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Harm Reduction for High-Risk Adolescent Substance Abusers
Maurice S. Fisher Sr.
ISBN: 978-0-87101-455-9. 2014. Item #4559. 230 pages.
Can your device download this eBook? Click here before purchasing! eBooks are available in single quantities only.
ISBN: 978-0-87101-455-9. 2014. Item #4559. 230 pages.
Can your device download this eBook? Click here before purchasing! eBooks are available in single quantities only.
Book Type:
In Harm Reduction for High-Risk Adolescent Substance Abusers, Maurice S. Fisher Sr. shares his experience of helping adolescent clients take charge of their life after negative consequences of substance use or abuse, and empowering young men and women to make better choices and minimize risky behaviors, using harm reductive methods.
Harm reductive methods are used for adolescents who are at higher risk for aggression and violence during three phases: while obtaining the drugs, during active use, and during withdrawal from the substances. Fisher explains harm reduction as an evidence-based method that concentrates on behavior modification and refrains from making moral judgments. He recognizes abstinence-only programs as unrealistic, moral value-laden frameworks based on dishonesty and simplification. It is not the substance use, but rather the physical, psychosocial, emotional, and often legal consequences of use that lead to terrible consequences among adolescents.
Harm Reduction for High-Risk Adolescent Substance Abusers provides the research, discussion, and specific clinical techniques that can be used in private practices. Cognitive-behavioral therapy and skill development, psychoeducational and interpersonal skills, anger management, and support group therapies are discussed, as are ethical issues that may come up in practice.
The book serves as a good resource for therapists, counselors, and clinicians to help adolescents who have lost control and are signaling for help to get their life back on track and grow into adulthood as successful members of society.
Harm reductive methods are used for adolescents who are at higher risk for aggression and violence during three phases: while obtaining the drugs, during active use, and during withdrawal from the substances. Fisher explains harm reduction as an evidence-based method that concentrates on behavior modification and refrains from making moral judgments. He recognizes abstinence-only programs as unrealistic, moral value-laden frameworks based on dishonesty and simplification. It is not the substance use, but rather the physical, psychosocial, emotional, and often legal consequences of use that lead to terrible consequences among adolescents.
Harm Reduction for High-Risk Adolescent Substance Abusers provides the research, discussion, and specific clinical techniques that can be used in private practices. Cognitive-behavioral therapy and skill development, psychoeducational and interpersonal skills, anger management, and support group therapies are discussed, as are ethical issues that may come up in practice.
The book serves as a good resource for therapists, counselors, and clinicians to help adolescents who have lost control and are signaling for help to get their life back on track and grow into adulthood as successful members of society.
In one way or another, substance use and abuse in this country affects practically every community and family. In addition, aggression and violence have affected individuals and families in immeasurable ways. Clear and convincing practical and empirical evidence links substance use with aggression and violence. The rate at which people use drugs has remained constant for years, whereas the age at which people use and abuse substances has become younger. Yet, the treatment approaches to address substance use disorders in adolescents have remained unchanged and incomplete. In fact, the historic treatment approaches have frequently been punitive and threatening, with the goal of scaring adolescents into not using substances. Unfortunately, these approaches have failed.
The purpose of this book is to help the reader develop a deeper understanding and recognition of the links between alcohol and various drugs of abuse and aggression and violent behaviors among adolescents. In addition, this book is designed to help the reader gain a deeper appreciation for the need for comprehensive evaluation of both aggression and violence relative to adolescent substance use disorders.
There are multiple methodologies for providing treatment to individuals with substance abuse disorders, but many do not consider potential risks and dangers during the drug acquisition phase, as well as the usage and recovery phases. Harm reduction methods and techniques serve the sole purpose of decreasing the risk and threat of aggression and violence to people having substance use disorders as well as to society at large. Harm reduction methods, therefore, are highlighted as a progressive way to address both substance use and aggressive and violent behaviors.
Chapter 1 addresses the magnitude of the substance use among adolescents. There is an attempt to make critical historical comparisons related to adolescent substance abuse patterns. Moreover, prevalence rates are explained and described within the larger societal context. Chapter 2 examines aggression and violent behaviors among adolescents. Again, there is an attempt to make historic comparisons in the rates of aggression and violence. The link between aggression and violence and substance use is described in general and is then explored specifically for adolescents in Chapter 3.
Chapter 4 provides a methodical approach for evaluating adolescents to rule out substance use disorders. This comprehensive multidimensional substance abuse evaluation includes seven dimensions: (1) a developmental and medical history; (2) a psychosocial history that includes family, social, sexual, and drug use histories and a physical examination; (3) the client’s cited problems related to use (for example, medical, behavioral, social, and financial); (4) the severity of an identified problem (that is, mild, moderate, intermediate, or severe stage); (5) the collection of objective data for a formal diagnosis of a possible problem; (6) the clarification of a baseline of the client’s status to which future conditions can be compared; and (7) the determination of the appropriate level of care and treatment.
Chapter 5 focuses on available effective treatments for adolescents who have been evaluated and diagnosed with substance use disorders. Ineffective substance abuse treatments are also described in this chapter. Chapter 6 describes the harm reduction method and techniques that are effective in treating adolescents. This is a general overview of harm reduction and sets the basis for later chapters that explain the use of social group work methods to manage risk and harm associated with active substance use and withdrawal from substance use. Social group methods include the development of cognitive-behavioral skills in mood and stress control and in improving adaptive life and coping skills (chapter 7); identification of the psychoeducational aspects of substance use and efforts to improve general social and interactional skills (chapter 8); direct treatment of substance use (chapter 9); and treatment of anger (chapter 10), the underlying emotion associated with aggression and violent behaviors.
The discussions about the harm reduction social groups in chapters 7 through 10 underscore the use of traditional social group work methods and relevant and current clinical interventive skills. The use of group models has consistently been demonstrated as both efficient and effective in a variety of environments such as substance abuse, mental health, and health treatment settings (Corey & Corey, 1977; Getzel, 2004). Harm reduction substance abuse and anger management groups are described and discussed in terms of the following areas:
Chapter 11 addresses clinical methods that improve adherence in adolescent substance abuse treatment. Although motivation should be assessed on an ongoing basis, this chapter describes a group work model that can be used to assess motivation based on the seminal work of Prochaska, Norcross, and DiClemente (1994) and suggests techniques to enhance motivation to change based on the clinical tools developed by W. Miller and Rollnick (2002). Motivational interviewing and motivational enhancement techniques are described and explored relative to how they can best be applied to adolescents evaluated with substance use disorders. Furthermore, this chapter addresses issues of compliance, follow-up, and clients’ follow through with their recovery plan. It describes methods to assess the level and degree of adherence and motivation of adolescent clients. Chapter 11 also helps the social group worker to develop a theoretical and practical understanding of how to match the adolescents evaluated with substance use disorders to appropriate levels of treatment relative to their needs.
The role of substance abuse support groups in the treatment of adolescents is highlighted in chapter 12. This chapter explains and explores the fundamental differences between self-help groups, support groups, and social group work models (that is, treatment groups). The role of the social worker is described within the context of the support group as an adjunct to harm reduction substance abuse treatment.
Chapter 13 explores the ethics of harm reduction methods. This chapter discusses the logical advocacy for the harm reduction model and the arguments against it. In addition, social work ethical principles outlined by NASW that specifically apply to working with people having substance use disorders are described. A description is also offered of those ethical principles espoused by the Association for Addiction Professionals (NAADAC) that directly apply to the direct treatment of people with substance use disorders. Finally, because many substance abuse counselors are educated as social workers, a comparison of the major principles of NASW and NAADAC is set forth.
I have actively evaluated and treated adolescents with substance use problems for over 30 years. Many of these adolescents were coerced into treatment, because of aggressive and violent acts that occurred while they were under the influence of substance, during a period of active withdrawal, or during the course of obtaining the drugs. Frequently, these adolescents were overcome with shame, guilt, and remorse when faced with the direct effects that their aggression and violence had on others, especially the residual effects on their own families. Once referred into treatment, these same adolescents soon reverted to feelings of anger and resentment as they were labeled "alcoholics" and "drug addicts" by well-meaning counselors using traditional, but ineffective, disease and recovery treatment approaches. The harm reduction methods built on a strengths model of social work practice attempt to destigmatize adolescents from negative and projective clinical labeling and work to enhance the freedom of these clients to make self-determined choices about their substance use and abuse.
There are many who would argue that adolescents should not be empowered to make such critical decisions about life-changing behaviors. Moreover, there are those who seem to think that harm reduction methods aid and abet individuals in using substances – this is simply not the case. Nowhere do harm reduction methods sanction the use of illicit substances by adolescents or adults. The reality is that for those adolescents who have made the decision to use and abuse illicit substance, the decision is life-altering. Helping adolescents develop strategies to minimize the risk and harm of their current substance use and abuse simply allows them to make better decisions out of their arguably initial bad one. That is to say, for the adolescents who have taken the initial steps to use or abuse drugs, harm reductive methods give them the tools to make better judgments and decisions as well as a way to improve the course and direction of their lives. Harm reduction for adolescents with substance use disorders is a hopeful and refreshingly welcome approach that builds on their strengths.
The purpose of this book is to help the reader develop a deeper understanding and recognition of the links between alcohol and various drugs of abuse and aggression and violent behaviors among adolescents. In addition, this book is designed to help the reader gain a deeper appreciation for the need for comprehensive evaluation of both aggression and violence relative to adolescent substance use disorders.
There are multiple methodologies for providing treatment to individuals with substance abuse disorders, but many do not consider potential risks and dangers during the drug acquisition phase, as well as the usage and recovery phases. Harm reduction methods and techniques serve the sole purpose of decreasing the risk and threat of aggression and violence to people having substance use disorders as well as to society at large. Harm reduction methods, therefore, are highlighted as a progressive way to address both substance use and aggressive and violent behaviors.
Chapter 1 addresses the magnitude of the substance use among adolescents. There is an attempt to make critical historical comparisons related to adolescent substance abuse patterns. Moreover, prevalence rates are explained and described within the larger societal context. Chapter 2 examines aggression and violent behaviors among adolescents. Again, there is an attempt to make historic comparisons in the rates of aggression and violence. The link between aggression and violence and substance use is described in general and is then explored specifically for adolescents in Chapter 3.
Chapter 4 provides a methodical approach for evaluating adolescents to rule out substance use disorders. This comprehensive multidimensional substance abuse evaluation includes seven dimensions: (1) a developmental and medical history; (2) a psychosocial history that includes family, social, sexual, and drug use histories and a physical examination; (3) the client’s cited problems related to use (for example, medical, behavioral, social, and financial); (4) the severity of an identified problem (that is, mild, moderate, intermediate, or severe stage); (5) the collection of objective data for a formal diagnosis of a possible problem; (6) the clarification of a baseline of the client’s status to which future conditions can be compared; and (7) the determination of the appropriate level of care and treatment.
Chapter 5 focuses on available effective treatments for adolescents who have been evaluated and diagnosed with substance use disorders. Ineffective substance abuse treatments are also described in this chapter. Chapter 6 describes the harm reduction method and techniques that are effective in treating adolescents. This is a general overview of harm reduction and sets the basis for later chapters that explain the use of social group work methods to manage risk and harm associated with active substance use and withdrawal from substance use. Social group methods include the development of cognitive-behavioral skills in mood and stress control and in improving adaptive life and coping skills (chapter 7); identification of the psychoeducational aspects of substance use and efforts to improve general social and interactional skills (chapter 8); direct treatment of substance use (chapter 9); and treatment of anger (chapter 10), the underlying emotion associated with aggression and violent behaviors.
The discussions about the harm reduction social groups in chapters 7 through 10 underscore the use of traditional social group work methods and relevant and current clinical interventive skills. The use of group models has consistently been demonstrated as both efficient and effective in a variety of environments such as substance abuse, mental health, and health treatment settings (Corey & Corey, 1977; Getzel, 2004). Harm reduction substance abuse and anger management groups are described and discussed in terms of the following areas:
- 1. Rationale for using the social group work method: the underlying logic for using this group model.
2. Purpose and goals: the overarching goals.
3. Functional characteristics: how the group operates, including process oriented, skill-development, and so on.
4. Structural characteristics: how the social work group is operationally managed (for example, whether the group is open or closed, whether the group operates homogeneous or heterogeneous relative to sex and substance use disorder).
5. Group leadership skills: what instrumental social group work skills and what specific skills are needed to lead the group.
6. Clinical techniques: the specific skills necessary and sufficient to lead the group, beyond the fundamental social group work skills.
7. Expected clinical benefits and outcomes from using the model: positive outcomes that the social group leader strives to attain.
Chapter 11 addresses clinical methods that improve adherence in adolescent substance abuse treatment. Although motivation should be assessed on an ongoing basis, this chapter describes a group work model that can be used to assess motivation based on the seminal work of Prochaska, Norcross, and DiClemente (1994) and suggests techniques to enhance motivation to change based on the clinical tools developed by W. Miller and Rollnick (2002). Motivational interviewing and motivational enhancement techniques are described and explored relative to how they can best be applied to adolescents evaluated with substance use disorders. Furthermore, this chapter addresses issues of compliance, follow-up, and clients’ follow through with their recovery plan. It describes methods to assess the level and degree of adherence and motivation of adolescent clients. Chapter 11 also helps the social group worker to develop a theoretical and practical understanding of how to match the adolescents evaluated with substance use disorders to appropriate levels of treatment relative to their needs.
The role of substance abuse support groups in the treatment of adolescents is highlighted in chapter 12. This chapter explains and explores the fundamental differences between self-help groups, support groups, and social group work models (that is, treatment groups). The role of the social worker is described within the context of the support group as an adjunct to harm reduction substance abuse treatment.
Chapter 13 explores the ethics of harm reduction methods. This chapter discusses the logical advocacy for the harm reduction model and the arguments against it. In addition, social work ethical principles outlined by NASW that specifically apply to working with people having substance use disorders are described. A description is also offered of those ethical principles espoused by the Association for Addiction Professionals (NAADAC) that directly apply to the direct treatment of people with substance use disorders. Finally, because many substance abuse counselors are educated as social workers, a comparison of the major principles of NASW and NAADAC is set forth.
I have actively evaluated and treated adolescents with substance use problems for over 30 years. Many of these adolescents were coerced into treatment, because of aggressive and violent acts that occurred while they were under the influence of substance, during a period of active withdrawal, or during the course of obtaining the drugs. Frequently, these adolescents were overcome with shame, guilt, and remorse when faced with the direct effects that their aggression and violence had on others, especially the residual effects on their own families. Once referred into treatment, these same adolescents soon reverted to feelings of anger and resentment as they were labeled "alcoholics" and "drug addicts" by well-meaning counselors using traditional, but ineffective, disease and recovery treatment approaches. The harm reduction methods built on a strengths model of social work practice attempt to destigmatize adolescents from negative and projective clinical labeling and work to enhance the freedom of these clients to make self-determined choices about their substance use and abuse.
There are many who would argue that adolescents should not be empowered to make such critical decisions about life-changing behaviors. Moreover, there are those who seem to think that harm reduction methods aid and abet individuals in using substances – this is simply not the case. Nowhere do harm reduction methods sanction the use of illicit substances by adolescents or adults. The reality is that for those adolescents who have made the decision to use and abuse illicit substance, the decision is life-altering. Helping adolescents develop strategies to minimize the risk and harm of their current substance use and abuse simply allows them to make better decisions out of their arguably initial bad one. That is to say, for the adolescents who have taken the initial steps to use or abuse drugs, harm reductive methods give them the tools to make better judgments and decisions as well as a way to improve the course and direction of their lives. Harm reduction for adolescents with substance use disorders is a hopeful and refreshingly welcome approach that builds on their strengths.
About the Author
Acknowledgments
Preface
Introduction
Chapter 1: Prevalence of Adolescent Substance Use
Chapter 2: Aggression and Violence among Adolescents
Chapter 3: Link between Aggression and Violence and Substance Use
Chapter 4: Evaluating Substance Use Disorders
Chapter 5: Substance Abuse Treatment for Adolescents
Chapter 6: Harm Reduction Methods for Treating Substance Use Disorders in Adolescents
Chapter 7: Cognitive-Behavioral and Skill Development Groups
Chapter 8: Psychoeducational and Interpersonal Skills Groups
Chapter 9: Adolescent Substance Abuse Group Work
Chapter 10: Anger Management Group Therapy
Chapter 11: Compliance Issues Associated with Adolescent Substance Abusers: A Social Work Model
Chapter 12: Adolescent Substance Abuse Support Groups
Chapter 13: Social Work and Substance Abuse Treatment Ethical Issues
Conclusion
References
Index
Acknowledgments
Preface
Introduction
Chapter 1: Prevalence of Adolescent Substance Use
Chapter 2: Aggression and Violence among Adolescents
Chapter 3: Link between Aggression and Violence and Substance Use
Chapter 4: Evaluating Substance Use Disorders
Chapter 5: Substance Abuse Treatment for Adolescents
Chapter 6: Harm Reduction Methods for Treating Substance Use Disorders in Adolescents
Chapter 7: Cognitive-Behavioral and Skill Development Groups
Chapter 8: Psychoeducational and Interpersonal Skills Groups
Chapter 9: Adolescent Substance Abuse Group Work
Chapter 10: Anger Management Group Therapy
Chapter 11: Compliance Issues Associated with Adolescent Substance Abusers: A Social Work Model
Chapter 12: Adolescent Substance Abuse Support Groups
Chapter 13: Social Work and Substance Abuse Treatment Ethical Issues
Conclusion
References
Index
There is no doubt about it – we live in a world that seems to be increasingly dangerous. The news is filled with aggressive events that give us pause. Due to the aggression and violence in the world, as helping professionals we experience increased numbers of clients who are anxious and fearful. We also live in a drug-oriented society. Television commercials are filled with advertisements for new pharmaceuticals that are designed to help us manage our health, increase life expectancy, or make life experiences more tolerable. Increased amounts of illicit drugs of various types are flooding our academic institutions. Much of the aggression and violence in our society is perpetrated by individuals obtaining the substances (typically through illegal means), using the substances, and withdrawing from the use of these drugs.
Violence, such as assault, malicious wounding, or murder, is an extreme form of aggression. Violence has many causes, including frustration, exposure to violent media, violence experienced in the home or neighborhood, substance use, and a tendency to see other people’s actions as hostile even when they are not. Certain situations, such as insults and other provocations, and environmental factors, such as heat and overcrowding, increase the risk of aggression.
According to the 2011 Centers for Disease Control and Prevention (CDC, 2012) Youth Risk Behavior Surveillance survey, 16.6 percent of high school students carried a weapon at least once during the 30 days before they were surveyed, with 7.4 percent reporting that they had been threatened or injured with a weapon. Many factors cause violent behavior. Although not the singular cause of aggressiveness and violent behaviors, alcohol and other drugs play a significant role. The more of these factors that are present in a person’s life, the more likely that person is to commit an act of violence.
According to the American Psychological Association (2012), people often commit violence, because of one or more of the following:
Anger is the underlying feeling associated with aggression and violence. However, anger is not always the only symptom or an exact predictor of aggression or violence. Although anger may be a warning sign and underpins aggression and violence, it should be placed in context. In fact, when it is assumed that anger or increased substance abuse will always lead to violence, many nonviolent people who are in need of help are unfairly characterized as violent (American Psychological Association, 2012).
Alcohol and drug use among adolescents has been a public health concern for decades. Although substance use trends have fluctuated over the years, research continues to show alarming rates of drug and alcohol use. Many adolescents drink alcohol even though it is illegal for anyone in the United States under age 21 to buy or possess alcohol. Alcohol use and the abuse of prescription drugs are common among teens. The use of illicit drugs such as marijuana appears to be increasing across most of the adolescent age span (Gfroerer, 1995). According to the National Household Survey of Drug Abuse (NHSDA), in 2006 an estimated 20.4 million Americans aged 12 or older were currently illicit drug users, meaning that they had used an illicit substance at least once during the month prior to the survey. This estimate represents 8.3 percent of the population (ages 12 or older) (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007a).
Illicit substances include marijuana, cocaine (including "crack"), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically. Marijuana was the most frequently used substance (14.8 million users in the month prior to the survey). Number of cocaine users was estimated at 2.4 million (up from 2 million in 2002). Hallucinogens were used by 1 million people (0.4 percent), including 528,000 (0.2 percent) who used Ecstasy (SAMHSA, 2007a). An estimated 731,000 people (0.3 percent of the population) used methamphetamine. (The 2006 estimates for hallucinogen and methamphetamine use do not significantly differ from 2002 estimates.) There were 7 million (2.8 percent) individuals who used prescription-type psychotherapeutic drugs nonmedically. Of these, 5.2 million used pain relievers, which is an increase from 4.7 million in 2005. Among adolescents aged 12 to 17, illicit substance use rates declined significantly between 2002 and 2006, from 11.6 to 9.6 percent, with noticeable change in use of marijuana, hallucinogens, Ecstasy, LSD, prescription-type drugs used nonmedically, pain relievers, and benzodiazepines. The rate of current marijuana use among adolescents aged 12 to 17 declined from 8.2 percent in 2002 to 6.7 percent in 2006. Among male adolescents, the rate declined from 9.1 to 6.8 percent, but among female adolescents the rates in 2002 (7.2 percent) and 2006 (6.4 percent) were not as significantly different (SAMHSA, 2007a).
As for alcohol use, the 2006 NHSDA found that slightly more than half of Americans aged 12 or older (an estimated 125 million individuals) reported being drinkers. That year, heavy drinking, defined as binge drinking on at least 5 days during the past 30 days, was reported by 6.9 percent of the population aged 12 or older (17 million individuals). The rate of alcohol use among adolescents aged 12 to 17 was 16.6 percent, and adolescent binge and heavy rates were 10.3 percent and 2.4 percent, respectively (SAMHSA, 2007a).
The University of Michigan annually surveys adolescents nationwide in grades 8, 10, and 12 as part of its Monitoring the Future study to determine trends in tobacco, alcohol, and other drug use. The 2010 survey indicated that daily marijuana use among high school seniors has increased to its highest point in 30 years (Johnston, O’Malley, Bachman, & Schulenberg, 2011). Daily cannabis use among adolescents across all three grades surpassed daily tobacco use, which has been on the decline. Although alcohol use has declined slightly in comparison with previous years, nearly two-thirds (65 percent) of high school seniors and nearly one-third (29 percent) of eighth graders had used alcohol in the previous month (Johnston, et al., 2011). It is estimated that about 1.5 million teenagers meet criteria for a substance use disorder. Of those adolescents, only 111,000 (7 percent) receive treatment for the disorder (Johnston, et al., 2011). This lack of treatment is due to a variety of factors, such as poor health care coverage, low motivation by the adolescents or parents, a lack of specialized adolescent treatment programs, and inconsistent quality in adolescent treatment services.
Adolescent substance abuse is a risk at a cellular and social level. Recent research shows that the human brain does not fully develop until around the mid-twenties (Winters & Arria, 2011). The area of the brain that is last to develop is the prefrontal cortex, which is in charge of judgment and decision making. This is thought to be one reason why risky behaviors among adolescents are so common and why adults question the decisions that teens make. Adolescent brain research suggests that the prefrontal cortex (that area of the brain that monitors impulsivity, goal setting, reasoning, and judgment) is maturing and developing throughout adolescence. These biological immaturities increase the propensity to act impulsively and to disregard negative consequences and risks associated with drug and alcohol use (Winters, Botzet, & Fahnhorst, 2011). In sum, adolescents are more likely than adults to experience physiological consequences from their use of addictive substances, including damage to the areas of the brain responsible for higher level cognitive functions such as decision making, memory, impulse control, and the overall exercise of appropriate interpersonal and social judgments. Therefore, one can logically conclude that adolescents will have a greater likelihood of successful recovery when their treatment options are tailored to their specific psychological, developmental, and social needs.
Second, adolescents are more likely than adults to take social risks, including experimenting with addictive substances and engaging in dangerous behaviors while under the influence of these substances. In addition, adolescents are highly susceptible to external social influences such as negative peer influence to engage in risky behaviors while using substances. Equally important, adolescents are more susceptible to the development of addictive disorders than adults, due to negative peer influences; lack of emotional, social, and intellectual maturity; poor parental supervision; and dysfunctional families of origin.
Researchers have found that adolescents start using drugs and alcohol for four main reasons: (1) to improve their mood, (2) to receive social rewards, (3) to reduce negative feelings, and (4) to avoid social rejection (Kuntsche, Knibbe, Gmel, & Engels, 2005). Adolescents who reported social reasons for drinking were more likely to report moderate drinking. Those who wanted to improve their mood reported heavy alcohol use, whereas those who wanted to reduce negative feelings showed problematic drinking patterns. Experts point to peer pressure and other social reasons for adolescents’ initial use of substances (Terry-McElrath, O’Malley, & Johnston, 2013). Adolescents will sometimes imitate what their peers do to feel accepted and included, and some are curious about the effects of drugs on their mood and behavior.
The public health significance of adolescent drug use is exacerbated by the fact that the early initiation of drug use is correlated with an increased risk of a constellation of problem behaviors, such as driving under the influence of a substance; physical, sexual, and emotional abuse; as well as aggressive and violence-related legal charges. With "zero tolerance" as the standard for schools and other social institutions in which adolescents are involved, any variation from the mean serves to label the adolescent as either a substance abuser or an aggressor.
Several investigators have suggested that violence plays a role in adolescent and adult substance abuse. In these conceptualizations, substance use represents a strategy to cope with the stress produced by interpersonal aggression (Bean, 1992; Dembo, Pacheco, Schmeidler, Fisher, & Cooper, 1997; Ireland & Widom, 1994; Lindberg & Distad, 1985). Hypothetically, distress produced by assault drives individuals to engage in behaviors that reduce negative emotions, such as situational avoidance or substance use (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997). That is, use or abuse of substances following assault may be an effective but maladaptive strategy to diminish negative affect. Support for this learning theory model is provided by studies that demonstrate an association between affect regulation and substance use (for example, Levenson, Oyama, & Meek, 1987; Stasiewicz & Maisto, 1993).
Fortunately, most alcohol and drug use occurs among adults and adolescents who are not aggressive or violent (Wenzel, Brown, & Beck, 2008). However, alcohol and to a lesser extent illicit drugs have been used by both offenders and victims at many aggressive and violent events. The links between psychoactive substances and violence involve myriad complex social and economic forces, such as the settings in which people obtain and consume the substances and the biological processes that underlie all human behavior. In the case of alcohol and several other drugs, evidence from laboratory and empirical studies supports the possibility that they play a causal role in violent behavior (Murdoch, Pihl, & Ross, 1990).
Similarly, psychostimulants, such as amphetamines and cocaine, could play a contributing role in aggressive and violent behaviors. Most real-world studies indicate that this relationship is exceedingly complex and moderated by a host of factors in the individual and the environment. In addition to psychopharmacological effects, substance use may lead to aggression and violence through social processes such as drug distribution systems (systemic violence) and behaviors used to obtain drugs or money for drugs (economic compulsive violence).
There are three basic ways in which substance abuse is related to aggression and violence. First, violence can be perpetrated under the influence of substances. This type of aggression and violence can be labeled as psychopharmacological violence (Boles & Miotto, 2003). Psychopharmacological violence occurs as a result of the short- or long-term use of certain drugs that produce excitability, irritability, paranoia, or violent behavior. Psychopharmacological violence can also occur when the use of substances results in changes or impairments in cognitive functions, intensifies emotional states, or disrupts physiological functions that motivate or restrain aggression and violence. This form of violence may involve substance use by either the perpetrator or victim. Substance use may contribute to a person behaving aggressively, or it may alter a person’s behavior in such a manner as to bring about that person’s violent victimization. The most relevant substances in this regard are alcohol, stimulants (cocaine and amphetamines), phencyclidine (PCP), and barbiturates (Boles & Miotto, 2003). There is evidence supporting the relationship between psychopharmacological violence and the use of marijuana and opioids. Several drugs, such as heroin or tranquilizers, may actually ameliorate violent tendencies during active use, but not during drug seeking or withdrawal.
The second type of aggression and violence related to substance use is labeled systemic violence. Systemic violence refers to the aggressive patterns of interaction within the system of drug distribution and use (Boles & Miotto, 2003). Examples of systemic violence include murders over drug turf and violence perpetrated by drug distributors in the course of territorial disputes, retribution for selling illicit drugs, the use of threats and violence to enforce rules within a drug-dealing organization, fights among users over drugs or drug paraphernalia, conflicts with police, and murders of drug informers. A substantial number of users of any substance become involved in drug distribution as their drug-using careers progress and, hence, they increase their risk of becoming a victim or perpetrator of systemic violence (Appelbaum, Robbins, & Monahan, 2000; Monahan, 1993; Monahan & Steadman, 1994).
The third type of aggression and violence is called economic compulsive violence and is related to the acquisition of drugs (Boles & Miotto, 2003). Economic compulsive violence is intentional violence that results from profit-oriented behavior to generate money to support addiction. Aggression and violence generally results from some factor in the social context in which the economic crime is committed. For example, violence may be related to the perpetrator’s nervousness, the victim’s reaction, or weaponry carried by either the perpetrator or victim. In general, economically based violence applies to all substances for which there is no legal market; this is always the case for adolescents. Because of their expense, the two substances most commonly linked to economic compulsive violence are heroin and cocaine.
The three types of aggression and violence are often combined. For example, a heroin user who is preparing to commit a robbery may ingest some alcohol or stimulants to gain courage. This event contains elements of both economic compulsive and psychopharmacological violence. Various studies have found evidence of all three types of drug-related violence (Babor et al., 1976; Lindquist, Lindsay, & White, 1979; Miczek et al., 1993).
Aggression and violence can occur in various phases of drug use, including acts of drug seeking, acute intoxication, and drug-seeking behavior associated with withdrawal. Episodes of drug-induced psychosis and paranoia are associated most often with stimulant use. Acute intoxication, most notably with alcohol, causes uninhibited behavior and leads to aggression in people prone to violent behavior. In addition, substance-induced aggression during intoxication can occur in dependent or nondependent users. In the case of alcohol, researchers have consistently noted that alcohol use by the perpetrator or victim immediately precedes many violent events (Boles & Miotto, 2003). In addition, drinking more than five drinks per occasion increases the likelihood that the drinker will be involved in violence, either as perpetrator or victim (Boles & Miotto, 2003). More than any other group, young adults and adolescents are likely to have been drinking prior to being either a perpetrator or victim of fatal or nonfatal violence. Alcohol use by both attacker and victim is common in incidents of rape and incest, assault, robbery with injury, and family violence.
The consequences of adolescent substance use are devastating. Some of the typical consequences include injuries; medical conditions such as asthma, cardiovascular problems, and digestive problems; unwanted pregnancies; mental health problems such as anxiety, depression, thought disturbance, and impaired brain function; decreased academic performance; and criminal and legal entanglements. The consequences of substance abuse problems extend beyond the user and involve the families, sexual partners, and significant others and peers who do not use or abuse substances. Moreover, even occasional use of alcohol or other drugs can have life-changing consequences, such as alcohol-related driving accidents. The financial costs of substance abuse include the estimated 68 billion dollars that are associated with underage alcohol use alone (Hedlund, Ulmer, & Preusser, 2001) and the 14 billion dollars associated with substance-related juvenile justice programs spent annually. These figures do not necessarily include monies for active treatment.
Adolescent substance use that is correlated with aggression and violence requires targeted assessment, evaluation, and treatment interventions. Given the correlation between substance use and aggressive and violent behaviors, especially for adolescents who are psychosocially and biologically immature, there is a need for a holistic treatment approach based on a comprehensive substance abuse evaluation. This evaluation needs to take into consideration the biologic (genetic propensity and developmental), psychologic (mental health and emotional issues), and social (family and peer inference) environments. In addition, these biopsychosocial factors need to be grounded and based on a strong social history. Proven empirically based instruments need to be used to objectively determine the severity of substance use as well as the patterns of substance abuse.
Treatment interventions need to avoid negative labeling and a singular abstinence-only goal, and instead should focus on helping adolescents develop social skills and critical decision-making skills. Because there are no known critical empirical studies that validate a disease and recovery (12-step) approach to treatment for adults of adolescents (B. Johnson, personal communication, May 12, 2013), this approach needs to be replaced with treatments that do work. Also, long-term treatments have not been proven to be effective; briefer, more directed treatment is more effective (B. Johnson, personal communication, May 12, 2013). The seeds for the success of treatment are planted at the beginning of treatment with the development of a strong therapeutic relationship.
The method that simultaneously deals with reduction of risk in substance use and abuse and aggression and violent actions associated with substance use is harm reduction. Harm reduction methods empower the client to minimize risky substance use and consequently reduce the potentiality of aggression and violence.
There are several components to effective treatments. First, the individuals must have appropriate motivation for seeking treatment and staying in treatment. Despite the notion that "if you don’t do it for yourself," recovery will not be attained, whatever motivator a client may have that is realistic (for example, improving health or avoiding involvement with the criminal justice system) is sufficient. Second, they need to develop critical decision-making skills so that they can make responsible judgments about substance use. Third, they need to have a positive peer support system. This support system can come from self-help or support groups, religious affiliations, or positive (non-drug-using) peers. Finally, these individuals need to develop healthy life skills to enable them to deal with life on life’s terms.
The treatment modality most often suggested in the treatment of substance use disorders is the social group process. Social groups and substance abuse treatment are natural allies. One reason for this is that individuals who abuse substances often are more likely to choose abstinence and commit to recovery when treatment is provided in groups. Groups provide rewarding and therapeutic forces such as affiliation, confrontation, support, gratification, and identification. This capacity of social groups to link clients to treatment is an important aspect and asset, because the amount, quality, and duration of treatment affect the clients’ prognosis (Leshner, 1997; Project MATCH Research Group, 1997). The effectiveness of social groups in the treatment of substance abuse can also be attributed to the nature of addiction and several factors associated with it, such as depression, anxiety, isolation, denial, shame, temporary cognitive impairment, and character pathology (personality disorder). Clients with these problems often respond better to group treatment than to individual therapy (Fisher, 2004; Kanas, 1985; Kanas & Barr, 1993). Group therapy is also effective, because people are fundamentally relational creatures.
Multiple studies have validated the use of social group models in the treatment of substance use disorders. There are multiple advantages to the use of social groups in substance abuse treatment (S. Brown & Yalom, 1977; Flores, 1997; Vannicelli, 1987, 1992, 2002). Social groups provide positive peer support and appropriate healthy social pressure to alter substance abuse patterns. Social groups reduce the sense of isolation that many individuals who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with similar issues. Social groups enable individuals who abuse substances to vicariously experience the recovery of others, which gives them hope for themselves. In addition, social groups help members learn to cope with their substance abuse and other problems by allowing them to see and hear how others deal with these problems.
Social groups can provide useful information for clients who are new to recovery. With abstinence as a priority, clients can learn how to avoid certain triggers for use and how to self-identify as people recovering from substance abuse. Moreover, social groups provide feedback concerning the values and abilities of other group members. This information can help members improve their self-image or modify faulty, distorted conceptions. In terms of process groups that work on topics such as anger management or stress control, members provide repetitive feedback to the group on how to manage faulty or distorted conceptions regarding the topic being discussed.
Social groups can effectively confront individual members about their substance abuse and other harmful behaviors. These encounters are possible because groups speak with the combined authority of people who have shared common experiences and common problems. Confrontation plays a vital role in substance abuse treatment groups, because individuals who have substance use disorders tend to deny their problems. By participating in the confrontation, group members can help others and can recognize and defeat their own denial.
Social groups offer several other advantages over individual therapy. Social groups are a cost-effective method of treatment, because they require fewer professional staff members. They also instill a sense of hope in the participants that they can be successful. Process groups can expand this hope to deal with the full range of what people encounter in life. These groups also set the stage for the clients to develop positive peer recovery groups outside the therapeutic environment.
The ultimate goal of effective substance abuse treatment is to aid the clients in reducing risky behaviors and harmful effects from the use of these substances; this is done by presenting the clients with a model of recovery that embraces hope and change. Recovery is different from simply stopping drug use. Recovery implies a change in lifestyle through managing harm and minimizing the risk involved in substance use. A colleague and co-leader of a substance abuse group has opined her view of recovery:
There is a huge difference between a person who is truly in recovery and a person who is simply sober. Recovery means I have made a decision and a commitment to completely change my life. Recovery is: a leap of faith; a new beginning; a gift of forgiveness from myself and from others; a gift of peace in my life; a time of many changes; time of healing; learning to live life on life’s terms without a drink or another drug; finding myself; finding new friends; accepting myself and others; surrendering my life to the will of God; facing my disease and learning to live with it; learning to love; helping others to find the way; and a wonderful experience. Recovery is my life for without recovery I will surely die. (E. Allie, personal communication, September 23, 2013)
A major challenge in helping adolescents who have a substance use disorder is to engage them in the evaluative and treatment process. Until engagement occurs, there will be no reduction of risk or acceptance of anything called recovery. Berating and negatively labeling clients does not promote or engage them; this is especially true for adolescents who have authority issues. The harm reduction model espoused in this book is based on a traditional social work strengths perspective. The strengths perspective is an approach to the process of practice rather than a theory. The primary goal of this practice concept is to minimize the weaknesses and maximize the strengths of the client. Strengths-based practice is client led; it focuses on the strengths that the client brings to a problem or crisis and is aimed toward future outcomes. Client empowerment is a central theme to this approach. Empowerment comes from (a) valuing oneself, (b) having achievable goals, and (c) creating a plan to reach these goals that has the potential to be successful.
Critics of the strengths perspective suggest that it is simply reframing problems in a better light, and to some degree this is true, but the use of the strengths perspective is more than reframing. It is using the skills and gifts that the clients bring to the evaluation and treatment. In this light, the strengths perspective honors the dignity and worth of the clients who have substance use problems and views them as human beings with potential to change; this is the core of what the practice of social work ethically espouses.
The chapters that follow are designed to improve the adolescent clients’ chances to be successful in their management of substance use disorders. My goal would be for the adolescent who abuses substance to abstain and embrace a recovery that is free from the effects of psychoactive drugs, but several realities need to be accepted here. First, irrespective of the potential consequences, many adolescents experiment with, use, and abuse substances. Second, many of these adolescents are aggressive and have a propensity to violent actions while seeking the substances, while under the influence of these substances, or while withdrawing from the drugs. The final reality is that all clients have the right to self-determination related to whether they use substance and ultimately they have the choice whether to make substantive changes or not. Abstinence is the preferable choice for adolescents, but it is certainly not the only choice. Hence, although there is no promotion of substance use by adolescents within the context of these pages, there is an acceptance of the reality that adolescents frequently engage in substance use.
There is a strong correlation between substance abuse and aggression and violence, and there need to be advances in research to establish the nature and degree of this relationship. Moreover the helping professional needs to determine whether the aggressive actions of an individual are based solely on the use of drugs or whether the individual has a core issue with aggression and violence.
Violence, such as assault, malicious wounding, or murder, is an extreme form of aggression. Violence has many causes, including frustration, exposure to violent media, violence experienced in the home or neighborhood, substance use, and a tendency to see other people’s actions as hostile even when they are not. Certain situations, such as insults and other provocations, and environmental factors, such as heat and overcrowding, increase the risk of aggression.
According to the 2011 Centers for Disease Control and Prevention (CDC, 2012) Youth Risk Behavior Surveillance survey, 16.6 percent of high school students carried a weapon at least once during the 30 days before they were surveyed, with 7.4 percent reporting that they had been threatened or injured with a weapon. Many factors cause violent behavior. Although not the singular cause of aggressiveness and violent behaviors, alcohol and other drugs play a significant role. The more of these factors that are present in a person’s life, the more likely that person is to commit an act of violence.
According to the American Psychological Association (2012), people often commit violence, because of one or more of the following:
- Expression: Violence is used to release feelings of anger or frustration. Some individuals think there are no answers to their problems and turn to violence to express their out-of-control emotions.
- Manipulation: Violence is used as a way to control others or get something.
- Retaliation: Some people use violence to retaliate against those who have hurt them or someone they care about.
- Learned behavior: Aggression and violence are learned behaviors, and like all learned behaviors they can be changed.
Anger is the underlying feeling associated with aggression and violence. However, anger is not always the only symptom or an exact predictor of aggression or violence. Although anger may be a warning sign and underpins aggression and violence, it should be placed in context. In fact, when it is assumed that anger or increased substance abuse will always lead to violence, many nonviolent people who are in need of help are unfairly characterized as violent (American Psychological Association, 2012).
Adolescent Substance Abuse
Alcohol and drug use among adolescents has been a public health concern for decades. Although substance use trends have fluctuated over the years, research continues to show alarming rates of drug and alcohol use. Many adolescents drink alcohol even though it is illegal for anyone in the United States under age 21 to buy or possess alcohol. Alcohol use and the abuse of prescription drugs are common among teens. The use of illicit drugs such as marijuana appears to be increasing across most of the adolescent age span (Gfroerer, 1995). According to the National Household Survey of Drug Abuse (NHSDA), in 2006 an estimated 20.4 million Americans aged 12 or older were currently illicit drug users, meaning that they had used an illicit substance at least once during the month prior to the survey. This estimate represents 8.3 percent of the population (ages 12 or older) (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007a).
Illicit substances include marijuana, cocaine (including "crack"), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically. Marijuana was the most frequently used substance (14.8 million users in the month prior to the survey). Number of cocaine users was estimated at 2.4 million (up from 2 million in 2002). Hallucinogens were used by 1 million people (0.4 percent), including 528,000 (0.2 percent) who used Ecstasy (SAMHSA, 2007a). An estimated 731,000 people (0.3 percent of the population) used methamphetamine. (The 2006 estimates for hallucinogen and methamphetamine use do not significantly differ from 2002 estimates.) There were 7 million (2.8 percent) individuals who used prescription-type psychotherapeutic drugs nonmedically. Of these, 5.2 million used pain relievers, which is an increase from 4.7 million in 2005. Among adolescents aged 12 to 17, illicit substance use rates declined significantly between 2002 and 2006, from 11.6 to 9.6 percent, with noticeable change in use of marijuana, hallucinogens, Ecstasy, LSD, prescription-type drugs used nonmedically, pain relievers, and benzodiazepines. The rate of current marijuana use among adolescents aged 12 to 17 declined from 8.2 percent in 2002 to 6.7 percent in 2006. Among male adolescents, the rate declined from 9.1 to 6.8 percent, but among female adolescents the rates in 2002 (7.2 percent) and 2006 (6.4 percent) were not as significantly different (SAMHSA, 2007a).
As for alcohol use, the 2006 NHSDA found that slightly more than half of Americans aged 12 or older (an estimated 125 million individuals) reported being drinkers. That year, heavy drinking, defined as binge drinking on at least 5 days during the past 30 days, was reported by 6.9 percent of the population aged 12 or older (17 million individuals). The rate of alcohol use among adolescents aged 12 to 17 was 16.6 percent, and adolescent binge and heavy rates were 10.3 percent and 2.4 percent, respectively (SAMHSA, 2007a).
The University of Michigan annually surveys adolescents nationwide in grades 8, 10, and 12 as part of its Monitoring the Future study to determine trends in tobacco, alcohol, and other drug use. The 2010 survey indicated that daily marijuana use among high school seniors has increased to its highest point in 30 years (Johnston, O’Malley, Bachman, & Schulenberg, 2011). Daily cannabis use among adolescents across all three grades surpassed daily tobacco use, which has been on the decline. Although alcohol use has declined slightly in comparison with previous years, nearly two-thirds (65 percent) of high school seniors and nearly one-third (29 percent) of eighth graders had used alcohol in the previous month (Johnston, et al., 2011). It is estimated that about 1.5 million teenagers meet criteria for a substance use disorder. Of those adolescents, only 111,000 (7 percent) receive treatment for the disorder (Johnston, et al., 2011). This lack of treatment is due to a variety of factors, such as poor health care coverage, low motivation by the adolescents or parents, a lack of specialized adolescent treatment programs, and inconsistent quality in adolescent treatment services.
Adolescent substance abuse is a risk at a cellular and social level. Recent research shows that the human brain does not fully develop until around the mid-twenties (Winters & Arria, 2011). The area of the brain that is last to develop is the prefrontal cortex, which is in charge of judgment and decision making. This is thought to be one reason why risky behaviors among adolescents are so common and why adults question the decisions that teens make. Adolescent brain research suggests that the prefrontal cortex (that area of the brain that monitors impulsivity, goal setting, reasoning, and judgment) is maturing and developing throughout adolescence. These biological immaturities increase the propensity to act impulsively and to disregard negative consequences and risks associated with drug and alcohol use (Winters, Botzet, & Fahnhorst, 2011). In sum, adolescents are more likely than adults to experience physiological consequences from their use of addictive substances, including damage to the areas of the brain responsible for higher level cognitive functions such as decision making, memory, impulse control, and the overall exercise of appropriate interpersonal and social judgments. Therefore, one can logically conclude that adolescents will have a greater likelihood of successful recovery when their treatment options are tailored to their specific psychological, developmental, and social needs.
Second, adolescents are more likely than adults to take social risks, including experimenting with addictive substances and engaging in dangerous behaviors while under the influence of these substances. In addition, adolescents are highly susceptible to external social influences such as negative peer influence to engage in risky behaviors while using substances. Equally important, adolescents are more susceptible to the development of addictive disorders than adults, due to negative peer influences; lack of emotional, social, and intellectual maturity; poor parental supervision; and dysfunctional families of origin.
Researchers have found that adolescents start using drugs and alcohol for four main reasons: (1) to improve their mood, (2) to receive social rewards, (3) to reduce negative feelings, and (4) to avoid social rejection (Kuntsche, Knibbe, Gmel, & Engels, 2005). Adolescents who reported social reasons for drinking were more likely to report moderate drinking. Those who wanted to improve their mood reported heavy alcohol use, whereas those who wanted to reduce negative feelings showed problematic drinking patterns. Experts point to peer pressure and other social reasons for adolescents’ initial use of substances (Terry-McElrath, O’Malley, & Johnston, 2013). Adolescents will sometimes imitate what their peers do to feel accepted and included, and some are curious about the effects of drugs on their mood and behavior.
The public health significance of adolescent drug use is exacerbated by the fact that the early initiation of drug use is correlated with an increased risk of a constellation of problem behaviors, such as driving under the influence of a substance; physical, sexual, and emotional abuse; as well as aggressive and violence-related legal charges. With "zero tolerance" as the standard for schools and other social institutions in which adolescents are involved, any variation from the mean serves to label the adolescent as either a substance abuser or an aggressor.
Linkage between Substance Abuse and Aggressive Actions
Several investigators have suggested that violence plays a role in adolescent and adult substance abuse. In these conceptualizations, substance use represents a strategy to cope with the stress produced by interpersonal aggression (Bean, 1992; Dembo, Pacheco, Schmeidler, Fisher, & Cooper, 1997; Ireland & Widom, 1994; Lindberg & Distad, 1985). Hypothetically, distress produced by assault drives individuals to engage in behaviors that reduce negative emotions, such as situational avoidance or substance use (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997). That is, use or abuse of substances following assault may be an effective but maladaptive strategy to diminish negative affect. Support for this learning theory model is provided by studies that demonstrate an association between affect regulation and substance use (for example, Levenson, Oyama, & Meek, 1987; Stasiewicz & Maisto, 1993).
Fortunately, most alcohol and drug use occurs among adults and adolescents who are not aggressive or violent (Wenzel, Brown, & Beck, 2008). However, alcohol and to a lesser extent illicit drugs have been used by both offenders and victims at many aggressive and violent events. The links between psychoactive substances and violence involve myriad complex social and economic forces, such as the settings in which people obtain and consume the substances and the biological processes that underlie all human behavior. In the case of alcohol and several other drugs, evidence from laboratory and empirical studies supports the possibility that they play a causal role in violent behavior (Murdoch, Pihl, & Ross, 1990).
Similarly, psychostimulants, such as amphetamines and cocaine, could play a contributing role in aggressive and violent behaviors. Most real-world studies indicate that this relationship is exceedingly complex and moderated by a host of factors in the individual and the environment. In addition to psychopharmacological effects, substance use may lead to aggression and violence through social processes such as drug distribution systems (systemic violence) and behaviors used to obtain drugs or money for drugs (economic compulsive violence).
There are three basic ways in which substance abuse is related to aggression and violence. First, violence can be perpetrated under the influence of substances. This type of aggression and violence can be labeled as psychopharmacological violence (Boles & Miotto, 2003). Psychopharmacological violence occurs as a result of the short- or long-term use of certain drugs that produce excitability, irritability, paranoia, or violent behavior. Psychopharmacological violence can also occur when the use of substances results in changes or impairments in cognitive functions, intensifies emotional states, or disrupts physiological functions that motivate or restrain aggression and violence. This form of violence may involve substance use by either the perpetrator or victim. Substance use may contribute to a person behaving aggressively, or it may alter a person’s behavior in such a manner as to bring about that person’s violent victimization. The most relevant substances in this regard are alcohol, stimulants (cocaine and amphetamines), phencyclidine (PCP), and barbiturates (Boles & Miotto, 2003). There is evidence supporting the relationship between psychopharmacological violence and the use of marijuana and opioids. Several drugs, such as heroin or tranquilizers, may actually ameliorate violent tendencies during active use, but not during drug seeking or withdrawal.
The second type of aggression and violence related to substance use is labeled systemic violence. Systemic violence refers to the aggressive patterns of interaction within the system of drug distribution and use (Boles & Miotto, 2003). Examples of systemic violence include murders over drug turf and violence perpetrated by drug distributors in the course of territorial disputes, retribution for selling illicit drugs, the use of threats and violence to enforce rules within a drug-dealing organization, fights among users over drugs or drug paraphernalia, conflicts with police, and murders of drug informers. A substantial number of users of any substance become involved in drug distribution as their drug-using careers progress and, hence, they increase their risk of becoming a victim or perpetrator of systemic violence (Appelbaum, Robbins, & Monahan, 2000; Monahan, 1993; Monahan & Steadman, 1994).
The third type of aggression and violence is called economic compulsive violence and is related to the acquisition of drugs (Boles & Miotto, 2003). Economic compulsive violence is intentional violence that results from profit-oriented behavior to generate money to support addiction. Aggression and violence generally results from some factor in the social context in which the economic crime is committed. For example, violence may be related to the perpetrator’s nervousness, the victim’s reaction, or weaponry carried by either the perpetrator or victim. In general, economically based violence applies to all substances for which there is no legal market; this is always the case for adolescents. Because of their expense, the two substances most commonly linked to economic compulsive violence are heroin and cocaine.
The three types of aggression and violence are often combined. For example, a heroin user who is preparing to commit a robbery may ingest some alcohol or stimulants to gain courage. This event contains elements of both economic compulsive and psychopharmacological violence. Various studies have found evidence of all three types of drug-related violence (Babor et al., 1976; Lindquist, Lindsay, & White, 1979; Miczek et al., 1993).
Aggression and violence can occur in various phases of drug use, including acts of drug seeking, acute intoxication, and drug-seeking behavior associated with withdrawal. Episodes of drug-induced psychosis and paranoia are associated most often with stimulant use. Acute intoxication, most notably with alcohol, causes uninhibited behavior and leads to aggression in people prone to violent behavior. In addition, substance-induced aggression during intoxication can occur in dependent or nondependent users. In the case of alcohol, researchers have consistently noted that alcohol use by the perpetrator or victim immediately precedes many violent events (Boles & Miotto, 2003). In addition, drinking more than five drinks per occasion increases the likelihood that the drinker will be involved in violence, either as perpetrator or victim (Boles & Miotto, 2003). More than any other group, young adults and adolescents are likely to have been drinking prior to being either a perpetrator or victim of fatal or nonfatal violence. Alcohol use by both attacker and victim is common in incidents of rape and incest, assault, robbery with injury, and family violence.
The consequences of adolescent substance use are devastating. Some of the typical consequences include injuries; medical conditions such as asthma, cardiovascular problems, and digestive problems; unwanted pregnancies; mental health problems such as anxiety, depression, thought disturbance, and impaired brain function; decreased academic performance; and criminal and legal entanglements. The consequences of substance abuse problems extend beyond the user and involve the families, sexual partners, and significant others and peers who do not use or abuse substances. Moreover, even occasional use of alcohol or other drugs can have life-changing consequences, such as alcohol-related driving accidents. The financial costs of substance abuse include the estimated 68 billion dollars that are associated with underage alcohol use alone (Hedlund, Ulmer, & Preusser, 2001) and the 14 billion dollars associated with substance-related juvenile justice programs spent annually. These figures do not necessarily include monies for active treatment.
Evaluation and Treatment
Adolescent substance use that is correlated with aggression and violence requires targeted assessment, evaluation, and treatment interventions. Given the correlation between substance use and aggressive and violent behaviors, especially for adolescents who are psychosocially and biologically immature, there is a need for a holistic treatment approach based on a comprehensive substance abuse evaluation. This evaluation needs to take into consideration the biologic (genetic propensity and developmental), psychologic (mental health and emotional issues), and social (family and peer inference) environments. In addition, these biopsychosocial factors need to be grounded and based on a strong social history. Proven empirically based instruments need to be used to objectively determine the severity of substance use as well as the patterns of substance abuse.
Treatment interventions need to avoid negative labeling and a singular abstinence-only goal, and instead should focus on helping adolescents develop social skills and critical decision-making skills. Because there are no known critical empirical studies that validate a disease and recovery (12-step) approach to treatment for adults of adolescents (B. Johnson, personal communication, May 12, 2013), this approach needs to be replaced with treatments that do work. Also, long-term treatments have not been proven to be effective; briefer, more directed treatment is more effective (B. Johnson, personal communication, May 12, 2013). The seeds for the success of treatment are planted at the beginning of treatment with the development of a strong therapeutic relationship.
The method that simultaneously deals with reduction of risk in substance use and abuse and aggression and violent actions associated with substance use is harm reduction. Harm reduction methods empower the client to minimize risky substance use and consequently reduce the potentiality of aggression and violence.
There are several components to effective treatments. First, the individuals must have appropriate motivation for seeking treatment and staying in treatment. Despite the notion that "if you don’t do it for yourself," recovery will not be attained, whatever motivator a client may have that is realistic (for example, improving health or avoiding involvement with the criminal justice system) is sufficient. Second, they need to develop critical decision-making skills so that they can make responsible judgments about substance use. Third, they need to have a positive peer support system. This support system can come from self-help or support groups, religious affiliations, or positive (non-drug-using) peers. Finally, these individuals need to develop healthy life skills to enable them to deal with life on life’s terms.
The treatment modality most often suggested in the treatment of substance use disorders is the social group process. Social groups and substance abuse treatment are natural allies. One reason for this is that individuals who abuse substances often are more likely to choose abstinence and commit to recovery when treatment is provided in groups. Groups provide rewarding and therapeutic forces such as affiliation, confrontation, support, gratification, and identification. This capacity of social groups to link clients to treatment is an important aspect and asset, because the amount, quality, and duration of treatment affect the clients’ prognosis (Leshner, 1997; Project MATCH Research Group, 1997). The effectiveness of social groups in the treatment of substance abuse can also be attributed to the nature of addiction and several factors associated with it, such as depression, anxiety, isolation, denial, shame, temporary cognitive impairment, and character pathology (personality disorder). Clients with these problems often respond better to group treatment than to individual therapy (Fisher, 2004; Kanas, 1985; Kanas & Barr, 1993). Group therapy is also effective, because people are fundamentally relational creatures.
Multiple studies have validated the use of social group models in the treatment of substance use disorders. There are multiple advantages to the use of social groups in substance abuse treatment (S. Brown & Yalom, 1977; Flores, 1997; Vannicelli, 1987, 1992, 2002). Social groups provide positive peer support and appropriate healthy social pressure to alter substance abuse patterns. Social groups reduce the sense of isolation that many individuals who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with similar issues. Social groups enable individuals who abuse substances to vicariously experience the recovery of others, which gives them hope for themselves. In addition, social groups help members learn to cope with their substance abuse and other problems by allowing them to see and hear how others deal with these problems.
Social groups can provide useful information for clients who are new to recovery. With abstinence as a priority, clients can learn how to avoid certain triggers for use and how to self-identify as people recovering from substance abuse. Moreover, social groups provide feedback concerning the values and abilities of other group members. This information can help members improve their self-image or modify faulty, distorted conceptions. In terms of process groups that work on topics such as anger management or stress control, members provide repetitive feedback to the group on how to manage faulty or distorted conceptions regarding the topic being discussed.
Social groups can effectively confront individual members about their substance abuse and other harmful behaviors. These encounters are possible because groups speak with the combined authority of people who have shared common experiences and common problems. Confrontation plays a vital role in substance abuse treatment groups, because individuals who have substance use disorders tend to deny their problems. By participating in the confrontation, group members can help others and can recognize and defeat their own denial.
Social groups offer several other advantages over individual therapy. Social groups are a cost-effective method of treatment, because they require fewer professional staff members. They also instill a sense of hope in the participants that they can be successful. Process groups can expand this hope to deal with the full range of what people encounter in life. These groups also set the stage for the clients to develop positive peer recovery groups outside the therapeutic environment.
The ultimate goal of effective substance abuse treatment is to aid the clients in reducing risky behaviors and harmful effects from the use of these substances; this is done by presenting the clients with a model of recovery that embraces hope and change. Recovery is different from simply stopping drug use. Recovery implies a change in lifestyle through managing harm and minimizing the risk involved in substance use. A colleague and co-leader of a substance abuse group has opined her view of recovery:
There is a huge difference between a person who is truly in recovery and a person who is simply sober. Recovery means I have made a decision and a commitment to completely change my life. Recovery is: a leap of faith; a new beginning; a gift of forgiveness from myself and from others; a gift of peace in my life; a time of many changes; time of healing; learning to live life on life’s terms without a drink or another drug; finding myself; finding new friends; accepting myself and others; surrendering my life to the will of God; facing my disease and learning to live with it; learning to love; helping others to find the way; and a wonderful experience. Recovery is my life for without recovery I will surely die. (E. Allie, personal communication, September 23, 2013)
A major challenge in helping adolescents who have a substance use disorder is to engage them in the evaluative and treatment process. Until engagement occurs, there will be no reduction of risk or acceptance of anything called recovery. Berating and negatively labeling clients does not promote or engage them; this is especially true for adolescents who have authority issues. The harm reduction model espoused in this book is based on a traditional social work strengths perspective. The strengths perspective is an approach to the process of practice rather than a theory. The primary goal of this practice concept is to minimize the weaknesses and maximize the strengths of the client. Strengths-based practice is client led; it focuses on the strengths that the client brings to a problem or crisis and is aimed toward future outcomes. Client empowerment is a central theme to this approach. Empowerment comes from (a) valuing oneself, (b) having achievable goals, and (c) creating a plan to reach these goals that has the potential to be successful.
Critics of the strengths perspective suggest that it is simply reframing problems in a better light, and to some degree this is true, but the use of the strengths perspective is more than reframing. It is using the skills and gifts that the clients bring to the evaluation and treatment. In this light, the strengths perspective honors the dignity and worth of the clients who have substance use problems and views them as human beings with potential to change; this is the core of what the practice of social work ethically espouses.
Conclusions
The chapters that follow are designed to improve the adolescent clients’ chances to be successful in their management of substance use disorders. My goal would be for the adolescent who abuses substance to abstain and embrace a recovery that is free from the effects of psychoactive drugs, but several realities need to be accepted here. First, irrespective of the potential consequences, many adolescents experiment with, use, and abuse substances. Second, many of these adolescents are aggressive and have a propensity to violent actions while seeking the substances, while under the influence of these substances, or while withdrawing from the drugs. The final reality is that all clients have the right to self-determination related to whether they use substance and ultimately they have the choice whether to make substantive changes or not. Abstinence is the preferable choice for adolescents, but it is certainly not the only choice. Hence, although there is no promotion of substance use by adolescents within the context of these pages, there is an acceptance of the reality that adolescents frequently engage in substance use.
There is a strong correlation between substance abuse and aggression and violence, and there need to be advances in research to establish the nature and degree of this relationship. Moreover the helping professional needs to determine whether the aggressive actions of an individual are based solely on the use of drugs or whether the individual has a core issue with aggression and violence.
Maurice S. Fisher Sr., PhD, has been in clinical practice for 30 years. He is currently in full-time clinical practice at Comprehensive Counseling Services, Inc., in Roanoke, Virginia.
Dr. Fisher holds a master’s degree in clinical social work and a doctoral degree in clinical social work and social policy. He is licensed in the Commonwealth of Virginia in mental health and substance abuse. He is certified in Virginia as a sex offender treatment provider and a certified substance abuse counselor. He holds numerous other national mental health and substance abuse treatment certifications. He chaired and was a full member of the Alcohol, Tobacco, and Other Drugs (ATOD) section committee for NASW.
Dr. Fisher is proficient in comprehensive psychosocial health evaluations, substance abuse disorders, mental health disorders, sex offender status, risk assessments, victim impact analysis, and custody evaluations as well as assessments of parent-child psychosocial alienation.
Dr. Fisher is experienced in the treatment of substance-abusing mentally ill adolescent and adult consumers; people with thought, major mood, anxiety, and personality disorders; people with anger management or domestic violence problems; sexual offenders; and people with other forensic needs. On average, Dr. Fisher is in court as an expert witness twice weekly throughout Virginia.
Dr. Fisher holds a master’s degree in clinical social work and a doctoral degree in clinical social work and social policy. He is licensed in the Commonwealth of Virginia in mental health and substance abuse. He is certified in Virginia as a sex offender treatment provider and a certified substance abuse counselor. He holds numerous other national mental health and substance abuse treatment certifications. He chaired and was a full member of the Alcohol, Tobacco, and Other Drugs (ATOD) section committee for NASW.
Dr. Fisher is proficient in comprehensive psychosocial health evaluations, substance abuse disorders, mental health disorders, sex offender status, risk assessments, victim impact analysis, and custody evaluations as well as assessments of parent-child psychosocial alienation.
Dr. Fisher is experienced in the treatment of substance-abusing mentally ill adolescent and adult consumers; people with thought, major mood, anxiety, and personality disorders; people with anger management or domestic violence problems; sexual offenders; and people with other forensic needs. On average, Dr. Fisher is in court as an expert witness twice weekly throughout Virginia.
Harm Reduction for High-Risk Adolescent Substance Abusers was reviewed by Hannah A. D. Kimbrough for the journal Social Work.
Maurice Fisher is an expert in the treatment of substance abuse among high-risk adolescents. In his book, Harm Reduction for High-Risk Adolescent Substance Abusers, Fisher provides a well-researched timeline of the past, present, and future treatments as well as the difficulties involved. He addresses some barriers to treatment, including the teenagers’ need to integrate with peers while simultaneously maintaining their individuality. This paradox causes both interpersonal and intrapersonal conflicts for the adolescent that can be interpreted by adults as opposition and defiance. The addition of a substance use disorder further complicates the already difficult task of engaging adolescents in the therapeutic process.
In addition to the complexities involved in adolescent treatments, Fisher indicates that many of the past and current treatments for substance abuse in adolescents have been correctional and threatening in nature. He argues that these treatments are ineffective and offers a paradigm shift in how to approach this population. Fisher boldly states, “A review of the professional literature shows a general lack of empirically based treatment approaches but a plethora of treatment approaches that are based on legion, myth, and folklore” (p. 65).
Read the full review. Available to subscribers of Social Work.
Maurice Fisher is an expert in the treatment of substance abuse among high-risk adolescents. In his book, Harm Reduction for High-Risk Adolescent Substance Abusers, Fisher provides a well-researched timeline of the past, present, and future treatments as well as the difficulties involved. He addresses some barriers to treatment, including the teenagers’ need to integrate with peers while simultaneously maintaining their individuality. This paradox causes both interpersonal and intrapersonal conflicts for the adolescent that can be interpreted by adults as opposition and defiance. The addition of a substance use disorder further complicates the already difficult task of engaging adolescents in the therapeutic process.
In addition to the complexities involved in adolescent treatments, Fisher indicates that many of the past and current treatments for substance abuse in adolescents have been correctional and threatening in nature. He argues that these treatments are ineffective and offers a paradigm shift in how to approach this population. Fisher boldly states, “A review of the professional literature shows a general lack of empirically based treatment approaches but a plethora of treatment approaches that are based on legion, myth, and folklore” (p. 65).
Read the full review. Available to subscribers of Social Work.
