Prevention and Intervention on the Care Continuum

Abstract

Historically, there has been a palpable schism between preventionists and interventionists in the field of social work. Although great strides have been made in evidence-based pursuits in both areas, very little overlap has been explored. In fact, the two realms are often viewed as being in competition with one another for resources, agency priorities, and funding. At the risk of recreating dichotomy, we first examine these two distinct areas and then illuminate and transform the existing model by analyzing the links between prevention and intervention in the realms of social work practice and research. Starting in the late 1990s and early 2000s, the burgeoning field of social work prevention leaned heavily, if not solely, on information provision in an attempt to change behaviors and norms for youths and adults. Substance abuse prevention programs like Drug Abuse Resistance Education (DARE) were designed and implemented widely without knowledge of their potential for iatrogenic effects (that is, unintended negative impacts). In fact, the first research evaluations of DARE showed that the program actually increased curiosity about and use of drugs like marijuana. And no wonder! The early version of the DARE program that youths received had police passing around a bag of marijuana for students to see and smell, being told that this is what you shouldn't use. Other dramatic prevention attempts such as Scared Straight (a program that attempted to instill fear about drug use as a technique) and Shattered Dreams (a psychodramatic recreation of a fatal driving while intoxicated accident and its aftermath for high school students) made adults feel good about their efforts to prevent dangerous, high-risk behaviors and outcomes. However, subsequent research has continually found these programs to be ineffective at best and injurious at worst (Ringwalt, Ennett, & Holt, 1991; Stewart et al., 2006). Fortunately, prevention research has progressed, and we now know that effective programs have a combination of the following elements: information provision, social skills building, problem-solving techniques, resistance strategies, and self-efficacy enhancements. A prime example of a substance abuse prevention program for youths is the keepin' it REAL (kiR) program, designed in the late 1990s and declared a model program by the Substance Abuse and Mental Health Services Administration (SAMHSA) (Marsiglia & Hecht, 2005). It has now been culturally adapted for a variety of populations and international locations (Holleran Steiker, Goldbach, Hopson, & Powell, 2011). Another exemplar, for women at risk for alcohol-related pregnancy, is Project CHOICES (Floyd et al., 2007). This program combines assessment of risky behaviors in women of childbearing age, primarily alcohol consumption and lack of contraceptive use, with a six-session program to prevent fetal alcohol spectrum disorders (FASDs) in newborns. Although prevention is often categorized into primary (or universal), secondary (or selective), and tertiary (or indicated) target areas, some argue that--by definition--tertiary programs are not actually preventive because they address those individuals who are already displaying the behaviors they intend to prevent. Those who argue point believe that juncture marks a distinct delineation between prevention and intervention. However, we support the argument that tertiary prevention is a necessary component of the care continuum, because those displaying problematic behaviors are rarely open to formal treatment, much less fully aware of the need or ready for intervention. This is the theoretical foundation of the stages of change model (Prochaska & DiClemente, 1992), which is currently widely embraced by the social work profession because of its attention to meeting clients exactly where they are. Rather than defining intervention programs as treatment that occurs in relation to diagnosis and comes after any failed prevention efforts, model broadens the definition to include prevention as a form of intervention before formal clinical diagnosis and treatment. …