practice

Is harm reduction a viable choice for kids enchanted with drugs?

Erik K. Laursen and Paul Brasler

While the dominant approach to substance abuse treatment has been a disease model, this article describes a strengths-based alternative. Many contemporary youth are experiencing problems with alcohol or other drugs but reject the message of total abstinence and disease models of treatment. The authors draw from their experience with challenging youth and research on adolescent substance use to combine a strength perspective with a harm-reduction approach to substance abuse.

The senior author first experienced the influence alcohol and other drugs had on youth as a captain and counselor with a group of Danish delinquents on a 42-foot boat traveling the Rhine and Danube rivers:

At the time, I considered their interest in alcohol as normal experimentation, and I talked with them about using responsibly - remember, this was Europe in the mid '70s. Two years later, I came to the U.S. as a counselor with a group of Danish adolescents to spend 10 months riding motorcycles across the American continent. Again, I implemented a risk-reduction approach of "Don’t ride under the influence." The drinking age was lower in those years, and the 12 youth in the group followed this expectation. Over the next 10 months, we rode 65,000 miles in 42 states, and, while we had incidents with substance use, we did not have a single accident. While our group did not include anyone with serious substance abuse problems, this approach seemed to work because it was reasonable and made sense to youth.

In our current work, we approach substance abuse prevention in a graded manner: 1) providing information to delay the first use; 2) preventing recreational and experimental users from becoming regular users; and 3) helping those experiencing problems with substances from getting worse. The first two phases are addressed through health education, while special educational groups serve youth who are in phase three. We advocate abstinence and highlight the possible consequences of underage and illicit use, and we also stress reducing the risks associated with such activity Our approach is an alternative to the disease model and does not criminalize adolescent use. In earlier years, many kids told us: "If abstinence is the only option, I am not going to make any changes in my drug use." Now, we often hear, "If I can be more responsible with my use, maybe one day I'll be abstinent."

Alcohol and adolescence

Among many adolescents, alcohol and drug experimentation is normal behavior, although certainly one fraught with risk. Jessor (1985) noted that experimentation may serve various functions during the developmental process. This can be a way of asserting autonomy by opposing adult authority, finding affiliation and connection with peers, coping with feelings of inadequacy, and relieving boredom and loneliness.

Research has demonstrated that the age when adolescents first start using alcohol, tobacco, and other illicit drugs is a predictor of later alcohol and drug problems. More than 40% of youth who start drinking at age 14 or younger develop alcohol dependence, compared with 10% of youth who begin drinking at age 20 or older. Tobacco use, particularly among girls, is a powerful predictor of future use of other drugs. For males, alcohol use can be a gateway to other drugs (Ericson, 2001).

As kids move into early adolescence, they change dramatically The new developmental tasks involve establishing independence, developing a coherent self-identity and adjusting to psychosocial changes associated with physical maturation. Adolescents begin to question adult standards and the need for parental guidance and increase their time with peers, and they begin to identify themselves with certain peers, while distancing themselves from others. They seek advice from friends who are understanding and sympathetic, and they experiment with new values with their peers - sometimes to seek adults' reactions to their experimentation.

Substance use increases in adolescence (Johnston, O'Malley, & Bachman, 1998) as smoking, drinking, and other drugs become a way to appear mature while fitting in with peers. For kids challenged by abuse and neglect, alcohol or drug use is likely to amplify risks to their health and wellbeing. There is an association between smoking, depression, and anxiety in teens, and teens who smoke report more symptoms of depression (Kandel & Raveis, 1989).

While the disease model was designed to assist substance-abusing adults, adolescent substance problems differ from those of adults with chronic alcohol dependence (Bailey & Rachal, 1993; Kilty, 1990). Thus, very few adolescents and young adults meet the DSM-IV criteria for alcohol dependence (Baa, Kiviahan, & Marlatt, 1995). Most young adults reduce heavy drinking as they learn their limits and begin to assume other responsibilities, such as work and parenting. Consequently, interventions for adolescents should be different from those we use with adults.

When we talk with kids about why they use drugs, they answer, "to numb the pain of abuse and neglect" "to be accepted," "peer pressure," "to take control of my own life," "for relaxation and pleasure," "to chill," "to improve my self-image," "because I’m curious, stressed, or bored," and "to assert myself." It is obvious that adolescent substance abuse is not a younger version of adult substance abuse.

Disease versus Strength

Over the last 20 years, the federal government has engaged in a war on drugs - the cigarette industry has been limited in its advertising targeted at adolescents, alcohol advertisements have been restricted, and states have increased the legal drinking and smoking age. Nevertheless, kids continue to smoke, drink, and use other drugs. During this same time, the disease model has shaped most research in the field. This framework has inevitably focused on the negative outcomes of illicit drugs, rather than a preventive, health-promoting perspective that could have explored patterns of adaptation and competence of kids and adults who have learned to manage their lives.

Strengths-based practitioners work from the premise that children and youth have strength and competence and can recover and bounce back from adversities (Garmezy, 1987). The focus becomes "finding, enhancing, and encouraging the utilizations of coping skills with which to navigate troubled waters" (Norman, 1997, p. 74). Research shows that youthful alcohol problems are often intermittent and may remit without formal treatment, rather than becoming fatal and progressive (Sobell, Cunningham, Sobell, Agrawal, Gavin, Leo, & Singh, 1996; Tucker, & King, 1999). This is congruent with resiliency research showing that most who struggle as teens and young adults overcome their problems and are well functioning in their 30s and 40s (e.g., Werner & Smith, 1992). Emerging studies (Smith, House, Croghan, Gauvin, Couigen, Offord, GomezDahi, & Hurt, T996; Hurt, Croghan, Crohan, Wolter, Patten, & Offord 2000) suggest that a decrease in cigarette smoking may be a viable alternative to cessation.

The strengths perspective offers a different lens to describe youths' enchantment with cigarettes, alcohol, and other drugs and allows us to begin to see opportunities, hope, and solutions. Rather than channeling efforts toward correcting deficits of adolescent alcohol and substance use, we aim to achieve the desired outcome, i.e., that kids don’t become lifelong abusers or addicts. True growth only takes Place when individuals' strengths are channeled toward goals that they themselves set.

The strengths perspective posits that work with kids at the policy, management, and direct service levels should focus on cultivating protective factors. Alcohol and drug problems are common among disenfranchised kids. Thus, our primary intervention should be to create reclaiming niches that provide kids opportunity for belonging, mastery independence, and generosity (Brendtro, Brokenleg, & Van Bockern, 2002).

As the strengths approach to working with young people has been refined, we have been able to apply it to adolescents who engage in risky use of substances. Most of the kids with whom we work do not perceive themselves as alcoholics or as drug addicts, and they believe they are able to control their use. For some, addiction terminology turns them off and makes them unwilling to listen to adults. The dichotomous choice of either abstinence or relapse invalidates kids who manage to drink or use drugs more moderately Coming from a strengths perspective, we engage youth when they say, "I want to use substances more responsibly". We then challenge them to explore what responsible use would be. Here is an example from a discussion in our substance abuse group:

Jeremy: I know I can drink responsibly

Counselor: You and the group know that underage drinking is illegal, and we have talked about the consequences of continuing before, But what do you mean by responsible drinking?

Jeremy: Not drinking on school nights.

Counselor: OK. What else?

Jeremy: Not drinking and driving.

Natasha: That’s easier said than done. How would you then get around?

Nathan: You could have a designated driver. You know, someone who doesn’t drink for the evening.

Susan: No one would do that be clear-headed all evening when everybody else was partying.

Jeremy: I would do that if everybody would take turns.

Counselor: How would you arrange for a designated driver?

Jeremy: My friends and I would take turns “I would go first.

The counselor collaborates with Jeremy, building on what Jeremy believes is possible. Such discussions strengthen pro-social values and foster more responsible behavior.

Since the kids with whom we work are already faced with multiple challenges, our intervention should focus on reducing the risk associated with their drug and alcohol use. Marlatt (1998) described the principles which underlie a harm-reduction approach to adolescent alcohol and drug use:

Harm reduction is an alternative to the moral, criminal, and disease models.

Harm reduction accepts alternatives if total abstinence is not a realistic goal.

Harm reduction is a bottom-up, consumer-oriented approach.

Harm reduction promotes easier access to services.

Harm reduction involves compassionate pragmatism rather than moral idealism.

The question can be raised as to whether harm reduction allows youth to remain in denial about their substance abuse instead of holding them accountable. We have concluded that it allows us to engage and influence youth who would otherwise not be reached by other approaches. But this requires a shift from a narrow focus on deficit to discover untapped strengths, even in youth with problems. Frederick Douglass wrote, "If there is no struggle, there is no progress." As we train our eyes to look for strengths and to acknowledge the struggle of young people, we can assist them in their growth.

A strength-based approach to kids who use drugs and alcohol focuses on reducing the risk in their lives. We promote abstinence and identify possible consequences for continued use of illicit drugs. Additionally we collaborate with youth who are unwilling to accept abstinence as a solution in order to reduce the risks of harm from their use. Success comes as each young person develops inner controls and lives a balanced and healthy life in harmony with self and others.

References

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Bailey, S. L., & Rachal, J. V. (1993). Dimensions of adolescent problem drinking. Journal of Studies on Alcohol, 54, 555-565.

Brendtro, L., Brokenleg, M., & Van Bockern, S. (2002). Reclaiming youth at risk: Our hope for the future. (2nd ed.) Bloomington, TN: National Educational Service.

Ericson, N. (2001). Substance abuse: The nation's number one health problem. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention.

Garmezy, N. (1987). Stress, competence and development: Continuities in the study of schizophrenic adults, children vulnerable to psychopathology and the search for stress resistant children. American Journal of Orthopsychiatry, 57(2), 159-1 74.

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Kilty, K. M. (1990). Drinking styles of adolescents and young adults. Journal of Studies on Alcohol, 51, 556-564.

Marlatt, G. A. (1998), Basic principles and strategies of harm reduction, In G.A. Marlatt (Ed.), Harm reduction: Pragmatic strategies for managing high-risk behaviors (pp. 49-66). New York: Guilford Press.

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Tucker, J. A., & King, M. P (1999). Resolving alcohol and drug problems: Influences on addictive behavior change and help-seeking processes. In J. A. Tucker, D. M. Donovan, & C. A. Marlatt (Eds.), Changing addictive behavior: Bridging clinical and public health strategies (pp. 97-126). New York: Guilford Press.

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This feature: Laursen, Erik K. and Brasler, Paul. (2002) Is Harm Reduction a Viable Choice for Kids Enchanted with drugs? Reclaiming children and youth. Vol. 11 No. 3 Fall 2002 pp. 181-183