Issue Date: Online Exclusive, Posted On: 12/2/2009 Online Exclusive
Can abstinence-based treatment and harm reduction meet in the middle? A New York psychologist tries to start a discussion around a blended approach to treatment by Gary A. Enos, Editor
Scott Kellogg, PhD, is trying to coin a new word for the addiction treatment community. He sees the future of effective services as borrowing from the best aspects of both traditional abstinence-based treatment and harm reduction, in a blended approach he refers to as “gradualism.”
Kellogg, a clinical psychologist and clinical assistant professor at New York University, says his effort grew out of lingering dissatisfaction with both traditional treatment and harm reduction approaches. Coming from a mental health background, he found the traditional programs with which he was involved in the 1990s to be overly authoritarian and punitive toward the addict. But when he later turned his attention to harm reduction efforts originating from a public health model, he sometimes wondered if the discussion in these programs ever would turn to actually helping clients overcome substance use problems.
Two months ago Kellogg established a website (http://gradualismandaddiction.org) that he hopes will serve as a vehicle for discussion around a more nuanced approach to treatment. He says that after he began using the term “gradualism,” he noticed that practitioners in non-abstinence based initiatives in Europe in the 1970s had used the term “gradual change” to describe what they were trying to instill in persons with substance use problems.
A Gestalt-trained therapist, Kellogg holds some views that seem to place him closer to the harm reductionist’s way of looking at substance use and recovery. He questions treatment center practices that appear to profess abstinence at the risk of losing many clients before they can start making progress. He states his belief that “there’s a crisis in our treatment world because many people don’t like treatment.”
Yet he also says his perspective goes against the tenets held by many harm reductionists. He is most impatient with the attitude in some needle exchange programs and similar initiatives that “we would never tell people what to do.” Offering a shower, a sandwich and a clean needle and then repeating the process time and again are fine in the short term, but at some point you need to help build a life after you’ve saved one, he suggests.
Kellogg’s website includes three published journal articles that discuss the concept of gradualism, with the first having been published in 2003 in the Journal of Substance Abuse Treatment. The site also includes several talking points on gradualism, such as “Embraces the states of abstinence, moderation, or non-addictive use as the ultimate, if not necessarily the immediate, goal of the treatment process” and “Emphasizes that many patients need to work not only on their addictive behavior, but also on their psychological and emotional pain and anguish and that these issues may need to be addressed simultaneously or even first.”
I agree with the comments here and have felt for a long time that disease model "true believers" do more harm to many people seeking help than the few who actually are helped. My opinion has earned me many detractors who see my views as anti AA. My position is that AA does not work for everyone and we need to be able to couch disease model ideology into public health, or mental health, terminology. This is part of a process needed by the alcohol and drug counseling profession to become more versatile, and adaptable, in the way they work with people.
Friday, December 11, 2009 10:42:19 AM by SoberByChoice
A harm reduction approach enables us to develop a positive therapeutic relationship with our clients. As the last issue of AP discussed, harm reduction is a collaborative rather than confrontational approach. Properly implemented, harm reduction practices NEVER minimizes the very real harm substance abuse brings to the lives of our client, and abstinence often emerges as the plan or goal FROM the client. Obviously, we are then in a good position to help them realize their goals.
Quote, “there’s a crisis in our treatment world because many people don’t like treatment.” Perhaps clients/patients need to experience a degree of discomfort before they can begin the first step of the recovery process. Conceivably by commingling aspects of controlled drinking - (sorry, I meant harm reduction) - into the abstinence based treatment model, say a drink or fix a day, unhappy addicts would be more comfortable. In the 1960's and 70's many treatment programs prescribed librium and valium for patients whilst they underwent treatment. This practice did not work and typically clients soon returned to their drug of choice. Recovery involves change of behavior - how may addicts change while still using the very substance to which they are addicted?
Using harm reduction as one, of the many, therapeutic tools should be embraced by all counselors. Guiding our client, in their effort to reduce use, builds a strong bond one that can influence the direction of treatment, possibly resulting in abstinence. This bond, or "rapport" (I do not like the word, as it is overused by 'professionals' who practice ignorance on a daily basis), is utilized, practically, personally, and professionally. The practical use allows for a setting that is entirely relaxed, unlike the traditional treatment settings. The client opens up, thanks to the newly-appreciated self-disclosure, interpretting the relationship as a friendship. It is up to the counselor to ensure that the relationship, actual or perceived, stays in the office, in a professional manner. Personal therapuetic bonds, are deeper than the traditional therapuetic bonds, in that there are no cut and dry boundaries. A skilled counselor, will be able to direct the course, merely by being there, so-to-speak. Any degree of 'sharing' is perceived by the client as a peer-formation, and as long as it is kept in this light, by the counselor, it is therapeutically valuable. When it comes to the the professional bond, a skilled counselor will know, when to advance the course of therapy based on the client's cues. When the client is involved, not just compliant, in the development of his or her change-goals, there is progress, or 'advancement' cues. The bond is especially important when guiding the old-timers, or baby boomers, as they usually have more experience than the counselor assigned to them. A slick, "era"-educated counselor would do wonders with this group. Offering a harm reduction approach, which has never been an option for this group, would change the attitudes, bad or otherwise, justified or not, present and persistent, resulting in eventual abstinence. I believe that if we approach substance abuse as: 1) a behavior, 2) a choice, 3) a crutch, 4) an excuse for failure, and/or, 5) reversible, we can reach all abusers. They can come forward now, unashamed. When they come forward, we give them the reins, because we do not control any sector of their lives. A new, approach is appealing to this hard core group however, working with them, instead of against them, they will practice harm reduction. When the evidence is undeniable, as to the rewards of harm reduction, we can then introduce the subject of 'age'. Patience+harm reduction+maturing outabstinence, eventual and eternal.
RSS - Blogs
