Harm Reduction
— Meeting Clients Where They Are
By Kate Jackson
Social Work Today
Vol. 4, No. 6, Page 34
12-step programs have been the gold standard in addiction
recovery for decades. Others say one size does not fit all.
For years, there’s been only one way for problem
drinkers and alcoholics to get help: by committing themselves to abstinence.
The zero-tolerance precept, embraced by the majority of recovery programs,
is generally just one part of a multistepped effort, such as the 12-step
model of Alcoholics Anonymous (AA). It’s been handed down and
modified through the years and upheld as the only game in town for
people who need help.
With AA and other programs that demand abstinence,
there’s no middle ground, no shades of gray. It’s their
way or the highway. One drinks or one doesn’t. If an individual
continues to drink, professional treatment or an invitation to the
self-help environment is not an option.
“The 12-step proponents say that alcoholism
is a progressive disease for which there’s no cure,” explains
G. Alan Marlatt, PhD, professor of psychology and director of the
Addictive Behaviors Research Center, University of Washington. “They
believe you can only try and arrest the course of the disease by committing
to total, lifelong abstinence. Unless you buy into that, they believe
you’re in denial, and denial—according to their criteria
for what constitutes a disease—is seen as a major symptom of
the disease.” Hence, he says, there’s a need for professionals
to confront people, break down their defenses, get them to admit as
step one that they’re alcoholics before they can get on board
with the program. If people are willing to go through that, they’re
asked to turn their individual control over to a higher power, he
explains. “People in the research field,” says Marlatt,
“wonder what other kind of disease there is for which a higher
power is the cure.”
Harm Reduction — A New Voice
In recent years, voices have gathered to form a movement that approaches
addiction from another vantage point. Unlike models that aim to foster
abstinence, a harm-reduction model, as its supporters like to say,
meets people where they are. It eliminates judgment and values progress
toward the alteration or elimination of behaviors that cause harm
to the individual and society. Less idealistic than other models,
it acknowledges that these behaviors will occur yet recognizes the
value in any reduction of harm, no matter how imperfect.
Although harm reduction in the addiction field also
prizes abstinence as an ultimate goal, it doesn’t insist on
it as a prerequisite of therapy. Rather than demand immediate success,
it strives to offer tools that will lead an individual toward success
in a stepwise manner.
Although some research suggests that harm-reduction
approaches can be as effective as abstinence programs in reducing
alcohol consumption and its negative repercussions, many helping professionals
are unaware of the options or fail to offer such choices to their
clients. Others are quick to dismiss the philosophy by labeling it
as enabling, illegal, unhealthy, or immoral and prefer to stick to
more traditional approaches such as AA.
According to Marlatt, approximately 90% of the treatment
centers in the United States are 12-step. Despite the fact that other
approaches have been shown to be as effective, he says, dissemination
is slow to occur. He’s quick to point out that 12-step programs
have helped thousands and thousands of people but laments the fact
that few are aware of the approaches that might help those for whom
programs such as AA don’t work.
Supporters of harm reduction are often somewhat surprised
that these alternatives to abstinence-based programs have not been
eagerly embraced and observe that they’re not radical departures
from commonly accepted medical approaches. Explains Alexander DeLuca,
MD, executive director of Moderation Management Network, Inc., a non–abstinence-based
self-help group and perhaps the best known of the self-help harm-reduction
approaches, “Harm reduction is the way everything else works
in medicine. If you have a patient with heart disease, for example,
you try to catch things early on the curve, when you can make minimal
interventions. If you miss it early, then the changes that you have
to make are more difficult, more severe, and more disrupting to the
patients’ life. With heart disease, we start the patient on
diet and exercise, and if they can’t maintain it, we give them
medicine. If that doesn’t work, we give them triple bypass.”
That, he says, is harm reduction. “It’s
a continuity of illness to which you apply a continuity of response
that’s rational. We accept that if the patient can’t or
won’t do the best thing, then we’re going to get them
to do the second best thing. It makes natural sense to everybody”—except,
he says, when it comes to addiction medicine, where only immediate
and ultimate change is acceptable.
According to Marlatt, harm reduction is taking off
among private practice clinical psychologists and therapists who recognize
the need to work with people even if they’re still using or
drinking. “It’s really about being able to continue to
meet with people even if they’re not completely clean and sober
all the time, yet trying to work them toward that as a more eventual
goal,” he says.
According to Marlatt, DeLuca, and other experts in
the field, research supports moderate drinking as a goal of treatment
for some individuals who drink excessively and suggests that it often
leads to abstinence over time. Explains Marlatt, “This more
motivational acceptance-based approach establishes a strong therapeutic
alliance that lets clients know you’re going to stick with them
no matter what happens, and it really starts to turn things around.”
Harm-Reduction Approaches
Social workers and other service providers and treatment agencies
may offer clients and patients moderation-based cognitive behavior
therapy (CBT), which research indicates can help individuals assess
risks and develop coping behaviors after treatment for problem drinking.
Two variations of CBT—Behavioral Self-Control Training and cue
exposure training—says Marlatt, have been demonstrated to be
particularly helpful. The former helps clients identify risks, set
goals, monitor their behaviors, and acquire and practice skills. The
latter helps individuals recognize cues that entice them to drink
and teaches them how to counter conditioned responses.
An additional tool that falls within the mantle of
harm reduction is pharmacology. Drugs such as naltrexone, an opiate
antagonist, are available to be used in conjunction with other interventions.
Because alcohol causes the release of endogenous opiates and thus
makes drinking pleasurable, naltrexone works by blocking endogenous
opiate receptors to short-circuit the positive feedback that occurs
when alcohol is consumed. Although drugs such as this are not without
side effects, research has shown them to reduce cravings and alcohol
intake in individuals in nonabstinence treatment.
Another drug that studies indicate helps reduce alcohol
cravings associated with withdrawal is acamprosate. Also helpful for
many drinkers are antidepressant and antianxiety medications when
administered along with psychosocial treatment.
According to Marlatt, the harm-reduction movement
has evolved to include approaches that absorb bibliotherapy and Internet
and PC aids as well as telephone interventions, all of which may appeal
to individuals who wish to retain their privacy and are disinclined
to seek more public types of assistance due to stigma or shame. All
varieties of harm-reduction approaches may be employed in programs
specifically for adolescents and college students, in primary care,
in self-help groups, and in both inpatient and outpatient centers.
DeLuca not only knows firsthand the model from which
Moderation Management diverges, he thrived in it. But he recognizes
that addiction treatment isn’t a one-size-fits-all proposition.
In his youth, DeLuca developed severe drug and alcohol problems, which,
as a closet drinker and user, he kept hidden beneath the facade he
presented to the world: a successful family medicine practitioner
who’d completed Vassar College and Albert Einstein College of
Medicine. In 1986, however, after several car crashes and a divorce,
he had what he terms as a “classic hitting-bottom experience”
that led him to AA.
DeLuca, who describes himself as an “affiliative
sort of person,” says AA was made for him. Because of it, he
was able to get back into medicine and ultimately to direct a hospital-affiliated
addiction treatment program. He saw, however, that AA isn’t
for everyone, and that for many, there had to be a better way. When
he was new in AA, he recollects, all he wanted to hear were the war
stories—the worst tales that told him that the individual understood
the depths of despair that he’d experienced. But it was those
stories, he recognized, that frightened or repelled what he terms
the lighter-weight drinkers. AA may be a lifesaver for more extreme
cases, but it often fails to resonate with people with less severe
alcohol problems.
Moderation Management, a nine-step self-help approach
with meetings or online groups, gives them an alternative to abstinence
and provides tools and strategies for lifestyle changes. DeLuca now
considers himself a permanently abstinent member of Moderation Management.
Skepticism
While experts such as Marlatt and DeLuca defend harm-reduction strategies
for many but by no means all individuals who struggle with problem
drinking, others in addiction medicine are quick to put their claims
in a different light. David Rosenker, executive vice president of
treatment services, Caron Foundation, an abstinence-based chemical
dependency treatment program, notes that while approaches such as
Moderation Management may be helpful in some circumstances, he disputes
some of its philosophies and counters the notion that such harm-reduction
programs are equally effective as more traditional routes. “It’s
very well-proven that people who have problems with their drug and
alcohol use tend to do better with abstinence-based programs than
Moderation Management-type programs,” Rosenker says. He takes
exception, for example, to the program’s suggestions that problem
drinkers are more willing to try Moderation Management than 12-step
programs because it offers anonymity and notes that he’s unaware
of much data to support that notion.
He agrees, as do Moderation Management proponents,
that people who have problems drinking would rather continue to drink
than remain abstinent, but doesn’t see it as positive. “That’s
just part of the process of addiction that people would much rather
continue to use and are always looking for ways in which they can
curtail their use,” Rosenker says. It goes without saying, he
notes, that they’d much rather take that route than listen to
someone telling them they need to be abstinent.
Another aspect of Moderation Management that Rosenker
takes issue with is its suggestion that it appeals to women and some
minorities who may already feel victimized in life and may be uncomfortable
with the sense of powerlessness that’s highlighted in abstinence-based
12-step programs.
“There’s no data to support that whatsoever,”
Rosenker says. “Abstinence-based programs talk about being powerless
over an addiction and a process of a disease, not that they’re
morally powerless or that the fiber of their being is powerless. They
certainly have control over whether or not they drink, but they don’t
have a lot of control over the disease process itself,” he says.
Furthermore, Rosenker disagrees with those proponents
of Moderation Management-type approaches who suggest that they have
an appeal to individuals who are uncomfortable with the 12-step emphasis
on a higher power. Efforts at prevention, which may involve reflections
upon the purpose of life and one’s overall self-worth, is inherently
spiritual, he insists, adding that there’s a significant amount
of data indicating that spirituality is a major part of prevention,
intervention, and recovery. He’s also quick to point out that
there’s no religious agenda in 12-step programs but rather a
spiritual base. When they talk about a higher power, he says, they
refer to “God as you understand him, not how anyone else understands
him.” He defends the strong spiritual grounding, observing that,
“It’s very well-proven that if people who are experiencing
any kind of problems in their life do much better in any kind of recovery
setting if they have some kind of spiritual—not necessarily
religious—base.”
Despite these criticisms and misgivings, Rosenker
recognizes that Moderation Management-type approaches have a place
in the treatment of addiction—but a limited place. “There
are certainly people out there who abuse alcohol who can control their
use and who definitely do not have to be abstinent,” he says.
He stresses, however, that when it comes to drugs, the situation changes.
Most drugs are not socially acceptable and moderation is a reflection
of social norms, he says, “so it’s a little tough to say
that moderation management is OK for heroin users.”
When it comes to drinking, harm-reduction approaches,
he says, are fine for individuals who are able to cut back, still
continue to drink, yet change their lives and have fewer negative
consequences. Others may curtail their drinking for a limited amount
of time and become angry and dysfunctional users who still exhibit
the behaviors and pathology that got them in trouble in the first
place, he explains.
Expanding the Treatment Menu
Social workers who take the time to explore the options and offer
alternatives, say harm-reduction proponents, can greatly influence
their clients’ lives. “Professionals need to begin to
see the alcohol and drug problem not just as a single problem but
as multiple problems affecting people across all the aspects of their
lives,” says Marlatt. “They must look at the alcohol and
drug use but also at family interactions, employment issues, other
health problems, and legal programs.” When you’re doing
outreach, he advises, “take a look at what the clients’
needs are, ask them what would they like to work on first, rather
than insisting that they take care of their drug problems before you’ll
help them with anything else. If you work with the consumers’
choices and stay with them, amazing things will happen.”
Practitioners, says DeLuca, need to open their minds
and become less defensive and humble enough to see that the traditional
route leaves something to be desired. Moderation Management is in
its infancy, he says, but it’s developing a rich set of tools
and beginning to accumulate wisdom. “It’s important that
we start to offer patients with substance abuse disorders the same
medical respect that we offer to those with other types of illnesses,”
he says. Therapists, he insists, must not only explain the illness
to the client but also offer without judgment more than one approach
so some individuals don’t flee from treatment. “In the
helping profession, job one is that the patient returns for follow-up.
If we don’t engage the patient in a healing process, we fail.”
In addiction medicine, he laments, there’s a
tendency for practitioners to tell clients and patients that there’s
only one choice, although there’s no basis for such a limited
approach. “No approach does so well that any of us are justified
in being dogmatic,” DeLuca says. “Patients are diverse,
demanding that we research and provide a diversity of treatment approaches
so we can better meet patients where they are.”
— Kate Jackson is a staff writer for Social
Work Today.
For More Information:
Moderation Management
www.moderation.org
Dr. DeLuca’s Addiction & Chronic Pain Web
Site
www.doctordeluca.com
Addictive Behaviors Research Center
http://depts.washington.edu/abrc/
The Caron Foundation
www.caron.org
|
 |
