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Harm Reduction, Part Two: Moving Away from the Moral and Disease Models

12/17/2015

Welcome back, and thank you for your comments on my first installment in this series of posts about harm reduction! This week, we'll take a look at the larger historical context of our belief systems concerning psychoactive substances and their misuse.

The full history of drug and alcohol use in human society, obviously, lies way outside the purview of this post, since we would have to track back at least 10,000 years. Additionally, these substances are always inextricably bound up in the cultural, social, economic, political, religious, agricultural, and medical developments of a people.

(For fun, see A History of the World in 6 Glasses by Tom Standage for a pop-history take on the significance of fermented beverages in the evolution of human culture.)

The United States, in particular, has always struggled with a highly conflicted set of attitudes regarding drinking. The Puritanical roots of the colonial people, and later temperance organizations, had a hand in shaping the MORAL MODEL, seen in the 19th and early 20th centuries. This model can be characterized by these beliefs:

Addiction stems from a weakness of character, and is the result of poor choices.
It is naturally associated with crime, poverty, sin, domestic violence, and laziness.
The appropriate response should be punishment, not sympathy. (For an example of how this principle continues to impact our political policy, look no further than the War on Drugs.)

This was gradually (and perhaps only partially) replaced by the DISEASE MODEL, which has been viewed as our standard approach since the inception of Alcoholics Anonymous in 1935. The precepts of this model are:

Addiction stems from a biological disease, which follows an inevitable progression from use, to dependence, to extreme consequences, to death.
It is a black-and-white issue (either your're an addict or you're not) and is incurable (once an addict, always an addict).
This malady is marked by loss of control and powerlessness, as well as the addict's denial of the severity of the problem.
The only way to arrest the disease process is total abstinence, ongoing participation in 12-step community, and turning one's life over to a higher power.

In contrast, the HARM REDUCTION MODEL of substance misuse holds that:

There is no one single cause—it is as complex as any human behavior, and often multi-determined (vs. a biological, inherited disease).

It is not a black-and-white matter, but rather a continuum of use that flows from abstinence to dependence.

(Additionally, people may skip around on this continuum, depending on their life context and emotional state.)

There is actually a diversity of outcomes for substance misuse (vs. the “inevitable progression”). For example, it has been shown that most people stop using drugs by age 29 (and few start after this age), a process Peele calls "maturing out," which reflects how competing values and goals can have an effect on our choices.
The most common outcome of chemical dependency treatment is relapse, and continued abstinence the exception*. However, this typical over-focus on black-and-white treatment outcomes overlooks large amount of improvement in those who do not maintain perfect abstinence.
Many people are able to quit or stop using problematically without outside help (by some accounts, up to 35% recover with no help from others).
We are more likely to see positive outcomes from a focus on self-efficacy and the power to set one's own goals (vs. powerlessness and surrender).

Thank you for reading! Next time, in Part III, I hope to discuss some treatment issues, such as redefining success, substance use as a biopsychosocial phenomenon, and looking at our complex relationships with our substances of choice.

* For example, Miller & Hester’s review of the literature on outcome studies regarding the efficacy of methods for treating alcoholism (from 1980 through 2002) concluded that, in the year following a treatment episode:
- 1 in 4 remained continuously abstinent
- 1 in 10 drank moderately and without problems
- Mortality during this period averaged less than 2%
- Even clients who DID drink in the year following treatment showed substantial improvement, abstaining on three out of four days, and reducing their overall alcohol consumption by 87% on average, with a 60% reduction in alcohol-related problems.

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Harm Reduction, Part One: Origins and Overview

12/10/2015

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The remarkable progress made this year towards ending our disastrous war on drugs make this an optimal time to define and discuss the concept of harm reduction*.

I was trained in and practice from a harm reduction perspective (see my services for more information), so I'd like to provide some background and information about what this means, as well as invite some conversation around alternative ways to approach alcohol and substance use.

So what IS harm reduction, and how did it begin?
Though we can trace its roots back for several decades, harm reduction largely became visible in the 1980s as an international public health movement that recognized HIV as a larger health risk than drug use in and of itself, and aimed to reduce transmission via the distribution of condoms and clean needles.

The primary principles of this health movement are an acceptance of the reality that people DO engage in high-risk behaviors, and a commitment to helping them reduce the harm associated with those behaviors, without requiring that the behaviors
themselves stop.

Out of these principles grow many of our well-known public safety regulations and health education programs, such as seat belt and helmet laws, minimum drinking age requirements, nicotine replacements, safer sex practices, and designated driver programs.

General Philosophy
Harm Reduction is a pragmatic stance, rather than one based in moral idealism, and is grounded in scientific research, human rights, compassion, and common sense.

It is consumer-oriented, maintaining a low threshold for participation; providers are committed to meeting people where they ARE, rather than requiring abstinence before treatment begins.

It is collaborative, rather than punitive; people are encouraged to participate in setting their own goals for treatment, and to work together with their providers towards those goals.

This stance represents a major shift in how we approach individuals with high-risk behaviors, opening the doors of treatment to many more people than ever before.

That's it for today--stay tuned for Part II: Moving from Away From the Moral and Disease Models!

* Much of the information in these posts and my practice was gleaned not only from the excellent book Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol, but also via live trainings with Patt Denning, Ph.D., one of the authors. For those seeking further reading in this topic, I can not recommend this book highly enough.

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Harm Reduction, Part Two: Moving Away from the Moral and Disease Models

Harm Reduction, Part One: Origins and Overview

Jessica Katzman, Psy.D.

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