Wednesday, March 26, 2008

What is Alcohol Harm Reduction?

Excerpt from

Alcohol is no ordinary commodity. It is a legal drug which brings health, personal, cultural and social benefits for many people around the world – yet causes significant mental, physical and social harms for many others. To effectively tackle this dilemma, the alcohol field in general needs to generate and embrace new ideas and more practical approaches.

Alcohol harm reduction can be broadly defined as measures that aim to reduce the negative consequences of drinking.

A comprehensive alcohol policy needs population-level interventions, which focus on the availability and accessibility of alcohol (such as taxation and restricted licensing hours). But it needs more than this - such measures alone will not reduce alcohol related harms. In the last 20 years there has also developed an increasing (but less promoted) interest in alcohol harm reduction interventions. These tend to focus on particular risk behaviours (such as drinking and driving, binge drinking), particular risk groups (such as pregnant women, young people) and particular drinking contexts (such as bars and clubs). These approaches have broadened the sphere of interest in alcohol related harms to include social nuisance and public order problems. Very often (but not exclusively) such interventions operate at the community level.

Examples of this approach in practice are:
  • Campaigns against drinking and driving (including designated driver schemes and improved public transport in the evenings)
  • Serving alcohol in shatter-proof glass to prevent injuries
  • Training bar staff to serve alcohol responsibly
  • Promoting the safer design of drinking environments (such as bars)
  • Managing the ‘night-time economy’ and the ‘drinking environment’ in order to maximise pleasure and minimise violence and anti-social behaviour
  • Brief interventions advising people on moderate or controlled drinking
  • Education in schools and universities advising people on moderate or controlled drinking
  • Providing shelters for homeless drinkers (known as ‘Wet Centres’)
  • Providing shelters for heavily intoxicated individuals (known as ‘Sobering-Up Centres’)

The benefits of alcohol harm reduction approaches are as follows:
  • They are practical approaches (so much so that many people deliver alcohol harm reduction on a regular basis without realising it)
  • They are realistic approaches in that they (often) do not rely upon national consensus, funding, policies or legislation
  • They can be designed and delivered by local communities and stakeholders to address specific local needs and contexts
  • Their short-term aim is to minimise the impacts of drinking alcohol
  • Their longer-term aim is to change drinking cultures – encouraging the benefits of responsible drinking and discouraging harmful drinking

Introduction to Harm Reduction Psychotherapy

Ideas have different meanings at different moments in history. Ideas that once appeared crazy, dangerous, or incomprehensible later become so much a part of accepted truth that society temporarily forgets the time when these ideas were dormant. New ideas arise in response to current conditions as an attempt to make sense of and help guide us in responding to these conditions. Ideas determine our view of reality both expanding and limiting our possibilities. As history marches on and conditions change, ideas that were once progressive and useful can become stale, empty, regressive barriers to change. When the dinosaurs of outmoded ideas die, the ideas that have been hiding in the hinterlands creep back into the mainstream to repopulate the field, New ideas once again arise that attempt to explain the limitations of those that came before. This is as true for individual psychology as it is for scientific paradigms.

Within the drug and alcohol treatment field, there have been a number of great ideas that have represented new paradigms for understanding problematic substance use. The application of these ideas to clinical treatment led to revolutionary changes in practice that resulted in dramatic improvements in the care available to people with substance use problems. The addiction-as-disease concept (Jellinek, 1962) challenged the moral model of drug misuse which blamed the problem on the inappropriate values or immoral character of the user. The disease paradigm opened the way to treatment rather than punishment, for these problems. The self-medication hypothesis (Khantzian, 1985) pointed out that for many, drug use is a form of self-care that reflects an attempt to cope with painful feelings. This idea highlighted the important dimension of the meaningfulness of drug use and the necessity to recognize and address the under- lying issues the user is trying to heal through drug use. Relapse prevention (Marlatt and Gordon, 1985) pointed out that, rather than viewing a return to problematic drug use after a period of abstinence or diminished use as failure, relapse should be seen as a common natural part of the process of changing behavior, which can be an opportunity for learning that might decrease the possibility of future relapses.

Harm reduction is the most recent of these important new ideas in the substance use treatment field. It heralds a paradigm shift in the way we understand and respond to problematic drug and alcohol use. Harm reduction rejects the presumption that abstinence is the best or only acceptable goal for all problem drug and alcohol users. Harm reduction sees substance use varying on a continuum of harmful consequences to the user and the community. In doing so, harm reduction accepts small, incremental steps in the direction of reduced harm with the goal being to facilitate the greatest reduction in harm for a given person at this point in time. Inherent in this change in the treatment focus is a radical redefinition of the relationship between the client and the clinician, a departure from the paternalistic model associated with more traditional substance use treatment. Harm reduction places respect for the client's strengths and capacity to change as the starting point for developing egalitarian relationships in which clients are encouraged to collaborate in setting up the treatment and choosing goals and strategies that they find useful. This shift in basic assumption is actually consistent with psychodynamic and behavioral models of drug misuse and has many beneficial implications for treatment that will be discussed in this book. A growing group of clinicians, researchers, and public policy makers have recognized that the philosophy of harm reduction has a critically important role to play in our efforts as a field and in the larger society to improve the treatment of people struggling with substance use problems.