INFLUENCE OF ABORTION STIGMA, BEHAVIOUR PATTERN AND DISTRESS TOLERANCE ON SUBSTANCE USE AMONGST ADOLESCENTS

1.0 Introduction

1.1 Background to the study

Adolescence is “the period of life that starts with the biological, hormonal and physical changes of puberty and ends at the age at which an individual attains a stable, independent role in society”, (Balocchini, Chiamenti, & Lamborghini, 2013). During adolescence one is vulnerable to engaging in a lot of risky behaviours. Substance abuse is one of such set of behaviours. Adolescents experience many problems , including teen pregnancy, alcohol and drug use and violence, school failure and eating disorders (Callaham, 2003, Stein, Jaycox, kataoka, Rhodes; & Vestal ,2003).

Adolescence is a period when people usually begin using substances such as alcohol and other kinds of drugs, (Chia, et. al. 2015). Adolescence is also a period of intense brain development, and mind-altering substances could potentially have more of an effect at this stage compared with other age groups. The use of psychoactive substances by adolescents has been the topic of extensive research activity over many decades. Adolescence is also seen as a critical period both for starting to smoke, drink or use other drugs and for experiencing more harmful consequences as a result.

Substance use is when someone consumes alcohol or drugs. Drug use is a broad term to cover the taking of all psychoactive substances within which there are stages: drug-free (i.e. non-use), experimental use, recreational use and harmful use, which is further sub divided into misuse and dependence. This definition does not discriminate between alcohol, tobacco, caffeine, solvents, over the counter drugs, prescribed drugs, illicit drugs, rather it focuses on changes in the body and/or behaviour brought about through the use of such substances. These substances are also referred to as psychoactive drugs, meaning that they affect the central nervous system and alter mood, thinking, perception and behaviour.

Equally, the definition makes no distinction between the legality, social acceptability or ‘value' of drugs. Blanket definitions which attempt to cover these areas as well as the substance/user/affect nexus often have weak logic underpinning their meanings, making them vulnerable to challenge, particularly in terms of highlighting inconsistencies. For example, if alcohol and tobacco are not defined as drugs, what does that say about adult society which approves and endorses their use, (not minding the health and social costs they can both incur) but disapproves of the use of cannabis and ecstasy by young people.

The use of multiple substances, sometimes termed poly-use, is perhaps the most disturbing. There are several theories that can account for the clustering of substance-use behaviours. On a biochemical level, frequent use of one substance may alter the dopamine system, and hence the reinforcement value of substances. On a psychological level, a positive evaluation of a used substance may generalize to other substances, including those not consumed before. Adolescents who smoke and drink regularly have more positive attitudes towards illicit drugs and higher odds of using them than non-smokers who do not drink . Factors like family cohesion and friends condoning substance use seem to have similar influences on adolescents' indulgence in smoking, alcohol and marijuana use. Different forms of substance use may also have a common function. For example, both alcohol and cannabis can counter feelings of depression, and help to manage the after-effects of other drugs.

Drinking, marijuana use and delinquent behaviours could all serve the function of ‘maturity landmarks', or allow the adolescent to break societal norms. Sensation seekers derive positive consequences from new experiences. For some, high-risk sports provide excitement; others are inclined to experiment with psychotropic substances. Finally, it is likely that substance-use behaviours co-occur because they occur in the same context. In many bunks, people drink alcohol and smoke. Expectancy-value theories, on the other hand, state that the immediate determinants of use are substance specific. For example, according to theory of planned behaviour (TPB) and related models, marijuana use is predicted by thoughts and feelings concerning marijuana use. If an adolescent happens to use a second substance (e.g. alcohol), intra- and interpersonal factors specific to alcohol use are the most important variables.

Within an Irish context, young peoples' experimentation with drugs will often feature alcohol and/or tobacco, given their prevalence and the ease of access to them. Availability (particularly alongside curiosity), anticipation of effects, youth culture and current fashions regarding substance use each play a role in young peoples' experimentation with drugs. For the majority of people, experimentation is confined to those drugs which are socially acceptable. Experimentation with substances does not automatically lead to recreational drug use or, indeed, dependent use and may cease once the initial motivating factors have been satisfied.

Issues of abortion for adolescents are embedded in the status and meaning of abortion in the country in which they are living. Unwanted pregnancies and abortion have existed since time immemorial. The seminal work of George Devereux in 1976 on the history of abortion around the world points to the frequency of abortion across cultures and time. Chinese, Greek and Roman cultures all developed systems of dealing with unwanted pregnancies and regulating population growth in their respective societies. The Egyptians were some of the first to create abortion techniques, which were discussed and reported in some of their first, and our oldest, medical texts (Devereux 1976). Today, abortion is one of the most common gynecological experiences; perhaps the majority of women will undergo an abortion in their lifetimes (A°ahman and Shah 2004). Despite its existence across time and its persistence across geographic location, the impact of abortion on women, families, communities and societies differs drastically across the world. Safe abortions — those done by trained providers in hygienic settings — and early medical abortions (using medication to end a pregnancy) carry few health risks (World health organization 2003). However, every year, close to 20 million adolescents risk their lives and health by undergoing unsafe abortions (Sedgh, G., S. Henshaw, S. Singh, E. Ahman, and I.H. Shah. 2007). Twenty-five percent of these women will face a complication with permanent consequences and close to 66,500 women will die (WHO, 2007). The majority of these women live in the developing world and half of those who die are under the age of 25 years (WHO 2007).

International Project Assistance Services (Ipas) in 1978, defined abortion stigma as “negative attribute ascribed to women who seek to terminate a pregnancy that ‘marks' them as inferior to ideals of womanhood.”. Abortion stigma, an important phenomenon for individuals who have had abortions or are otherwise connected to abortion, is under-researched and under-theorized. The few existing studies focus only on women who have had abortions, which in the United States represents about one third of women by age 45 (Henshaw, 1998). Kumar, Hessini, and Mitchell (2009) recently theorized that women who seek abortions challenge localized cultural norms about the “essential nature” of women. It is posited that abortion stigma may also apply to medical professionals who provide abortions, friends and family members who support abortion patients, and perhaps even to prochoice advocates. The following questions are essential here; does abortion stigma affect persons stemming from the same root as the victim? Do they experience this stigma in the same way as the victim? This questions are predicated on Kumar et al', (2009) work by exploring how different groups experience abortion stigma and what this tells us about why abortion is stigmatized.

Silence is an important mechanism for individuals coping with abortion stigma; people hope that if no one knows about their relationship to abortion, they cannot be stigmatized. Nevertheless, even a concealed stigma may lead to an internal experience of stigma and health consequences (Quinn & Chaudior, 2009). Goffman in 1963 described stigma as “an attribute that is deeply discrediting,” reducing the possessor “from a whole and usual person to a tainted, discounted one.” Many have built on Goffman's definition over the past 45 years, a but two components of stigmatization consistently appear across disciplines: The perception of negative characteristics and the global devaluation of the possessor. On their part, Kumar et al. (2009) define abortion stigma as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” (p. 628, emphasis added). Like Kumar et al. (2009), we dispute any “universality” of abortion stigma. We retain their useful multilevel conceptualization, understanding stigma as created across all levels of human interaction: between individuals, in communities, in institutions, in law and government structures, and in framing discourses (Kumar et al., 2009).

The experience of abortion stigma can be transitory or episodic for some abortion patients. Abortion may not become a salient part of their self-concept and may re-emerge only at key moments. For example, a woman who rarely thinks of the abortion she had 20 years ago may find herself face-to-face with abortion stigma when her new father-in-law loudly asserts anti-abortion rhetoric at a holiday dinner or she may re-experience it when she is asked about her reproductive history by her obstetrician. Thus, caution is made against reification of individually experienced abortion stigma as something that one always “has” or is always salient. Women who have had abortions are a heterogeneous group (Jones et al., 2010). Their reasons for terminating their pregnancies also vary (Finer, Frohwirth, Dauphinee, Singh, & Moore, 2005). In public discourse and from the perspective of women having abortions, however, the idea that there are “good abortions” and “bad abortions” stemming from “good” and “bad” reasons for having them, is prevalent. Stigma experienced by women who have had abortions may be mitigated or exacerbated by whether their abortions fall into one category or the other. “Good abortions” are those judged to be more socially acceptable, characterized by one or more of the following: A fetus with major malformations, a pregnancy that occurred despite a reliable method of contraception, a first-time abortion an abortion in the case of rape or incest, a very young woman, or a contrite woman who is in a monogamous relationship. “Bad abortions,” in contrast, occur at later gestational ages and are had by “selfish” women who have had multiple previous abortions without using contraception (Furedi, 2001). Women who have had abortions may be both the stigmatizer and the stigmatized, believing they had “good abortions” and distancing themselves from others who had “bad abortions” (Rapp, 2000). These moral distinctions may be drawn by any woman having an abortion, whether anti-abortion or prochoice (Arthur, 2000).

As Kumar et al. (2009) deftly demonstrate abortion violates two fundamental ideals of womanhood: Nurturing motherhood and sexual purity. The desire to be a mother is central to being a “good woman”. Abortion, therefore, is stigmatized because it is evidence that a woman has had “no procreative” sex and is seeking to exert control over her own reproduction and sexuality, both of which threaten existing gender norms (Kumar et al., 2009). The stigmatization adolescents experience may not be rooted in the act of aborting a fetus; stigma may instead be associated with having conceived an unwanted pregnancy, of which abortion is a marker. Stigma may be associated with feelings of shame about sexual practices, failure to contracept effectively, or misplaced faith in a partner who disappoints. Abortion can be seen here as one of several “bad choices” about sex, contraception, or partner (Furedi, 2001).

Behavior pattern is a recurrent way of acting by an individual or group toward a given object or in a given situation. Behavior pattern A is a type of personality that concerns how people respond to stress. However, although its name implies a personality typology, it is more appropriately conceptualized as a trait continuum, with extremes Type-A and Type-B individuals on each end. Friedman and Rosenman (both cardiologists) actually discovered the Type A behavior by accident after they realized that their waiting-room chairs needed to be reupholstered much sooner than anticipated .When the upholsterer arrived to do the work, he carefully inspected the chairs and noted that the upholstery had worn in an unusual way: “there's something different about your patients, I've never seen anyone wear out chairs like this.” Unlike most patients, who wait patiently, the cardiac patients seemed unable to sit in their seats for long and wore out the arms of the chairs. They tended to sit on the edge of the seat and leaped up frequently. Friedman and Rosenman in 1976 labeled this behavior pattern Type A personality. They subsequently conducted research to show that people with type A personality run a higher risk of heart disease and high blood pressure than people with Type B behaviour pattern.

Type A individuals tend to be very competitive and self-critical. They strive toward goals without feeling a sense of joy in their efforts or accomplishments .Interrelated with this is the presence of a significant life imbalance. This is characterized by a high work involvement. Type A individuals are easily ‘wound up' and tend to overreact. They also tend to have high blood pressure (hypertension).Type A personalities experience a constant sense of time urgency: Type A people seem to be in a constant struggle against the clock. Often, they quickly become impatient with delays and unproductive time, schedule commitments too tightly, and try to do more than one thing at a time, such as reading while eating or watching television. People with Type B personality tend to be more tolerant of others, are more relaxed than Type A individuals, more reflective, experience lower levels of anxiety and display a higher level of imagination and creativity.

Also, Type A personality implies a temperament which is stress prone, concerned with time management. They are ambitious, rigidly organized, hard-working, anxious, highly status conscious, hostile and aggressive. Type B in the other hand is one that is less prone to stress, easy going, work steadily, enjoy achievement, modest ambition, and live in the moment. They are social, creative, thoughtful, procrastinating. Type B personality, by definition, are noted to live at lower stress levels. They typically work steadily, and may enjoy achievement, although they have a greater tendency to disregard physical or mental stress when they do not achieve. When faced with competition, they may focus less on winning or losing than their Type A counterparts, and more on enjoying the game regardless of winning or losing.

Unlike the Type A personality's rhythm of multi-tasked careers, Type B individuals are sometimes attracted to careers of creativity: writer, counselor, therapist, actor or actress. However, network and computer systems managers, professors, and judges are more likely to be Type B individuals as well. Their personal character may enjoy exploring ideas and concepts.

Scientific attention has increasingly been focused on distress tolerance due to its potential role in the development and maintenance of multiple forms of psychopathology, and as a trans diagnostic clinical target for intervention/prevention programs. Distress tolerance reflects an individual's perceived or behavioral capacity to withstand experiential/subjective distress related to affective, cognitive, and/or physical states (e.g., negative affect, physical discomfort). Scholars have therefore suggested it is an individual difference factor for stress responsivity and psychological vulnerability. Conceptual models of distress tolerance suggest that the construct may be hierarchical in nature. Specifically, there may be one global “experiential distress tolerance” constructs incorporating other, specific low order construct.

Distress intolerance in the other hand is a perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable emotions. Difficulties tolerating distress are often linked to a fear of experiencing negative emotion. Often distress intolerance centers on high intensity emotional experiences, that is, when the emotion is ‘hot', strong and powerful (e.g., intense despair after an argument with a loved one, or intense fear whilst giving a speech).

An important thing to consider when assessing levels of distress tolerance is that like many things in life, doing anything at the extreme can be unhelpful. Think of distress tolerance as a continuum where at one end people can be extremely intolerant of distress, and at the other end people can be extremely tolerant of distress. Distress tolerance is widely accepted to be a clinically relevant capacity to both internalizing and externalizing symptoms ( Leyro et al., 2010). Consequently, a negative reinforcement approach has been adopted to understand the commonality of distress tolerance to this broader scope of psychopathology (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). Negative reinforcement refers to the motivation to avoid or escape negative affective states, and has typically been applied within an addiction framework, wherein repeated substance use alleviates distress associated with withdrawal ( Baker et al., 2004). In studies of adults, substance-dependent individuals are reported to have lower tolerance of distress (Quinn, Brandon, & Copeland, 1996), and distress tolerance is related to recent abstinence duration and treatment retention among residential treatment-seeking substance abusers ( Daughters, Lejuez, Bornovalova, et al., 2005; Daughters, Lejuez, Kahler, Strong, & Brown, 2005).

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1.2 Statement of Problem

Substance use by young people is on the increase, and initiation of use is occurring at ever-younger ages. Patterns of substance use over the past 20 years have been documented by two surveys—the National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1998, and the Monitoring the Future Study conducted by the National Institute on Drug Abuse (NIDA,) in 1996.

The explosive increase in the misuse of prescription and nonprescription medications has been referred to as “pharming.” The term Generation Rx has been used to describe this increase in prescription-drug misuse among the current generation of youths. In 2007, 9.5% of adolescents aged 12 to 17 years indicated that they had used an illicit drug (marijuana, cocaine, heroin, hallucinogens, inhalants, or psychotherapeutics used nonmedically) within the past month. While marijuana was the most-used illicit drug (6.7%), past-month nonmedical use of psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) came in second (3.3%). Although past-month nonmedical use of prescription medications among adolescents declined slightly from 2002 to 2007 (4.0% and 3.3%, respectively), this should still be an area of great concern and attention in the medical community, (Flisher A, Parry CDH, Evan J, Muller M, Lombard C, 2003)

Drug use remains a significant problem in the United States, however adolescent drug use is particularly damaging as such use can affect the physical and mental development of younger people and can impact their opportunities later in life. In 1991, approximately 30.4 percent of those in school grades 8, 10, and 12 had used illicit drugs at some point in their lives. This number reached a high of 43.3 percent in 1997, but dropped back to around 33 percent in 2017. As of 2017, marijuana was still one of the most used drugs among adolescents with around 80 percent of 12th graders perceiving marijuana as fairly easy to obtain, compared to 27.3 percent of those perceiving the same for cocaine .