Gradualism, Identity, Reinforcements, and Change

Gradualism, Identity, Reinforcements, and Change

Scott H. Kellogg1 and Mary Jeanne Kreek2
1New York University and 2The Rockefeller
University

Kellogg, S.H., & Kreek, M. J. (2005). Gradualism, identity,
reinforcements, and change. International Journal of
Drug Policy,
16, 369-375.

Scott Kellogg, PhD
New York University
Department of Psychology
6 Washington Place
New York, NY 10003

scott.kellogg@nyu.edu

Keywords:

harm reduction, psychotherapy, addiction treatment, contingency management, identity theory

Abstract

This paper reflects the ongoing development of gradualism, a drug treatment perspective that seeks to make use of the
full array of effective, creative, and innovative harm reduction
and abstinence-oriented treatments available to help addicted
individuals move along a continuum from active/chaotic use
to abstinence or moderation, as appropriate. The essence of
gradualism is an emphasis on positive change and transformation
as therapeutic goals. The paper first looks at manifestations
of gradualism in harm reduction treatment facilities. Following
this is a discussion of the role of identity transformation
in the change process. The final section explores how contingency
management or motivational incentive interventions could be
used in harm reduction settings to facilitate this kind of
therapeutic movement.

Keywords: harm reduction, contingency management, identity,
addiction treatment

Introduction

Gradualism (Kellogg, 2003) is a vision of drug-addiction treatment
that seeks to unify and integrate the harm reduction and the
abstinence-oriented treatment communities in order to create
a change-focused system that utilizes the best of both paradigms.
The impetus for this is the belief that there are so many valuable
resources in harm reduction, traditional drug treatment, and
science-based practices that it seems imperative to find a
way to offer them all to those who suffer from addictions.
Gradualism, which has much in common with the work of Marlatt
(Marlatt, Blume, & Parks, 2001), is an attempt to create
a structure that would allow clinicians and programs to utilize
all of these resources.

This paper focuses on change and movement as the essence of
gradualism. The first part of the paper reviews some of the
core ideas, the second part touches on identity as a vehicle
for transformation, and the third part proposes that contingency
management, and the use of positive reinforcements, could be
a valuable change-oriented intervention.

Gradualism

As Majoor and Rivera (2003) have argued, it is important that
a continuum of care be developed that can address the needs
of all drug and alcohol users, regardless of their level of
addiction or their motivation to change. The goal is to create
a system in which drug users could be engaged in a process
in which they went from states of active/chaotic use (Denning,
Little, & Glickman, 2004) to states of safer/reduced use
and then to states of abstinence or, where appropriate, moderation.
Abstinence is defined here as freedom from the illicit or problematic
use of licit or illicit drugs while including the proper use
of such pharmacotherapies as methadone and buprenorphine-naloxone.
Capturing a key component of this idea, one recovering person
stated, “I see harm reduction as the gradual introduction to
total abstinence” (Body Positive, 1997). Along these lines,
Kellogg (2003) expressed concerns that the abstinence-oriented
world: (1) did not sufficiently see the recovery experience,
especially the cessation of drug use, as a process; and (2)
did not emphasize the importance of relationship and affirmation
in its clinical perspective; in turn, the harm reduction movement:
(1) did not place sufficient emphasis on change and transformation;
and (2) were unclear or conflicted about embracing abstinence
as an appropriate endpoint or long-term goal for their efforts.

Harm reduction classifications

To review an earlier discussion, harm reduction interventions
can be sorted out into one or more categories based on the
goal of the intervention (Kellogg, 2003). The first category
is Staying Alive. Here the intent is to keep the individual
as safe as possible from the immediate negative effects of
the substance. The concern is that the drug users could severely
damage themselves or die. The time frame of the interventions
tends to be very immediate, and pure examples of this would
include overdose and safe injection information, naloxone distribution
for overdose prevention, and designated drivers.

The second category is Maintaining Health. Here the time frame
is somewhat longer and the focus is on protecting the individual
from problems that may come not only from repeated exposures
to substances, but also from being exposed to dangers that
may occur in environments in which drugs and alcohol are being
consumed. This would encompass the range of HIV and hepatitis
B and C interventions, and would include needle/syringe exchange,
heroin maintenance, server training, safety glassware in bars
(to prevent injury during fights; Single, 1997), and adding
thiamine to alcoholic beverages to help decrease the danger
of vitamin B1 deficiency (Strang, 1993). Interventions that
would encompass both of these goals would include low threshold
methadone maintenance, dance drug/“ecstasy” testing, low-beverage
alcohol (Single, 1997), and safe use/injection rooms.

The third category is Getting Better. Here the emphasis is
on those interventions that are intended to make longer-term
changes in use patterns – be it to control, moderate, or eliminate
use. Examples that, in some cases, also tackle the issue of
Maintaining Health include motivational interviewing (Miller,
2000), harm reduction psychotherapy (Tatarsky, 2002, 2003),
substance use management (Denning et al., 2004), medium/high
threshold methadone treatment, moderation interventions, acupuncture
and herbal treatments, drop-in centers, naltrexone and/or acamprosate
for alcohol problems, appropriate methadone (Kreek, 1991) or
buprenorphine treatment with adequate doses combined with behavioral
treatment, and contingency management focused on use reduction
(Preston, Umbricht, Wong, & Epstein, 2000). Getting Better
interventions frequently have a physician-patient or therapist-patient
relationship, while the other types of interventions are more
often based on the distribution of paraphernalia and the dissemination
of knowledge. Lastly, drug use education permeates all three
categories.

Expanding the gradualist vision

The original gradualist paper was concerned with the adoption
of an abstinence-eventually treatment stance for the majority
of patients, with the acknowledgment that there may some for
whom moderation is a possibility (Kellogg, 2003). With further
reflection on this, it is the central importance of therapeutic
movement, change, and transformation that is at the heart of
the gradualist vision. Gradualism is the place where public
health meets psychotherapy, where medicine meets metamorphosis.
Within this context, an important differentiating aspect may
be the relative commitment to, or primacy of, safety versus
that of change.

Role and philosophy

The mission statements of various harm reduction organizations
can reveal different orientations toward the purpose of their
interventions and their feelings about change. Exponents, a
New York-based facility utilizing harm reduction components,
felt that their role was to “assist individuals and their families
through difficult transitions – from addiction to recovery” (Exponents,
2005). Safe Horizon, another agency in New York, focused on
the needs of “homeless and street-involved youth” and felt
that their mission was “to act as a catalyst for their self
empowerment” (Safe Horizon, 2005). The Positive Health Project
emphasized that in their street work and outreach that they
served “as a bridge to other services such as: drug treatment…” (Positive
Health Project, 2005).

Other organizations seem more firmly entrenched in the first
two goals. The Harm Reduction Project (2005) sees the aim of
harm reduction as being centered on “reducing the physical
and social harms associated with risk-taking behavior. …Harm
reduction is about making dangerous behaviors less dangerous.” Prevention
Point Pittsburgh (2005) notes that “Our harm reduction philosophy
seeks to reduce the negative effects of drug use, both to the
user and to the community.”

It should be noted that these are mission and philosophy
statements; the actual work of these organizations and the
individual philosophies and behavior of the staff may differ.
Nonetheless, differing energies, stances, and attitudes do
emerge. The issue seems to be how broadly the organizations
and their members are willing to define themselves as active
change agents and how broad a scope that are willing to envision.
Those that use words like “transitions”, “catalyst”, and “bridge” would
appear to be more focused on Getting Better goals and would
be more likely to be seen as gradualist programs.

Identity and change

As a number of researchers and clinicians have affirmed, an
essential psychosocial core of the recovery process is the
transformation of identity (Anderson, 1998; Biernacki, 1986;
Christiansen, 1999; Granfield & Cloud, 1996; Kellogg, 1993).
Individuals who are successfully able to create and maintain
identities that are not solely focused on drug use are more
likely to reduce or even eliminate their involvement in these
activities.

Friedman and colleagues (2001) looked at the impact of helping
drug users fight for their rights on their drug use behavior. “Thus
we see the possible emergence of yet another phase of harm
reduction – ‘redemption through social struggle.’ Here, drug
users become activists; and this leads them to engage in less
risk” (p. 9).

User-run or user-involved needle exchanges also provide the
possibilities for new roles and identities. VANDU, the Vancouver
Area Network of Drug Users, is organized to allow members to
choose from a wide range of activities that they can participate
in. They find that these kinds of actions sometimes lead to
positive changes in drug use behavior (Kerr et al., in press)

The Springfield Users Council is another example of this kind
of change process. A needle exchange group that is run by active
drug users, their involvement in this process also led to positive
identity changes. “Not only are user-run programs the most
viable and effective way to reach active drug users, the users
become activists through their work. Since becoming active
in our organization, many council members have been able to
move away from ‘unmanageable’ drug use towards the stability
that maintenance brings” (Zibbell, 2005). Through this “identity
work” (Deaux, 1991), both of these organizations are providing
venues for their participants to change their lives using methods
that indirectly confront the addictive or high-risk behavior.

The Young Women’s Empowerment Program (YWEP, 2005) in Chicago
addresses the needs of girls and young women who are sex workers.
Like other harm reduction agencies, they offer a peer education/outreach
worker training. This is a paid training. The identity transformation
is contained in the fact that the client is no longer “just” a
sex industry worker; she is now an HIV educator as well.

Identity can be a crucial variable in maintaining change,
whether it be for safer behavior, moderation, or abstinence.
Drug users may have lost their sense of possibility; that is,
their images of the future may be filled with negative possible
selves (Markus & Nurius, 1986). A transformational harm
reduction setting would ideally balance their traditions of
respect for drug users and drug user autonomy with an affirmation
that the person can change and heal and that they can be something
other than an addict. In some cases, as was shown here, the
vehicle may be more one of emphasizing identity change rather
than drug use, per se. Ultimately, the new identities will
need to be competing identities, self-definitions that not
only include affiliations with positive groups or institutions
that provide pleasure and meaning, but also are incompatible
with excessive and, perhaps, any drug use.

Contingency management

One very powerful behavioral technology that could help with
these transitions and which is well-suited to the harm reduction
movement is contingency management (Petry, 2000). Contingency
management, or motivational incentives as it is increasingly
called (Petry & Simcic, 2002), is a form of operant conditioning
that is based on the work of B. F. Skinner (1983). The core
ideas in addiction settings are that drug users are in a state
of ambivalence. This is because the addictive experience provides
a complex array of reinforcing and punishing consequences.
There are the direct, reinforcing pharmacological aspects of
the drugs that lead to increases in pleasure or reductions
in suffering (Brehm & Khantzian, 1997), and the co-existing
excitements of the lifestyle; in contrast, there are also a
wide array of negative consequences – family tensions, financial
difficulties, and legal entanglements (Mid-Atlantic Node, 2000).

Contingency management interventions seek to change this balance
through the use of positive reinforcement systems. These interventions
typically target such behaviors as drug use, program attendance,
and treatment goal accomplishment. Using such reinforcers as
money, vouchers, gift certificates, and a wide range of goods
and services, investigators have sought to create a situation
in which treatment and recovery would be an attractive and
competing reinforcer to drug use and the drug-using lifestyle.

The purposeful use of reinforcements was first applied to
the problem of alcohol dependence in the 1960’s and early 1970’s
(Cohen, Liebson, Faillace, & Allen, 1971; Miller, 1975).
It was then applied to the problem of drug addiction by Dr.
Maxine Stitzer (Stitzer, Iguchi, Kidorf, & Bigelow, 1993)
in the 1970’s and 1980’s. She worked primarily with methadone
patients. In both cases, despite very successful outcomes,
this approach was not embraced by the mainstream addiction
treatment field (Bigelow & Silverman, 1999; Higgins, Heil, & Lussier,
2004)

This situation began to change with the emergence of the “crack” cocaine
epidemic of the late 1980’s. Dr. Stephen Higgins showed that
the use of reinforcements in the form of financial vouchers
could have a major impact on the drug use of cocaine-dependent
patients (Higgins et al., 2004). His work was further expanded
by Dr. Ken Silverman who focused on cocaine-dependent methadone
patients in inner-city settings (Silverman et al., 1996). This
was followed by Dr. Nancy Petry’s innovative use of an intermittent
reinforcement model that resulted in significant reductions
in cost without a loss of effectiveness (Petry, Martin, & Kranzler,
2000).

To further test the effectiveness of the approach and to
promote its use, motivational incentives was chosen as one
of the first protocols of the Clinical Trials Network of the
National Institute on Drug Abuse. The results were, again,
positive (Peirce et al., in press; Petry et al., in press).
During this process, the first adoption of the contingency
management approach by a major addiction treatment system also
began (Kellogg et al., 2005). As the body of research has grown,
it is clear that incentives have proven to be effective in
a wide range of treatment settings, with both genders, and
among different ethnic and cultural groups.

Curiously, with the exception of work by Marlatt (i.e., Marlatt & Kilmer,
1998), the harm reduction world appears to have been relatively
unaware of this approach to treatment. This is paradoxical
in the sense that the clinical philosophy that develops from
contingency management is quite compatible with that of harm
reduction in that it involves: (1) giving desirable things
to patients; (2) emphasizing the positive; and (3) and when
experiencing a setback, encouraging, not criticizing, patients
(Kellogg et al., 2005). In addition, these interventions are
particularly well-suited for treating the least-motivated,
most-troubled, and most-addicted patients (Kellogg et al.,
2005; Petry et al, 2001). It is possible, however, that the
noninterventionist stance of some harm reduction providers
has interfered with their realizing the implications of these
approaches for their work.

Relevant studies

As noted above, there are a number of studies, both classic
and contemporary, that have relevance to the activities and
interventions of harm reduction providers. In an in-patient
study conducted in the late sixties, Cohen et al. (1971) examined
the question of whether severely alcohol-dependent individuals,
in a situation in which alcohol was readily available, could
control their drinking in response to external consequences.
In reaction to an environmental reinforcer (a pleasant room
and greater privileges), the alcohol-dependent individuals
were able to moderate their alcohol use 86% of the time.

Miller (1975), in another classic study, tested whether distributing
desirable goods and services on a contingent basis to “skid-row” alcoholics
would have a greater effect on sobriety than if they were provided
noncontingently. The contingent or reinforced group showed
a significant decrease in mean number of arrests for public
drunkenness (1.7 to 0.3; p < .01) and a significant increase
in mean weekly hours of employment (3.2 to 12.0; p < .01).
There was also a significant reduction in alcohol use. There
were no significant changes in the control group. The results
showed that contingency management had a significant positive
impact on drinking behavior and its consequences. In this case,
it was also attractive because it did so without additional
costs to the providers.

In a discussion based on work by Bickel, Madden, and Petry (1998),
Marlatt and Kilmer (1998) presented a case for making treatment
an alternative reinforcer to drug use. To make treatment a desirable
proposition, they suggested a change in attitude and procedure
to increase the likelihood that patients would want to enter
and stay in treatment. Among other things, they suggested that
the abstinence requirement may be too high for many patients
and that contingency management could be used to reinforce gradual
changes in drug use.

This idea has actually been tested. Preston et al. (2001)
was able to successfully shape cocaine use with positive reinforcements
using a successive approximation model (Kazdin, 1994). Among
other things, this study showed the possibility of using reinforcements
to gradually change addictive behavior.

Lastly, in another study that addressed other issues close
to the heart of the harm reduction project, Elk and colleagues
(Elk, 1999) used monetary reinforcements to change drug use
behavior and increase medication compliance in cocaine-dependent
patients who were infected with tuberculosis. When compared
with the control group, significantly more patients in the
reinforcement condition remained in treatment (80% : 34%; p
= .017), their compliance with INH medication was significantly
better (92% : 50%; p = .003), and there was trend toward higher
rates of cocaine-free urine toxicology reports (71% : 45%;
p = .081). A similar finding was reported more recently in
HIV-positive patients who were reinforced for taking their
antiretroviral (HAART) therapy (Rigsby et al., 2000).

All of these studies have relevance to the harm reduction
project. Cohen et al. (1971) and Miller (1975) worked effectively
with populations that are similar to those found in many harm
reduction settings – at least in terms of the severity of the
addiction. Preston et al. (2001) demonstrated that drug use
can be changed gradually through shaping or successive approximations
(Kazdin, 1994). Elk (1999), in turn, showed that contingencies
could be used to make striking differences in outcome in the
nexus of drug use and medical illness. The implication is that
it might be possible for harm reductionists to be more effective
in their efforts to change drug use patterns, to increase compliance
with HIV and hepatitis C risk reduction measures, and to facilitate
motivation for change and recovery through a creative use of
positive reinforcement methods.

Pleasure and deprivation

One of the common dilemmas that drug users face in both harm
reduction and abstinence-oriented settings is that they are
frequently asked to substitute highly rewarding activities
for those that are less so. For example, if a drug user goes
from IV use (“mainlining”) to intranasal use (“snorting”),
they may find that the drug-using experience is less intense.
Some of them may also find that the use of condoms leads to
decreases in pleasure and/or added discomfort. More broadly,
change and recovery typically involve leaving a drug-centered
subculture for a new one; one that may not be as rewarding,
at least at first.

This problem has been addressed in some of the behavioral
economic studies of addictive behavior. Bickel and Marsch (2001)
pointed out the crucial issue of delay discounting in substance
abuse and recovery. Delay discounting means that where there
is a time delay before the reinforcement is received, the value
of the reinforcement diminishes. Given equal value, an immediate
reinforcer is likely to be “worth more” than a delayed one,
especially as the time of the delay increases.

Studies have shown that opioid-dependent, alcohol-dependent,
and nicotine-dependent individuals discount at greater rates
than nondependent controls (Bickel & Marsch, 2001). For
example, Madden, Petry, Badger, & Bickel (1997) using a
hypothetical situation, found that opioid-dependent patients
would rather receive $400 now versus $1000 in a year. For normal
controls, they would only accept $400 as a substitute for the
$1000 if the delay were five years.

In a similar vein, Petry, Bickel, and Arnett (1998) found
that heroin users had a shorter future time perspective than
controls, and these results were similar to those found for
individuals dependent on alcohol or heroin in other studies.
This finding has important implications. First, “a truncated
time horizon may result in a decreased sensitivity to delayed
consequences of one’s behavior”, and second, “drug abusers
may prefer the immediate benefits of drugs (high, relief from
withdrawal or dysphoria) over larger, delayed rewards (successful
career, healthy life) because preference for these latter rewards
may require an elaborate time perspective” (p. 735).

Given this differential time perspective and the possibility
that both harm reduction and abstinence-oriented treatment
may not only involve deprivation, but also may be addressing
the issue of future harm, these researchers recommended the
use of positive reinforcements for recovery-oriented behaviors
as they may both improve retention and lead to reductions in
high-risk behaviors and drug use. The reinforcements could
help make up for some of the “pleasure deficit” that the drug
users who are changing their behavior frequently experience
as they provide immediate, rather than delayed, reinforcement
for positive behavior changes.

Reinforcements and identity

Pulling several themes together, reinforcements can potentially
play two roles in identity formation. Contingency management
interventions have the potential to bring about reduced-used
or drug-free behavior in substance-using individuals. For most
individuals, the more serious the involvement in drug use,
the more central the addict identity (Biernacki, 1986; Kellogg,
1993). To the degree that individuals are in a state of reinforcement-induced
abstinence or moderation, there is a potential for involvement
in other activities and the possibility that they can engage
in behaviors that are related to other identities (i.e., work,
family, or religion) and other relationships. As these relationships
are activated and given time to grow, a restructuring of the
identity hierarchy becomes possible (Biernacki, 1986; Stryker & Serpé,
1982).

The second way in which reinforcements can be used for identity
transformation has been demonstrated in the discussion above
about peer counseling. Here drug users receive a stipend for
attending classes that give them the possibility of becoming
a peer counselor or an HIV educator. The financial reinforcements
help to bring them into contact with groups that have the potential
of providing new identities. Hopefully, many will resonate
with these possibilities.

Future directions

Contingency management may be approaching a “tipping point” moment
(Gladwell, June 3, 1996) in the abstinence-oriented treatment
world. To date, the harm reduction world has not yet consciously
embraced this powerful behavioral technology.

Harm reduction agencies have a rich tradition of providing
goods and services noncontingently to their clients. Examples
would be needles, safe-using supplies, condoms, literature,
naloxone combined with intramuscular delivery equipment for
overdose prevention, and food. The research studies discussed
here would support the idea that positive behavior change might
be accelerated if goods and services were provided both noncontingently
and contingently. This could take many forms, depending on
the needs of the drug-using community and the goals of the
organization. In situations in which getting users to attend
harm reduction facilities is an issue, money, vouchers, gift
certificates, food, clothing, stipends, and other reinforcements
could be used to encourage attendance. Positive reinforcements
could also be used to encourage other change-oriented behaviors – returning
needles, meeting with a counselor, providing a drug-free sample,
using a condom, and bringing another drug user to the site
for the first time.

To be clear, the actions of harm reduction organizations that
involve the distribution of supplies or the provision of services
that are immediately connected to the goals of Staying Alive
and Maintaining Health should be provided noncontingently (i.e.,
clean needles). Interventions oriented toward behavior change
and the Getting Better goals could be made more effective through
the use of reinforcements.

In fact, this kind of work may already be going on, but perhaps
without a conscious embracing of motivational incentives as
a treatment modality. Making contingency management a core
motivational intervention has the potential to improve the
effectiveness of both harm reduction and abstinence-oriented
enterprises. Additionally, the creation of bi-directional linkages
between harm reduction and abstinence-oriented treatment programs
could help make the therapeutic continuum a reality. In both
cases, positive reinforcements have the potential to help drug
users choose the transformational path that is at the center
of the gradualist vision.

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Author’s Note

Scott H. Kellogg, New York University, and Mary Jeanne Kreek, Laboratory of the
Biology of the Addictive Diseases, The Rockefeller University.

This study was supported by NIH-NIDA Grants P60-DA-05130
and KO5-DA-00049. We give our thanks to Maxine Stitzer for
her helpful comments.

This paper was adapted from a presentation given at the Fifth
National Harm Reduction Conference, New Orleans, LA, on November
14, 2004. Correspondence concerning this article should be
sent to

Scott Kellogg, PhD

Department of Psychology

Faculty of Arts and Sciences

New York University

6 Washington Place, Room 403

New York, NY 10003

e-mail can be sent to scott.kellogg@nyu.edu.