Teaching youth to "just say no" has long been viewed as the first line of defense in the war on drugs. And several studies have provided compelling evidence that refusal skills training, which teaches participants strategies for resisting social pressure, can be successful at preventing youth from trying drugs and alcohol.
However, a new study by scholars at the University of Illinois offers sobering evidence that refusal skills training may not be the best approach for African-American adolescents who are trying to stay sober after being treated for alcohol or drug abuse.
The solution that will improve outcomes for minorities with substance use problems likely needs to be more sophisticated and comprehensive than simply teaching them to resist social pressure, said Douglas C. Smith, a U. of I. professor and lead author of the study.
A small study of African-American adults with alcohol problems in 2004 indicated that participants benefited more from interventions that included refusal skills training. Surprised by those findings, Smith sought to replicate them and determine if refusal skills training provided differential benefits for African-American adolescents as well.
Smith also wanted to explore whether substance use was indeed higher among African-American adolescents' peer groups, making relapse more likely, as other researchers suggested.
Smith and coauthor Karen M. Tabb compared the outcomes of 214 African-American adolescents who received refusal skills training with those of 212 African-American youth who did not receive it. The study pool also included 214 white adolescents whose treatment programs included the training.
The youth in the study were clients of 37 outpatient treatment centers across the U.S. that offer a treatment program called the Adolescent-Community Reinforcement Approach, an individualized, cognitive-behavioral therapy that strives to make sobriety more rewarding for adolescents.
Slightly less than half of the youth in the study received refusal skills training during treatment.
Follow-up assessments were completed three and six months after participants' intake into treatment. Participants were considered abstinent and in early remission if they had not consumed drugs or alcohol during the month prior to the assessment.
Receiving refusal skills training during alcohol/drug treatment programs did not significantly improve African-American teens' chances of staying abstinent afterward, Smith and Tabb found.
About 48 percent of the African-American youth who received refusal skills training were still abstinent at follow-up, versus about 45 percent of their same-race peers who did not receive the training.
By contrast, about 51 percent of the white teens who received the training were still abstinent three to six months later.
Substance abuse was consistently high across all participants' peer groups, regardless of race, the researchers found.
However, youth who were alcohol- or drug-dependent prior to treatment were more likely to be using again at follow-up, even if they had undergone the refusal skills training.
"Based on this study, it seems that there is no compelling evidence to support refusal skills training as a required component of treatment for African-American youth," Tabb said. "African-American adolescents that did not engage in the training did not have significantly worse outcomes than their African-American or white peers that did."
"What did make a difference, though, was participants' overall treatment exposure – the longer they were in treatment, the more services they received, the more likely they were to be abstinent at follow-up," Smith said. "One implication of this study may be that all youth, regardless of race, should receive as many treatment procedures as possible to enhance their chances of staying sober."
According to Smith, their study underscores the importance of not looking for a simple solution that will improve treatment for minority youth.
"A big problem in substance abuse treatment has been that minority youth tend to drop out earlier than white youth, and we have responded for years by trying to increase the cultural competence of staff members, diversifying the workforce and making content more culturally relevant," Smith said. "I think this study cautions us against taking the view that changing one small thing in a large package of services will have a significant impact on treatment outcomes for minorities."
Smith and Tabb are professors in the School of Social Work at Illinois. Darnell Fisher, the student affairs coordinator in the school, and doctoral student Leah Cleeland were co-authors of the study.
The paper, "Drug Refusal Skills Training Does Not Enhance the Outcomes of African-American Adolescents with Substance Use Problems," appeared recently in the Journal of Substance Abuse Treatment.
Douglas C. Smith, Karen M. Tabb, Darnell Fisher, Leah Cleeland, "Drug refusal skills training does not enhance outcomes of African American adolescents with substance use problems," Journal of Substance Abuse Treatment, Volume 46, Issue 2, February 2014, Pages 274-279, ISSN 0740-5472, DOI: 10.1016/j.jsat.2013.07.004.