Providing young people with assistance in all necessary life domains, and ensuring timely access and continuity of care through coordination across multiple service sectors approaches the construct of comprehensive or holistic care at a relatively gross or course grained level of analysis. The principle of holistic care can be extended to a finer grained level of analysis of the processes that take place within and around young people. This more nuanced approach includes a consideration of experiential or subjective dimensions, psychological and social processes, and the implications of these for the design of interventions.
A fundamental part of the knowledge-base that guides practice is the biopsychosocial model of health, or the understanding that the challenges young people face are shaped by the complex interaction between biological, psychological, and social factors. While most service providers tend to focus on one type of factor or system, an ecological approach recognises that significant and lasting improvements in health and wellbeing usually require complementary or synergistic changes in each of these systems. Where there is a focus mostly on the psychological and social issues affecting young people, ecological understanding helps us to recognise how the work intersects with the work of providers who focus on other systems such as psychiatrists and psychologists.
A closely related aspect of the ecological and systemic approach is the understanding of the connection between the individual and the social world. The issues that are happening for an individual such as their use of alcohol and other drugs cannot be separated from their social circumstances.
While problems with alcohol and drugs may be the main reason that a young person comes to AOD services, these issues are not the only focus, and they may not even be the first thing that to focus on. Consistent with a client-focused and holistic practice orientation, issues can be prioritised for attention according to the unique experiences, needs and preferences of individuals. These priorities may involve biological factors such as immediate health concerns, psychological factors such as depression or difficulty controlling anger, or be related social factors such as lack of housing.
The ecological and systemic orientation however goes another step further than this holistic approach, and seeks to understand and address the experiences of the young person within complex social systems.
A type of experience that is very common to our clients is disruption or disturbance of processes that link individuals into social systems such as families, schools and communities, leading to their disconnection from these systems. For example, disturbances within families involving neglect, conflict or abuse deprive young people of many of the experiences they need to develop health and wellbeing such as positive role modeling, and often trigger events such as young people being removed from the home by child protection authorities or young people disconnecting from families of their own accord (Keys, Mallett, & Rosenthal, 2006). Disturbances in emotional regulation and behaviour occurring in the context of schools that lack capacity to respond appropriately to children’s needs may gradually lead to school failure and disconnection from school by affected adolescents. When adolescents experience problems in multiple social systems, these initial disconnections, unless addressed early, can set young people on a pathway to long term marginalisation from education and work until they find themselves trapped in a cycle of social exclusion that can be very difficult to escape from.
Turning this situation around generally requires attention to all of the relevant social systems. An ecological and systemic perspective also helps build understanding of how different factors can interact to precipitate crises or negative spirals of events that can lead to deterioration in a young person’s health and wellbeing. These spirals are examples of ways in which harmful consequences often attributed to simplistically substance misuse actually arise through interaction of substance use within complex ‘systems’ of factors. Thus the systemic perspective helps illustrate that many different windows of opportunity exist for intervention to reduce harms.
Consistent with the ecological and systemic understanding, an important trend in treatment development is the emergence of integrative treatment models that combine therapeutic elements derived from different therapeutic traditions, and which target multiple interacting systems. Integration of elements from family therapy (targeting the family system) and cognitive-behaviour therapy (targeting the individual) has been a strong focus, examples of which include Multi Systemic Therapy (Henggeler et al., 1996)and Multidimensional Family Therapy (MDFT) (Liddle, 2004). Other programs such as the Adolescent-Community Reinforcement Approach (A-CRA) and Community Reinforcement and Family Training (CRAFT) are combining these elements with motivational interviewing and contingency management (Godley et al., 2001; Waldron et al., 2007), while Dialectical Behaviour Therapy as adapted for adolescents combines elements of cognitive behaviour therapy (skill development), family therapy, person-centred counselling (emotional validation and acceptance), and mindfulness meditation (Hawkins, 2009; Lynch, Trost, Salsman, & Linehan, 2007; Rathus & Miller, 2002; Woodberry & Popenoe, 2008).
Meta-analyses and other reviews of evidence-based treatment programs for adolescent behaviour problems including substance abuse and misuse are finding that these integrative models generally demonstrate consistent effectiveness in clinical trials, including for populations of hard-to-reach youth with complex needs (Dennis et al., 2004; Hawkins, 2009; Sukhodolsky & Ruchin, 2006; Waldron & Turner, 2008). There is also some direct evidence of superior, or longer lasting, outcomes for integrative treatment models compared to singular treatment approaches (Liddle, 2004; Waldron, Slesnick, Brody, Turner, & Peterson, 2001). ‘Integrative’ treatment models that combine elements from different therapeutic traditions and which target different life domains could also constitute a valuable approach to developing ‘integrated’ treatments that simultaneously treat co-occurring disorders such as AOD and mental health problems (Hawkins, 2009).