rsm92

PJ - he was street wise - a mercurial kid - the little loveable rogue - either on the street or in the shop. He rode the trains - grabbing the back= of a train and riding to the next station - he crossed the tracks for exciteme= nt - classic risk taking - his friend John did not speak for a week after it happened and then he poured it all out in a group session I held for the children after the funeral - ‘I told him not to go - but he would nev= er listen - I told him that when you hear a click the electricity is coming on strong and you have to run - = he was walking behind Perry and we heard him say ‘ouch’ then we turned round and his body was jumping - then it stated to burn and his mobile phone went off - I was scared to answer it because of the current - but I could s= ee the face said ‘mum’.”&nb= sp; We could not bring ourselves to tell his mother that as she rang her= son was dying on the track.

<= span lang=3DEN-GB>This sad event - rather than stop the kids tagging on the rail= way lines – has encouraged them to put up memorial tags - ORA RIP. – At the funeral, they could n= ot tear themselves away and physically held the coffin - I’ll never feel the sa= me about Eric Clapton’s ‘Tears = in Heaven’ which was played over and over again .... Our late night refuge / youth club= is going to be called PJs - we h= ave an appeal for that at the moment -

A Transition

As a transition adolescence achieves more of a level of legitimacy, this is an adjustment and we need to lo= ok at the needs of anybody adjusting. There are no other periods of our life when we change so much, at no other times do we change more physically, physiologically, emotionally, mentally and within our roles. In many ways modern life has diminished the other changes, the other adolescence’s in our lives. For instance, maybe the menopause male or female does not hold the f= ears that it once did, it is not linked with reproduction and with new understan= ding of hormone replacement therapy it is not linked with sexual activity either. Retirement is no long= er the threshold phase it used to be, it is now a more of a prolonged phase. Marriage, divorce do not have the significance they had in the past, there are often many marriages and divor= ces so there are not so many big watersheds in life and for some the role chang= es in adolescence can all coincide.

Who are we? - The pregnant school girl is an example par excellence where all transitions coincide, adulthood, motherhood etc. Interfering with the establishment of identity.

Of course the physical and physiological transition is of very= great importance but I will mainly limit myself in this discussion to the emotion= al and physiological parts of the transition and change. I should not want to sound too depressing or have you going away with a negative image, but we have to loo= k at the problems in order to find solutions.&n= bsp; Denial is one of our biggest enemies, so is the very natural mutual = patting on the back which can happen at big congresses like this one, but we have to bite the bullet and look the problems full in the face and if we are being honest we will see that the main problems for youths is adults, we create society, we run it, we perpetuate problems because it suits us because we e= arn money from them and we turn away and don’t want to see them,

Resilience?

We talk in a blasé fashion that = the universal panacea the “resilience” of youths, but basically you develop resilience by being knocked, resilience is in relation to the assau= lts and problems in life.

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Roger Tonkin wri= tes on his email, “lets create opportunity out of challenge”, this is = good and I find it uplifting to see this on his messages - but perhaps we could = try to remove some of the challenges. Of course, just as our bodies develops somatic strength from physical challenge, training, weight lifting etc. so our psyche develops emotional strength from learning to survive hurt and pain.

What we need to ask is:- 1. Is it desirable to be “emoti= onally strong” implying a certain coldness, distancing, blocking perhaps . 2. Is the learning process maladaptive. Each conce= pt, the physical and emotional, can be taken to extremes.

Emotional development encompasses a basic necessity to learn tolerance of frustration, we can’t have everything we want. Mother can’t supply the milk= to her infant instantaneously and satisfy the baby’s every whim, thus ob= ject relations are born. The good breast, the good mother fulfils the child’s needs, thus the good object. The bad breast, the b= ad mother frustrates the child and does not supply immediately, hence the bad object, an essential part of emotional physiological development.

However, in order to develop emotionally one does not need to = take this to extremes, the child does not need to be abused, neglected or abandoned. It is when this ha= ppens that the response to abuse, the survival mechanism, coping strategy, the resilience if you like, can be maladapted - like Ellen speaking of her uncle’s abuse of her “I= can take it, he can punch me as hard as he likes, I don’t feel it”. On her sexual abuse “I didn’t think it hurt me until I stopped to think about it, I thought it was normal, she ca= lled it just a game, it didn’t hurt me because I blanked it off”.

So looking again at preserving this valuable resource for the future, perhaps we could break it down into looking at early patterns, prevention of abuse, the early chi= ldhood with the long term consequences that it carries through into the adolescent phase and then into adulthood. And then at the additi= onal assaults and stresses that we= place upon these young people as they go through their adolescence.

Abuse

Abuse of whatever type naturally produces harm in the present,= hinders the development and carries a maladaptive pattern = into adulthood. The ch= ild who grows up secure in the relationship with a parent is not so vulnerable = to subsequent abuse, the child learns how to deal with emotions by using this relationship with mother or a parent as a prototype for future relationship= s.

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More primitive feelings, profound love, deep hate can not be h= eld by the infant without the moderating effect of mothers reactions, the child projects his feelings onto the parent who mirrors them back in tolerable fo= rm. A child learns to love himself fro= m the way he is loved by others, however, the child will also learn to hate him or herself by the way he is hated / abused by others. The child will feel bad about hims= elf, will feel guilty that he cannot make mother happy and be ready to meet the = reinforcement of other abusing situations. = He may be unable to show his real feelings, may substitute one permitted feeling f= or another taboo feeling and will learn coping mechanisms and maladapted forms= of behaviour.

The main hurdles we need to confront in helping to heal these = wounds are the damaged self esteem, self concept,= value system of the young person entering the turmoil of adolescence. So here we do ha= ve some advantages in that albeit adolescence is a period of turmoil, and also= a period of vulnerability to further assaults with other harmful messages, it= is also a window of opportunity for the establishment of positive change. The young abused person enters this scenario of adolescence with a value system which is warped by his or her previous experiences affecting the way he or she feels about themselves, self worth, the way he or she judges others wh= o is safe who is good, the way the= young person judges the world around him, a code of behaviour and a code of relationships.

Such a young person is also a needy child, an empty vessel who= has never had enough of mother, who can be jealous of others, attention seeking, insensitive, develops shallow relationships and be unable to give - hence t= he difficulty of being seen as someone who is unable to place others needs abo= ve their own. This comes up freq= uently in the context of early parenting, a mother who can not put her child’= ;s needs above her own, certainly she can not until she is also re-parented and given love, affection and being able to fulfil some of her own needs in the safety and security of a therapeutic relationship or therapeutic environment. This young person will also be ent= ering adulthood with no concept of security or of knowing that someone cares about you enough to show you what’s right or wrong. If no one care’s about the consequences of your actions then your actions are worthless and perhaps you are worthless too, no one care’s about you. An experience of= misplaced trust, attempting to tru= st people who then abuse them, mean they enter the scenario of adolescence una= ble to trust. They are also unable to communicate and often do so in indirect and more harmful ways acting out self harming, delinquency, suicide attempts, always of attempting to break the silence. ..= ... Can we learn how to listen.

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Wasted Resources

The other side of the coin which unfortunately often goes hand in hand with the factors we have already described, is how are adolescents abused and exploited during their adolescence? We have seen how they can be damaged prior to adolescence and = as the young person enters the scene of adolescence. But this exploitation continues on= a grand scale throughout adolescence. Again wasted res= ources –

Her are some ‘wasted resources’ - Gary the son of a teenage mother who was brought up by his grandmother and when she died, became a street child and = then attempted to use his meagre personal resource to protect his sick mother and younger sisters from an abusive man. He lost his childhood. John who fled from an abusive mother in= to the hands of a needy damaged and abusive girlfriend and ended up in prison, tak= ing the blame when she abused their child. Lee who was beaten by his fa= ther, led into crime and drug abuse by his brothers and ended up a very angry you= ng man screaming out for someone to listen to him. We need to stop these kids f= rom being trapped in the perpetuating system of abuse

How else can we waste the resource? By professional abuse. By the care system - in the pregnant scho= olgirl survey (The child that rocks the cradle) girls in care had a worse history - higher incid= ence of abuse, crime, disruptive behaviour and in their pregnancies showed more harmful patterns of repeat pregnancy - their children fa= re worse at 5 yrs - 10 yrs - 15 yrs follow up. By not allowing adequate funding to break the cycle of waste we are perpetuati= ng the problem from one generation to the other.

Exploitation

Let us look again at exploitation - let me take you briefly th= rough a progression of exploitation. We had a very successful workshop on exploitation in Atlanta last year in which I concluded= that it is very important to regard youth as a resource rather than a commodity,= not a commodity we can use but a resource in we value and value together, in so doing we need to encourage youth and not exploit them. However exploite= d they are, on a number of different levels they exploited because of their attrib= utes which include youth, vitality, vibrance, sexual energy, a need to be independent, a need to get out there and work and earn a living and a need = to experiment and explore there surrounding.&= nbsp;

All these attributes are exploited in the work force by being = used as cheap labour or by unsafe situations, thy are exploited in the fashion market, whether it’s in advertising or in purchasing goods ranging fr= om CD’s, music, trainers and other more harmful substances such as drugs, alcohol,= alco pops, tobacco etc. and they are exploited sexually in pornography, paedophi= lia, they are exploited by their families, by friends, by other young people and= by society and by society at any level.

Action

So what can we do about this?= The first things is that we need to stand up and be counted, we need= to discuss these issues out in the open and we need to confront the denial surrounding some of these activities. Many of these activities are covert= and sometimes as professionals we can collude with the covert nature because we don’t want to face some of the wider issue’s, but the issue’s are wide and world-wide and we need to look at them together.= Many of the issue’s also inv= olve danger, because in speaking out against pornography and prostitution, we are not only exposing activities but we are challenging and taking away the sou= rce of livelihood of those involved in the sex industry, the drugs industry etc. The situation becomes and dangerous game of issues money, finance, power and politics are interwoven = in a dangerous web, so we need to stand up and be counted not only in order to expose perpetrators and to expose exploitation of youth but also to allow y= outh to understand and see that we have a value system, that certain activities = are acceptable, concern others and are not acceptable.

As we have seen many of our young people from deprived backgro= unds and from abusive backgrounds have grown up without a value system of their own. We do not wish to impose= ours, but we do need to show that we have one and they can sample our value system and then decide on their own set of values. Perhaps if you have a value system= they can respect themselves and value themselves enough not to allow others to exploit them. So we need to w= ork on two levels, we need to work on those who would harm and exploit youth, who would waste our resource for the future and we will also need to work on yo= uths themselves to make sure that they value themselves, as an important resource for the future.

Heal the Wounds

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And in order to value themselves for the future they need to h= ave a sense of future and a sense of future which is worthwhile, we need to give = them a future worth investing in. And perhaps we can do that - here is Beverley - 15 years = ago as a pregnant schoolgirl and now= a solicitor - We can be encoura= ged by this and buy the positive work done in Jamaica - self esteem boosted - peer counselling; And the It= alian earthquake - How many f= riends in London - and an apt catch phrase - ‘Rimarginiamo le ferite ‘= - ‘Lets heal the wounds’ &n= bsp; Our youth have many wounds - let us help them to heal and conserve t= heir strengths for all of our futures.

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= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp;

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Stevie= Miller, Child Health NurseTutor, Bournemouth University

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The pe= riod of adolescence is described as a time of transition from childhood to adulthoo= d. It is characterised by interrelated changes in the body and mind and in soc= ial relationships. In recent years, interest in the scientific study of adolesc= ence has increased considerably. Despite the accumulation of knowledge, however,= the effect of much research has possibly been obviated by persisting myths about adolescents, still held to be true by many healthcare professionals and oth= ers. According to some adolescents are ‘troubled’ subject to fluctua= ting emotions and incapable of rational thought.

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Little information is therefore available on the needs of adolescents, potentially hindering the delivery of appropriate healthcare services. But this informa= tion is becoming increasingly important. More children with chronic or life threatening conditions now survive into adolescence. At present, they are o= ften cared for in facilities designed either for children or for adults not gear= ed to acknowledging the unique characteristics of adolescents. Hospitals tend = to concentrate on addressing young peoples’ physical problems but may neglect their emotional needs.

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Curren= tly there appears to be no special training for healthcare staff in caring for adolescents. Consequently professionals tend to be less aware of the needs = and rights of this age group. Hospitalised adolescents are on a different plane= to children and adults in relation to such issues as independence, privacy and social needs and can feel ‘displaced’

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This s= ense of displacement may extend to the paediatric outpatient setting. For some time, the provision of services for adolescents attending the children’s outpatient department at our general hospital has been a matter of concern.= An inductive study of the views of adolescents attending the department was therefore initiated.

Background

Background The lit= erature suggests that there have been informal attempts to obtain the views of young people about the provision of care. The Court Report, however, points out t= hat their youth and relative lack of secondary disease or handicap may have led professionals to assume that adolescents had fewer definable needs than oth= er groups, such as children or elderly people. Historically, paediatric servic= es have tended to extend to providing care for adolescents and young adults; specific provision for their needs may therefore not be deemed necessary.

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An inn= ovatory programme or new service is usually set up because a perceived need is one being met by current provision. Such a discrepancy seemed to be existing in= the paediatric outpatients department of our regional general hospital. The department provides a service for children from infancy to 16 years, but yo= ung people beyond this age who have chronic problems such as cystic fibrosis or diabetes may continue to be seen, sometimes until they have reached their twenties.

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Methods = Consideration was given to both quantitative and qualitative methods and the latter was chosen. Qualitative research is based on the inference that knowledge is be= st gathered from people as they experience situations. These experiences are t= hen described and defined by the individuals themselves. Theory is subsequently based on the information generated by these perceptions. The method chosen = was unstructured interviews, which appeared to offer the best means of eliciting the views of adolescents.

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Long term experiences &= nbsp; The sample consisted of seven adolescents, four male, three female aged 12-19 y= ears who were not new attenders to the department. Impressions gained on a first= clinic visit may be valid in assessing the service but this study was concerned wi= th exploring long term experiences. All adolescents in the sample had a chronic medical condition which required regular attendance at the clinic. They were randomly selected from the regular attenders aged between 12 and 20 years a= nd were interviewed while at the hospital for a clinic visit, involving minimal disruption to those taking part. The interviews, which took place in a quiet room off the main department, were tape recorded and lasted approximately 40 minutes. All interviewees were given guarantees about confidentiality.

It was considered that for analysis purposes a great deal of relevant data could be obtained from a small sample.

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Findings &= nbsp; As the interviews progressed the theme of decision making emerged strongly in = the conversations with all seven adolescents. One l5 year old female talked abo= ut taking risks. It appeared important to her that she should learn from her o= wn experiences. This was echoed by a l7 year old female who also spoke about t= he learning that came from making a decision which involved some risk. All respondents said that they wanted to be active participants in decisions ab= out their care.

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Risk t= aking is inherent to change and may be regarded as a catalyst in the process of maturation but it is also likely to increase the incidence of disease or dysfunction. Several of the respondents recognised the need to practise the skills of decision making in preparation for adult life. This was also link= ed with the importance of feeling a sense of ownership of their condition and autonomy in its daily management.

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One l5= year old female with asthma indicated the need for information about her condition t= o be comprehensive so she could accurately assess her current ability to take pa= rt in sport. There was also discussion related to the way in which information could be presented to this age group with visual presentation highlighted by several of the young people.

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The im= portance of information giving as a contributory factor in the decision making proce= ss has been acknowledged. Information is deemed essential if informed choices about health care are to be made, and must be offered to young people undergoing treatment as well as to their carers. The Department of Health emphasises the right of children and adolescents to information appropriate= to their age, understanding and circumstances.

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The yo= ung people discussed how a process of transition from paediatric care might occur. Sev= eral indicated the need for the process of transition to be a gradual one and the importance of adequate preparation. The literature is not particularly help= ful in suggesting when and how a transfer from paediatric to adult care should = be effected. Many variables come into play; the medical condition, the availab= le facilities, the young person’s level of maturity, the wishes of the individual and the family. Even in a direct transfer of care, it is helpful= if there is a common approach shown by paediatricians and physicians featuring= good communication and sharing of information. The adolescents then gave their perceptions of the children’s outpatient department. They indicated t= heir views on how the department:

- &= nbsp; predominantly catered for younger children

- &= nbsp; lacked age appropriate recreational material

- &= nbsp; had somewhat rigid seating arrangements

- &= nbsp; could be noisy and had no separate quiet area they could use

Carlyle emphasises how design considerations are important to environments which support care and promote healing. In healthcare environments where needs are frequently changing there may be conflict between the physical confines of = the department and the activity going on inside it; the former is static, the latter fluid. The focus of design should therefore be on how people use the= facility rather than the appearance of the physical space. The arrangement of clinics was then explored revealing a belief that separate clinics for adolescents might be beneficial

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Missing school

Concer= n about missing school appeared to be the prime reason for dissatisfaction with the appointments system. Losing time at school can be a handicap for the adoles= cent faced with frequent clinic attendance but individual levels of concern are likely to be affected by age and how much school is valued by the individua= l. Flexible appointments and the possibility of late and weekend clinics would= be welcomed by those interviewed. The third component of clinic arrangements w= as the concept of being seen by a nurse rather than a doctor, and what function the nurse might fulfil. The young people indicated that they would be willi= ng to see a nurse for consultation under certain conditions but their understanding of what nurses were able to do was limited.

Discussion and implications Responses seemed to converge broadly on four themes:

- &= nbsp; decision making and participation in care

- &= nbsp; transition to adult care settings

- &= nbsp; the departmental environment

- &= nbsp; arrangement of clinics

Each is discussed in turn

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Decision making&= nbsp; Issues related to decision making were most common in the inte= rviews, and encompassed risk taking, autonomy, control and information giving. The importance of being invited to be active participants in the planing, implementation and evaluation of care evident. There are clear implications here for healthcare professional.

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A heal= thy environment in which adolescents feel comfortable in contributing to decisi= ons affecting their lives is facilitated by promotion of discussion and negotiation. If staff and adolescents co -operate in problem solving and discussion it can enhance the latter groups sense of control. A supportive environment which encourages a gradually increasing degree of independence = but sets appropriate parameters is likely to foster more positive approaches to self care.The demonstration of respect, which good communication provides, builds self esteem and is perhaps the single most important factor in contributing to healthy development during adolescence.

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Allied= to this are the needs to provide appropriate information. There are moves in the UK to set up family information centres with a number of children’s’ units actively exploring feasibility. In Nor= th America and Australia such centres are located in outpatients departments and provide a mechanism= by which trained nurses can offer health education, advice and support. Adolescents require information to make informed choices about their health care; such information may be provided through the creation of a family information centre.

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Transition of care= At so= me stage, adolescents must move on to adult services. How and when this is done varies from clinic to clinic. There are three possible models that may be adopted in this process of transition:

- &= nbsp; paediatric service - adult service direct. In this model the adolescent reaches an age determined by policy, paediatrician or family when it is felt to be no long= er appropriate to continue care in the children’s environment. A referral report with a summary of the medical history and the are to date is sent to= the adult service and the young person then makes an abrupt change over to the = new system of care, often without introduction or preparation. There were indications from the interviews that the change may be well accepted if the= re has been some preparation and the quality of the service matches the previo= us one.

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- &= nbsp; Paediatric service - transition clinic - adult service. This model acknowledges the differing needs of the child, the adolescent and the adult. In a transition clinic the emphasis changes to recognise the emerging needs of adolescents = for independence while acknowledging continuing parental responsibility. The clinic environm= ent is concerned primarily with providing the adolescent with respect, privacy = and confidentiality

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- &= nbsp; Paediatric service - adolescent clinic - young adult clinic - adult service.The third model extends the transition a further step. Young adult clinics extend the personal care t= hat the young person has come to expect and are usually characterised by informality in the waiting area with the opportunity to meet with other you= ng adults. To correspond with educational and vocational schedules these clini= cs are usually held in the late afternoon or early evening.

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Departmental environment Noise and facilities w= ere two aspects of the clinic environment commented on by the adolescents interviewed. With some expenditure and creativity it should be possible to create a quiet area within paediatric outpatient departments. Consideration should also be given to the type and arrangement of seating available to the differing age groups using the facility and to whether decor reflects the philosophy of family centred care

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Active participation

If cha= nges are made it is important to consult the users of the service; young people, car= ers and nurses should actively participate in any new or ongoing design process=

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Arrangement of clinics <= /span>

The re= spondents voiced concern about missing schooling to attend clinics. For this reason it would seem that later appointment times and Saturday morning clinics could = be well utilised by this age group. The practicality of such a change in clinic arrangements would need careful consideration but constraints might be over= come more easily if clinics were held for adolescents as a distinct group=

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Conclusion

The st= udy was on a small scale and therefore cannot be generalised. From the subjective perceptions of these seven individual young people, however, four themes wh= ich give insights into the concerns and needs of this client group emerged. Consideration of these themes and how practice must change to accommodate t= hem may help in the assessment of present services provided to adolescents and = give impetus to creative change

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&nbs= p;

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Daniel= Anderson

North = West London Mental Heal= th Trust

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Many y= oungsters will experiment with drugs as part of the developmental process towards individual identity. Many wil= l be unscathed by periodical usage and experimentation, however, a number of youngsters will become dependent upon drugs and develop addictive traits. In treating such, it is essential = for professionals to have a good knowledge of some of the primary aetiological factors that result in addiction, to develop appropriate responses based up= on individual need.

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The co= ncept of drug addiction is seen to have two elements. “An individual has to contin= ue usage to ward off withdrawal symptoms” (Plant, 1987) and the dependen= ce is on a substance that “alters the way the body functions”. From the introduction of opium to = the western world, to the modern epidemics of ecstasy, drug use has remained prevalent within society, whilst often being an integral part of many individuals lives, (Redhead, 1993). Two primary reasoning, based upon societal explanations, (Young, 197= 1, Kiev, 1975, Plant, 1981) and individual understanding the aetiological fact= ors associated with addictive behaviour, (Plant, 1981). These provide a foundation for whi= ch treatment initiatives can be modelled upon.

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The qu= est for spiritual meaning and solidarity have long been established within society, (Durkheim, 1912, Bottomore and Rubel, 1963, Robertson, 1970). Since the last century, religious grounding and importance has declined throughout the years, (Robertson, 197= 0). The need to re-establish some form= of spiritual sense in individuals and society, has been offered as a primary reason for the continued terms “religious as the opiate of the people”, (McLellan, 1977) referring to how religion seeks to numb the pain of poverty, is no longer a substantial part in many peoples lives, (Turner, 1983). This inevitab= ly turns people to look for other comforts and spiritual experiences, that can namely manifest in continued drug use, (Laurie, 1970). Leary, writing in 1964 about the e= ffects of hallucinogenics, places emphasis upon the spiritual and sensual properti= es of the drug, (Leary et al, 1964). This has further being supported by anthropological studies, where tribes will use hallucinogenic substances to talk to and see their Gods, (Newman, 1979). The spiritual= need of the individuals, need not necessarily reside with religion, but with oth= er aspects of self fulfilment, (Cohen, 1965).

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During= the 1960’s and onwards drug use had been predominant within British Socie= ty, (Edwards, 1981). The quest for spiritual meaning and social identity resulted in the formation of sub-cultures, who shared similar ideals, values and the meaning of life, (Cohen, 1955, Downes, 1966, Young 1971, Plant, 1987). Feeling oppresses by societal cons= traints, the subcultural groups reacted to the feelings of oppression by establishing their own norms and values as part of the contra culture ideals, (Downes, 1= 966, Plant 1975). Further to this,= there was a need to overcome individual problems, (Young, 1971) of which the substance use within the sub-culture catered for, (Goode, 1973). As Young emphasises, individuals c= hoose there drugs based on individualised need, (Young, 1971).

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Social= identity and sense of purpose is a fundamental pre-cursor to being part of an addict= ive culture, (Glass, 1991). Justi= fication of illegal substance use is identified as one accepted factor within the so= cial meaning of an individuals lifestyle, (Johnson, 1973, Redhead, 1993, Pearson, 1992), where deviance from the norm and reinforcement from peers provides a form of autonomy of identity, (Young, 1971, Plant and Reeves, 1973, Goode, 1973, Plant, 1975, Redhead, 1993).

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In the continuation of escapism from “oppressive controls” the sub-cultures were and continue to be reinforced by the world around them, (Robertson, 1987, Dickerson and Stimson, 1995). The “peaceful” perspec= tive of the “hippy” scene in <= span lang=3DEN-GB>USA, reinforced by the accompanying musical scene, culminated in a lifestyle whe= re cannabis use was part of a continuum of the culture, (Young, 1971, Wyatt, 1973). The use of the substan= ce reinforced the protest elements that the scene was central to (Glatt et al, 1967, Jones, 1967, Boyd, 1970). Other researchers have concentrated on musical eras, values, (Plant, 1975, Redhead, 1993, Henderson, 1996).&nbs= p; The musical drug culture circle is reinforced by drug experienced/induced composers, creating music that requires drug induced listeners, to heighten sensation, analysis and subliminal thought, (Plant, 1975, Redhead, 1993, Henderson, 1996).&nbs= p; The recent epidemic of the use of ecstasy within the rave scene, provides further argumentation for these theories around sub-cultural ident= ity and a need to belong, (Redhead, 1993).&nbs= p; Anti-rave campaigners, placed full emphasis upon the use of ecstasy, which initially was peripheral to the cultural scene, (Nasmyth, 1985). Consistent media focus then transf= ormed the substance to being central to the ideology of rave culture (Henderson, 1996). Sociological research = has argued that the peripheral use not only becomes central due to media amplif= ication (Young, 1971a), however escapes from the boundaries of that particular scene and into mainstream society, (Ford, 1990, Measham et al, 1993, Parker et al, 1995).

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The so= ciological concentration on the aetiology and continuation of drug cultures, rests hea= vily on the notion that certain drugs within certain situations have sub-cultural acceptability, (Young, 1971, Plant, 1975, 1981, Redhead, 1993, Balding, 1994). Dependency has been ar= gued as a result of when the use of the substance becomes predominate over the cultural context that it was once placed within, (Plant, 1981). Drift theory, (Matza, 1964) provid= es an explanation for why many individuals may use substances within the contextu= al aspect of acceptance and therefore do not become dependent, (Goffman, 1968), for example, only at a party. Drifting into and out of “scenes” at periodical times throughout life, may well include a drug scene. The “episodic release from m= oral restraints”, (Matza, 1964, Goffman, 1968). However, sociology has attempted to understand why some individuals become addicted and others are periodical users, (Goode, 1970, Reeves, 1973), often using the distinction between “hard” and “soft” drugs as a basis for the determin= ant towards addiction or non-addiction (Hindmarch, 1970). However, the main focus on addicti= on versus periodical use comes from the social situation of the individual, (Cohen, 1955, Goode, 1970, Young, 1971, Plant, 1975, 1981, Redhead, 1993).<= span style=3D'mso-spacerun:yes'> Strong social standing and foundat= ions outside of the sub-culture is one explanation, (Goode, 1970, Cockett, 1971, Plat, 1975, 1981). For = those whose lives are completely dependent on the value consensus of the drug sub-culture, addiction/dependence may be inevitable, (Edwards and Busch, 19= 81).

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Povert= y and oppression within society creates a need for escapism from reality and feel= ings of hopelessness, (Robertson, 1987, Dickerson and Stimson, 1995). Studies on heroin addicts have sho= wn that the bleakness of existence is the major factor resulting in addictive behaviour and dependency on a substance that offers some feelings of euphor= ia, however short-lived, (Robertson, 1987, Donoghoe et al, 1992, Pearson, 1995). Khat use amongst Somal= ian refugees has resulted in an increase in mental health admissions, due to th= e psychosis of over use, (NWLMHT, 1997). = Again, the feelings of failure and oppression are given as direct contributory fac= tors to the over use, (NWLMHT, 1997).

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It has= been argued that Capitalist society results in a rich/poor divide, (Miliband, 19= 74), whereby those in poverty need some form of de-realisation from their deprav= ity (Mack and Lansley, 1985). Stu= dies on the crack mothers in the USA, (see Allen and Jekel, 1991) and street heroin users in the UK, (Donoghoe et al, 1992) offers some clarification as to why addictive behavi= our prevails in today’s society. There is an underlying notion that society needs to change in order = to deal with the drug epidemic, (SMC, 1975).&= nbsp; A more liberal and “drug friendly” system of prevention needs to be initiated, (Friedman et al) and wider issues around poverty and stratification must be addressed, (Rogers, 198= 2). To understand the psychological perspectives, which concentrate more on internal theories to societal const= ruct and functioning.

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Psycho= logical explanations for addiction centre around the dependence prone personality, (Laurie, 1970), psychodynamics’’’, (McMurran, 1994) and social learning, (Bandura and Walters, 1968). = The primary emphasis is placed on the behaviour of the dependent and not the substance itself, (McMurren, 1994). It has been argued that many individuals seem to need a drugs influe= nce to gain respite from their troubles or surcease from pain, (Bakalar and Grinspoon, 1984). Whilst at t= he same time drugs provide an esoteric mystique that can repress negative experiences and mask pain, (SMC, 1975) in the same vain as perhaps religion once played.

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The ne= ed for immediate gratification is of the essence within the addictive personality, (Laurie, 1970) where deferment is difficult to contemplate, (Blumberg, 1981). Freud argues that such behaviour in the immediate sense derives from the concept of Eros and the pleasure progresses, deferred gratification from immediate gratification becomes apparent, (urinating and defecating, for example), (see Bee, 1992). Unresolved psychosexual conflicts can manifest in regression, of which within the addictive persona= lity can be in a state of constancy, (Chapman, 1996). The use of drugs in later life pro= vides immediate gratification that cannot be achieved without the use of the substance, (Rhodes and Hartnoll, 1996).&nb= sp; This has been supported by the notion of transference of mood states, especially in relation to feelings of anxiety and depression, (Laurie, 1970= ). The need to transfer to states of pleasure and euphoria are paramount to such an extent, that the addict cann= ot face the bleak reality of their existence, (Robertson, 1987). Therefore, the addict became depen= dent on a substance to maintain the state of “high”, (Haw, 1985).

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Psycho= logical explanations conclude that the constant state of “high” results= in the addict not being able to deal with living in reality, where such becomes unbearable, (Dickerson and Stimson, 1995).= This has implications of withdrawal and treatment, where the pain of abstinence and reduction is so unbearable, that the need for immediate gratification, (more drug use), will prevail over the deferred gratificatio= n of being drug free, (Pearson, 1995). The immediate sense is of paramount importance within the context of= the addictive personality, (Chein, 1964, Laurie, 1970). The 1969 WHO definition of addicti= on provides a useful synopsis of addiction based around psychological understanding. It states that= :

“= ;addiction is characterised by behavioural and other responses that always include a compulsion to take the drug on a continuos or periodic basis to experience it’s psychic effects and sometimes avoid the discomfort of it’s absence”. (WHO, 1977). Although the definition rests heavily on psychological presumption, sociolo= gical and psychological disciplines do find some common ground within the theoret= ical framework of social learning and drug addiction.

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Influe= nced by the world around us, media projections, peers, family and agents of control, there is a body of research that concentrates on how these factors influence our lifestyles, behaviour and thought, (see Bandura, 1968). Being brought up in a culture wher= e drug use is accepted and seen, may well result in the continuation throughout generations, (cigarettes, alcohol, cannabis) (<= span lang=3DEN-GB>Kiev, 1975)= . The need for social identity and p= urpose requires individuals to be modelled by peers, current trends and fashions, (Plant, 1975, Power, 1995). S= uch theoretical underpinning has been readily identified in the rave scene, (Redhead, 1993). The continua= tion of behaviour can be argued from labelling theory, (Becker, 1963) where the words deviant and delinquent are strongly associated with drug cultures, (Becker, 1963). Conforming to the self fulfilling prophecy is= a social learning aspect. The psychological process of need for autonomy, social identity and negative labelling will maintain and sustain such behaviour, (Young, 1971a).<= /p>

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Using = the outlined theories around causation and continuation, there are a number of factors that need to be taken into consideration when planning treatment.

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Social= networks, including the prominence and current involvement with peers, (Robertson, 19= 87) in balance to supportive networks assisting with risk minimisation or abstinence is an important consideration when planning treatment, (see Jarv= is et al 1995). It has been evid= enced that it is perhaps the biggest factor of relapse, when a client returns to their previous network of peers and other drug users, (Robertson, 1987). They then subsequently fall into t= he subcultural world that they were trying to avoid, (Plant, 1981).

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Addres= sing the need for change, be it against the backdrop of societal determinants or internal behaviours should be discussed, (Robertson, 1987). However, one had to be aware of not implementing discriminatory models in relation to cultural norms, for examp= le, khat chewing within Somalian culture is an accepted behaviour, (NWLMHT/Junction, 1997). Risk results from constant over use of substance, (NWLMHT/Junction, 1997). The wider picture should address poverty, social despair and oppression that individuals face, which result = in restoration to substance use, (Dickerson and Stimson, 1995). Sociological theory has attempted = to address societal oppression as a major cause of drug addiction, (see Young, 1971a, Laurie, 1970, Plant, 1975,1981).&nb= sp; With emphasis upon societal change, it becomes apparent that there n= eeds to be some form of acceptance of the addict as a product of deterministic societal constraints, (Farrell and O’Brien, 1995). Such factors should be addressed w= ithin the planning stage in conjunction with more individualised emphasis that psychological theory concentrates upon.

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Psycho= logy, through its interpretation of addictive causation, requires that factors to= be taken into consideration will be far more individualised in planning treatm= ent, (see Prochaska and DiClemente, 1986). Motivation from the individual to want to change is perhaps the larg= est factor to take into consideration, (Rollnick et al, 1992). An ability to change within, e.g. = belief system and patterns of behaviour are essential to the psychological concern= of planning treatment, (Rollnick et al, 1992). On the presumption of addictive personalities, issues around abstinence or risk minimisation will need to be identified as a pre-cursor to treatment, (see Jarvis et al, 1995). In dealing with drug addiction on a individual level, assessment of patterns of behaviour and addiction levels = is an important feature, (see Jarvis et al, 1995). Such things as frequency of depend= ency, the amount of substance taken and risk taking behaviour, (see Jarvis et al, 1995) assist in the initial assessment of level of intervention and to whet= her abstinence or control is appropriate, (Jarvis et al, 1995). It may be detrimental to a clients physical health to completely abstain from certain addictions, (Heston, 198= 6).

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In rel= ation to treatment plans in parallel to the separate theoretical explanations, there needs to be a distinction drawn in terms of differentiation of approach. Sociological models appear to look= at acceptability of drug use within each subculture, (Young, 1971, Plant 1975, 1981, Bakalar and Grinspoon, 1984, Redhead, 1993). Societal constraints, oppression a= nd sub-cultural theories seek to explain the prevalence of drug addiction as b= eing partly caused by external societal forces, (see Dickerson and Stimson, 1995). It is clear that resea= rch has influenced treatment in respect of social education, based around harm minimisation on a macro level, (see SMC, 1975, Robertson, 1987, Rhodes and Hartnoll, 19= 96).

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The psychological models place a greater emphasis upon the individual being the focal point for change, (McMurren, 1994), where addiction is the causation = of individual abnormality, internalised repression and addictive personality, (Orford, 1992). For these rea= sons, psychological theory will concentrate upon a cognitive behavioural approach= , to treatment, which is individualised and is an attempt to modify the addictive personality, (Goldfried and Golfried, 1975).

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Sociol= ogical theories of drug use rest predominantly with society, its construct, change, values, norms and ideals, (see Young , 1971, Plant, 1975, Bakalar and Grinspoon, 1984, redhead, 1993). There is a presumption that society needs to change in order to prev= ent or minimise drug use, (Rhodes and Hartnoll, 1996).

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Pro-ac= tive approaches in the battle against drug addiction is paramount in minimising = risk and providing social education, (SMC, 1975, Rhodes and Hartnoll, 1996). The move from hard line reactive measures, (see Epstein, 1977) aims to provide an acceptance that drug use w= ill continue, whatever societal constraints are developed, (Musto, 1973).

Outreach

The us= e of outreach workers, ex-addicts, street contacts and media information have st= arted to have an effect on issues relating to risk minimisation, (see Rollnick and Hartnoll, 1996, Keene, 1997). Needle exchanges and drug counsellors within nightclubs are providing education and services to persistent drug users in an attempt to minimise r= isk, (Rollnick and Hartnoll, 1996). Pro-active measures are becoming more of a reality and being initiat= ed and requested by nightclubs, police and politicians alike, (News Broadcasts, 1997). Literature, written in street language, such as Smack In The Eye and Peanut Pete are also being us= ed to provide information that is user-friendly and non authoritarian, (Linnel= l, 1993). However such methods d= o have their critics, who argue that providing services as described above, there = is not only an acceptance of illegal drug use, there is actual promotion for continuation, (see Bakalar and Grinspoon, 1984).

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Howeve= r, in response to secondary prevention, primary prevention is targeting young children in an attempt to dissuade usage and how to handle vulnerable situa= tions, (e.g. the playground), (Implemented within school curriculum’s) (News Broadcasts, 1997). It will ta= ke longitudinal research to conclude whether this is effective, however transcultural research had evidenced promising success rates, (the Dutch model), (DeZart et al, 1994).

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It is = clear that the pioneering work within the UK, is still not being as effective as some other European countries, (Leuw, 1995). There is still a predo= minant anti-drug consensus, where addicts and users are classified as deviants, (s= ee Bakalar and Grinspoon, 1984). It had been argued that only when a more generalised liberal approach to the i= ssue of drugs, (Netherlands), which de-values the illegality buzz, then progress will remain slow, (Leuw, 1995). However, it mush be noted that the objectives of social education are directly comparable to individualised treatment programmes, where the overa= ll goal is either a drug safe/drug free society, (Robertson, 1987). For this reason, there is a defini= te need to continue with the treatment of the individual, which is usually encompassed within cognitive behavioural programmes.

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For individualised treatment encompassed around cognitive behavioural therapy to commence, there primarily, has to be, firstly, an acceptance of the depende= nce as a problem, (Rollnick et al, 1992), secondly the motivation to change, (Saunders and Wilkinson, 1990) and thirdly the scope and support to maintain change, (Martlett and Gordon, 1985).

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Motiva= tion for change must not be confused with motivation in general, as many persistent = drug users already have large amounts of motivation, the motivation to continue = to take drugs, (see Saunders and Wilkinson, 1990). The use of the ABC model is paramo= unt in tackling these issues, (see Jarvis et al, 1995), where cognitive restructur= ing, (see Jarvis et al, 1995), works to a prefix of bypassing negative behaviour, (Jarvis et al, 1995). The sys= tems attempts to relate antecedents, such as vulnerable situations and temptatio= ns, to thoughts of the consequence of action, i.e. dependence, risk, overdose, crime, (see Goldfried and Goldfried, 1975). This should then help the addict in recovery to bypass the behaviour of taking the drug. Differences in approach of cogniti= ve therapy will be dependent upon the characterisation of the individual clien= t, defined through assessment, (see Jarvis et al, 1995). Rational Emotive Therapy, (Ellis, = 1975) where irrational beliefs are modified, to Problem Solving Therapy, (Goldfri= ed and Goldfried, 1975), which identifies one specific problem area can be use= d to effect. Personal Construct Th= eory could be another treatment model concentrating on how people view their own world, (Goldfried and Goldfried, 1975).&nb= sp; Individual behavioural blindspots and reactions have been successful= ly modified to help overcome substance abuse, (Scott, 1989). Such models address individuals perception, behavioural traits and embedded belief systems. In modifying the addictive persona= lity, it is essential that these areas are addressed, (McMurran, 1994). The impulsiveness of immediate gratification is addressed and m modified through a process of change that = the addict in treatment goes through. Prochaske and DiClemente’s model is fundamental as a foundation for successful cognitive restructuring.&nb= sp; Pre-contemplation, contemplation, determination to stop, action and maintenance are the transitions that the addict needs to go through during = the treatment process, (Prochaske and DiClemente, 1986). Relapse is the reversion stage bac= k to pre-contemplation. Cognitive behavioural models are important to achieve individualised change, however,= to tackle the societal effects of drugs there needs to be a combination of approaches, including social education, (Keene, 1997= ).

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In con= clusion, the sociological and psychological explanatory theories offer two distinct = and contrasting opinions as to the prevalence of drug use and addictive behaviour. Each theoretical standpoint has influence for factors planning treatment and treatment models based around theoretical explanations.&nbs= p; In current thinking, there is a need to draw upon a number of theoretical explanations to get a fuller understanding of drug dependence within society and reactive measures to respond to these. The macro (sociological) and micro (psychological) aetiology have given distinct contributions on two very different levels in explaining and treating drug use. No one approach has precedence ove= r the other and it is commonsensical to amalgamate a multi theoretical stance in dealing with the individualistic and societal rehabilitation. And who knows what the genetic lin= k on addiction will bring to the debate?

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(Full = References excluded due to lack of space but will be provided on request – conta= ct editor)

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&nbs= p;

The Journal of Adolesc= ent Health and Welfare

is publis= hed by:- Youth Support,

Tel No 01= 81 325 8162 = Charity No 296080 = Fax No 0181 325 8647

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The Journal of the Youth Support

British Society for Ado= lescent

Health and Welfare

The British Society for Adolescent Health and Welfare

European Meeting / IAAH European Chapter / Youth Support

Adolescents’ view= s of outpatient services

Aetiological Factors of= Drug Addiction