Waking from a schizophrenic's nightmare

By Lori Schiller

I remember little of what happened in my life in the past eight years -- probably
because of 21 shock treatments. I suppose it's a lot like an alcoholic's blackout.
Life seems dark, scary and fragmented. I battled strange, ominous Voices and
Sights in a forever tormented day-to-day nightmare. I couldn't get relief from
my psychotic world. I wanted to die desperately in an effort to free myself from
this world. The first time I heard those derogatory Voices was as a teenager. I
didn't know what was happening to me. I felt like I was possessed, and my
mind was infected by demonic spirits.

I was afraid to tell anyone about the Voices for fear of being carried off by the
"white coats." Imagine being a 15 year-old kid hearing the words over and over
again: "You must die. You will die." And, imagine a naive little squirt keeping
the echoing vicious Voices inside of herself for many, many years without
sharing the pain and fright with anyone. Eventually, I entered the "revolving
door" into the so-called mental health system. The doctors, so dapper and
professional in their psychiatric style and attire, told my parents that I was a
paranoid schizophrenic who had little chances of getting better. My diagnosis
was just another "sick chronic psychiatric patient" to be shoved away forever in
some hospital. I can imagine how crushed my parents were, with their
ignorance about mental illness and suffering along with me. But they didn't give
up hope. Never.

I have always wanted to be someone special. If I lived a regular, ordinary life to

age 85, it would be like living under cobwebs in an old attic. I'd be a nobody.
Dead by my own hand (a "me-murder") was my answer. So my imagination
became infested with all kinds of me-murders. Some of my favorites to relish
were standing on a bridge, pouring a can of gasoline over my head, lighting a
match, and as I went up in flames, jumping onto the highway to my end. How
about death by jumping inside a ferocious animal's cage at the Bronx Zoo? Or
maybe hoarding pills of whatever sort, grinding them all up in a blender as
ingredients to a chocolate milk shake and drinking it down with a straw?

As frightening as these potential suicidal scenarios seem, they are all held for
me a real ending of tranquillity and eternal peace. I'd prayed for this, and then
visualize myself in a coffin, rotting like an old potato, with worms coming out of
my nostrils, and all kinds of crawly things eating away at me like a
Thanksgiving banquet. I had many terrorizing experiences while in the hospital
that were so frightening at times I became physically sick to my stomach. My
behavior often left me acting out, necessitating medications and restraint.
Sometimes, I'd be in my room and afraid to leave because there were
creatures sitting on my bed and coming through my window. I couldn't leave
and I couldn't stay, so I'd "freak out" and smash my fist into a wall or window
safety screen and curse out those faces. I wanted those ugly, loathsome
disfigurations executed as I begged for relief. I did learn, however, from
repeated psychotherapy sessions over many years, that the Voices and Sights
are a part of me. If you push your thoughts and feeling down far enough and
for long enough, symptoms will become volatile and will eventually erupt.

I used to dread every morning for what was going to transpire on what day.
Every night when I went to bed, I was petrified that the foreboding Voices
would leave me sleepless. If it weren't for the new medication, clozapine (with
which I was a part of an experimental group), I would never have survived this
continuously exhausting mental illness.

I felt as though I was weakening; the Voices were going to conquer. With the
assistance of that new medication and the comfort and support from my
psychiatrist and others, I have been able to make distances down my path to
recovery.

I am now involved in working part time in a gift shop and part time as a
counselor in a halfway house. I am currently working on a book about "my
story" in a form of expansion of this article. I co-lead a class once a month with
two nurses about schizophrenia; my part of the class is about managing the
illness. I am a spokesperson for the Mental IIlness Foundation in New York
City. The bottom line, I believe, is that I'm on my way to being a "cured"
schizophrenic. With hope, motivation and courage, and proper care, there can
be recovery for the mentally ill.

???
[Link]

Preventing Drug Abuse among Children and

Adolescents

Applying Prevention Principles to Drug Abuse Prevention Programs

How are risk and protective factors addressed in prevention programs?

The risk and protective factors are the primary targets of effective prevention
programs used in family, school, and community settings. The goal of these programs
is to build new and strengthen existing protective factors and reverse or reduce risk
factors in youth.

Prevention programs are usually designed to reach target populations in their primary
setting. However, in recent years it has become more common to find programs for
any given target group in a variety of settings, such as holding a family-based
program in a school or a church.

In addition to setting, prevention programs can also be described by the audience for
which they are designed:

 Universal programs are designed for the general population, such as all
students in a school.
 Selective programs target groups at risk or subsets of the general
population, such as poor school achievers or children of drug abusers.
 Indicated programs are designed for people already experimenting with
drugs.

In the Family - Prevention programs can strengthen protective factors among young
children by teaching parents better family communication skills, appropriate discipline
styles, firm and consistent rule enforcement, and other family management
approaches. Research confirms the benefits of parents providing consistent rules and
discipline, talking to children about drugs, monitoring their activities, getting to know
their friends, understanding their problems and concerns, and being involved in their
learning. The importance of the parent-child relationship continues through
adolescence and beyond. (See examples of family-based programs in Examples of
Research-Based Drug Abuse Prevention Programs.)

In School - Prevention programs in schools focus on children’s social and academic

skills, including enhancing peer relationships, self-control, coping, and drug-refusal
skills. If possible, school-based prevention programs should be integrated into the
school’s academic program, because school failure is strongly associated with drug
abuse. Integrated programs strengthen students’ bonding to school and reduce their
likelihood of dropping out. Most school prevention materials include information about
correcting the misperception that many students are abusing drugs. Other types of
interventions include school-wide programs that affect the school environment as a
whole. All of these activities can serve to strengthen protective factors against drug
abuse. (See examples of school-based programs in Examples of Research-Based Drug
Abuse Prevention Programs.)

Recent research suggests caution when grouping high-risk teens in peer group
preventive interventions. Such groupings have been shown to produce negative
outcomes, as participants appear to reinforce each other’s drug abuse behaviors. 10

In the Community - Prevention programs work at the community level with civic,
religious, law enforcement, and other government organizations to enhance anti-drug
norms and pro-social behaviors. Many programs coordinate prevention efforts across
settings to communicate consistent messages through school, work, religious
institutions, and the media. Research has shown that programs that reach youth
through multiple settings can strongly impact community norms. 7 Community-based
programs also typically include development of policies or enforcement of regulations,
mass media efforts, and community-wide awareness programs. (See community-
based programs in Examples of Research-Based Drug Abuse Prevention Programs.)
For example, it is important to note that some carefully structured and targeted
media interventions have been proven to be very effective in reducing drug abuse. 22

What are the core elements of effective research-based prevention

programs?

In recent years, research-based prevention programs have proven effective. These

programs were tested in diverse communities, in a wide variety of settings, and with
a range of populations (for example, family-based programs in schools and churches).

As community planners review prevention programs to determine which best fit their
needs, they should consider the following core elements of effective research-based
programs.

 Structure—how each program is organized and constructed;

 Content—how the information, skills, and strategies are presented; and
 Delivery—how the program is selected or adapted and implemented, as
well as how it is evaluated in a specific community.

When adapting programs to match community needs, it is important to retain these

core elements to ensure that the most effective parts of the program stay intact.

The table below provides examples of these core elements of prevention programs by
sample program types—for example, Community (Universal), School (Selective), and
Family (Indicated). In brief, the core elements are described below.

Structure - Structure addresses program type, audience, and setting. Several

program types have been shown to be effective in preventing drug abuse. School-
based programs, the first to be fully developed and tested, have become the primary
approach for reaching all children. Family-based programs have proven effective in
reaching both children and their parents in a variety of settings. Media and computer
technology programs are beginning to demonstrate effectiveness in reaching people
at both community and individual levels.

Research also shows that combining two or more effective programs, such as family
and school programs, can be even more effective than a single program alone. These
are called multi-component programs.

Content - Content is composed of information, skills development, methods, and

services. Information can include facts about drugs and their effects, as well as drug
laws and policies. For instance, in a family intervention, parents can receive drug
education and information that reinforces what their children are learning about the
harmful effects of drugs in their school prevention program. This opens opportunities
forfamily discussions about the abuse of legal and illegal drugs.

Drug information alone, however, has not been found to be effective in deterring drug
abuse. Combining information with skills, methods, and services produces more
effective results. Methods are geared toward change, such as establishing and
enforcing rules on drug abuse in the schools, at home, and within the community.
Services could include school counseling and assistance, peer counseling, family
therapy, and health care. Parental monitoring and supervision can be enhanced with
training on rule-setting; methods for monitoring child activities; praise for appropriate
behavior; and moderate, consistent discipline that enforces family rules.

Delivery - Delivery includes program selection or adaptation and implementation.

During the selection process, communities try to match effective research-based
programs to their community needs. Conducting a structured review of existing
programs can help determine what gaps remain. This information can then be
incorporated into the community plan, which guides the selection of new research-
based programs. Chapter 4 presents brief program descriptions. More comprehensive
program information is included in the complete second edition. Also, planning and
program sources can be found in Selected Resources and References.

Adaptation involves shaping a program to fit the needs of a specific population in

various settings. To meet community needs, scientists have adapted many research-
based programs. For programs that have not yet been adapted in a research study, it
is best to run the program as designed or include the core elements to ensure the
most effective outcomes.
Implementation refers to how a program is delivered, which includes the number of
sessions, methods used, and program follow-up. Research has found that how a
program is implemented can determine its effectiveness in preventing drug abuse.

Use of interactive methods and appropriate booster sessions helps to reinforce earlier
program content and skills to maintain program benefits.

How can the community implement and sustain effective prevention

programs?

Following selection of its prevention plan, the community must begin to implement
programs that meet its needs. In many communities, coalitions formed during the
planning process remain involved in oversight; but the responsibility for running
individual programs usually remains with local public or private community-based
organizations. Running an effective research-based program often requires use of
extensive human and financial resources and a serious commitment to training and
technical assistance. Outreach efforts to attract and keep program participants
interested and involved are important, especially with hard-to-reach populations.
Research has shown that extra effort in providing incentives, flexible schedules,
personal contact, and the public support of important community leaders helps attract
and retain program participants.

How can the community evaluate the impact of its program on drug abuse?

Evaluating community prevention programs can be challenging. Community leaders

often consult with evaluation experts, such as local universities or State agencies, to
assist in evaluation design.

An evaluation needs to answer the following questions:

 What was accomplished in the program?

 How was the program carried out?
 How much of the program was received by participants?
 Is there a connection between the amount of program received and
outcomes?
 Was the program run as intended?
 Did the program achieve what was expected in the short term?
 Did the program produce the desired long-term effects?

The community plan should guide actions for prevention over time because
community needs change. Therefore, it is important to check program progress and
decide if the original goals are being met. Evaluations may offer the chance to change
plans and methods to better address current community problems.
 What are the cost-benefits of community prevention programs?

Research has shown that preventing drug abuse and other problem behaviors can
produce benefits for communities that outweigh the monetary costs. The cost-
effectiveness and benefit-cost of two long-term effective interventions, 26 the
Strengthening Families Program: For Parents and Youth 10–14 (SFP 10–14), and
Guiding Good Choices (GGC), produced net benefits in preventing adult cases of
alcohol abuse. For every dollar spent, a $10 benefit was measured as a result of the
SFP 10–14 program, and a $6 benefit was the result of the GGC program. In addition,
an analysis of the Skills, Opportunity, And Recognition (SOAR) program had a benefit-
to-cost ratio of $4.25 for every dollar spent. 1,13 An earlier study found that for every
dollar spent on drug abuse prevention, communities could save from $4 to $5 in costs
for drug abuse treatment and counseling.23

Prevention Principles

These principles are intended to help parents, educators, and community leaders
think about, plan for, and deliver research-based drug abuse prevention programs
at the community level. The references following each principle are
representative of current research.

Risk Factors and Protective Factors

PRINCIPLE 1 - Prevention programs should enhance protective factors and

reverse or reduce risk factors.14

 The risk of becoming a drug abuser involves the relationship among the
number and type of risk factors (e.g., deviant attitudes and behaviors) and
protective factors (e.g., parental support).32
 The potential impact of specific risk and protective factors changes with
age. For example, risk factors within the family have greater impact on a
younger child, while association with drug-abusing peers may be a more
 significant risk factor for an adolescent.11, 9
 Early intervention with risk factors (e.g., aggressive behavior and poor
self-control) often has a greater impact than later intervention by changing a
child’s life path (trajectory) away from problems and toward positive
behaviors.15
 While risk and protective factors can affect people of all groups, these
factors can have a different effect depending on a person’s age, gender,
ethnicity, culture, and environment.5, 20

PRINCIPLE 2 - Prevention programs should address all forms of drug abuse,

alone or in combination, including the underage use of legal drugs (e.g., tobacco
or alcohol); the use of illegal drugs (e.g., marijuana or heroin); and the
inappropriate use of legally obtained substances (e.g., inhalants), prescription
medications, or over-the-counter drugs. 16

PRINCIPLE 3 - Prevention programs should address the type of drug abuse

problem in the local community, target modifiable risk factors, and strengthen
identified protective factors. 14

PRINCIPLE 4 - Prevention programs should be tailored to address risks specific

to population or audience characteristics, such as age, gender, and ethnicity, to
improve program effectiveness. 21

Prevention Planning

Family Programs

PRINCIPLE 5 - Family-based prevention programs should enhance family bonding

and relationships and include parenting skills; practice in developing, discussing,
and enforcing family policies on substance abuse; and training in drug education
and information.2

Family bonding is the bedrock of the relationship between parents and children.
Bonding can be strengthened through skills training on parent supportiveness of
children, parent-child communication, and parental involvement.17

 Parental monitoring and supervision are critical for drug abuse prevention.
These skills can be enhanced with training on rule-setting; techniques for
monitoring activities; praise for appropriate behavior; and moderate, consistent
discipline that enforces defined family rules. 18
 Drug education and information for parents or caregivers reinforces what
children are learning about the harmful effects of drugs and opens
opportunities for family discussions about the abuse of legal and illegal
substances.4
 Brief, family-focused interventions for the general population can positively
change specific parenting behavior that can reduce later risks of drug abuse. 27

School Programs

PRINCIPLE 6 - Prevention programs can be designed to intervene as early as

preschool to address risk factors for drug abuse, such as aggressive behavior,
poor social skills, and academic difficulties. 30, 31
PRINCIPLE 7 - Prevention programs for elementary school children should
target improving academic and social-emotional learning to address risk factors
for drug abuse, such as early aggression, academic failure, and school dropout.
Education should focus on the following skills: 8, 15

 self-control;
 emotional awareness;
 communication;
 social problem-solving; and
 academic support, especially in reading.

PRINCIPLE 8 - Prevention programs for middle or junior high and high school
students should increase academic and social competence with the following
skills: 6, 25

 study habits and academic support;

 communication;
 peer relationships;
 self-efficacy and assertiveness;
 drug resistance skills;
 reinforcement of anti-drug attitudes; and
 strengthening of personal commitments against drug abuse.

Community Programs

PRINCIPLE 9 - Prevention programs aimed at general populations at key

transition points, such as the transition to middle school, can produce beneficial
effects even among high-risk families and children. Such interventions do not
single out risk populations and, therefore, reduce labeling and promote bonding
to school and community. 6, 10

PRINCIPLE 10 - Community prevention programs that combine two or more

effective programs, such as family-based and school-based programs, can be
more effective than a single program alone. 3

PRINCIPLE 11 - Community prevention programs reaching populations in

multiple settings—for example, schools, clubs, faith-based organizations, and the
media—are most effective when they present consistent, community-wide
messages in each setting. 7

Prevention Program Delivery

PRINCIPLE 12 - When communities adapt programs to match their needs,

community norms, or differing cultural requirements, they should retain core
elements of the original research-based intervention27 which include:

 Structure (how the program is organized and constructed);

 Content (the information, skills, and strategies of the program); and
 Delivery (how the program is adapted, implemented, and evaluated).

PRINCIPLE 13 - Prevention programs should be long-term with repeated

interventions (i.e., booster programs) to reinforce the original prevention goals.
Research shows that the benefits from middle school prevention programs
diminish without follow-up programs in high school. 25

PRINCIPLE 14 - Prevention programs should include teacher training on good

classroom management practices, such as rewarding appropriate student
behavior. Such techniques help to foster students’ positive behavior,
achievement, academic motivation, and school bonding. 15

PRINCIPLE 15 - Prevention programs are most effective when they employ

interactive techniques, such as peer discussion groups and parent role-playing,
that allow for active involvement in learning about drug abuse and reinforcing
skills.
6

PRINCIPLE 16 - Research-based prevention programs can be cost-effective.

Similar to earlier research, recent research shows that for each dollar invested in
prevention, a savings of up to $10 in treatment for alcohol or other substance
abuse can be seen. 1, 13, 23,26

Risk Factors and Protective Factors

What are risk factors and protective factors?

Research over the past two decades has tried to determine how drug abuse begins
and how it progresses. Many factors can add to a person’s risk for drug abuse.
Risk factors can increase a person’s chances for drug abuse, while protective
factors can reduce the risk. Please note, however, that most individuals at risk for
drug abuse do not start using drugs or become addicted. Also, a risk factor for
one person may not be for another.

Risk and protective factors can affect children at different stages of their lives. At
each stage, risks occur that can be changed through prevention intervention.
Early childhood risks, such as aggressive behavior, can be changed or prevented
with family, school, and community interventions that focus on helping children
develop appropriate, positive behaviors. If not addressed, negative behaviors can
lead to more risks, such as academic failure and social difficulties, which put
children at further risk for later drug abuse.

Research-based prevention programs focus on intervening early in a child’s

development to strengthen protective factors before problem behaviors develop.

The table below describes how risk and protective factors affect people in five
domains, or settings, where interventions can take place.
Risk factors can influence drug abuse in several ways. The more risks a child is
exposed to, the more likely the child will abuse drugs. Some risk factors may be
more powerful than others at certain stages in development, such as peer pressure
during the teenage years; just as some protective factors, such as a strong parent-
child bond, can have a greater impact on reducing risks during the early years.
An important goal of prevention is to change the balance between risk and
protective factors so that protective factors outweigh risk factors.

What are the early signs of risk that may predict later drug abuse?

Some signs of risk can be seen as early as infancy or early childhood, such as
aggressive behavior, lack of self-control, or difficult temperament. As the child
gets older, interactions with family, at school, and within the community can
affect that child’s risk for later drug abuse.

Children’s earliest interactions occur in the family; sometimes family situations

heighten a child’s risk for later drug abuse, for example, when there is:

 a lack of attachment and nurturing by parents or caregivers;

 ineffective parenting; and
 a caregiver who abuses drugs.

But families can provide protection from later drug abuse when there is:

 a strong bond between children and parents;

 parental involvement in the child’s life; and
 clear limits and consistent enforcement of discipline.

Interactions outside the family can involve risks for both children and
adolescents, such as:

 poor classroom behavior or social skills;

 academic failure; and
 association with drug-abusing peers.
Association with drug-abusing peers is often the most immediate risk for
exposing adolescents to drug abuse and delinquent behavior.

Other factors—such as drug availability, trafficking patterns, and beliefs that

drug abuse is generally tolerated—are risks that can influence young people to
start abusing drugs.

What are the highest risk periods for drug abuse among youth?

Research has shown that the key risk periods for drug abuse are during major
transitions in children’s lives. The first big transition for children is when they
leave the security of the family and enter school. Later, when they advance from
elementary school to middle school, they often experience new academic and
social situations, such as learning to get along with a wider group of peers. It is at
this stage—early adolescence—that children are likely to encounter drugs for the
first time.

When they enter high school, adolescents face additional social, emotional, and
educational challenges. At the same time, they may be exposed to greater
availability of drugs, drug abusers, and social activities involving drugs. These
challenges can increase the risk that they will abuse alcohol, tobacco, and other
substances.

When young adults leave home for college or work and are on their own for the
first time, their risk for drug and alcohol abuse is very high. Consequently, young
adult interventions are needed as well.

Because risks appear at every life transition, prevention planners need to choose
programs that strengthen protective factors at each stage of development.

When and how does drug abuse start and progress?

Studies such as the National Survey on Drug Use and Health, formally called the
National Household Survey on Drug Abuse, reported by the Substance Abuse
and Mental Health Services Administration, indicate that some children are
already abusing drugs at age 12 or 13, which likely means that some begin even
earlier. Early abuse often includes such substances as tobacco, alcohol, inhalants,
marijuana, and prescription drugs such as sleeping pills and anti-anxiety
medicines. If drug abuse persists into later adolescence, abusers typically become
more heavily involved with marijuana and then advance to other drugs, while
continuing their abuse of tobacco and alcohol. Studies have also shown that
abuse of drugs in late childhood and early adolescence is associated with greater
drug involvement. It is important to note that most youth, however, do not
progress to abusing other drugs.

Scientists have proposed various explanations of why some individuals become

involved with drugs and then escalate to abuse. One explanation points to a
biological cause, such as having a family history of drug or alcohol abuse.
Another explanation is that abusing drugs can lead to affiliation with drug-
abusing peers, which, in turn, exposes the individual to other drugs.

Researchers have found that youth who rapidly increase their substance abuse
have high levels of risk factors with low levels of protective factors. Gender,
32

race, and geographic location can also play a role in how and when children
begin abusing drugs.