Andrew Tatarsky, an innovative clinical psychologist practicing in Manhattan, has produced a timely and targeted professional document-of-practice. Timely, because the idea of harm reduction (making drug policy not based on punishment, but on the broadest possible assessment of the net-least harm to society) is just beginning to be accepted in policy and practice. Targeted, because it is a document of and for clinical practice, one that cuts across theoretical orientations. Each of the ten chapters is written by a different practitioner, each with a client case study (five dealing with alcohol, one with opiates, one with amphetamines and three with multiple substances) and each with an analysis by Dr. Tatarsky. The net effect is to bring the audience into the authors’ process and experience as professionals: This is a book by clinicians and for clinicians (and students), only secondarily for the policy makers and the lay-activist audience, and only indirectly meant to communicate with the scientific community.
One complaint that can be made about the book concerns its application to policy. In practice, an “N of 10″ is actually a good-sized data set for case-based clinical research. (As an old methods professor used to intone: “One subject to hypothesize; two to validate; three to publish.”) Yet Tatarsky attempts little policy-directed scientific generalizing from the quite rich database the book presents. Of course, one book can’t be all things to all audiences and this volume doesn’t try to be, but rather offers an expert and deeply felt clinical manual and roadmap for the dissemination of operational harm reduction practices to the psychotherapeutic community.
Twelve-Step Degrees of Separation
Harm reduction diverges sharply from the currently accepted treatment model for alcohol and drug problems: abstinence and twelve-step treatment. According to Tatarsky (2002a) however, the Big Book of AA is “the original harm reduction text” and abstinence can be the best harm reduction approach. In fact, the 12-step approach pioneered by Alcoholics Anonymous (AA) does not actually require abstinence – only the “desire” to stop. The original idea was that talking with other recovering alcoholics made it easier to not drink, that night. Tatarsky believes that today’s AA, with its embarrassing “day counting” (as in, “Hi, I’m Joe, and I’ve been sober for [only] one day…”) and advice to “stick with the winners” (i.e., avoid those who still drink) reflects a contamination of the original spirit of AA by competitive, shaming trends in the larger culture.
What if the “abuser” is not sure he or she wants to stop? Paradoxically, to tap a 12-step community for support in making this decision, the user must already have the “desire to stop.” Since most alcoholics and drug addicts are, by definition, not at a point where they can consistently choose to stop, AA’s abstinence requirement in essence skims the cream off the top of the pool seeking to be cured. Alcoholics Anonymous outcome data look better as a result, as does its reputation and funding options. With only five percent of those who come to AA staying with it, is AA successful? It’s hard to say – remember, AA is “anonymous” – but Tatarsky believes that for many, AA has not been a success. And these individuals should not be forgotten; they are just as deserving of a brighter future in which their destructive patterns of drug and/or alcohol abuse are reduced, if not eliminated.
Alcoholics Anonymous is a highly structured program with specific, enforced requirements for thinking and acting. These cult-like qualities can potentially be used for the good, but frequently do enormous damage to those who don’t remain. In the world of AA – and so, in most treatment programs – if you are not abstinent, then “You still must have to hit a lower bottom.”
Alcoholics Anonymous has changed from a community of peer assistance to something much more akin to the “disease concept” of medicine. Once the user has been “in disease” with any substance, then any future use of any intoxicating substance is evidence of “relapse.” The beauty of harm reduction is its “compassionate pragmatism.” Harm reduction psychotherapies take no a priori position about drug use; what matters is the way that use may be harmful to users, family, community – a net-least detriment, systems approach.
Policy Implication: First Do No Harm
One of the more profound conclusions frequently raised by the book’s authors is simply that we must return to “good clinical practice” in the treatment of addicts. Why should people having difficulty with their (albeit unprescribed) medications be treated any differently than any other patients? Psychotherapy for drug abuse is no different than other forms of treatment, and a major accomplishment of Harm Reduction Psychotherapy is to humanize the face of the drug user, who has been the only patient told: “I’ll only treat you if you come to treatment cured.”
That harm reduction practice has grown so rapidly is all the more impressive when one considers that essentially all government funding and program licensing require user abstinence. There is now a multi-billion dollar drug and alcohol treatment industry, paid for by the government, that sets up failure with its high hurdle of absolute abstinence. When they can’t – or don’t choose to – comply, many end up feeling even worse – like failures – resulting in further escalation in their substance abuse. Such lapses are then viewed as moral failures, with the implicit message from the authorities to go even lower, to hit bottom, in order to be allowed treatment. Even when this policy ends in long-term abstinence as claimed, it makes treatment more volatile, eliciting more harmful, costly behavior on the road to success than the more moderate harm reduction approach.
Strengths and Weaknesses
This is a book whose weaknesses are truly also its strengths. Chapter One overview of harm reduction reviews the literature, but the reference list at the end of the chapter doesn’t include many of the studies cited. There is little effort to draw generalizations across the ten cases or to integrate the book’s findings with the literature review in Chapter One. The book comes with theoretical foundations, but does not attempt to extend that theoretical scaffolding. Harm Reduction Psychotherapy never purports to be a college text, yet in foregoing the potential to contribute to the policy research literature, it limits its utility in all but clinical training courses.
As William James famously said, “The cure for dipsomania is religiomania,” that is, alcoholism can be cured by peak spiritual experience. Yet while the authors frequently discuss “dual diagnosis” (substance abuse in addition to another psychological or physical ailment) and the implications of multiple substance use, the book doesn’t discuss the extensive literature on the use of psychedelics to treat substance abuse, for example, Dr. Evgeny Krupitsky’s 2002 research with Ketamine at the Leningrad Regional Center for Alcoholism and Drug Addiction Therapy. Similarly, while the “self-medication” concept is discussed at length, the book does not take up the possibility of “benefit enhancement” coming from psychedelic psychotherapy, as shown in the research on the use of peyote in the Native American Church to assist alcoholics, most recently by an author of this review, Dr. John Halpern (2001, 1996).
Yet in part by focusing on practice rather than research, Harm Reduction Psychotherapy emerges as a groundbreaking, heartfelt and ultimately successful book. It takes as its formidable task the promulgation of a new treatment paradigm for therapy with substance users – not necessarily for substance abuse. This is a field manual for psychotherapists and trainees which, if followed, has the potential to make “good clinical practice” the normative experience for substance abusers and users.
Tatarsky’s Path Harm reduction is a new and controversial movement and most government agencies and HMOs still view it with hostility or suspicion. It is not surprising then that earlier in his career as a practitioner, Tatarsky experienced great anxiety and uncertainty about how to navigate this issue. His outpatient practice was fully caught up in the requirement for abstinence. Tatarsky “felt like an imposter,” unable to discuss the things he was noticing and feeling with his clinic supervisor. He was alienated, uncertain – conceptually, “in the closet” – and in conflict. After starting a private practice, Tatarsky felt more freedom to experiment with the unconventional treatments he was increasingly drawn to for his drug and alcohol using patients. It was only later, during a conversation with a mentor, Alan Marlatt (who co-wrote the fledgling field’s more data-oriented book) that Tatarsky was informed, “You are doing harm reduction,” and found a community to support him. Reassured and empowered, Tatarsky came into his own as a practitioner, with this important book one result. We can only hope that the policy-making community will follow Tatarsky’s path and arrive at the same outcome.
Neal M. Goldsmith, Ph.D. is an applied social psychologist and President of Tribeca Research, Inc., a strategic planning consulting firm specializing in innovation, change and the process of research utilization in policy making.
John H. Halpern, M.D. is an Instructor in Psychiatry conducting research on the correlates of cocaine abuse at the Harvard Medical School -McLean Hospital Alcohol and Drug Abuse Research Center. He is currently completing field research on the behavioral and physiological correlates of peyote use in the Native American Church.
Book review from Moderation Management’s website (www.moderation.org):
Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems
by Andrew Tatarsky, Ph.D.
This ground-breaking volume provides readers with both an overview of harm reduction therapy and a series of ten case studies that vividly illustrate this approach with a wide variety of clients, treated individually and in groups by different therapists. The stories are framed by commentary from Dr. Tatarsky, who draws out their therapeutic features and builds a powerful argument for harm reduction as an approach that meets clients where they live.
Research has found that it is easier for some people to begin counseling when specific goals are not required to enter treatment. In harm reduction therapy, any treatment goal that helps reduce harm to an individual is valid. Total abstinence, which may be an outcome of treatment, is one goal among several alternatives. Both abstinence and moderate drug and alcohol use fall under the umbrella of harm reduction.
This approach tailors the treatment to fit the individual, rather than forcing the individual into a treatment model. It employs the methods of psychoanalysis, in addition to cognitive-behavioral strategies, to engage the whole person, not just the addictive behavior. Key to this is helping the client, who is viewed as unique, not part of a problem population, to unlock the hidden meanings that his or her behavior expresses. Once identified, these meanings (or coping mechanisms) can be altered through a combination of psychoanalytic, cognitive, and behavioral techniques.
Though written primarily for clinicians, Dr. Tatarsky’s book provides valuable perspectives for laypersons who are considering moderating their drinking or abstaining from alcohol altogether. Many will identify with one or more of the individuals portrayed in the case studies: Tom, a gay museum curator who expresses his anger and depression in drunken behavior toward his coworkers; Gary, a physician whose bravado masks deep personal pain and who self-medicates rather than betray his vulnerability by asking for help; Diana, a single woman who uses wine to free herself from the critical inner voice of her mother. About half of the individuals portrayed choose moderation over abstinence.
Those in search of professional guidance will be encouraged to learn that there are clinicians out there who will help them to set and meet realistic and healthy goals, and do so with understanding and compassion. And although lay-led support groups like Moderation Management are outside the scope of the book, MM members will benefit from Dr. Tatarsky’s wise observations about the interconnection of emotions and behavior, and the incremental nature of personal change.
More about the book:
This book presents harm reduction as a new model for helping drug and alcohol users who cannot or will not stop completely (the majority of users) reduce the harmful consequences of using substances. Harm reduction accepts that abstinence may be the best outcome for many but relaxes the emphasis on abstinence as the only acceptable goal and criterion of success. Instead, smaller incremental changes in the direction of reduced harmfulness are accepted. Harm reduction hinges on the fact that substance users are a broadly diverse group of people who need individually tailored treatment that meet their unique needs and strengths. After a critique of the mainstream “abstinence-only” substance abuse treatment approach that prevails in the United States, the book shows how harm reduction’s simple but radical and profound changes in assumptions and expectation have dramatic implications for improving the effectiveness of psychotherapy with the full spectrum of problem drug and alcohol users.
The book introduces Tatarsky’s integrative approach to harm reduction psychotherapy. The approach blends a psychodynamic emphasis on the multiple meanings of substance use and the importance of the therapeutic relationship with a more strategic focus on the process of changing behavior. Then the book discusses the valuable contributions of the psychodynamic and cognitive-behavioral traditions to this work. Emphasis is placed on the “unwrapping” of the multiple personal meanings contained within or expressed by substance use and the development and strengthening of the capacities required for using these discoveries in the service of making positive changes in thought, feeling and action. Later chapters explore the specific value that harm reduction has for addressing the complexity of issues commonly associated with substance use, strengthening the therapeutic alliance, working with individuals who have experienced early trauma and when drug use functions as an attempt at coping or as a revolt against the “inner critical voice.” Chapters also discuss the value and limitations of traditional therapeutic community treatment, harm reduction groups, 12-Step programs and other alternative self-help groups such as Moderation Management.
The book is also a collection of stories. It is the story of Tatarsky’s own professional transformation from a traditionally trained substance abuse expert, through his disillusionment with the limitations of the traditional “abstinence-only” model, to his discovery of harm reduction as a philosophy, treatment theory and growing movement of clinicians, drug policy and criminal justice workers, researchers and academics. Each chapter also contains a detailed psychotherapy story that illustrates the theme of the chapter. All but one are contributed by other psychotherapists in the field. The stories show the range of treatment approaches that fall under the harm reduction umbrella and the variety of clients who can be treated by this approach.
What the experts are saying:
From the forward by Alan Marlatt, PhD, Director, Addictive Behaviors Research Center, University of Washington, Seattle.
“This ground-breaking volume provides readers with both an overview of harm reduction therapy and a series of ten case studies treated by different therapists that vividly illustrate this treatment approach with a wide variety of clients. In his introduction, Andrew Tatarsky describes harm reduction as a new paradigm for treating drug and alcohol problems. Some would say that harm reduction embraces a paradigm shift in addiction treatment, as it has moved the field beyond the traditional abstinence-only focus typically associated with the disease model and the ideology of the twelve-step approach. Others may conclude that the move toward harm reduction represents an integration of what Dr. Tatarsky describes as the “basic principles of good clinical practice” into the treatment of addictive behaviors.”
Stanton Peele, PhD, JD; psychologist, attorney and author.
“Harm reduction represents a new, but timeless, way of approaching substance abuse. It is based on four recognizable realities: (1) most substance abusers do not quit ‘using’ altogether, (2) substance abusers face multiple difficulties in life apart from their substance abuse, (3) current treatment is highly judgmental and rejecting, and (4) most people who suffer from their use of substances either do not attend or fail at current treatment options. The solution to these problems is to help people where they live, by recognizing and addressing the multitude of their problems, and by accepting all progress as beneficial and something to be built upon. In addition to the valuable techniques and information in this book, the cases present a primer in the realities of substance abuse treatment and its failure in the United States.”
Edith Springer, CSW; harm reduction consultant and master trainer.
“Andrew Tatarsky’s book, using cases submitted from different schools of thought, clearly elucidates the way harm reduction philosophy can be integrated into clinical work. The cases are varied, the practitioners have unique styles and varying approaches, and the realistic conclusions offer the reader a way to integrate slow, incremental change at the client’s pace into whatever model they currently use. No longer do therapists have to send people away to become abstinent before they can work with them; no longer do therapists have to feel responsible to set goals for their clients’ drug use. This is a must read for today’s psychotherapists who want to practice state-of-the-art-healing.”
Ethan Nadelmann; executive director, The Drug Policy Alliance.
“Personal dignity and responsibility as well as compassion and the recognition that one’s steps take place one day at a time are fundamental to both harm reduction and the 12-Step approaches to drug addiction. Tatarsky’s excellent new paradigm rescues these principles with courage, compassion and intellectual rigor. Harm reduction psychotherapy has come of age.”