Med.
2008;6(1):44-52.
7. Breslau J, Kendler KS, Su M, Gaxiola-Aguilar S, Kessler RC. Lifetime risk and persistence of
psychiatric disorders across ethnic groups in the united states. Psychol Med. 2005;35(03):317327.
8. Wells K, Klap R, Koike A, Sherbourne C. Ethnic disparities in unmet need for alcoholism,
drug abuse, and mental health care. Am J Psychiatry. 2001;158(12):2027-2032.
9. Takeuchi DT, Sue S, Yeh M. Return rates and outcomes from ethnicity-specific mental health
programs in los angeles. Am J Public Health. 1995;85(5):638-643.
10. Santisteban DA, Szapocznik J. Bridging theory, research and practice to more successfully
engage substance abusing youth and their families into therapy. J Child Adolescent Subst Abuse.
1994;3(2):9-24.
11. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu.Rev.Clin.Psychol.
2005;1:91-111.
12. Flicker SM, Waldron HB, Turner CW, Brody JL, Hops H. Ethnic matching and treatment
outcome with hispanic and anglo substance-abusing adolescents in family therapy. Journal of
Family Psychology. 2008;22(3):439.
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13. Hughes PH, Coletti SD, Neri RL, et al. Retaining cocaine-abusing women in a therapeutic
community: The effect of a child live-in program. Am J Public Health. 1995;85(8 Pt 1):11491152.
14. Saunders EJ. A new model of residential care for substance-abusing women and their
children. Adult residential care journal. 1993.
15. Mindfulness-related treatments and addiction recovery. 1st ed. London: Routledge;
2012:136.
16. Health Resources in Action. Provider information.
http://hria.force.com/ProviderInformation?id=001A000000rggtqIAA. Accessed Feb/06, 2015.