Printed in APA Division 50 Newsletter

The vast majority of individuals grappling with addiction problems are not connected with substance abuse services (NIDA, 1991, Regier et al, 1993).

Those adhering to the disease model might contend that the primary reason these individuals have not accessed treatment or a support group is because their disease has not progressed to the extent that they have "hit bottom."

Those of a "non-disease" orientation might argue that these individuals have not accessed services because they find the 12-step model and associated black and white treatment mandates unattractive.

Though I am more inclined to agree with the latter as a major obsticle, I don't believe it is the primary one.

Would throngs of addicted individuals, who would not otherwise have accessed treatment, suddenly flock to treatment agencies if the overriding treatment philosophy changed?

I think it is highly unlikely. I believe that the "standard" model of treatment provision is the primary barrier to connectign with these individuals.

By standard, I mean the popular model in which providers wait in an office or agency for patients to show up for appointments.

In this article I will discuss outreach as a model of addiction care from which we can learn a great deal.

The standard model of treatement is sort of like fishing in the harbor. A few fish might venture in, but the vast majority aren't going to go near it. You have to use completely different gear to get to the others, and it requires leaving the harbor, into turbulant waters.

The addicts who show up at agencies or at our offices represent "the motivated elite." The majority of individuals in the throes of addiction are far from the sort of motivation which drives them to weekly sessions.

Why? First, there is the phenomenon of ambivalence. As Miller and Rollnick (1991) pointed out, this is a term seldom used by addiction professionals who opt for more pejorative terms like "denial" or "resistance."

For many, the use of substances is a primary means of coping. It is all but maladaptive to refuse to give up a mechanism of survival without a fight.

Many people experiencing ambivalence don't come into treatment agencies because they don't want their ambivalence attacked.

Moreover, some people have no intention of giving up their addictive habits. As we all know, this can be a source of great frustration. Many addicts know this, and simply don't wish to the recipient of voiced frustration and dichotomous requirements, so they keep away.

Also, if drug use is occurring, there is the potential for further life disruption if discovered (e.g. If she is pregnant and still using, there is the risk of Child Protective Services being notified, resulting in the loss of custody of her other children because she is deemed neglectful. She is likely to keep away too).

Not surprisingly, unless they are court mandated, these folks are not going to come into treatment agencies.

Outreach, in contrast to this standard model of provision, attempts to make a connectiuon in the addict's environment.

This is done either by placing an agency in a convenient and unthreatening location with hours which are conducive to the addict, or by leaving the shelter of the agency all together, going to where the addicts dwell.

Outreach workers respect that the therapist/client dichotomy is different "out there." "What can I do to help you?" is asked, instead of "Here is what you must do." Sometimes the answer will be "Nothing, get lost."

Other times needs will be expressed, often having nothing to do with the reduction of substance use. Respecting these agendas is tantamount to making a connection with individuals who haven't' even considered entering treatment. This connection makes further aid more likely because trust has been established.

The outreach model respects the survival tactics developed by the substance user and his ambivalence to change. Outreach workers connect with precontemplators and those in tenuous contemplation.

The substance users who voluntarily venture to an agency, office or meeting have already "tipped the scale" of ambivalence.

This is a monumental achievement! These fortunate few are already on the road to change. Many others require some help in the tipping.

Does outreach work?

Using Needle exchange as an example, studies have suggested that well designed programs are associated with eventual entrance into drug treatment programs, a reduction or cessation of high risk behavior and an increase in behaviors which minimize the harm for active users (Centers for Disease Control, 1990, Frisher and Lawrence, 1993) and a leveling off of HIV and Hepatitis B seroprevalence curves (Waters, et.al, 1990; Moss, et.al, 1990).

Countries in which outreach is widely utilized and supported appear to have a much larger contact rate than those which don't. Consider Marlatt and Tapert's citation (1993) that Dutch authorities report 60 - 80% of the addict population are registered in some program.

Most of us are well aware of the prevalence of Harm Reduction interventions and wide acceptance of Harm Reduction philosophy and outreach in Holland.

I'm not suggesting that psychologists should abandon lucrative practices and become outreach workers. Rather, psychologists specializing in addiction can integrate the harm reduction/outreach model into their practices and access a great many more individuals.

Many already do, and have for some time (The "stepped-care prevention" on-campus program for heavy drinking college students outlined by Marlatt and his colleagues (1992) is a perfect example).

My insights are largely based on the work of such ground breaking psychologists. What can psychologists do specifically? Here's some ideas:

Psychologists specializing in empirically-driven modes of addiction assessment and treatment can use their knowledge and experience to help train outreach workers in the principles of motivational interviewing and cognitive disputation.

Psychologists could devote a day or even an afternoon to work alongside outreach workers, venturing into the inner city and making connections with the precontemplator who is miles away from visiting a psychologist's office, a treatment agency or even a meeting.

Psychologists can orchestrate inner city harm reduction support groups for active users with the only suggestion that they show up and listen.

Psychologists can aid in the targeting of hard-to-reach patients, such as the amphetamine user with concurrent Schizophrenia who is repeatedly hospitalized but ineligible for partial hospitalization upon discharge, save for board and care housing.
The idea of making a home visit to the individual who repeatedly "misses" that initial session is not unheard of from an outreach perspective.

When the Harm Reduction philosophy becomes a mind set, the sky's the limit in terms of creative interventions!

Addictive behavior, like poverty and disease, has myriad causes and is perpetuated by numerous factors. Addictive behavior is different from poverty and disease in that it is driven by an adaptive process--to find relief however it has been defined in the confines of each person's unique existence.

Optimal change will be defined differently and will require different pathways depending on the unique attributes of each individual. Treatment providers embracing the Harm Reduction philosophy are flexible about goals and flexible about the manner in which "treatment" is rendered.

What is most important is the connection, which in and of itself is a move toward enhanced well being. No matter how attractive our treatment invitation appears in terms of its empirical foundation, coping techniques will not be relinquished unless a solid case is made that it is worth wile.

Making that case requires inordinate flexibility and necessarily requires stepping out of the office and into the trenches once in a while.

References

Centers for Disease Control Update: Reducing HIV transmission in intravenous drug users not in treatment--United States. MMWR 1990. 39, 529-530/535-538.

Marlatt, G.A., Larimer, M.E., Baer, J.S. & Quigley, L.A. (1993). Harm reduction for alcohol problems: moving beyond the controlled drinking controversy. Behavior Therapy 24(4), 461-503.

Marlatt, G.A. & Tapert, S.F. (1993) Harm Reduction: Reducing the Risks of Addictive Behaviors. In J.S. Baer, G.A. Marlatt, & R.J. McMahon,(Eds.). Addictive Behaviors Across the Lifespan: Prevention, Treatment and Policy Issues. Sage Publications: Newbury Park.

Miller, W.R.(1995). Increasing Motivation For Change. In R. K. Hester & W. R. Miller (Eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. Allyn and Bacon: Boston.

Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford: New York.

Moss, A.R. Vranizan, K. Bacchetti, P., Gorter, PR., Osmond, D., and Brondie, B. Seroconversion for HIV in intravenous drug users in treatment. San Francisco 185 -1990. Sixth International Conference on AIDS. San Francisco, June 1990.

National Institute on Drug Abuse. (1991). National household survey on drug abuse: Main findings 1990 (DHHS Publication No. [ADM]91-1788). Washington, DC: Government Printing Office.

Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z. & Goodwin, F.K. (1993). The de facto US mental and addictive disorders service system. Archives of General Psychiatry, 50, 85 - 94.

Springer, E. Drug Treatment, Harm Reduction Style: Substance Use Management. Symposium presented at the Harm Reduction Conference in Seattle, 1995.

Snow, M.G., Prochaska, J.O., & Rossi, J.S. (1992). Stages of change for smoking cessation among former problem drinkers: A cross-sectional analysis. Journal of Substance Abuse, 4, 107 -116.

Watters, J.K., Cheng, Y., Segal, M., Lorvick, J., Case, P. & Carlson, I (1990). Epidemiology and prevention of HIV in intravenous drug users who are not in drug treatment. Sixth International Conference on AIDS. San Francisco, June 1990.