“My daughter said to ask you can I drink this weekend.” I was just about to digest this question and come up with an answer that put the question back on the client, when he said “I know you won’t give me an answer to that, but what I really want to know is am I an alcoholic”. I wasn’t going to get away that easily. When I asked why that “label” was so important, he explained that if he were an alcoholic this meant he could never drink again, because it was a disease, a disease that couldn’t be cured, and that he would just have to accept that this illness had control over him.
Traditionally, the most dominantly used model for explaining addiction is the Medical or Disease Model. This model posits that addiction only affects certain people, those with a biological dysfunction, often as a result of a genetic predisposition. Loss of control is considered a symptom of the disease, denial a factor that maintains it. Any social or psychological factors that might be contributing factors to a person’s addiction are considered irrelevant. Consequently, confrontation of denial is essential, so is the acceptance that one is powerless over the addiction, and the only acceptable treatment is lifelong abstinence. While this explanation has the advantage of being a straightforward definition that is easy to understand and takes the blame away from people by considering them “sick” rather than “bad”, it has the disadvantage that the notion of “lack of control” actually legitimises and reinforces the addictive behaviour, as addicts are convinced that they are not at fault for their behaviour. Describing addiction as a primary disease that can’t be cured turns addicts into victims rather than them being active agents, and robs them of all hopes of getting better. It also posits that these people are different from others which can lead to stigmatisation.
Harm reduction therapy, on the other hand, is a client-centred approach to working with people that aims at reducing the harmful consequences of addictive behaviours without requiring abstinence. Interventions are designed to meet clients where they are, rather than where the therapist would like them to be. The therapist accepts the client’s view of the problem as a legitimate starting point and small, incremental steps to reduced harm as legitimate goals. Aside from steps towards abstinence or moderation, this may include resolving the client’s ambivalence about using, using in a safer manner, clarifying personal goals with regards to alcohol or substance misuse, or working on interpersonal issues. The rationale is that clients’ confidence in their ability to change increases with each small step, and they learn that positive change is possible – contrary to the traditional 12 step belief that the person is powerless over their addiction.
As addictions exist on a continuum (non-use, moderate use, persistent addiction) and people’s personal goals regarding their addiction, their motivation, and their readiness to change, their strengths and vulnerabilities and psychological and socioeconomic factors can differ greatly, an abstinence-only, one-size-fits-all approach is unlikely to be successful for the majority of users. Harm reduction therapy offers a more flexible approach addressing the multifaceted needs of this client group and each individual client. It also recognises the importance of addressing the clients’ ambivalence about changing and other motivational issues before it is possible to pursue behavioural change.
For many clients, their addiction has an important personal meaning or function, like dealing with negative emotions or a sense of identity. Giving up their addiction, unless a viable alternative solution can be identified, can cause fear and anxiety and a reluctance to change. It is therefore often necessary for users to explore the meanings and functions their additive behaviour has for them and to come up with healthier solutions before they can consider changing their alcohol or substance abuse pattern.
The therapeutic alliance, the collaborative relationship between the therapist and the client, is of utmost importance. Motivation is considered the result of the interaction between client and therapist. Confrontation is to be avoided, the focus is on the mutual development of needs, goals and strategies. This empowers the client to be active and involved in treatment, and may as a consequence lead to a reduction in attrition and dropout.
Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing. Preparing People for Change. New York: The Guilford Press.
Tatarsky, A. (2002). Harm reduction psychotherapy: A new treatment for drug and alcohol problems. Northvale, NJ: Jason Aronson, Inc.
Tatarsky, A. (2003). Addiction as a Disease: Birth of a Concept. Journal of Substance Abuse Treatment, 25, 249-256.
Thombs, D. L. (2006). Introduction to Addictive Behaviors (3 ed.). New York, USA: The Guilford Press.
White, W. (2000). Addiction as a Disease: Birth of a Concept. Counselor, 1(1), 46-51.