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Can abstinence-based treatment and harm reduction meet in the middle?

December 2, 2009
by Gary A. Enos, Editor
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A New York psychologist tries to start a discussion around a blended approach to treatment

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.”

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