Narrative Practices and Adolescents: A Strategy for Substance Abuse Prevention

From the 2015 issue of the Advocates' Forum

Narrative Practices and Adolescents: A Strategy for Substance Abuse Prevention
Grant Buhr

Abstract
This paper presents Story Squad: Stories of Substance, a community-based intervention for adolescent substance use prevention. This narrative-based design takes a person-centered approach to prevention and prioritizes the lived experiences and active involvement of young people in developing prevention messages. The article discusses concepts central to contemporary adolescent prevention initiatives, and describes their integration with elements of narrative therapy (NT) and digital storytelling (DST) as a means to engage typically hard to reach adolescents. As illustration, the author describes how Stories of Substance could be implemented within the context of a violence prevention agency.

When developing interventions for adolescents and substance use, one variable worthy of consideration is the stories that they tell about drugs and alcohol. The stories youth tell about drugs and alcohol can exhibit how they perceive substance use, reflect and influence the choices they might make in regards to use, and provide insights into how those working in substance-use prevention can best influence them to make healthier decisions (Miller-Day and Hecht 2013). For these reasons, narrative-based youth media projects have grown in popularity in substance use prevention programs (Gant et al. 2009; Hartley 2007; Podkalicka and Campbell 2010). Proponents of these projects claim that narrative practices hold unique potential for substance use prevention by engaging even hard-to-reach youth (Miller-Day and Hecht 2013; Nilsson 2010; Chan, Ngai, and Wong 2012).

The purpose of this paper is to present Story Squad: Stories of Substance, a community-based substance use prevention program based in narrative practice. To accomplish this, the paper first outlines substance use interventions for adolescents. It then describes how the use of Narrative Therapy (NT) assists individuals in understanding how they make sense of their lives and create alternatives to that understanding (White 2007). It considers how Digital Storytelling uses media production to further the goals of NT (Polk 2010) before presenting Story Squad: Stories of Substance.

SUBSTANCE USE INTERVENTIONS FOR ADOLESCENTS

Two psychosocial models underpin the majority of contemporary prevention programs: competence enhancement and social influence (Hill 2008). Both models account for how individual risk factors interact with social influences.

The competence enhancement model postulates that individuals engage in harmful behaviors to achieve acceptance among peers and to deal with negative emotions (Hill 2008). It shows the influence problem behavior theory, which views an adolescent act like substance use as both learned and functional; the result of adolescents lacking adequate personal, social, and coping skills (Hill 2008; Skiba et al. 2004).

The social influence model posits that behavior is shaped by psychological factors, such as perceived norms, expected consequences, values, and intentions. These factors interact with self-efficacy and social modeling to increase or decrease the likelihood of something like substance use (Hill 2008; Skiba et al. 2004). It draws from Bandura’s social learning theory, which proposes that individuals both shape—and are shaped by—their surroundings; behavior is shaped through an interactive process involving cognitive, behavioral, and environmental influences (Bandura 1977). Substance use prevention programs for adolescents, with origins in social learning theory, attempt to strengthen anti-substance norms and instruct youth in how to identify and resist social pressure by building skills to plan for high-risk scenarios (Hill 2008).

When it comes to adolescent substance use prevention, both the competence enhancement and social influence models are built on the experiential knowledge of young people (Skiba et al. 2004). While older didactic approaches tended to emphasize the passing on of preferred behaviors, these models use a narrative-base. This approach works from and with the complex personal experience and behavior patterns of individuals (Miller-Day and Hecht 2013).

A recent review of community-based substance-use prevention programs for adolescents found that effective prevention interventions target risk and protective factors (Hill 2008). Risk factors include perceived norms regarding substance use, peer pressure, beliefs about consequences of use, and family and peer use (Cleveland et al. 2008). Protective factors include bonding with family, positive adult relationships, decision-making and other life skills, and substance refusal skills (Hill 2008). Furthermore, because substance use is found to begin typically early in adolescence, and the age of early onset of substance use has progressively declined, early intervention is of great importance (White et al. 2003; Hill 2008; Cleveland et al. 2008). Early onset is associated with a higher severity of problems related to use (e.g., more regular use, use of more harmful substances, higher risk of dependence) and preventing or delaying the initial onset can reduce problem severity (White et al. 2003; Hill 2008).

Adolescent substance use has been linked with unsupervised out-of-school time, in particular among youth with low levels of parental supervision (Tebes et al. 2007). A study by the National Institute of Health suggests that after-school, community-based programs are well positioned to prevent substance use among youth. These programs can not only occupy typically unsupervised time, but also organize collaborations with community partners and thereby expose youth to additional positive relationships with adults and expanded opportunities to establish meaningful community roles (Tebes et al. 2007). Other key components associated with effective prevention interventions include appropriate cultural tailoring, combined implementation with other prevention strategies, the use of media to raise public awareness, the provision of mechanisms for community feedback, and the targeting of self efficacy, refusal skills, and drug expectancies (Tebes et al. 2007; Hill 2008; Cleveland et al. 2008; Skiba et al. 2004).

THE ROLE OF NARRATIVE THERAPY AND DIGITAL STORYTELLING

Narrative Therapy (NT) gives prominence to the client’s understanding of the problem, and presents an opportunity to contextualize and collaboratively explore problems with clients (Madigan 2011). It helps people to develop alternative storylines about their lives, and to subvert the dominant, problem-ridden self-stories that trouble them. Narrative Therapy draws influence from the ideas of social work, feminism, queer theory, anthropology, and literary criticism (Williams and Baumgartner 2014; Chan et al. 2012). Taken together, these theoretical influences encourage clinicians or project facilitators to view individuals not as flawed or problematic people, but rather as people facing and responding to complex challenges.

Rooted in anti-oppressive and systems-level thinking, NT gives prominence to the client’s understanding of the problem. It can be seen as part of the legacy left by the critical pedagogy scholar Paulo Freire (1970), who argued that action is brought about by way of reflection and understanding developed through a combination of self-awareness, the awareness of others, and the perspective taking aspect of empathy. Mobilizing adolescents to engage with others through collecting, producing, and disseminating narrative-based substance abuse prevention messages offers the opportunity for self-reflection, connection with others, and seeing the world from others’ perspective. An important element of NT is its insistence on context and collaboration in exploring problems (Madigan 2011). This process is relevant to adolescents most at risk for substance abuse because the problems they may be experiencing within the context of their lives (addiction, poverty, mental illness, trauma, low school achievement, etc.) are typically mapped onto their individual person (Williams and Baumgartner 2014).

Miller-Day and Hecht (2013) provide an example of narrative practices in adolescent substance use prevention interventions. The authors utilize an adolescent drug prevention curriculum called keepin’ it REAL (kiR) to demonstrate the link between narrative and prevention. The program—implemented in seventh grade classrooms in forty-five countries, reaching more than two million youth annually (Miller-Day and Hecht 2013)—operates on the assumption that youth base their substance using choices on the narrative storylines available to them. It uses actual stories of young people and their drug-related experiences (Miller-Day and Hecht 2013).

Miller-Day and Hecht (2013) argue that while dispensing health information in areas such as adolescent drug use have been proven ineffective—especially for typically “hard to reach” populations (Nilsson 2010)—narratives of youth experience engage existing psychosocial risk factors (Miller-Day and Hecht 2013). The program was found to create significant reductions in substance use when participants viewed the program videos that covered refusal skills, norms, and socio-emotional competencies (Miller-Day and Hecht 2013).

Similarly, Chan et al.’s (2012) work with NT and substance abuse also demonstrated promise as an effective prevention program. Their program has participants use photography to create, with the help of a therapist, stories that could “externalize” substance-related problems and thus lead to the composing of alternative, non-oppressive discourses about their social reality. The authors state that the use of storytelling provided the client with both an opportunity to externalize problems and recall and record positive past achievements. The positive elements were then revisited for insight towards present actions, and helped to mitigate discouragement experienced during substance relapse (Chan et al. 2012).

The Digital Storytelling (DST) approach overlaps with NT within substance use prevention programs. Digital Storytelling aims to give voice to marginalized communities through multimodal mediums, including script, sound, music, photography, and video (Nilsson 2010). It strives for the empowerment of community members to effect change through increased self-awareness and efficacy, relationship building, and validation, and provides tools for education and the cultivation of social empathy among those who listen to/view the stories (Polk 2010; Nilsson 2010). Both DST and NT can be seen as novel tools for educational and therapeutic aspects of the work related to adolescent substance abuse, and although it is beyond the scope of this paper, evidence supports that DST holds unique potential for participatory research as well (Polk 2010).

THE CASE OF STORY SQUAD: STORIES OF SUBSTANCE

The Story Squad initiative is an audio and music production program (created and facilitated by this author) that engages youth in media production and critical thinking skills with process-oriented goals of increasing self-awareness, self-efficacy, trauma processing, and community engagement. It is a component of a violence prevention agency that serves six communities on the west and south sides of Chicago. Enrolled youth have been exposed to direct or indirect violence. Agency programming is rooted in restorative justice practices; aiming to reduce violence by engaging young people in creative and cathartic expression, athletic development, and concrete life skills such as stress management and peaceful conflict resolution.

Following the public health model of violence prevention, youth enrolled in the program generally fall into one of three levels: primary preventions are meant to stop problems from emerging; secondary preventions attempt to reverse harm “in the moment;” and tertiary preventions hope to reduce harm among the most severely involved adolescents (YMCA 2013). The level of prevention appropriate for each participant is determined through an amalgam of data that includes: reason for initial referral, intake assessment, criminal record, academic record, and other information obtained through collateral contacts from various domains of the young person’s life. Stories of Substance is a pilot intervention designed to fit within the Story Squad initiative.

Stories of Substance would be an eight-week program that meets once a week for two-hour sessions. It will integrate key components of effective adolescent substance abuse prevention programs with elements of DST and NT. It is designed to account for relevant risk factors for the participants: peer pressure, childhood abuse and other traumatic events, lack of coping skills, poor adult relationships, and low socioeconomic status. It also seeks to account for relevant protective factors for the participants—positive adult relationships, decision making and other life skills, positive neighborhood attachment, and academic or employment competence—and enhance those protective factors.

Those enrolled in this intervention would collect, engage with, and disseminate narrative-based substance abuse prevention messages that are culturally grounded (i.e., messages by and for a particular cultural group). Early sessions are designed to consist of listening to, and discussing, youth-produced audio stories about substance use. Participants would also practice recording and production skills and engage in creative writing activities. Approximately twenty minutes of out-of-session journaling time is structured for participants each week, since journaling encourages reflection and helps maintain continuity between weekly topics and activities.

Consistent with DST and NT linked to substance use prevention, a key component of the program is engaging participants who, in other institutional settings, have likely had their experiences devalued or dismissed. On one hand, the facilitator is tasked with providing vulnerable young people with parameters to create a story that contains cohesive narratives (i.e., narratives entailing chronology, causal sequences, and identified consequences), and can assist them with attributing connections and significance to a series of life moments that may otherwise feel chaotic and fragmented. On the other hand, the program must be adaptable and encourage participants’ voice and identity formation. As a result, this proposed program offers a series of flexible story prompts to stimulate exploration. These prompts will, ideally, shift the adolescent’s focus from strictly inner reflection to situating oneself in a larger social context.

One exercise asks participants to choose a substance and give it a detailed personality—including histories, friends and relatives (other substances), hobbies, styles of dress, and stories to tell. This exercise will provide, it is hoped, youth, their peers, and agency staff with nuanced portrayals of how youth perceive various substances. (In the context of violence prevention, perception of substances will likely be connected to their functions in relation to soothing past/current trauma.) Participants will be encouraged to include multiple voices within these recordings, giving them the opportunity to engage in more sophisticated audio production techniques. This exercise is consistent with NT’s emphasis on externalizing problems, an act which separates the problematic substance from the essence of the young person’s being (White 2007). Upon completion of their productions, participants will act as a “panel of experts,” presenting their works and participating in a dialogue with an audience consisting of peers, agency staff, and family and community members. With proper consent, the participants’ stories will be posted and shared online as a means to disseminate the knowledge and behavioral models.

In order to gauge the effectiveness of the intervention, youth are asked to participate in a pre- and post-program data collection survey comprised of questions focusing on self-efficacy (e.g., refusal skills), critical thinking, consequences of use, and perception of various substances.

Although it is harder to measure in this pilot program, the hoped-for effects include: improved multi-textual literacy (script, sound, music), increased marketable media skills, and increased civic engagement and positive relationships by positioning participating youth as community educators. If successful in achieving the desirable outcomes, selected youth participants can be utilized as peer leaders/assistant instructors as the agency expands the program. Consistent with the agency’s mantra of “healing is prevention,” this program aims to provide a supportive space for young people that typically do not seek mental health services for fear for being perceived as weak or flawed, to deepen relationships, and process experiences in a way that can improve an individual’s capacity for positive change.

The use of NT in substance abuse prevention with adolescents is, at present, under-researched, thus, a substantial gap exists in regards to large-scale meta-analysis and systematic reviews of the process (Chan et al. 2012). Additionally, existing research studies concerning the therapeutic use of DST are not tightly connected with the concepts of NT. It is this author’s hope that this review, and the subsequent intervention plan, may contribute to the discussion of the potential intersection of NT and DST in the realm of adolescent substance abuse prevention.

References

Bandura, Albert. 1977. Social Learning Theory. New York: General Learning Press.

Chan, Chitat, Kee-Hung Ngai, and Chi-Keung Wong. 2012. “Using Photography in Narrative Therapy to Externalize the Problem: A Substance Abuse Case.” Journal of Systemic Therapies 31, no. 2: 1–20.

Cleveland, Michael J., Mark E. Feinberg, Daniel E. Bontempo, and Mark T. Greenberg. 2008. “The Role of Risk and Protective Factors in Substance Use Across Adolescence.” Journal of Adolescent Health 43, no. 2: 157–164.

Hill, Natalie, L. 2008. “Adolescent Substance Use Prevention Interventions Outside of Classroom Settings.” Child and Adolescent Social Work Journal 25, no. 6: 451-467.

Madigan, Stephen. 2012. Narrative therapy. Washington D.C.: American Psychological Association.

Miller-Day, Michelle and Michael L. Hecht. 2013. “Narrative Means to Preventative Ends: A Narrative Engagement Framework for Designing Prevention Interventions.” Health Communication 28, no. 7: 657–670.

Nilsson, Monica. 2010. Developing Voice in Digital Storytelling Through Creativity, Narrative and Multimodality. International Journal of Media, Technology, and Lifelong Learning 6, no. 2: 148–160.

Polk, Emily. 2010. “Folk Media Meets Digital Technology for Sustainable Change: A Case Study of the Center for Digital Storytelling.” Global Media Journal 10, no. 17: 1–30.

Skiba, David, Jacquelyn Monroe, and John S. Wodarski. 2004. “Adolescent Substance Use: Reviewing the Effectiveness of Prevention Strategies.” Journal of Social Work 49, no. 3: 343–53.

Tebes Jacob K., Richard Feinn, Jeffery J Vanderploeg, Matthew J. Chinman, Jane Shepard, Tamika Brabham, Maegan Genovese, and Christian Connell. 2007. “Impact of a Positive Youth Development Program in Urban After-school Settings on the Prevention of Adolescent Substance Use.” Journal of Adolescent Health 4: 239–247.

White, William, L., Mark D. Godley, and Michael L. Dennis. 2003. “Early Onset of Substance Abuse: Implications for Student Assistance Programs.” Student Assistance Journal 16, no.1: 22–25.

White, Michael. 2007. Maps of Narrative Practice. New York: Norton.

Williams, Brian D., and Barbara Baumgartner. 2014. “Standing on the Shoulders of Giants: Narrative Practices in Support of Frontline Community Work with Homelessness, Mental Health, and Substance Use.” International Journal of Child, Youth and Family Studies 5, no. 2: 240–257.