Fred Rotgers on Harm Reduction Therapy
By Lynn Mollick
On January 13, 2013 Frederick Rotgers, Psy.D. delivered NJ-ACT’s Winter workshop. His topic was “Harm Reduction Therapy for Substance Abuse.” The Harm Reduction approach asserts that besides abstinence, there are many ways that therapists can improve the lives of their substance-abusing patients. Alcohol and drugs will be used more safely when patients:
1. Switch from illegal drugs to legal drugs (e.g. from heroin to synthetic opioids).
2. Choose safer routes of administration (e.g. not sharing needles).
3. Avoid using drugs in dangerous circumstances (e.g. driving under the influence).
4. Reduce the frequency or intensity of use (e.g. controlled drinking).
Dr. Rotgers also pointed out that use of psychoactive substances is not necessarily abuse. But even without abuse, alcohol and drug use can cause harm. For example, any use of illegal substances, regardless of frequency or amount, carries the risk of arrest. Also, individuals who have developed tolerance can function effectively with high blood alcohol levels, but still do harm to their health.
Longitudinal research indicates that with or without formal treatment, many substance abusers moderate their intake so that it no longer constitutes abuse. So why should clinicians demand abstinence from every abusing patient?
Especially at the beginning of treatment, many patients do not want to be abstinent. Some substance-abusing patients begin treatment wanting to moderate their drug use, and others seek treatment for depression, anxiety, or marital difficulties when they also have a substance abuse problem. Dr. Rotgers asserted that therapists can treat substance misuse and other psychological problems without requiring abstinence.
Instead, the therapist should determine what goal the patient will commit to working toward. Most patients enter treatment ambivalent about their substance use. Motivational Interviewing helps them resolve their ambivalence. In treatment, focus on the costs of alcohol and substance abuse -- the negative effects they have on health, career, and relationships. But also focus on the benefits of substance use. The benefits can be powerful, and successful treatment must find more constructive ways to achieve these benefits.
Forty studies have compared confrontation with less aggressive approaches to treatment of substance misuse. None of these studies has found that confrontation was more effective. Follow the Motivational Interviewing model and be gentle and reflective instead.
Support groups can be helpful, but not for every patient. Twelve Step programs like AA are not the only option. Smart Recovery, Moderation Management, Secular Organization for Sobriety (SOS), Life Ring, and Women for Sobriety are other options. For patients who won’t attend a group, or who are technologically inclined, Smart Recovery and Moderation Management are available online.
Although Harm Reduction is an empirically supported approach, it contradicts the conventional wisdom that abstinence is the only treatment for substance misuse. To avoid liability, therapists should always offer patients choices and document thoroughly.
In his presentation, Dr. Rotgers emphasized always using empirically supported treatments for substance abusing patients – e.g. behavioral self-control training, behavioral couples counseling, mindfulness.
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