Addictions Anonymous 35: Harm Reduction
This article belongs to Addictions Anonymous column.
Harm reduction is an ancient and natural plan for minimizing the unpleasant and harmful effects of dangerous behavior. Addictions certainly are dangerous behaviors, and some experts have championed the idea of a harm reduction strategy for addictive behavior. Unfortunately, there is a great deal of misunderstanding about what harm reduction means for the addict and for the recovery movement.
At different times in the history of warfare using a shield in battle was thought to be cowardly and unfair, but the intelligent warrior, finding honor in survival, decided shields were invaluable. Taking cover in combat is also an obvious and valuable harm reduction method, but there was a time when firing on the enemy from behind a tree was viewed as dishonorable. In about 1960, automobile seat belts began to appear as options; they were condemned as foolish and laughed at by most drivers. Now they are the law. Next, our national fifty-five mile per hour speed limit came and went for reasons that go well beyond the issues of harm reduction and public safety. All of this demonstrates the inseparability of harm reduction, money, ego, and politics. But, it also shows that harm reduction works in many areas of human behavior.
Don't forget to get your flu shot this fall.
Harm reduction efforts for potentially dangerous behavior and events range from water fluoridation to limits on Wall Street trading, from earplugs to vaccinations, from food labels to emission control for gas engines, and from clean needle exchanges for drug addicts to disk drive back-ups on computers. Far from being some new and radical form of therapy or psychological theory, harm reduction is simply a useful new name for a very old set of survival mechanisms. We have rediscovered the obvious. Don't forget your umbrella, stay out of cold drafts, and eat your spinach. If you reduce the effect of harmful things, you maximize long life and health.
The actual existence of the harm we seek to reduce or avoid is sometimes unclear, as in the case of imaginary damage caused by exposure to the harmless magnetic fields of cell phones and power lines. Worthless harm reduction treatments are freely sold to the public in the absence of any documented effectiveness; these include deep bowel cleansing, mega vitamin therapy and clumsy attempts at prohibition or micromanagement of addictives. The evils of early sex education, for example, have yet to be proved by research, yet this has no impact on those who are very sure it must be banned. At the extreme of foolishness we find some groups campaigning vigorously against voluntary euthanasia for terminally ill, pain-ridden patients, but from what harm we hope to protect these dying patients no one seems able to document or even articulate. Clearly, harm reduction has as much potential for foolish misuse as the medical, moral and disease models of addiction so vigorously rejected by some harm reduction theorists.
A few writers suggest the idea that harm reduction is a valiant and novel rebellion against some kind of ancient and powerful opposition. Marlatt, (1998, p. 49), for example, in reviewing his own opinions and those of others, stated: "Harm reduction is a public health alternative to the moral/criminal disease models of drug use and addiction."
There seem to be two important classes of harm reduction: social policy and self-imposed control strategies. I refer to the latter as auto-regulation or self-regulation. It is amazing to me that so many recovering addicts and mental health experts—people with no experience or training in political science—suddenly come forth with recommendations for social action. I rather like the idea of self-regulation through study and growth as the first step.
Should we apply harm reduction to addictive behavior? Of course, but Yes is too complicated an answer. If we want simple answers we have to ask simple questions, especially when it comes to badly needed research.
Should total abstinence be the only goal of treatment for addicts? Probably not, but that might depend on many situations, not on one's allegiance to the idea that addictions are medical diseases. Please remember that the first addiction treatment programs were established in psychiatric hospitals where there was zero tolerance for drug and alcohol abuse out of concern for patient and staff safety. Even today, I do not think that inpatient units would be willing to accept the general risks of allowing selected or special patients to violate basic institutional abstinence rules. When you're in the hospital you don't usually get to drink alcohol, smoke, or take recreational drugs. Use-tolerant programs would probably have to be moved away from the main psychiatric campus. In the 1970s, if we wanted to treat gamblers, we had to accept the abstinence goal, and it was certainly a good way to start considering the very severe and advanced forms of addiction we saw in clients.
If moderation is what harm reduction means, should we have tolerance for continued or moderate use of addictives among clients in treatment? Again, the question is too broad. The answer for individual outpatient clients might be Yes, if the therapist understands that heavy use of any addictive such as gambling may lead to an ongoing altered state from which what is learned in treatment may fail to generalize to a non-altered state. Then, of course, the answer in individual outpatient work would depend on the degree of involvement with other addictives and the client's inner resources for making important changes in life. We simply do not yet know who may or may not be a good candidate for controlled use of addictives, or any other dangerous behavior, as a treatment goal.
So, is the client to be the final judge of his or her own of treatment goal: abstinence or moderation? Of course—the choice is always theirs. They will do whatever they wish in the end, but as teachers, we should have a lesson plan of our own. What therapists call positive transference is a kind of hero worship, a love/respect feeling the client seems to develop toward a personal therapist. Like it or not, any good therapist becomes a moral authority in the eyes of the client when the magic dust of positive transference is scattered about. When we accept and encourage whatever goals the client sets, we surrender some of that moral authority and discard much of what makes therapy work.
Should we allow outpatient members of therapy groups in addiction treatment to continue gambling, drinking or abusing drugs during treatment? Pragmatically, will our peer counselors be tolerant of addictive use during treatment? Would the National Council on Problem Gambling certify gambling counselors who encourage moderation and who, themselves, may continue to gamble? Will insurance companies be willing to pay for sessions if members continue to use addictives? Will family members find the treatment credible if we tolerate other addictions? Only someone with firm moral principles could thread a path through such pragmatic considerations, but, in the eyes of some harm reduction writers, the moralist is evil.
We desperately need research on the value of total abstinence as opposed to limited use in clients with different personal characteristics. Obviously, one size does not fit all, but can we work effectively in group therapy with mixed goals? The fact is, we do, and it does work. Group members who use and confess to it actually provide the abstinence-oriented members with a chance to practice their Twelfth Step work. But perhaps, with such a mixed group, in a mistaken effort to make everyone comfortable, therapists might bid the abstainers be silent so the others will feel more comfortable.
Marlatt writes that the harm reduction movement is pragmatic, but he is not the only one to discover that pragmatism is invaluable in designing treatment. A major source of referrals in the early days to our gambling treatment programs was Gamblers Anonymous. To work comfortably and effectively with Gamblers Anonymous, a group that gave endless acceptance to our low bottom gamblers in the Veterans Administration, we stressed eventual abstinence as a treatment goal. That is what our best customers told us they wanted. But members of Gamblers Anonymous, like those in Alcoholics Anonymous, are incredibly accepting of human weakness. Champions of harm reduction like to vilify what they see as traditional, hide-bound opposition to any goal other than abstinence, and yet I have never in my life found any groups as tolerant, loving, accepting and patient with backsliders as Twelve Step groups. You will find more compassion in those groups than in most professional circles.
In two published follow-up studies we looked at many quality of life issues aside from relapse and abstinence and did find, in fact, that absolute abstinence is not necessarily indicative of improved overall quality of life. Many gamblers and alcoholics following treatment reported limited use and improved financial, family and vocational life. Also, most of those doing well were attending self-help groups whether or not they made slips back to use. I think the same results are true for drug abusers.
With respect to alcohol use, age restrictions on buyers and limits on sales to intoxicated individuals seem to work well, but prohibition has generally failed by causing worse problems than those we sought to solve. Warning labels may or may not prove useful, but they certainly can't hurt. Although moderation training for alcoholics has been with us for nearly thirty years, the lack of a reliable and valid treatment strategy, not dogmatic opposition from mental health workers, has discouraged widespread use. One suspects that those problem drinkers for whom moderation training would work best are those least in need of formal treatment. Natural, unaided recovery is probably the most effective solution to the majority of alcohol problems found in younger people, and maturational moderation can arise from personal and self-imposed psychological restraints gained through experience.
Members of Overeaters Anonymous have a very special definition of abstinence. For them, abstinence is not total food abstinence. It consists of avoiding certain food substances completely such as sugars, fats and refined starches. Restrained eating—controlled eating if you will—is still the best solution for obesity, and I think we would all have a great deal to learn in working with problem eaters. Some social policies such as food labeling have helped a great deal, and members of Overeaters Anonymous have learned many self-control tricks that work well. As with all addictions, pharmaceutical products may eventually help alleviate the dark feelings behind addiction, reduce craving, and make abstinence easier.
If we were discussing clients with poor sexual impulse control, what harm reduction measures would we recommend? In terms of social policy we have, as we do with drug abuse, a plethora of legal restrictions on sexual behavior, most of which seem to have little effect. Prohibition of prostitution, for example, is certainly a disaster serving only to create busy work and easy arrests for police. In those
If you were working with clients with disorders of sexual desire would you recommend harm reduction, and what form would that take? It has been argued that oral sex is not sex. Would you recommend feathers instead of whips and chains? Would you risk the fate of a recently fired Surgeon General and recommend masturbation as a safe, universal, and harmless outlet for the young? Should the errant husband be limited to one extramarital encounter per month?
Hard questions all. These questions remind us of the need for a consistent, compassionate morality and a clear code of professional ethics. Harm reduction is a powerful tool when used in making social policy, and as concerned citizens we ought to support efforts to protect addicts and their families from the disastrous results of addiction. If we again look outside of our narrow specialty, we see that driving is a potentially dangerous or risky behavior as is hunting, the practice of medicine or psychology, piloting an aircraft, building a building, or selling intoxicating beverages. Like gambling, these behaviors are privileges, not rights. Privileging risky behavior by granted formal certification or licensing works extremely well in many areas to reduce harm to the individual and to the public at large. The single most powerful harm reduction method I can think of would be licensing gamblers to gamble, drinkers to drink and drug addicts to use certain drugs if they prove they can do so in controlled moderation. A few simple questions, answered subject to perjury, would go a long way in protecting all of us from irresponsible addicts. It would make it illegal for vulnerable people to use in any amount.
Mental health professionals might well play a critical role in building a simple screening device and in checking its reliability and validity. To get a license to gamble in the first place, one would have to pass the equivalent of a driving license examination; one would have to demonstrate understanding of the laws of probability, knowledge of the signs of pathological gambling, the dangers of drinking while gambling, how casinos make money, and so forth. The license could be suspended or withdrawn, as it is with the driver's license, for illegal acts related to gambling and failure to meet financial responsibilities.
One possible good outcome of such general licensing of dangerous behavior might be in youth education. If someone knew he or she would be held responsible for irresponsible use, then the entire issue of pleasurable activities would be taken more seriously before one ever began to use an addictive.
I believe licensing should be required to engage in any potentially dangerous behavior, from flying an aircraft to drinking alcoholic beverages. Other social harm reduction measures would include posting the odds at every gambling device or game, labeling gambling events as potentially harmful to mental health, prohibiting dispensing intoxicants in gambling environments, and enforcing existing age restrictions on who may gamble or drink, etc.
Before we admit the goal of moderation into our treatment plans, I want to know exactly how we propose to convert a problem into an asset when we encourage or tolerate addictive behavior in those we try to help. Can we teach impulse control rather than abstinence, and how do we do that? Research has a long way to go and should not be inhibited by traditional views of what is morally right or wrong.
Although not a religious person, I do admit to being both an idealist and a moralist. I believe in the perfectibility of the human spirit. I believe moral principles are essential and, of course, our ideas and moral principles ought to be subject to an ongoing reevaluation based on the worldly pragmatism of survival.
Evolution itself is our ultimate harm reduction advantage. As species evolve, small mutations take aggressive advantage of environmental opportunities and build shields against all kinds of harm. Evolution constantly improves the shields and swords that make life possible. In its broadest sense, harm reduction is essential to life even if we have known it by different names in the past. Unlike harm reduction itself, gambling, drinking and drug abuse are hardly essential. These are, in fact, trivial and intellectually barren activities based merely on making a profit or self-medicating emotions. Why would anyone do any of these things to excess if they weren't trying to patch an emotional flat tire? A wonderful and productive life is completely possible without any amount of addictive use. What honor, what nobility, and what enduring psychological superiority can we ascribe to recreational gambling, drinking or drug use when they go beyond minor and infrequent experiments? If moderation cannot occur naturally in the life of a person, what makes that a worthy goal of therapy? I therefore argue that therapists should not encourage recreational mood altering activities. Artificial mood management is and always will be a far less desirable path than the learned ability to cope with dark feelings, and these are the skills we should be teaching clients.
I draw my own ethical and moral concepts not from mystical religion, but from the laws of natural science. Therefore, as a therapist, I did my best to dissuade others from any behavior that threatens survival, and I tried to instruct them in those skills that promote growth and development.
Controlled use of dangerous addictives by those who cannot alone master the skills of moderation is controlled foolishness. Let us save psychotherapy for more important goals.
As they say in Gamblers Anonymous: If you chose to gamble, that's your business. If you want to stop, that's our business.
Marlatt, G.A. (1998). Basic principles and strategies for harm reduction. In G. A. Matlatt (Ed.) (1998). Harm reduction. Guildford: