Further Discussion of Comprehensive Theory of Substance Abuse Prevention March, 2011 The prime dichotomy between profoundly challenged children and socially influenced teens may be similar to some other dichotomies common in discussions about substance abuse, but isn t identical with them. Here is how three of those dichotomies can be compared to the prime dichotomy and, to some extent, made clearer through application of the prime dichotomy. I. Environmental risk versus individual risk The public health disease prevention model of agent, host, and environment can be a useful tool for considering the prevention of youth substance use. In this model, the particular substance (alcohol, tobacco, marijuana, etc.) and formulation (beer, wine, liquor, cigarettes, cigars, chewing tobacco, etc.) can be considered the disease agent, the person who uses (or avoids using) the substance is the host, and the circumstances in which a substance is discussed, promoted, produced, and distributed are all part of the environment in which use can develop. As an outgrowth of that model and of the scientific approach of identifying risk factors, much conceptual progress has been made during the past two decades in broadening the meaning of substance abuse prevention, beyond only that which can be done to potential hosts to decrease their likelihood of starting to use a substance. The simplest version of a risk-reduction approach seeks to identify at-risk persons, restricting attention to just the host, but a more sophisticated approach recognizes multiple factors that combine to affect people, with some of the factors being traits of the person but others being traits of various social environments. The prime dichotomy ( profoundly challenged children and socially influenced teens ) grows out of that tradition, but is among those concepts that are anchored in the science of human psychosocial development rather than a behavioral taxonomy. According to developmental psychology, babies must accomplish particular developmental tasks in order to be whole to address childhood tasks; accomplish childhood tasks to be most prepared for adolescence; and so on forward into adulthood. A person who is only partly successful with the developmental tasks of one age can move forward but will have skill deficits when facing later challenges, unless later efforts are able to remediate or work around the earlier deficits. Such correction may be difficult if the skills in question depend on the brain being in a particular critical period of readiness (i.e. neither too soon nor too late) for learning that kind of skill. Applying this to substance abuse prevention: 1. The most important goal in regard to young children is to prevent neurological damage or psychological damage that impairs foundational social-emotional development. This kind of damage is most usually due to some combination of physical trauma, psychological trauma (such as may arise from witnessing ongoing domestic violence), severe neglect, or toxic fetal conditions (particularly those caused by maternal 1
substance use during pregnancy). Experiencing any of these can constitute a profoundly challenged childhood. 2. When a cohort of young people reaches adolescence, the most devastating and enduring forms of individual risk are those rooted in a profoundly challenged childhood. Some young people can rise above the challenges due to some combination of personal resilience and the caring efforts of their family and/or community, but many others retain social-emotional skill deficits that can make positive development in adolescence difficult. 3. Although these are individual risk factors that can be said to be personal attributes of the host adolescents, the original cause can be more individual or more environmental. 4. The further back one goes in the chain of causation, the harder it is to classify a particular risk factor s origin as being only individual or only environmental. For example, a baby born with neurological impairment that puts him or her at increased risk for substance abuse (and other problems) later in life would seem to have a very individual risk factor, but how did the impairment come to be? Was it random, or was it due to maternal alcohol or other drug use during pregnancy, in the context of a society in which such damage is a widespread occurrence that is insufficiently addressed by community preventive efforts? A profoundly challenged childhood often produces individual risk when the young person in question reaches adolescence, but the classification of the original cause as individual or environmental may depend on how far back one goes in the causative chain, or may mainly depend on who is asking the question. A young parent may want to know what he or she can do to keep each individual child healthy, while a community member (or a parent in the role of community member) may want to know what can be done by a community and society to decrease the number of youth who enter adolescence with existing risk for health-compromising behaviors. All the more so with substance abuse: as a social problem, one person s child is much more at risk if many of the child s peers use substances. Social influence and substance availability (which together are the most prevalent force in substance initiation) are environmental risks, but in some instances may narrow to specific events or people in the social environment. To a particular parent with a particular child who has a particular substance-using friend, the challenge at a point in time may be what to do about the child s contacts with that friend. When the social environment features one profound influence that outweighs, in the short run, the dangers posed by other pro-substance use influences, an environmental strategy may focus on what to do in regard to one individual. While it is accurate to think of some adolescents bringing individual risk factors from a profoundly challenged childhood, and all adolescents facing social influence and substance availability as environmental risks, the above discussion points out some of the limits of considering the prime dichotomy to be the same as the individual versus environmental dichotomy. 2
II. Compulsion versus responsibility One common version of the compulsion versus responsibility dichotomy is debate about whether substance abuse is more of a disease (something that happens to a person) or a personal choice. To some extent the categories of substance dependency (or addiction ) on the one hand and substance abuse on the other can be seen as an attempt to separate that which is relatively uncontrollable from that which is chosen. While the concept of alcoholism as a disease was originally based on the observations of people who experienced alcoholism in themselves and/or as a close observer, research has since confirmed that addiction (including alcoholism) is a chronic relapsing brain disease, and corresponds to specific biochemical changes in human brains. Addiction, however, is not the only issue with substance abuse. On many dimensions the collective damage done by non-dependent persons who abuse alcohol or other drugs (AOD) is much greater than the damage done by those dependent on AOD, because there are so many more substance users than people who have developed dependence, and many of the damages that can be done by AOD both directly to a body and indirectly through affecting behavior are very serious. Because of the societal costs of substance abuse, a focus on just preventing addiction or dependence isn t sufficient. So, the question about the respective roles of choice and internal compulsion in the development of substance abuse are very relevant to the study and practice of prevention. As part of a theory based in psychosocial development, the prime dichotomy of profoundly challenged children and socially influenced teens recognizes and helps preserve awareness of differences in how to understand personal choice depending on whether the persons involved are children, adolescents, or adults. The kind of brain changes characteristic of addiction may not be relevant to children who are years away from initiating substance use, but a different kind of compulsion may be involved. Babies and very young children essentially have neither the ability nor the opportunity to exercise individual choice as to whether they experience profound challenges. Among those who experience such challenges, the result for many can be ongoing impairment in decision-making. Through no choice of their own, their ability to avoid substance use (and many other problems) has been reduced. Some of this may be reversible during teen or adult years, while some impairments are not. Among a cohort of teens there will be some percentage with social-emotional skill impairment from childhood, and others who are not impaired. When they all face the influence of messages that encourage drinking or other drug use in the media and among some peers, what happens? On one hand, adolescents are becoming capable of exercising choice, but their brains (particularly parts relating to using good judgment) are not fully mature, and they (as well as many adults) are susceptible to images and messages that make substance use seem interesting, popular, and low-risk. This is all the more so with those who have impaired social-emotional thinking from events in childhood. So, if they begin to use a substance, has their initiation been a matter of choice? For the purposes of personal accountability, law must hold adults responsible for 3
actions that hurt others, and the same principle applies to some extent in regard to adolescents. For the purposes of prevention, prevention researchers and practitioners need to find out what elements of choice and compulsion are involved in the development of substance abuse. Prevention may be possible in cases of compulsion (by changing the environmental factors that led to the point of compulsion) and in cases of choice (by appealing to the decision-making of youth and/or adults who influence them), but the preventive actions needed may be very different. The prime dichotomy may help to understand this, since some teens may have the capacity to truly make a choice about social influences toward substance use, while others clearly have the cards stacked against them early in life, due to profoundly challenged childhoods. In the reality that results from the confluence of these factors, any absolute conclusion about substance abuse (short of addiction) being either beyond a teen s control or all a matter of individual choice is too simple, if not plainly wrong. III. Substance abuse as a health problem versus a social justice problem The preceding discussion sets the stage for consideration of whether substance abuse is (and should be treated as) a health problem or a social justice problem. Because substance abuse has elements of both compulsion and individual choice, and because laws against drug use and some forms of alcohol abuse (such as driving under the influence or underage drinking) exist due to known connections between substance use and societal damage, neither a public health approach alone nor a criminal justice approach alone are sufficient. For some individuals, substance abuse is purely a health problem, and needs a health solution. An example would be an adult drinker who doesn t use illicit substances but who develops alcoholism. Behavioral health intervention is needed. For some individuals, substance abuse is purely a social justice problem, and needs a criminal justice solution. An example would be a drug dealer who never uses substances but who sells thousands of doses of one or more illicit substances, including sales to children. Law enforcement is needed. In many cases, especially regarding the use of illicit drugs, both health and justice need to be involved. Drug courts may be among the best examples of how the health and justice elements of a situation can be addressed at the same time and in a mutually reinforcing manner. Law enforcements halts (at least temporarily) the illegal behavior and brings a substance abuser into the criminal justice system, where drug treatment is not only available, but required. In a well functioning drug court, the symbiosis of health services and legal justice services is carried to a day-to-day or week-to-week level, as a client is obliged to work toward sustained AOD abstinence in order to avoid a purely justicebased approach (typically jail). Prevention of AOD abuse is an approach that can and should function from both a health and social justice perspective. As was stated in regard to the compulsion versus responsibility dichotomy: for the purposes of prevention, prevention researchers and 4
practitioners need to find out what elements of choice and compulsion are involved in the development of substance abuse. Prevention may be possible in cases of compulsion (by changing the environmental factors that led to the point of compulsion) and in cases of choice (by appealing to the decision-making of youth and/or adults who influence them), but the preventive actions needed may be very different. Because the timeframe for prevention can include anything from preventing next week s substance use initiation by current teens to the prevention of deep-seated risk conditions among youth who won t be born for another twenty-five years, prevention ultimately has the potential to attain a combined health/justice solution without the price society pays by waiting for teen substance use to turn to substance abuse. Based on the etiology of substance use as described in the Comprehensive Theory of Substance Abuse Prevention, societies could make substantial progress if attention and resources are focused on stopping the circumstances that lead to profound challenges in childhood, and on countering pro-aod influences on teens. This doesn t mean such actions will prevent all instances of youth substance use, but current use levels could be substantially decreased. For teens who didn t experience profound challenges in childhood, it is reasonable to estimate that with sufficient national, state, and local work on reinforcing adult and teen norms (and policies) of no use of AOD by youth, use rates among that proportion of the teen population could be cut by 50-75% within 5-10 years. Preventing future profound childhood challenges would be a more difficult and lengthy process, but could attain decreases of 50% or more in the percent of youth who enter adolescence with risks from childhood. As the relative proportion of youth whose main causal factors for substance use are all social influence (and associated substance availability) rises, the number of teens successfully addressed by countering social influence aspects of prevention would rise. Of course, there would be many other benefits to success in decreasing profound childhood challenges, such as improved childhood mental health, decreased delinquency, and improved school achievement. However, because of the need to work back in the chain of causation and (ideally) start efforts before the parents of future teens start parenting, 15 or more years may be needed to start to see significant decreases in teen substance use and other problems of youth after new initiatives to prevent profound childhood challenges are in place. In regard to present day AOD problems, a combination of substance abuse treatment and laws about substance use, such as is actualized in drug courts, may be the best possible answer to the health versus justice dichotomy. In the longer term, successful prevention efforts that decrease teen AOD use decrease inherent tension between health and justice aspects of society s AOD problems. Currently most people recognize that criminal justice approaches to substance abuse are very costly and less likely to have success than a combined health and justice approach, but a health approach alone also won t work. There is no way to quickly eliminate some criminal justice elements of anti-drug policy without incurring substantial decreases in social justice, due to the impact of substance use on whole families and communities beyond the individual substance user(s). In other words, if there were no laws about the sale or use of AOD, damage done to public health and the public s economic well-being would be experienced as devastating and unfair. In that situation, a backlash that entails over-reliance on a criminal justice approach would 5
be likely. The prime dichotomy helps understand why the health and justice dichotomy is so important and what options are available for public policy that takes into account health and justice elements of AOD problems. IV. In closing Although the breadth of the discussion above draws from a wider range of theory than just that which is contained in the Comprehensive Theory of Substance Abuse Prevention, the prime dichotomy and other facets of the Comprehensive Theory make more possible the understanding of the multi-systemic dynamics that would be involved in better focusing prevention efforts for success, and avoiding the problems that arise from focusing on just one half of some of the crucial dichotomies of substance abuse. 6