In a striking example of polar viewpoints, 61% of 100 mental health professionals (psychiatrists, psychologists and social workers) in a national survey conducted by Wakefield Research on behalf of Adelphi University Center for Health Innovation, endorsed the goal of abstinence in contrast to that of harm reduction for their substance dependent patients. These very same clinicians believed that the opposite view held true for their patients; namely 61% of their patients would support a treatment goal of harm reduction as opposed to abstinence. Within this schism lie perhaps the keys to understanding some of the more telling secondary findings of this study: 1) Outpatient treatment programs often fail and 2) a vast majority of mental health professionals (67%) prefer to recommend new approaches including cognitive behavioral therapy, motivational interviewing, self management tools such as SMART recovery (with its roots in CBT), and contingency management reinforcement (with its roots in heightening motivation for change) as opposed to traditional 12-step interventions.
One does not need to go further then to understand that the perception of treatment failure might be closely linked to the disagreement between the mental health professional and their patient with respect to desired treatment outcome. This would be true for any helper-helpee relationship in which there was a lack of consensus with respect to course of treatment. In fact, our survey revealed that only 28% of mental health professionals think traditional outpatient programs are effective for a majority of their patients. Often, these programs are driven by abstinence-based mission statements upon which utilization reviews of treatment outcome and funding sources (insurance included) are predicated.
Patients seeking treatment on an outpatient basis, particularly within younger populations such as adolescents and young adults, where the line between abuse and addictive disorder is less delineated, may not be seeking abstinence as an initial goal of treatment. Perhaps their drugs of abuse are alcohol and/or marijuana and they would like to begin an exploration of harm reduction. In fact, they may not even be motivated for treatment at all, let alone seeking abstinence, instead having arrived at the doors of outpatient treatment through the leverage of others, courts, schools or parents. Naturally, treatment as measured by abstinence goals will fail, although if measured by reduction in use, or decrease in risk-taking behaviors, may be seen as successful outcomes. Implicit in the survey findings is the curious contradiction of these very same professionals to overwhelmingly “prefer” (67%) and be “open to” (93%) using newer approaches that often “begin where the patient is” (this does suggest tolerance of harm reduction) as opposed to traditional approaches such as that of the 12-Steps that foster spiritual surrender to goals of abstinence as the basis of recovery.
In the case where drug use shifts to that of opiates, methamphetamine, cocaine, alcohol dependence, or when addictive disorder becomes life threatening, or marked by repeated failed attempts to curtail use, then abstinence goals are certainly more appropriate. Our survey results reveal that 63% of mental health professionals think a person who has been treated for substance dependence cannot use that substance again responsibly. Perhaps their patients might ultimately come to share this point of view.
Written by Audrey Freshman, PhD, LCSW. CASAC
Adelphi University School of Social Work
Director of Continuing Education and Professional Development
Director of Postgraduate Certificate Program in Addiction
