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By: Garry Cooper, LCSW
Over a decade ago, a surprising survey by Bowling Green University psychologist Harold Rosenberg and graduate student Kristina Phillips, found that addictions counselors and administrators at addictions treatment facilities across the United States had a favorable view of harm reduction strategies, despite the fact that the agencies in which they worked did not utilize or stress harm reduction (Rosenberg & Phillips, 2003). At the time, ineffective strategies based on total abstinence and Just Say No were the dominant, and often only, treatment modality and paradigm. Scare tactics and harsher and harsher penalties were in vogue. Rosenberg and Phillips’ survey of over 220 addiction treatment personnel found that many agency directors, program coordinators, and supervisors were squeezed between what they believed worked and their agencies’ actual treatment philosophies and modalities. Agency treatments, he found, evolved more from the way grants were written than from cutting edge research and were more about maintaining funding and organizational structure rather than evolving their treatment philosophies and delivery as new findings emerged.
Psychologists Alan K. Davis and Harold Rosenberg recently took another look to see whether addictions counselors’ attitudes toward harm reduction have changed. (Davis & Rosenberg, 2013). In Rosenberg and Phillips’ earlier 2003 study, they had asked agency personnel to rate on a four-point scale how strongly they approved or disapproved of 17 harm reduction treatments. Then they asked whether these treatments were available at their agency and, if not, why not. The 48-state survey found that most agency personnel approved of 14 of the 17 harm reduction treatments.
In that earlier survey, acupuncture and massage, aimed at mitigating the cravings and distress of addicts and helping them to stay in treatment, garnered the highest approval rating (81 percent), but only 11 percent of the agencies offered those treatments. Sixty-one percent of the respondents approved of needle exchange programs, with only 1 percent agency availability; and 54 percent favored cue exposure therapy, which reprograms substance abusers by repeatedly exposing them to the drugs and to situations that lead to drugs, but only 11 percent of the agencies offered cue exposure. Only two harm reduction treatments had strong disapproval ratings: offering a safe place to stay after substance ingestion and substituting prescription amphetamines for street amphetamines. Overall, people were much more likely to endorse harm reduction strategies as way stations on the road to total abstinence, rather than as final destinations.
The link between practice, research, philosophy, and funding is complex. Rosenberg, who did a similar survey in England, points out that although agency personnel in both England and the United States view harm reduction favorably, British agencies use such treatments much more than do American agencies. Citing several studies (Robertson & Heather, 1982; Rosenberg, Melville, Levell, & Hodge, 1992; Rosenberg & Melville, 2005) Rosenberg and Davis point out that approximately three-quarters of British treatment programs use some form of harm reduction. The unavailability of many harm reduction treatments in America, he says, is due not just to calcified systems and funding, but to broader political considerations and attitudes about addiction. “The British recognize that what works for one addict may not work for another,” Rosenberg said, in an interview with me. “They even have a saying about their wider range of treatments: ‘You have to choose the right horses for the right courses.’” In a survey of Swiss alcohol treatment agencies done with Klingemann (2009), Rosenberg found that 90% of outpatient treatment providers felt that harm reduction was an acceptable goal for their clients, although only 40% of the respondents who worked in inpatient alcohol treatment centers endorsed harm reduction.
Noting that since his and Phillips’ 2003 survey, American attitudes toward harm reduction, as well as research demonstrating its effectiveness, have grown, Davis and Rosenberg decided to revisit harm reduction treatment personnel to see whether the gap between what they believe is effective and what they are actually practicing has narrowed. Their survey was comprised of a final sample of 913 members of the National Association of Alcoholism and Drug Addiction Counselors., and they described harm reduction (or, using their newer term nonabstinence) as a strategy aimed toward a reduction in the quantity and frequency of usage and a reduction or elimination of substance-related legal, familial, social, medical, or occupational difficulties.
The counselors were asked to rate their acceptance of harm reduction for clients diagnosed with substance use, substance abuse, alcohol use and alcohol abuse in five different settings: detox center, residential rehabilitation, group-based intensive outpatient, DUI/DWI education, or independent practice. The respondents were also asked to rate their endorsement of harm reduction as an intermediate or end goal.
The forced choice ratings were: completely acceptable, somewhat acceptable, somewhat unacceptable, and completely unacceptable. Respondents were first asked the percentage of each of the types of clients which they might favor using harm reduction with (none, 1-25%, 26-50%, and 76-100%). Those who indicated “none” were then asked to select one or more reasons why they did not favor harm reduction from the following list of reasons:
About half the respondents accepted harm reduction for alcohol abusing clients, either as an intermediate (58%) or final goal (51%). But for clients with alcohol dependence, the acceptance rates were much lower – 28% acceptance for harm reduction as an intermediate goal and 16% as a final goal. For clients diagnosed with substance abuse, just under half the respondents endorsed harm reduction as an intermediate goal (47%) but as a final goal, only 32% endorsed it. The percentages regarding clients with substance dependence were similar to those of alcohol dependence: 28% endorsed it as an intermediate goal and 16% as a final goal.
Among the respondents who said that they would not endorse harm reduction as either an intermediate or final outcome, the most common reasons why they would not endorse it were it would send the wrong message to clients, harm reduction is not effective, and harm reduction wasn’t consistent with their agency’s philosophy.
Davis and Rosenberg conclude that acceptance of harm reduction treatment has increased since Rosenberg’s earlier survey and it has especially increased in the past two decades. For example, half of the respondents now rate harm reduction as an acceptable strategy for alcohol abusing clients, as either an intermediate or final goal – roughly twice as many as endorsed harm reduction in their 1994 survey (Rosenberg & Davis, 1993). Further, in their 1993 survey, workers in residential treatment centers almost never endorsed harm reduction strategies, whereas in the current survey, significantly more clinicians in residential facilities endorsed harm reduction, especially as an intermediate goal.
Nevertheless, Davis and Rosenberg point out, harm reduction is more widely accepted in many European countries. That, they say, is regrettable. By offering harm reduction as a treatment alternative to abstinence, they believe, more people might be willing to enter treatment, and many of the problems associated with substance use – on an individual, community, or societal level–may be reduced.
Resources
Davis, A.K. & Rosenberg, H. (2013) Acceptance of non-abstinence goals by addiction professionals in the United States. Psychology of Addictive Behaviors, 27:4, 1102-1109.
Klingemann, H., & Rosenberg, H. (2009). Acceptance and therapeutic practice of controlled drinking as an outcome goal by Swiss alcohol treatment programmes. European Addiction Research, 15, 121–127. doi:10.1159/000210041.
Robertson, I. H., & Heather, N. (1982). A survey of controlled drinking treatment in Britain. Alcohol and Alcoholism, 17, 102–108.
Rosenberg, H. (1993). Prediction of controlled drinking by alcoholics and problem drinkers. Psychological Bulletin, 113, 129–139. doi:10.1037/ 0033-2909.113.1.129 .
Rosenberg, H., & Davis, L-A. (1994). Acceptance of moderate drinking by alcohol treatment services in the United States. Journal of Studies on Alcohol, 55, 167–172.
Rosenberg, H., Devine, E. G., & Rothrock, N. (1996). Acceptance of moderate drinking by alcoholism treatment services in Canada. Journal of Studies on Alcohol, 57, 559–562.
Rosenberg, H., & Melville, J. (2005). Controlled drinking and controlled drug use as outcome goals in British treatment services. Addiction Research & Theory, 13, 85–92. doi:10.1080/16066350412331314894.
Rosenberg, H., Melville, J., Levell, D., & Hodge, J. E. (1992). A 10-year follow-up survey of acceptability of controlled drinking in Britain. Journal of Studies on Alcohol, 53, 441–446.
Rosenberg, H., & Phillips, K. T. (2003). Acceptability and availability of harm reduction interventions for drug abuse in American substance abuse treatment agencies. Psychology of Addictive Behaviors, 17, 203– 210. doi:10.1037/0893-164X.17.3.203.