The Great Debate
Related Topics
imb ...@mindspring.com (David James Polewka)
Date: Fri, 23 Feb 2001 11:12:59 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: Atatar...@aol.com To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Great Debate Info Colleagues, I am copying the Great Debate Conference Info below that some have asked about. It has registration info at the bottom. Best, Andrew THEGREAT DEBATE ABSTINENCE VERSUS HARM REDUCTION IN ADDICTION TREATMENT A ONE DAY CONFERENCE ON FRIDAY APRIL 6TH 2001 AT THE NEW SCHOOL 66 W. 12TH ST.
NEW YORK, NY PRESENTED BY NEW YORK STATE PSYCHOLOGICAL ***OCIATION (NYSPA) NYSPA DIVISION ON ADDICTIONS THE MASTER'S PROGRAM IN MENTAL HEALTH & SUBSTANCE ABUSE THE NEW SCHOOL UNIVERSITY "Kick the habit!" "Controlled Drinking" "Easy does it" There is no greater controversy in addiction treatment than the one between the abstinence-only and harm-reduction schools of thought. Differences in conception of the problem, approaches to, and goals of treatment, distinguish these schools and their advocates. The implications of this debate have crucial bearing on clinical practice, government policy, and public awareness of the needs and difficulties of substance users. The Addictions Division of NYSPA has a history of promoting education about cutting-edge issues in addiction theory and treatment. It is our hope that this conference will further that tradition, and broaden our collective perspectives on treatment.
"Zero tolerance" "Moderation!" "Needle exchange" SCHEDULE OF EVENTS 8:00-9:00 Registration (includes coffee) 9:00-9:30 Opening Remarks Lisa Director, PhD 9:30-10:30 Abstinence: On not playing with fire Suzanne Spross, PhD Origins and current status of harm reduction Bart Majoor, Drs \ 10:30-10:45 BREAK \ 10:45-11:45 Abstinence, gradualism, & bringing them home safely Scott Kellogg, PhD Theoretical rationale and clinical applications of harm reduction Andrew Tatarsky, PhD 11:45-12:00 Panel Discussion 12:00-1:00 Facilitated Small Group Discussions \ 1:00-2:00 LUNCH \ 2:00-2:15 Re-introduction Lisa Director, PhD 2:15-3:15 Small Group Reports and Panel Discussion \ 3:15-3:30 BREAK \ 3:30-4:30 Case Presentation and Panel Discussion F. Michler Bishop, PhD 4:30-5:00 Question and Answer and Wrap Up FEATURED SPEAKERS F. Michler Bishop, PhD, CAS. Director, Alcohol and Substance Abuse Services, Albert Ellis Institute.
Lisa Director, PhD. Faculty, New School University, Institute for Child, Adolescent and Family Studies. Private practice, New York City.
Scott Kellogg, PhD. Clinical Psychologist, The Laboratory on the Biology of Addictive Diseases, The Rockefeller University; Psychotherapist, The Cognitive Therapy Center of New York, New York City.
Bart Majoor, Drs. Deputy Director, St. Ann's Corner of Harm Reduction.
Consultant & Trainer for the European Addiction Training Institute and the Netherlands Institute on Mental Health and Addiction. Private practice.
Suzanne Spross, PhD. Psychologist, Adolescent Diagnostic Unit. Daytop Village, Inc.
Andrew Tatarsky, PhD. Private Practice; Chairperson, Mental Health Professionals in Harm Reduction.
FEES Conference Non-NYSPA Member $75 at the door Non-NYSPA Member $65 in advance by 3/15/01 NYSPA Member $55 Student $35 CE Credit (Psychologists) $10 (6 credits) (Group rates available for 10 or more. Please inquire) CONTINUING EDUCATION A certificate of attendance will be issued to all attendees.
6 CE credits for psychologists are available for an additional $10. The Foundation of the New York State Psychological ***ociation is approved by the American Psychological ***ociation to offer continuing education to psychologists. The Foundation of NYSPA maintains responsibility for the program REGISTRATION NAME CREDENTIAL ADDRESS STATE ZIP NYSPA MEMBER NON-MEMBER STUDENT CONFERENCE: CE CREDIT: TOTAL: $ PAYMENT (Refunds if cancellation before 2/29/01) Check Enclosed (Payable to NYSPA)? Please charge MASTERCARD VISA CARD # EXPIRATION DATE / / SIGNATURE Detach & return to: NYSPA, 6 EXECUTIVE PARK DRIVE ALBANY, NY 12203 1-800-732-3933 ???????WANT TO FIND OUT MORE ABOUT THE NYSPA DIVISION ON ADDICTIONS????????
CONTACT: kell...@rockvax.rockefeller.edu Conference Planning Committee Members Julie Barnes, F. Michler Bishop, Lisa Director, Scott Kellogg, Bob Lichtman, A. Jonathan Porteus, Marlene Reil, Debra Rothschild, Suzanne Spross, Andrew Tatarsky, Alexandra Woods
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imb ...@mindspring.com (David James Polewka)
Date: Sun, 4 Mar 2001 18:00:12 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Jeffrey A. Schaler, Ph.D." <jsch...@american.edu> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate In fact, the following statement is inaccurate and misleading: | There is no greater controversy in addiction treatment than the one | between the abstinence-only and harm-reduction schools of thought.
| Differences in conception of the problem, approaches to, and goals of | treatment, distinguish these schools and their advocates. The implications | of | this debate have crucial bearing on clinical practice, government policy, | and | public awareness of the needs and difficulties of substance users. The | Addictions Division of NYSPA has a history of promoting education about | cutting-edge issues in addiction theory and treatment. It is our hope that | this conference will further that tradition, and broaden our collective | perspectives on treatment.
Abstinence-oriented and "harm reduction" approaches are both based on explanatory paradigms embracing the idea that addiction is a treatable disease. While self help programs such as SMART Recovery and the like are abstinence-oriented, and their supporters generally reject the disease model, most abstinence-oriented approaches are based in the idea that addiction is a disease characterized by loss of control. "Harm reduction" approaches rely on a similar myth: For example, most people who support "harm reduction" policies believe addiction is treatable. So, to frame the controversy in the way the Addictions Division of NYSPA is doing is misleading: One pseudo-medical approach compared to another isn't much of a controversy, let alone a "great" one.
Again: "It is our hope that this conference will further that tradition, and broaden our collective perspectives on treatment." How about if we "broaden our collective perspective" on the fact there's nothing to treat?
The greater controversy, if we are to speak of such things, is between the idea that addiction is treatable versus untreatable. For if addiction is not a disease, it cannot be treated. In many ways, this is why the disease model controversy won't go away: "Treatment" programs must be removed from the realm of science, and relegated to the realm of religion. Certainly, there are "treatment providers" who "treat" people for "addiction," yet they do not believe addiction is a disease. How can they do it? By lying to themselves and others--hypocrisy! If addiction is not a disease, it is not "treatable." No one "treats" addiction. It's impossible!
"Treatment" for "addiction" is conversation. Conversation is metaphorical, not literal, medicine.
The therapist/counselor asks a client, insists that a client, be honest.
Being honest is necessary in order to separate fact from fiction. Yet the therapist/counselor is being dishonest, confusing fact with fiction, when he or she believes or defends the idea that addiction is treatable, even when there is no disease to treat. The therapist/counselor is saying to the client "do what I say, not what I do." In this sense, it seems to me, "treatment" for "addiction" is a problem masquerading as a solution.
Jeff Schaler Jeffrey A. Schaler, Ph.D.
Adjunct Professor Department of Justice, Law and Society School of Public Affairs American University Washington, DC Telephone: 301.585.5664 Fax: 301.585.5668 http://www.schaler.net jsch...@american.edu
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imb ...@mindspring.com (David James Polewka)
Date: Tue, 6 Mar 2001 01:09:51 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Eric Bruns" <elbr...@email.msn.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate by Eric Bruns/ disease? harm-reduction?
Dear Henry and Jeff, The thread of the conversation has become rather esoteric and in playing the semantic game one has to concede that Jeff has solid ground to stand on.
However, I wish to be enlightened further (indeed Henry I will visit a book store this week - does Amazon carry the book you mentioned if my local Barnes and Noble does not carry it?) and will bring two other points into the discussion.
The DSM has some utility in the realm I choose to live in and it defines chemical dependency with several criteria including "clinically significant distress" for the individual impacting multiple life areas. Would not the consequence of drug use that leads an individual to prison and/or taking the life of others by being involved in the drug game and elective intoxication qualify as distress to the individual who now perhaps feels some remorse, shame or guilt? Or is it a matter of public policy as having defined illicit chemical use as illegal that is to blame for this individuals problems?
The population that I currently work with is incarcerated adult male felons who have chemical dependency histories. A common theme for these individuals is a running history of deceit, abusing the trust of families and other relationships, neglect of children and marriages, indeed spawning multiple illegitimate children through drug induced frenzies of intercourse with nameless and faceless females. Now that the criminal justice system has their attention many of them come genuinely motivated for treatment and wish to not repeat behaviors that have brought them many negative consequences in their lives. Or again is public policy that is to blame for their woes? If drugs were legal maybe the autobiographies of these individuals would have different outcomes? Who knows?
I'll agree that what happens in the context of treatment is conversation.
It seems to be the natural and easiest medium for communication. I believe we are hardwired biologically and for this to be so and our cultural context provides the software. Again, the form and direction of the conversation is directed by the need of the client and the motivation of the provider to enable the client to realize some relief. Perhaps in a society that provided for all equally only a few remaining altruistic individuals would remain in the treatment field and those in it for more materialistic ends would fade away.
Jeff, it would seem that you misunderstood or perhaps I wasn't clear in my reference to your credentials as being a basis for open-mindedness. I was indirectly questioning whether or not someone with an advanced degree was open to a "conversation" and an exchange of ideas that might then allow someone to adapt or shift in point of view, or perhaps does that indicate such an investment in your point of view that it then becomes dogma? If the latter is the case then conversation is not possible as two way communication will not take place. It simply then becomes a matter of people speaking at one another instead of to each other.
I look forward to further dialogue to help clarify my understanding of an issue that does indeed threaten our society in multiple and insidious ways.
Sincerely, Eric
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Eric L. Bruns, Psy.D.
Licensed Clinical Psychologist
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imb ...@mindspring.com (David James Polewka)
Date: Mon, 5 Mar 2001 12:08:37 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: Henry Steinberger <hsteinber...@earthlink.net> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate by Eric Bruns/ disease? harm-reduction?
--============_-1228310210==_ma============ Content-Type: text/plain; charset="us-ascii" ; format="flowed" Eric-
Thank you for your excellent response to Dr. Schaler. Hopefully you will read his book Addiction is a Choice which more fully states his interesting and provocative position.
I was glad that he made the point the addiction need not be regarded as a disease. It is rare to hear a presentation in this field without the genuflection to the "disease" concept in as a preface, even if the presenter is going to suggest approaches that have nothing to do with a disease. Yet we do, as psychologists treat behavior disorders [just as our medical counterparts "treat" people with injuries that are not diseases, problems related to poor behavior and even normal human functions like child birth] so it seem fine to drop the demand for as "disease" label, without Schaler's insistence that there is nothing to treat.
I find that there are useful outcomes from using the disease metaphor [e.g. the problem is serious, blame is not an issue, there are medical problems that may result from prolonged use or abuse, there are "treatments" available to help just as with a disease].
But the insistence that there is literally a "disease" rather than a complex of habit, intoxication, cultural proclivity, social acceptance, physiological adaption or habituation leading to biological change [not in itself a disease any more than getting pumped up via exercise], and genetic predisposition via some yet unknown route, definitely has a down side that is not addressed in the Great Debate.
I'd say that the disease model obscures what is being studied, creates excuses for irresponsible behavior, sets up barriers to change and treatment, leads to exploitation by people with religio-spiritual agendas, and in many other ways I cannot enumerate here, may interfere with the process of changing the harmful behavior.
In this it seems that you and Jeff have some agreement despite his extreme no disease = no problem stance. The debate that ought to be discussed, as I see it, is not between abstinence vs harm reduction, but rather between the abstinence/disease alliance vs the harm-reduction/bio-psycho-social approach.
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imb ...@mindspring.com (David James Polewka)
Date: Sun, 4 Mar 2001 19:07:20 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Eric Bruns" <elbr...@email.msn.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate Dear Jeff Schaler, I find your approach interesting but your use of terminology betrays a misunderstanding of mental health issues.
Indeed you are correct, chemical dependency (addiction is a lay term and misleading) is not a disease but is a treatable disorder, a problem with a biopsychosocial etiology. To formulate an intervention without an accurate understanding of what it is that you are treating will inevitably lead to poor outcomes.
Chemical dependency is not a disease because you cannot arrest a disease and send it into remission simply by stating "I'm sick of the symptoms of my disease therefore I quit." However, some people can indeed make just such an effort and become completely and permanently abstinent. However the majority of folks need help in identifying the biopsychosocial roots of their problem and learn coping strategies to become sober.
Ethics prevents deception in research and treatment. The American Psychological ***ociation has a strict ethical policy that prevents psychologists from acting in a way that would harm a client. Therefore part of the conversation in treatment is education that gives the client factual information about the basis of chemical dependency so that the client becomes empowered via a strengthened internal locus of control to implement sobriety based coping strategies.
As long as misinformation about the nature of chemical dependency is proliferated a coherent policy cannot be generated to deal with this incredibly debilitating individual and societal problem.
I hope that your scholarly credentials indicates that you are someone who is open to ***imilating new information that will allow you to come to a new understanding of an issue when you hear truth. The conference you malign is attempting to come to a greater understanding of how to help people who have trouble helping themselves.
Sincerely, Eric
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Eric L. Bruns, Psy.D.
Licensed Clinical Psychologist
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imb ...@mindspring.com (David James Polewka)
Date: Tue, 6 Mar 2001 18:08:39 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Rizzo, Anthony MD" <ARi...@scrippsclinic.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: RE: The Great Debate From: Rizzo, Anthony PHD To: 'Jeffrey A. Schaler, Ph.D. ' Cc: Subject: RE: The Great Debate Sent: 3/6/01 3:29 PM I congratulate someone coming to their senses to reframe this so-called "state of the art" conference in NY. I recently received the brochure and could see only one presentation defending the disease concept. I wonder if all the proponents of moderation management read the Hazelden Research Update of August 1998, "Addiction: A Disease Defined." It compared the compliance and relapse rates for Insulin Dependent Diabetes, Medication Dependent Hypertension, Adult Asthma, and Abstinence Oriented Addiction Treatment. All had comparable statistics and are viewed as bio-psycho-social illnesses prone to relapse. So, my proposal is to go to the next AMA Convention and suggest that physicians apply harm reduction and moderation management techniques to a diabetic or hypertensive; watch the mortality and malpractice rise.
It's amazing to see these psychologists and practictioners, many who appear to be in private practice, taking advantage of most addict/alcoholic's wishes to control their drinking/using. I asked this question recently in my treatment group, and all agreed they would seek out such "experts" if they knew they could "have just one drink." One real question for this debate is what are the malpractice rates like for these proponents and how many of their patient's have died or suffered additional traumatic loss, based on being "treated" with moderation management or harm reduction. And the bigger question...how much money has this private practictioner reaped from a desperate alcoholic/addict who would pay any amount just to learn how to have one drink. I've seen innumerable "moderation drop-outs" in my program, countless consequences later. Over the past ten years, when the idea of moderation management comes up in the group, I ask all to return to the group and give testimony if they learn how to drink/use successfully at some point in the future, and I would permit them to explain their methodology.
Do I need to even say how many have returned with success stories?
I work in a very large medical group with psychiatrists and internists...most just roll their eyes and laugh when I talk about this debate...and say something to the effect, "...so you psychologists are still in the Skinner box trying to recreate the wheel and put human lives at jeopardy while you are doing it?" No one can debate that motivational therapies and harm reduction work for prevention and to motivate someone to address their substance abuse problems. But once diagnosed with alcohol dependence according to ICD-10 or DSM-IV criteria...clinicians on both sides of the bell curve see learning how to remain abstinent, relapse prevention, and sober coping skills as the real treatments. The whole basis of NIDA and NIAAA are built on these principles.
There have been numerous articles written in health psychology about the power of support groups in recovery from various illnesses. When one analyzes the factors that comprise AA, has anyone even thought that it's not the "god" thing, it's the support and emotional growth that occurs from this. Innumerable physicians, scientists, and secular humanists who are devout atheists, can see through this " great debate," go to their AA meetings which fit their "demographic," and stay sober.
Anthony Rizzo, Ph.D.
Scripps Clinic Division of Mental Health San Diego, CA
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imb ...@mindspring.com (David James Polewka)
Date: Tue, 6 Mar 2001 21:09:12 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Eric Bruns" <elbr...@email.msn.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate Dr. Rizzo (MD and Ph.D.?), I would like to add my voice to those concerned about the use of "moderation" techniques in working with chemically dependent individuals.
This particular approach is contraindicated for the population I work with of incarcerated male felons. The rules of parole are very specific about ANY chemical use while still under the supervision of this part of the criminal justice population. However, even while completing an internship with a VA hospital and working with an acute inpatient population that often included detox needs, it was apparent that a moderation approach was just plain dangerous (malpractice is a valid concern here!).
While I am not conversant with Jellinek's work that described the different types of alcoholics (a continuum model) clearly the worst end (gamma?) of that continuum would be inappropriate candidates for moderation. I'm not sure where along the continuum that proponents of moderation would indicate that it is an appropriate choice for their clients. I would be very interested in reviewing the instruments or clinical decision model that identifies which clients are appropriate for moderation. Perhaps that is where the conference would educate me were I able to attend. However, working for a state government is limiting in the types of training/educational events that are approved. Hopefully as my career progresses I won't be so limited?!
I completely agree that "clinicians on both sides of the bell curve see learning how to remain abstinent, relapse prevention, and sober coping skills as the real treatments." We utilize AA exclusively for helping inmates on parole learn to join a positive peer group that has abstinence as its primary reason for existence. Whether they move on to a spiritual awakening is up to them and it may undoubtedly further help some while not being useful to others.
Thank you for your contribution.
Sincerely, Eric
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Eric L. Bruns, Psy.D.
Licensed Clinical Psychologist elbr...@msn.com -or-
eric.br...@mail.state.ky.us
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imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 01:09:06 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "DR. ROBERT DR. ROBERT M. LICHTMAN" <robert...@worldnet.att.net> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate I believe that my colleagues and myself are from Mars, way out-of-line and unaware of what is going on in addiction treatment. Again . . . I (we), if we had control over human behavior, would prefer that people remain abstinent. Even a correctional model fails. Punishment doesn't work, never did. I'm radically behaviorally trained (1960s & 1970s) "structure the environment and the behavior will change," yes, oh, well, as long as the external controls are always there. Once released though, the person resorts back to their old "substance preferred" behaviors, generalization never occurs. People learn how to play the AA game and tell us what we want to hear right up to their release. When will we realize this is a psychological phenomenon? Look at drive factors. If it is a disease, how come medical people have not come up with a cure or a treatment for it? If it's genetics, then geneticists will agree that genetics is not destiny. How can a person get high on life, when there is literally "no life" to get high on? Let's get real. People do not want to remain abstinent, they want to do their drugs. If that is what they want we have to "meet them where they are at." If Moderation Management works, do that. If another approach works better, then do that. "It's my way or take the highway," never worked. The Rockefeller laws have to be repealed. Now Ecstasy is on schedule one along with Heroin and Crack-Cocaine. Drug laws have always been based on emotion, never on reality. Can people use substances both licit and illicit in a rational fashion? You can bet your life on it. Should a person who was once dependant on any substance be encouraged to go back to use sensibly? Not in my book. Why go back to a behavior that was once so devastating? Then again, short of locking them up, or threatening them with a lock-up, how much control do we exercise over anybody. Enough said! Bob Lichtman
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imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 01:09:33 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Dr. J. Michael Faragher" <farag...@mscd.edu> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: RE: The Great Debate From: Rizzo, Anthony PHD I wonder if all the proponents of moderation management read the Hazelden Research Update of August 1998, "Addiction: A Disease Defined." It compared the compliance and relapse rates for Insulin Dependent Diabetes, Medication Dependent Hypertension, Adult Asthma, and Abstinence Oriented Addiction Treatment. All had comparable statistics and are viewed as bio-psycho-social illnesses prone to relapse.
........and that's just the beginning! Relapse (recidivism) rates for criminal behavior approximate those of addiction. AND, the disease of shop lifting has relapse rates that seem, in my clinical experience, to approach those of the disease of fingernail biting.
Mike Dr. J. Michael Faragher ***ociate Dean School of Professional Studies Metropolitan State College of Denver (303) 556-2978
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imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 06:08:49 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Jeffrey A. Schaler" <jsch...@american.edu> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate "Is Abstinence the Answer to Alcoholism?," November 19, 1997; and ""Do Drugs Cause Addiction?," August 26, 1996" Debatesdebates transcripts available at http://www.enabling.org/ia/szasz/schaler/ddtranscripts.html Jeffrey A. Schaler, Ph.D.
Adjunct Professor Department of Justice, Law and Society School of Public Affairs American University Washington, DC Telephone: 301.585.5664 Fax: 301.585.5668 Home page: http://www.schaler.net E-mail: jsch...@american.edu
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imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 09:18:39 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: Fred <fred_e...@yahoo.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate
--- Eric Bruns <elbr...@email.msn.com> wrote: Never one to duck an argument, I would ask on what research do you base this ***ertion? The Correctional Service of Canada has, for years, offered both moderation and abstinence approaches (offender chooses, not the clinician) in its substance abuse treatment programs, usually when the offender is alcohol dependent (there aren't any really good, tested treatments for moderated drug use, although there are two treatment manuals available--one from New Zealand, one from the Netherlands). They have collected some very interesting data in this regard.
First, only a small percentage of offenders choose moderation (about 20-25%). Of these, half shift their goal to abstinence once they are fully informed about what effective moderation entails. When those who choose and stick with moderation are compared with those who choose abstinence on criminal justice related outcomes (rearrests, parole violations, new convictions) following release, there is virtually no difference! In fact, those who choose and stick with moderation actually do marginally better!
If you're interested in the published work, Glenn Walters has a meta-analytic review of randomized trials of behavioral self-control training, which is inherently a moderation approach, that appeared in the Winter 2000 issue of "Behavior Therapy." He reaches the following, stunning conclusion based on this review: BSCT does as well as abstinence-focused treatments, regardless of problem severity!
Further, the treatment literature is quite clear about the disadvantages of imposing abstinence as a goal (even though, if CSC's data are correct, we'd only have to do that with a minority of offenders, anyway!). Bill Miller's article in the first volume of "Drugs and Society" provides a nice, though dated, review of this research. He omits Sanchez-Craig & Lei's cl***ic paper on the "Disadvantages of Imposing a Goal of Abstinence" that appeared in the British Journal of Addiction in 1986.
That's the research.
Isn't it ultimately *always* the client's choice how to deal with this? Since when is the therapist's role one of enforcing criminal justice sanctions? Isn't that the job of the parole officer? Since when have therapists become the arbitors of what clients should/shouldn't do with their lives? Sure, we can recommend, and ethics require us to recommend what we think will be the safest, healthiest options. But I think we forget at our (and our clients') peril, that the *client* makes the decisions about his/her life, not us, not the criminal justice system, not mom, not dad. The client. We may not like or approve of those decisions, but it is still *always* the client's choice how to behave.
Again, I challenge you to provide data to support this ***ertion.
How is it "malpractice" to treat patients according the what the scientific literature shows?
Research shows that many people detox, are treated and then moderate, even though they are treated in abstinence-focused programs. In fact, the outcome research is pretty clear that moderate use, abstinence, and continued problem use are all about equally prevalent post-treatment (again, I refer you to Miller's paper in Drugs and Society).
Perhaps, but again, the research is not strongly on your side. While it seems clear that moderation becomes more difficult the more dependent a patient is, there are still moderators among the most dependent patients. Walters's review shows this clearly, as do other data, such as Vaillant's longitudinal data (although he wishes they didn't, being a trustee of AA :-)!).
What *is* clear, then, and what I believe should guide our practice with patients, is that we work within the following model: 1) tell the truth--we simply can't predict who will be successful at moderating and who won't (although Rosenberg's review in Psych. Bulletin in the early 90s--"Prediction of controlled drinking in alcoholics and alcohol abusers" provides some parameters for making a reasonable guess based on a good ***essment). 2) As responsible clinicians, who want only the healthiest outcome for our patients, we recommend abstinence as the least risky course of action, although it is no more common an outcome than moderation. 3) We realize that it is the patient's choice what to do about his/her substance use, and we will provide any help we can in the decision-making and change process--but we cannot make the decision for the patient.
See Rosenberg's review, as well as the Project MATCH Motivational Enhancement Treatment manual for discussions of relevant ***essment variables.
I hope so, too! But then, that's up to you, isn't it ;-)?
Again, see Walters for a competing, research-based perspective.
Why AA "exclusively"? Why not SOS, SMART, RR? SMART has focused many of its efforts specifically on offenders.
And, given the research, why abstinence-only? It's clear that when clients are personally committed to goals they have chosen for themselves, they are much more likely to succeed in reaching those goals. Given that, when "allowed" to make the choice that they will make anyway, whether we "allow" them to or not, most of our clients choose abstinence, why would we "impose" that goal and risk the reactance and potential treatment drop-out that often occurs as a result?
*HOLD THAT THOUGHT!* "up to them!" As are all decisions about how to live their lives!
So, how do you know who will and who won't? And how do you decide that you will use AA "exclusively" given what you've just written? What happens when AA/abstinence-only fail to achieve the desired results?
Thank you for reading my long response.
Fred ===== Frederick Rotgers, Psy.D.212/523/6874http://www.addictionoptions.com"To avoid criticism, do nothing, say nothing, be nothing." Elbert Hubbard __________________________________________________ Do You Yahoo!?
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======================= "Endeavor to persevere" =======================
imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 17:38:00 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: JLSi...@aol.com To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate Fred, your comments below, in my opinion, raise some very significant ethics issues. To use my home state of Washington as an example, we have what is called deferred prosecution. What this amounts to is the individual is referred for evaluation for alcohol and or drug dependency. If the individual is found to be alcohol or other chemical dependent, he or she can petition the court of deferred prosecution. This consists of a two year treatment program, *total abstinence from alcohol and all illicit drugs. and attendance at two self-help support groups per week for the two year period. If the individual successfully completes the program, then all charges are dropped.
The law requires the treating facility to report the individual's progress in treatment and cooperation with the treatment plan that is entered with the petition. Also the state regulations that deal with certification of treatment facilities require that the goal of treatment for dependency in Washington State be abstinence. I cannot see how I could ethically work with a patient that did not agree with a goal of total abstinence. If I worked with a patient on a controlled drinking goal I would be violating the law if I did not report all drinking incidents. I would also be helping the patient violate the requirements of his deferred prosecution program. To me this would be not only unethical but also illegal. I would believe that would be the bind that Dr. Bruns would find himself in also working with the type patient that he works with. Is it our job to be a parole officer? No, but I do believe that it is our job to network with the parole officers and the probation officers.
Jim Shirk In a message dated 3/7/01 7:23:42 AM Pacific Standard Time,
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======================= "Endeavor to persevere" =======================
imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 12:09:43 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "Anne Fletcher" <annemfletc...@hotmail.com> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate As someone trained as a registered dietitian, I must interject that we use what I see as harm reduction approaches all the time for other medical problems (if you will, "diseases") such as hypertension and diabetes. For instance, when in clinical practice, I saw many obese adults with these disorders who were not willing to be "abstinent"--that is, to use the approach that the medical team felt ideal for the patient which might mean shedding 50-100 pounds, going on a low-sodium, low-fat, low-sugar, low-whatever diet. So we met them where they were--tried to get them to lose a little, cut back somewhat on fat or sodium, worked on exercise and put them on medication that may have had side-effects and didn't necessarily control their disease 100 percent. This approach may not have been ideal, but the clients were closer to where we wanted them to be.
For what it's worth, Anne M. Fletcher, M.S., R.D.
Author, Sober for Good: New Solutions for Drinking Problems--Advice from Those Who Have Succeeded _________________________________________________________________ Get your FREE download of MSN Explorer at http://explorer.msn.com
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======================= "Endeavor to persevere" =======================
imb ...@mindspring.com (David James Polewka)
Date: Wed, 7 Mar 2001 21:09:09 -0600 (CST) Reply-To: apadiv50-fo...@csd.uwm.edu Originator: apadiv50-fo...@csd.uwm.edu Sender: apadiv50-fo...@csd.uwm.edu From: "DR. ROBERT DR. ROBERT M. LICHTMAN" <robert...@worldnet.att.net> To: Multiple recipients of list <apadiv50-fo...@csd.uwm.edu> Subject: Re: The Great Debate Dear Colleague Jim: I (we) realize you are under regulatory constraints and have to, as the petitioners do comply with the mandates. Punishment has, and never will work to get people with substance use disorders to stop. Even with their lives falling apart, they don't stop. That in essence is the issue. That in itself is punishing to the substance dependent person and their significant others (if they have them at all). "Sentencing them to 12 step programs has no more efficacy for them than it does for the general public. Only specialized (meet the person where they are at) treatment has shown any successful outcomes. We are all tied into our government systems whether we agree with them or not. Just look at what happened at Smithers where Fred works. Fred in my estimation is one of the quintessential scientist-practitioners in the country. If you work for the "party" and don't follow the "party-line," you are apt to be relieved of your position. I refer you to Maia Szalavitz's article in New York Magazine, and its impact (loss of a job) of a vital person in the addiction's treatment world, Dr. Alex DeLuca. Addiction's treatment and the government's knee jerk regulatory change has always been driven by emotion, not research. The research usually follows the "clean sweep," not the reverse. Now Ecstasy has become the drug to focus on. The following is sarcastic, intended to be in good humor (not the ice cream, please) but its intention is clear. "Government sponsored research project finds that Kuala Bears, who usually prefer eucalyptus leaves to get high on, when switched to Ecstasy in 10 times the normal human dose have a tendency to procreate 10 times the national average of "normal" Kuala Bear subjects.
Therefore the research concludes, in a syllogistic fashion that humans too will fall prey to this most dangerous of drugs, so much so that it should now be included in schedule 1, along with heroin and crack-cocaine. How ludicrous. Bob Lichtman
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======================= "Endeavor to persevere" =======================
"David M" dh...@home.com
Get rid of the gratuitous reference to the Psych. Bulletin article. Change "patient" to something like "heavy drinker" or "newcomer." Make "responsible clinicians" read "AA members." Then read it again. See if you can find a single word which controverts any AA principle or belief.
So, why is this a "great debate" to which an AA centered news group needs to be alerted?
imb ...@mindspring.com (David James Polewka)
O.K., O.K., I'll stop!
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======================= "Endeavor to persevere" =======================
"David M" dh...@home.com
I didn't ask you to stop. I asked why you think this "great debate" is more than a tempest in a tea pot as far as AA is concerned.
anon2 ...@nyx10.nyx.net (Ace Renegade)
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That means you're qualified to run a cafeteria. What makes you an expert at treating alcoholism?
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"When cryptography is outlawed, bayl bhgynjf jvyy unir cevinpl!" JPB
Snertking postmas...@snerts-r-us.org
Let's start a new thread on the nutritional properties of ETOH.
Sean
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