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Harm Reduction - Meeting Clients Where They Are

by Kate Jackson, Social Work Today,  4(6); 2004. Originally posted: 2004-11-06 Was available from: [] but apparently has since been lost from the institutional memory of 'Social Work Today.'

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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.

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."

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For More Information:

Moderation Management

Dr. DeLuca's Addiction & Chronic Pain Web Site

Addictive Behaviors Research Center

The Caron Foundation




Addiction, Pain, and Public Health website

Alex DeLuca, M.D., FASAM, ABAM, MPH

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Originally posted: 2004-11-06 

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