Asked to write about harm reduction for the leading journal for addiction counselors in the U.S., Stanton presented the essentials of harm reduction treatment. In particular, he tried to shift the mentality of counselors from the delusion that they can consistently inspire clients to abstain, to an understanding of their limited, but potentially helpful, role in improving people's lives. Of course, the assignment was quite gratifying, since it its earlier incarnation, this magazine was militantly anti-harm reduction, and attacked Stanton and some of his colleagues regularly.

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Counselor: The Magazine for Addiction Professionals, August 2002, pp. 28-32.

Stanton Peele
Fellow
The Drug Policy Alliance

Harm reduction is a term best known in the substance abuse field as a way of reforming drug policy. Replacing zero-tolerance policy, it recognizes the certainty that some people will continue to use drugs and therefore that drug use will remain a fact of life in our society. With this in mind, it seeks to protect drug users — and non-drug users exposed to drug users — from the worst consequences of such use. Harm can occur for even casual drug users, but the worst consequences are likely to befall heavy users. In this way, harm reduction is a treatment strategy that may also be appropriate for alcoholics.

Research results are discouraging — and encouraging

By now it is clear that standard, one-on-one or group addiction therapy in the United States is not sufficiently comprehensive to deal with the range of alcoholism problems facing it. Only about one in four alcohol dependent individuals enters treatment (including AA) at all, according to the National Alcohol Epidemiologic Survey (NLAES), the largest household survey of Americans' drinking ever conducted (see Dawson, 1996). Only a further minority of this proportion seriously engages in available treatments (one rule of thumb derived from AA's biannual surveys is that one in ten of those who come to AA continues to engage for as long as a year).

Moreover, the largest trial of psychotherapy thus far, Project MATCH, was completed in 1996. It produced results that could be disheartening to standard treatment approaches (see Project MATCH Research Group, 1997). MATCH — in which treatments were designed by leading practitioners and researchers, with cutting-edge manuals for guidance, for which therapists were carefully trained and closely supervised, and where patients were high-prognosis volunteers — found that few alcoholics abstained for even as long as a year following treatment. MATCH used three treatments (12-step facilitation, coping skills therapy, and motivational enhancement therapy) and two treatment groups — a strictly outpatient group and a group which first underwent hospital treatment. Of the former group, fewer than one in ten (9 percent) abstained throughout the first follow-up year. Of the latter, only about a third (35 percent) did.

Yet, clients seemed to benefit from the treatment. Liver functioning for the group improved and their drinking problems were reduced. Representatives of the government sponsor of the research, NIAAA, viewed the project and the treatments it included as highly successful. However, in order to do so, the investigators couched the results in nonabstinence terms, pointing out that subjects began treatment averaging 15 drinks on every drinking day, which included 25 days of the month, while after treatment they were drinking on only six days of the month, and having only three drinks per occasion.

One further aspect of Project MATCH that stood out was the minimal amount of therapeutic contact required to produce its results. Twelve-step facilitation and coping skills therapy required only 12 one-hour sessions, while motivation enhancement included only four sessions. Moreover, subjects on average attended only two-thirds of assigned sessions. Motivational enhancement therapy consists of encouraging alcoholics to examine their lives and values and to decide for themselves that, on balance, they want to seek sobriety. This therapy places the weight of decision-making — and also the mechanics of changing drinking habits — on the individual.

In its brevity and the reliance on clients themselves, the motivational enhancement component of Project MATCH resembles brief interventions. These are usually physician-initiated interactions with patients in which doctors provide feedback on the level of a person's drinking, arrive with the patient at goals (usually for reducing rather than quitting drinking), and check up during subsequent office visits on the patient's success at achieving these. Tested in numerous clinical trials, brief interventions have by now shown the greatest success, as measured by research outcomes, of any treatment for drinking problems (see Babor et al., 1997; Fleming et al., 2002; Miller et al., 1995). At the same time, along with motivation enhancement, they are the least costly counselor-assisted therapies and are highly cost-effective (Fleming et al., 2002; Miller et al. 1995). (Brief interventions strategies have also shown success in the areas of smoking and weight reduction.)

While brief interventions are restricted generally to non-dependent drinkers, the Project MATCH population was nearly all alcohol-dependent, and at a fairly high level of dependence. Thus, MATCH suggests that benefits of brief interventions relying on patient initiatives and compliance have greater generalizability. One further aspect of MATCH should be noted in this regard, however. Although there was minimal therapist contact, and especially so in the motivational enhancement therapy component, there was frequent, regular follow-up contact for the purpose of performing research assessments. In other words, subjects knew and anticipated that Project personnel would be in touch with them to see how they were measuring up.