Most therapists have been led to believe the notion that complete abstinence is the best and only treatment for alcohol and other substance abuse. However, this paradigm has been losing ground for years. An alternative treatment called harm reduction, or controlled drinking, has been gaining empirical support and wider practice. This clinical update does not view harm reduction as a better or worse approach than abstinence. Instead, it aims to educate psychotherapists and other health care providers about another available option for the treatment of substance abuse.
Therapists work with a great variety of people with substance abuse problems. While 12-Step programs and abstinence may be highly appropriate treatments for many clients, they may not be realistic or effective with others. Proponents of harm reduction point out that therapists who insist upon complete abstinence as the first and only option with all clients are likely to scare people away from seeking any help at all. Harm reduction focuses on the presenting problems attendant to substance abuse, as well as the substance abuse problem itself. It addresses substance abuse as one piece of a much larger puzzle. Almost all clinicians should have a good grasp of harm reduction principles and techniques in order to treat the kinds of people with substance abuse problems who are most likely to walk into our offices.
Harm reduction is a therapeutic approach aimed at reducing the
negative consequences of drug and alcohol use. It incorporates
a spectrum of strategies from safer use, to managed use to
an intermediate step towards abstinence.
Harm reduction strategies meet drug and alcohol users "where
they're at," addressing the circumstances of the substance use and
not simply the use itself.
Harm reduction accepts that both licit and illicit drug use are part
of our world and strives to minimize their harmful effects rather
than simply to ignore or condemn them altogether.
Harm reduction calls for the non-judgmental, non-coercive
provision of services and treatments to people who use drugs and
alcohol.
Harm reduction is not better or worse than abstinence: it's just
different. Some clients may respond best to, and even require,
abstinence. Some may benefit most with harm reduction. For yet
other clients, medication and other approaches may be most
appropriate.
Harm reduction is another tool for therapy. A therapist's toolbox
should be equipped with a variety of tools, techniques, and
approaches. We must remember the saying, "If all you have is a
hammer, then everything you see looks like a nail."
A surprising survey reveals that many substance abuse clinicians
and administrators endorse harm reduction techniques, but cannot
practice them because of agency rules and protocols.
A harm reduction approach conforms with the most fundamental
precepts of good therapy: respecting the whole person,
establishing an empathic therapeutic alliance, and helping clients
recognize their intrinsic strengths and their motivation to change.
Harm reduction even works for many pregnant women, and it may
be the most effective and realistic approach for high school
and college students.
Harm reduction has been around for decades but enduring myths
about substance abuse have impeded its research and use. Many
researchers now understand that the disease model of addiction
and substance abuse has limited our thinking about treatment.
Several harm reduction techniques have acquired strong empirical
support.
Motivational Interviewing, which had its roots in harm reduction
substance abuse treatment, has proven so effective that it is
increasingly used to treat other disorders as well.
Some medications used to treat substance abuse work better with
harm reduction, while others work better with abstinence.
Researchers have identified several types of alcohol abusers. They
range from binge-drinking younger people who don't drink often, to
high functioning people with alcohol disorders, to chronic, older
heavy drinkers with co-morbid mood and personality disorders and
severe legal, social and/or financial problems. It seems likely that
the abstention model, which has grown out of the disease
paradigm, is more often appropriate for the most severe type,
whose recurrent relapse drinking over a long period of time results
in an increasingly severe tailspin. On the other hand, harm
reduction may be a more viable first option with the other, less
severe, types.
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