PREVENTION MUST BE PUT INTO CONTEXT
A common definition of prevention is “educating youth to abstain” – but this is doubly erroneous, explains Peter Stoker. First, all age groups can benefit. Second, education is only part of a process which also encompasses knowledge, attitudes and behaviour. And in limiting our attention to extremes of youth and addicts, we miss a large and costly population in between.
Sitting at the King’s Fund in London in November, listening to the inspiring description of the Betty Ford Center by CEO John Schwarzlose and children’s programme director Jerry Moe, there were clear parallels with prevention principles and practice. It was a welcome change: in some 25 years covering most sectors of our profession, I have observed that the fields of treatment and prevention are too often separated by a large wall. We must do better than this. The pay-off can be a more powerful way of working together, to the ultimate benefit of the people we help.
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WHAT IS PREVENTION?
Prevention has been the target of cheap shots throughout its existence. Some cynics allege that there is no technology in prevention – merely “apple pie sentiments”. This might come as a surprise to Lindsay Roberts [ref 1] who was recently awarded a Masters in Prevention Science at Oklahoma University, and to Bill Lofquist [ref 2] of Tucson, Arizona who as long ago as 1989 had a widely-regarded workbook published under the name of The Technology of Prevention.
Adding to prevention technology is Dr Barry Twigg who was awarded his doctorate [ref 3] for research focusing on the whys and wherefores of young people who choose not to use drugs: a valuable reverse of most of the research. And last August, the Independent newspaper [ref 4] published an article commending The Power of Prevention.
But simplistic prevention doesn’t cut it. To quote american humorist HL Mencken: “For every complex problem there is a simple solution – and it doesn’t work”.
Asked what prevention is, many will rely on the Oxford English Dictionary and opine that it is “obstructing” something – but obstructing is too late! Look at the Latin root: praevenire, meaning ‘to come before’, then savour Lofquist’s definition: “We need to get beyond the notion that prevention is stopping something happening, to a more positive approach which creates conditions which promote the well-being of people”.
Since the overall goal of prevention is to promote wellbeing – to improve health – it behoves us to agree on a usable definition of ‘health’. Too often, this is narrowly described in terms of physical capacity or mental illness Try instead this one derived from inter alia the World Health Organisation. Health comprises: physical, mental, intellectual, social, emotional, spiritual and environmental elements.
What is prevention? The usual answer is “educating youth to abstain”. This is doubly erroneous. First, all age groups can benefit from prevention [ref 5]. Second, education is but a part of the process. A useful acronym defining prevention elements is KAB: knowledge, attitudes, behaviour [ref 6]. Importantly, behaviour should not only be about penalising negatives; it should also be about encouraging positives.
Moreover, in limiting our attention to youth abstainers at one end, and to addicts at the other end, between us we are missing a large population in the middle. Regular users of varying degrees of use [ref 7] actually cost society more than all the addicts put together.
The US Centre for Substance Abuse Prevention as long ago as 1991 concluded that the best prevention results come through “coordinated prevention efforts that offer multiple strategies, provide multiple points of access, and coordinate and expand citizen participation in community activity”.
Caution is recommended in tackling the culture round behaviour. It can and should be considered as a kind of ‘social ecology’. In a paper [ref 8] submitted to the 2003 International Drug Prevention Conference in Rome, the point was made that “dabbling” with one aspect could bring the law of unintended consequences into play.
Of course, no consideration of drug policy and practice escapes the attention of the libertarian front. While the goal of prevention is to facilitate drug-free lifestyles for all, pro-drug adversaries cynically condemn it as part of a so-called “war on drugs”. With the benefit of hindsight we can see that the term “war on drugs is a finely conceived and executed meme. A paper by Brian Heywood [ref 9] usefully informs on memes and their deployment. In treatment as well as prevention, we need to learn from our opposition, and become adept ‘memesmiths’.
CULTURE IS THE KEY
It is not too much to say that culture drives behaviour, be it at individual or societal level. It follows that if you want to change behaviour, you must change the culture. No small task! Put another way, if much of drug use is to escape reality, it follows that the solution is to improve reality. So, what influences the culture round decisions to use or not use drugs? In no particular order, these are recognised as:
o Peer group influence
o Personal perceptions
o Income v cost of any action
o Health issues
o Moral structure, spiritual structure
o Family values
o The attraction of risk-taking
o Mental condition – depressed, elated, in-between
o Legislation, including laws and conventions
o Sports, leisure, the media, music, movies, TV, fashion, humour, and the like.
The media are major players in the culture game. They have transformed themselves from reporters of the culture into makers of the culture. A major US survey a few years ago found that an encouragingly high percentage of children got their information about life issues from their parents. But on asking parents where they got their information from, they answered “the TV”.
Societal factors overlay and influence culture. There is no shortage of societal factors which tend to encourage drug abuse. Here are some examples: self before society, rapid gratification, the ‘right’ to be happy, rights without responsibilities, youth supremacy, conspicuous consumption and political correctness. A drugs trainer once summed up the first four of these factors as a drug user’s rubric: “Me. Feel good. Now”.
If someone alters the culture in which decisions are made, it is almost certain that there will be different outcomes – and not all influences are positive. The ‘values clarification’ philosophy [ref 10] founded by Carl Rogers and Professor Sidney Simon, with some input by Abraham Maslow, had a seminal damaging effect on drug abuse. Melanie Phillips, in her paper The Trouble with the Liberal Elite is that it just isn’t Liberal [ref 11], laments the fact that today is an era in which truth has become relative. The American philosopher William James (1842-1910) went so far as to suggest that “Truth may be defined as that which it is ultimately satisfying to believe”.
Chuck Colson, in his paper The Cultivation of Conscience [ref 12], draws out today’s reality that many young felons simply do not know the difference between right and wrong. “How can you teach kids to act right when they don’t know what right looks like?”
CAN WE STRENGTHEN PREVENTION?
Prevention effectiveness is visible in the campaign to reduce tobacco smoking. KAB – knowledge, attitudes, behaviour – has produced a marked decrease in prevalence. We can learn from this. So how can we promote healthy lifestyles? Below are a few options:
o Work to the model of ‘Total Health’ – as in the World Health Organisation or similar
o Become ‘memesmiths’.
o Fix those ‘broken windows’.
o Establish ‘prevention cities’ as in San Salvador, Argentina
o Nurture an informal, international ‘Prevention Institute’
o Build ‘more bridges, fewer towers’ – reduce your ego quotient
o Get more funds for prevention (US State Dept told me that prevention is under 2% of their drugs budget.
1. Editorial: Prevention specialist Lindsay Roberts sees progress in Muskogee. www.muskogeephoenix.com (16 October 2011)
2. Lofquist WA. Discovering the Meaning of Prevention (1983) and Technology of Prevention Workbook. AYD Publications, Arizona (1989)
3.Twigg B, Dr. The Attitudes of Young People to the Non-Use of Drugs and to Drug Education and Prevention. Doctorate Thesis. Department of Education, Brunel University. (2006)
4. www.independent.co.uk The Power of Prevention (31 August 2011)
5. Blow CF et al. Evidence-based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults. Published by Older American Substance Abuse and Mental health Technical Assistance Center. (2005)
6. Benard B. Characeristics of Effective Prevention. Published in Project Snowball training materials, Illinois Teen Institute. Available via NDPA website. (1987)
7. Cunningham J. When is the Cost of Drinking Alcohol Too High? blogs.reuters.com (15 February 2010)
8. Stoker P. Drug Strategies and the Cultivators of Culture. Available via NDPA website. (2003)
9. Heywood B Assaying Information in the Substance Misuse World. Presented at St Petersburg Florida conference of International Task Force. Available via NDPA website. (2004).
10. Stoker P. Moralising… demoralising. The Fight over Personal, Social and Health Education. Available via NDPA website. (2001)
11. Phillips M. The Trouble with the Liberal Elite is that it just isn’t Liberal. See www.melaniephillips.com (2000)
12. Colson C. The Cultivation of Conscience. Available via NDPA website. (2002)
The NDPA website is http://drug prevent.org.uk – click on Papers.
PETER STOKER C.Eng is director of the National Drug Prevention Alliance. He has worked in the drugs and alcohol field for some 25 years – as a counsellor, treatment referral and support worker, educator and (DfES) adviser in schools and communities, social work practice teacher, trainer in many settings and across many age groups. He has been an advocate to local and national political figures, and has been extensively covered in print and broadcast media. He has had several papers published, and spoken at international conferences. Before entering the drugs field, in a 30-year civil engineering career he became a chartered civil engineer, designing and managing major projects at values up to £3,000million.