Scott H. Kellogg
New York University
Kellogg, S. H. (2003). On “Gradualism” and the building of the harm reduction-abstinence continuum. Journal of Substance Abuse Treatment, 25, 241-247.Scott Kellogg, PhD
New York University
Department of Psychology
6 Washington Place
New York, NY 10003
harm reduction, psychotherapy, addiction treatment
This paper makes the case that a perspective called “Gradualism” could serve as a foundation for building a therapeutic continuum between the harm reduction and abstinence-oriented treatment worlds. In contrast to other integrationist writers (Denning, 2001; Marlatt, Blume, & Parks, 2001), this paper argues for the incorporation of abstinence into harm reduction approaches. The goal is to build on the strengths of both perspectives while reducing their weaknesses, and examples of each are provided. Lastly, with the frequent occurrence of relapse among addicted patients, the building a continuum could also serve to provide a therapeutic “safety net” for those in need.
The main thrust of this paper is to build a bridge between the abstinence-based and harm reduction treatment communities. This approach, called “gradualism,” is centered on trying to create a therapeutic continuum that builds on the strengths of both the harm reduction and abstinence approaches, while trying to reduce their respective shortcomings. Although there has been some work that seeks to integrate harm reduction in abstinence-oriented settings (Denning, 2001; Marlatt, Blume, & Parks, 2001), the focus here is on integrating abstinence into harm-reduction endeavors.
The Categorization of Harm Reduction Activities
Harm reduction is an umbrella term that covers a wide rage of interventions. These take place in different settings, have varying goals, and are directed toward diverse populations. As an aid in developing a dialogue between the harm reduction and abstinence worlds, the compendium of harm-reduction approaches have been examined from three perspectives. The first connects the intervention with the diagnostic group that it is best suited for; the second groups interventions by the goal or goals that they are intended to achieve; and the third looks at interventions in terms of the motivational state of the substance-user or patient.
Table 1 locates 23 common or proposed interventions along a continuum from use to extreme states of dependence (not included in web site). From the table, it is clear that while some interventions are directed to all people in all situations, many have more limited targets. These same interventions can be sorted out by purpose or goal as well, and this has been done in Table 2. The objectives of the interventions have been divided into 3 overlapping categories – staying alive, maintaining health, and getting better (Marlatt, 1998a, 1998b; Wodak, 1994; see Note 1).
The interventions that are centered on keeping people alive tend to be aimed at preventing people from dying or seriously damaging themselves due to the direct effects of drug and alcohol use. The time focus of these interventions is frequently very immediate.
The approaches that focus on helping people stay healthy include those that attempt to protect the substance user from HIV, hepatitis B & C, and other negative consequences that can come from the direct use of drugs and alcohol and/or from being in situations in which drugs and alcohol are used (i.e., safety glassware). The time perspective is, generally, somewhat longer than those in the “staying alive” group.
The “getting better” group includes interventions that look more to control and reduce use – if not necessarily eliminate it. As can be seen from the list, most of these interventions have some kind of therapist-patient or physician-patient aspect to them, while the other two groups are more focused on paraphernalia and education.
Some of the concerns about harm reduction interventions can be clarified, if not necessarily resolved, through the use of this goal typology. For example, there has been some distress expressed over the therapeutic value of low threshold methadone programs (Ball & Wijngaart, 1994) in that continued drug use may be a common occurrence (Reuter, 1994). However, low threshold programs have been found to reduce HIV infection because they lead to lower levels of heroin abuse – even if they do not result in the rehabilitation of most of the patients (Rezza, 1994). In this respect, they meet the first two goals, if not the third. Wodak (1994) argues that this is not necessarily without some therapeutic potential as many drug- and alcohol-dependent persons do eventually terminate their use, and that “simply keeping alcohol- and drug-dependent people alive and well for as long as possible is a very important component of treatment” (p. 804).
The third harm reduction categorization seeks to look at the relationship between intervention and motivational state. For the most part, harm-reduction approaches and abstinence-only approaches are fundamentally addressing themselves to the needs of different groups. That is, the ideal target group for reduced-use interventions would be individuals who: (1) would quality for a DSM-IV diagnosis of alcohol or substance abuse or perhaps meet the minimum criteria for a DSM-IV dependence diagnosis; and (2) who are seeking to reduce but not discontinue their involvement with drugs and alcohol (Klaw & Humphreys, 2000; Larimer & Marlatt, 1990; Marlatt, Larimer, Baer, & Quigley, 1993a). One of the positives of this option is that by giving these individuals an opportunity to attempt moderation, a number of them will then chose to cease using drugs or alcohol (Marlatt et al., 1993a; Marlatt, Somers, & Tapert, 1993b; Tatarsky, 1998). In terms of men and women who would qualify for a diagnosis of alcohol or substance dependence, abstinence-oriented programs serve the needs of those who wish to stop using, while harm reduction interventions serve the needs of those who are not in treatment, do not presently wish to be, and may not be ready to discontinue their substance use. Again, some of the abstinence-harm reduction conflicts (Szalavitz, 2000-2001) are unnecessary since all of these approaches are catering to the needs of different audiences.
The harm reduction literature does not seem to be particularly bound by diagnostic categories; however, an informal motivational typology of substance users does emerge from the literature. This consists of: (a) those who are rationally choosing to use substances; (b) those who are unwilling to stop using at the present time (Westermeyer, n.d., a, c); and (c) those who are unable to stop at the present time (Westermeyer, n.d., a, c).
Harm reduction interventions for the first group would primarily be educational (i.e., DanceSafe, n.d.), but could also include substance-use management interventions (Denning & Little, 2001; Marlatt et al., 1993a; Moderation Management, n.d.). The second group includes those who are not ready to change their use pattern because they feel that their alcohol and drug use serves a purpose (Director, 2002; Tatarsky, 1998, This issue). As Tatarsky (1998) noted, “people use substances because they address some psychological, social, or biological needs…. [and] substances may come to serve important psychological functions that help the user cope more effectively” (p. 11). In addition to coping and self-medication functions (Khantzian, 1985; Kohut, 1977), the use of substances may be intimately connected with identities or relationships that appear to be central to the person’s sense of self (Biernacki, 1986; Kellogg, 1993; Moore, 1990), and the discontinuation of use may result in the disruption of various social networks. Lastly, the prospect of treatment itself may appear to be unattractive (Denning, 2001; Marlatt et al., 2001; Roche, Evans, & Stanton, 1997; Springer, 2003; Westermeyer, n.d., b).
In terms of intervention, patients in this group could be, and frequently are, understood within a stages of change model (Denning & Little, 2001; Prochaska, DiClemente, & Norcross, 1992; Springer, 2002), and Motivational Interviewing is a recommended technique (Denning, 2001; Denning & Little, 2001; Miller, Zweben, DiClemente, & Rychtarik, 1995; Springer, 2003; Westermeyer, n.d., a). The purpose of the encounter would be to help them move along the continuum toward taking some kind of action. A psychotherapeutic intervention might be focused on discerning the personal meaning and symbolism of the drug use, evaluating the cost-benefit analysis involved in the decision to keep using (Tatarsky, 1998), understanding the relationship between trauma and substance use (Springer, 2002, 2003), clarifying their drug-related identities and social networks (Biernacki, 1986; Kellogg, 1993), and understanding their conception of their personal life alternatives.
In contrast, the third group consists of those who are “unable” to stop. To see people as being unable to stop leads to what might be called the harm reduction of despair. In one approach, which humanistically emphasizes the needs of these terribly addicted users, harm reduction interventions may serve as a kind psychosocial hospice (see also Gelormino, 2002); a way of “being with” people who are incurably ill, a way of walking with them on a journey toward death. The other approach, which takes more of a societal view, is to see these highly addicted patients as a disease vector, be it for Hepatitis C, HIV, or crime; here, the emphasis becomes one of reducing the harm to the surrounding community. The covert (or not so covert) message, however, may be that they no longer matter as individuals (Ibrahim, 1996).
Harm Reduction as a Pathway to Abstinence
Gradualism, which has a great deal in common with the work of Marlatt (Marlatt, 1996, 1998a, 1998b; Marlatt & Kilmer, 1998; Marlatt et al., 1993 a, b, 2001), seeks to create a continuum between the world of harm reduction interventions and the abstinence-oriented treatment field. Again, this approach differs from other calls for integration (Denning, 2001; Marlatt et al., 2001) because there is a much greater emphasis on making abstinence the eventual endpoint of most harm-reduction enterprises. This paradigm would combine the harm reduction emphases on outreach to the addicted, incremental change, and gradual healing with the abstinence-oriented therapeutic perspective that the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans. As will be discussed below, this also means using the full compendium of recovery oriented interventions. Instead of being an abstinence-only model, this combined approach could best be understood as an “abstinence-eventually” model.
The strength of the harm reduction approach is in its ability to connect and form relationships (Tatarsky, This issue; Westermeyer, n.d., b). There is certainly something quite striking and quite noble about the outreach workers who go into potentially dangerous and unpleasant situations to make contact with societal “outcasts” (Springer, 2003). There is also something compelling about the creation of centers or subcultures for drug users in which they receive acceptance and welcome (Mechanic, 1996), and where they are greeted with the attitude of, “What can I do to help you?” rather than that of “Here is what you must do” (Westermeyer, n.d., b, p. 1). The warmth of this approach may be a manifestation of what Dean James Parks Morton (1996) referred to as a spirituality of being “radically welcoming,” and these interventions could also serve as an entry point to a life-change process.
Some harm reduction advocates might argue that gradualism is not necessary because harm reduction already includes abstinence as part of its continuum of care. This is not the case for two reasons. While some do believe that abstinence is a part of harm reduction (Marlatt et al., 2001), others do not. Roche et al. (1997) have clearly made the case that abstinence-oriented approaches should not be included under the harm-reduction umbrella.
The mixed feelings about the incorporation of abstinence in the model may also reflect some confusion and lack of clarity about the ultimate goal of the harm reduction enterprise. For example, Westermeyer (n.d., a) argued that, “small reductions are better than no reductions …[and] a …small improvement can pave the path for further reductions of drug use…. eventually to the point of abstinence” (p. 1). Tatarsky (1998), while acknowledging the desirability of abstinence as an ideal, maintained that, “the ideal outcome of this approach is to support the user in reducing the harmfulness of substance use to the point where it has minimal negative impact on other areas of his or her life. Whether the outcome is moderation or abstinence depends on what is practically realistic for the client, and emerges from the treatment process (p. 12).” Single (1997), in turn, goes a bit further and writes that, “Harm reduction is simply neutral about the long-term goals of intervention” (p. 8). The Harm Reduction Coalition, in their list of principles, sees the “quality of individual and community life and well-being – not necessarily cessation of all drug use – as the criteria for successful interventions and policies” (Harm Reduction Coalition, n.d., p. 1).
This neutrality about the ultimate goal of treatment also separates harm reduction from gradualism. The problem with neutrality is that it runs the risk of encouraging stagnation, of not fostering a kind of therapeutic or healing momentum.
This opposition to making abstinence the ultimate, if not the immediate, goal may well be connected to some of the social origins of the harm reduction approach, and it may be consistent with what Pearson (1991) called the “Orphan” archetype. In this vision, addicted people are seen as an oppressed and disenfranchised group. Not infrequently, they have been the victims of emotional, physical, and/or sexual abuse (Springer, 2003). The result is a network or community of wounded people who seek to care and nurture each other, while sharing contempt for the forces and symbols of authority. In this light, traditional drug-treatment programs are certainly seen as authoritarian and punitive.
Building the Continuum
Perhaps one way to understand how a gradualist continuum could exist would be to see it in terms of a developmental model involving child and parental images. The high level of acceptance of addicted people found in harm-reduction settings is likely to be experienced as a form of unconditional positive regard, of caring without demands. It is well reflected in the harm reduction emphasis on meeting the patient “where they’re at” (Denning, 2001; Denning & Little, 2001, p. 1; Harm Reduction Coalition, n.d.). This open nurturing may do a great deal to help build relationships and get these addicted persons re-connected again. The harm reduction site becomes something of a “holding environment” (Greenberg & Mitchell, 1983; Winnicott, 1963/1965). This may well work because, in my opinion, there is, among many of these patients, a deep longing for good, nurturing, affirming authority – perhaps especially for good fathers (Bly, 1992; Thompson, 1991). However, the good parent does not simply love unconditionally. And while it may be important to meet the patient where he or she is, it may not be such a good idea to leave him or her there (see also Gelormino, 2002). As Goethe wrote, and Viktor Frankl (1985) affirmed, “If I accept you as you are, I will make you worse; However, if I treat you as though you are what you are capable of becoming, I help you become that” (quoted in Mayo, 1996, p. 240). The good parent not only nurtures, but also affirms the possibility within the child. Within the context of the harm reduction classification schemes, this means working to keep them alive, to protect their health, and to help them to heal and get better. The parent that does not take action to help a child who is pain or in danger, may not be felt to be a good parent, and, since the patients themselves, for the most part, do not think that the use of drugs is a good or life-affirming activity, there is a question as to what kind of message the psychotherapist is giving if he or she does not ultimately (even if not immediately) direct them toward abstinence.
From this perspective, the eventual emphasis on abstinence, within a context of seeing both the woundedness and the potential within these individuals, also becomes a form of nurturing. The next step, then, would be for people to make a successful transition to an empowering, recovery-oriented treatment, and, hopefully, to a healthy, productive, and drug-free life. The comprehensive needle exchange program described by Majoor and Rivera (This issue) appears to embody many of these dynamics.
Tatarsky (1998) has made the point that some patients can learn to moderate and control their use of drugs and alcohol. Marlatt et al. (1993a), in their review of the literature, found that controlled drinking was a not uncommon treatment outcome. Taking this as a possibility, abstinence would still have a role here. Moderation Management, the self-help group dedicated to helping people control their alcohol use, asks members to refrain from drinking for 30 days before beginning a moderation program. They also ask them to spend that time analyzing their patterns of use and the meaning and role that alcohol has for them (Moderation Management, n.d.). Marlatt (Marlatt & Gordon, 1985) also saw abstinence as a preliminary step for those who might be able to moderate their use.
However, for the gradualist continuum to work, not only would the harm reduction field have to modify its perspective, but also the treatment community would need to transform itself as well. A good place to start would be to bring some of this “welcoming spirituality” to their treatment facilities, to create and foster an atmosphere that is less harsh and less judgmental (Denning, 2001; Marlatt et al., 2001; Roche et al., 1997; Springer, 2003). This means building on a crucial insight of the harm reduction movement – that healing and recovery are more likely to come through the development of relationship (Denning, 2001; Tatarsky, This issue), rather than through the imposition of authority. The next step would be to realize that we are living in a time of increasing therapeutic creativity in which there are more and more therapies that are helpful for addicted or drug-using people. One metaphor that could illuminate this is the idea of the “treatment mosaic,” an idea that is essentially synonymous with what is known as the treatment menu concept (Miller et al., 1995). A treatment mosaic would provide patients with a full range of therapeutic possibilities, and they would be encouraged to utilize the ones that resonated with them.
In another version of this argument, Marlatt and Kilmer (1998), building on the work of Bickel, have made the case that treatment has the potential to be an “alternative reinforcer” (p. 570) that could replace drug and alcohol use. For this to happen, treatment must be made attractive and patients must be treated well. As part of the process of making treatment a positive experience, patients, again, should be given a range of recovery options.
With this in mind, an abstinence-oriented healing network would want to utilize the entire range of existing therapeutic approaches that have been shown to have some utility. These would include the full range of self-help and support groups including Alcoholics Anonymous, Narcotics Anonymous, other Twelve-Step fellowships, SMART Recovery®, Rational Recovery®, Women (and Men) for Sobriety, and S.O.S. (see also Velten’s comments in Marlatt, 1998a, p. 21). In terms of psychological interventions for patients, there is relapse prevention (Marlatt & Gordon, 1985), other cognitive-behavioral interventions (Wright, Beck, Newman, & Liese, 1993), psychodynamically-based, addiction-oriented, long-term psychotherapy (Director, 2002), and the contingency-management and voucher-incentive behavioral programs (Higgins, Alessi, & Dantona, 2002; Petry, Martin, Cooney, & Kranzler, 2000; Stitzer, Iguchi, Kidorf, & Bigelow, 1993). Over the past few years, there have been a number of interesting and creative developments in the therapeutic community field and, ideally, these would continue. Clearly, the further development of therapeutic communities that incorporate patients who are being treated with methadone and other maintenance medications would also be a major breakthrough (De Leon, 1997).
There is also a growing literature on the “natural recovery” experience that addresses how people recover from addiction problems without self-help or program attendance (Biernacki, 1986; Granville & Cloud, 1996; Stall & Biernacki, 1986), and the insights from these studies could be incorporated into treatment. For those who are interested, religiously based treatment programs may be a possibility (Muffler, Langrod, Richardson, & Ruiz, 1997). Alternative medicine and holistic health practices may be helpful adjunctively as well (Nebelkopf, 1981), and these could include acupuncture (Moner, 1996), herbal teas and medicines (Odierna, n.d.), and yoga (Shaffer, LaSalvia, & Stein, 1997). Ibogaine may also be helpful for some as well (Alper, Lotsof, Frenken, Daniel, & Bastiaans, 1999). Lastly, there are an increasing number of medications available to help support efforts at recovery including methadone (in adequate doses; D’Aunno & Pollack, 2002; D’Aunno & Vaughn, 1992), LAAM, buprenorphine/naloxone, naltrexone, disulfiram, and acamprosate.
The Issue of Relapse
The final argument in favor of the gradualist continuum is the high rate of relapse among alcohol- and drug-dependent patients. Even abstinence advocates like Owen (in Owen & Marlatt, 2001), believe that only half of the patients in alcohol treatment will be likely to achieve sobriety. O’Brien and McLellan (1996), in a paper that strongly defended the efficacy of substance abuse treatment, put the treatment success rate for alcohol dependence at approximately 50%, for opioid dependence using methadone at 60%, and for cocaine dependence using a contingency management protocol, at 55%. (It should be noted that contingency management, while effective, is not a commonly used treatment intervention.) They repeatedly stress that relapse is a commonly occurring phenomenon, and that the treatment for substance and alcohol dependence should be considered a long-term endeavor.
The gradualist model being presented here may be able to respond to this situation. First, by offering a much wider range of options in a positive and affirming way and allowing patients to choose among them, the treatment field may be able to improve on its record of success. Second, by creating a continuum of care, a therapeutic “safety net” can be created (see also Marlatt, 1998b). The goal would be that the life and health of relapsing patients would be preserved through the work of the harm-reduction organizations, and, using the momentum of a gradualist approach, they would be able to return more rapidly to a drug- and alcohol-free life.
We are currently living in a time of rich therapeutic possibilities for working substance-using and substance-dependent patients. This creativity is taking place both within the harm-reduction and abstinence-oriented spheres. To optimize care for those are addicted, it would be ideal to connect harm reduction and abstinence treatment into a continuum that has the cessation of drug and alcohol use and the healing of mind and body as the desired end point. Gradualism has been put forward as an organizing principle to facilitate this development.
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- Wright, F. D., Beck, A. T., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse: Theoretical rationale. In L. S. Onken, J. D. Blaine, & J. J. Boren (Eds.). Behavioral treatments for drug abuse and dependence (pp.123-146). Rockville, MD: National Institute on Drug Abuse.
The three classifications used in Table 2 are based observations by Wodak (1994) and on a conversation with Dr. Bart Majoor.
Table 2. Typology of HR Interventions
|Staying Alive||Maintaining Health||Getting Better|
|Earlier Liquor Store Hours to Prevent Non-Beverage Alcohol Consumption*||X|
|Naloxone Distribution (proposed)||X|
|Overdose and Safe Injection Information||X|
|Low Threshold Methadone Treatment||X||X|
|Dance Drug/ “Ecstasy” testing||X||X|
|Safe Use/Injection Rooms||X||X|
|Low Beverage Alcohol*||X||X|
|Safety Glassware in Bars*||X|
|Needle/Syringe Exchange (Prevention Model)**||X|
|Needle/Syringe Exchange (Risk Model)**||X||(X)|
|Harm Reduction Psychotherapy||X||X|
|Medium/High Threshold Methadone Treatment||X||X|
|Acupuncture and Herbal Treatments||X||X|
|Substance Use Management||X||X|
|Acupuncture and Herbal Treatments||X||X|
|Medium/High Threshold Methadone Treatment||X|
|Contingency Management Approaches Based on Gradual Use Reduction||X|
|Drug and Alcohol Education||X||X||X|
* Single, 1997; ** Strike, Myers, & Millson, 2002