J.T.Stocks, Ph.D1Harm Reduction (HR): Harm Reduction (HR): Principles & StrategiesPrinciples & Strategies!HR is a community alternative to the moral/criminal and disease models of drug use and addiction!Abstinence is an ideal outcome, other alternatives that reduce harm are acceptable!HR is bottom up (based on addict advocacy) rather than a top down approach!HR promotes low-threshold access!HR is based in compassionate pragmatismThree Groups of Alcohol UsersThree Groups of Alcohol Users(NIAAA)(NIAAA)!Persons who drink with few, if any, problems.!Nondependent “Problem Drinkers” who have difficulties secondary to alcohol consumption.!Persons who are dependent upon alcohol and who suffer from the disease called alcoholism or alcohol dependence.Alcohol Dependence Alcohol Dependence --AlcoholismAlcoholism(NIAAA)(NIAAA)!Tolerance!Physical dependence!Impaired control over regulated drinking!Discomfort associated with abstinence or cravingProblem DrinkingProblem Drinking!No history of alcohol withdrawal symptoms!Short problem drinking history!Unexpected intoxication!More social and economic stability!More personal, social, and economic resources!Do not self-identify as alcoholicJ.T.Stocks, Ph.D2Is Problem Drinking Progressive?Is Problem Drinking Progressive?!Progressive Model (retrospective studies)"Once alcohol problems develop, they inevitably worsen and follow a predictable course if drinking continues!Current Findings (prospective studies)"Minority of cases (25%-30%) are progressive. More common is a pattern of abstinence or non-problem drinking with interspersed episodes of problem drinking.Alcohol ProblemsAlcohol Problems!Acute Intoxication"health (e.g., accidental injury)"behavioral (e.g., drunk driving)!Regular Heavy Drinking (Not Dependent)"health (e.g., cirrhosis)"behavioral (e.g., marital, financial)!Dependence"health (e.g.,withdrawal) "behavioral (e.g., loss of employment)Specific Therapeutic StrategiesSpecific Therapeutic Strategies!Precontemplation"Educate"Note discrepancies!Contemplation"Explore ambivalence!Preparation"Make realistic plans!Action"“Right-sized steps”!Maintenance"Choose support system"Explore core issues!Relapse"Learning opportunity!Termination"Review progress"Work on personal issues as neededTreatment of Problem DrinkersTreatment of Problem Drinkers!Treatment should be outpatient and non-intensive!Treatment should be largely motivational!Treatment goals should be flexibleNonNon--Intensive TreatmentIntensive Treatment!Identify “generic” risky situations.!Learn alternative ways of dealing with these situations.!Recognize own strengths for dealing with risk situations!Identify & emphasize adverse consequences of problem drinking (motivation)!Identify benefits of avoiding problem drinkingEnhancing MotivationEnhancing Motivation!Identifying and removing barriers to change!Giving clients as much perceived choice as possible in treatment process!Decreasing attractiveness of drinking!Arranging external contingencies to support and encourage change!Providing personal feedback about alcohol effects and appropriately using feedback to support progress!Setting clear and attainable goals.J.T.Stocks, Ph.D3Motivational InterviewingMotivational Interviewing!Avoid labeling!Use inquisitive rather than confrontational style!Provide objective feedback in a low key way!Reassure clients that change is possible!Allow clients choice in treatment planning and goal settingFlexibility of GoalsFlexibility of Goals!Abstinence!ModerationAdvantages to SelfAdvantages to Self--Selected GoalsSelected Goals!Strengthens sense of self-efficacy"maintenance of change!Places responsibility on client"appropriateness of goal"failure cannot be attributed to someone else"client