In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Patt Denning, Ph.D. on the topic of Harm Reduction, a relatively new approach to substance abuse treatment which, proponents claim, is both more effective and humane than current mainstream substance abuse treatment approaches.

Dr. Denning grew up in a small town in eastern Ohio during the 1950s and 1960s and, like many young people of her generation, had both good and bad experiences with drugs and alcohol during that growing-up process. As a university student at St. Louis University, she backed into a psychology major when it became clear that she was not well suited for her other interests, medicine and music performance. After completing a master's degree in psychology, she moved out to California's Bay Area to participate in the then newly developed Community Mental Health movement.

At that time, as is still generally the case today, substance abuse problems were handled by separate public agencies than mental health problems. This divide and the policies and politics that caused it to come into existence had never made sense to her, but it was not until the AIDS crisis in the early 1980s, when she was running a mental health clinic in San Francisco's Castro neighborhood (a place noted for the large numbers of gay men who live there). Many of her agency's patients died, but many surviving patients developed substance abuse problems secondary to the huge loss of live and the accompanying grief and trauma. She began hearing that many of the patients she had referred for substance abuse treatment had dropped out of treatment, or had bad experiences, and ended up going on a "journey" to see first hand what these patients were talking about. She attended numerous substance abuse treatment programs and twelve-step (Alcoholics Anonymous) meetings and was "personally and professionally appalled" at what she saw, which included aggressive confrontation by staff and sponsors, divisive labeling of patients as "addicts" (a term which conveys negative judgment and which defines someone as not a valued part of society), a demand for absolute sobriety as the only marker of treatment success, and a quasi-religious frame around the whole enterprise which took the form of a demand that participants submit and repent the "sin" of drug use. Though she understood these methods as a manifestation of the larger mainstream societal consensus concerning drugs as "bad" and sobriety as "good", her instincts told her that this was not effective treatment, and that this "us vs. them" way of thinking about people who had problems with substance use was not useful either.

Her research into the effectiveness of traditional substance abuse treatment further reinforced her disappointment. What she found (she reports) was that standard "Minnesota Model" treatment programs (which are based on work by the Hazelden organization, whose original treatment was derived in part from work done by Alcoholics Anonymous), which promote the idea that substance abuse problems are a medical disease and a spiritual problem, are at best helpful to 35% of participants, this figure being the most generous finding of multiple studies, and also not reflecting the fact that program dropouts are not counted. When program dropouts are counted (a frequent occurrence at just over 50% of starting participants dropping out), the actual success rate, measured as the number of people who remain abstinent post-treatment, is far smaller .

Her response to this revelation was to stop referring her patients out for substance abuse treatment, and to start offering alternative treatment within her mental health clinic. Her reading of the research literature on substance abuse treatment helped her to understand that programs emphasizing confrontation tended to not be very effective, while programs based on empathy and on cognitive behavioral interventions, including Motivational Interviewing, Relapse Prevention and the Stages of Change model due to Prochaska and DiClemente worked out better. At this time she also made contact with two inspiring figures, < href="http://www.amfar.org/cgi-bin/iowa/programs/prevention/record.html?record=97">Edith Springer, ACSW, (the "Grand Diva" of harm reduction) and psychological researcher Alan Marlatt, Ph.D. who encouraged her to develop and write about an integrated model of how to offer harm reduction psychotherapy, which she did, published in 2000 as Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions, published by Guilford Press. A later book followed, Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol , co-authored with Jeannie Little, LCSW, and Adina Glickman, LCSW, intended for a lay audience as a self-help workbook.

Dr. Denning has undertaken outcome measurement studies of the patients she has had supervisory responsibility for through her various clinics so as to be able to offer data regarding the utility of her harm reduction therapy approach. Her data are still preliminary, but initial results are positive. Post-treatment, almost fifty percent of patients whose drug use was judged to be "chaotic" self-reported as abstinent from the the drug they subjectively understood themselves to be having the most difficulty with managing prior to treatment. Importantly, this abstinence was not outlined to patients as a treatment goal by harm reduction therapists; this was an outcome these patients decided to pursue themselves. This finding should not be confused with complete abstinence. Many of these patients use more than one drug, and may still be using drugs post-treatment. But since the harm reduction world view rejects the notion that only complete abstinence can be called treatment success, these results are highly encouraging.

These days, Dr. Denning understands that there are two major reasons why people use drugs. These are: 1) to increase pleasure, and 2) to decrease pain. In her experience, people get into more trouble when their use of drugs is oriented towards the reduction of pain (physical, emotional, and otherwise) than when it is intended to increase pleasure. When people get themselves into trouble with drugs, what works is to treat them with respect and dignity and to help them learn ways of coping and to gain access to resources which will help them maintain and promote their own safety. The harm reduction approach is founded on the idea that all people are worth saving and are deserving of dignity; that no one deserves to be thought of as a 'hopeless' case undeserving of help; that people can benefit from help if it is well-presented, actually useful and offered without judgment, and that treatment success doesn't have to be defined in all or nothing terms.

Substance abuse related harm reduction, in a nutshell, has to do with attempts to reduce the health and safety impact of drug use on drug users, on their families and on society at large. The harm reduction philosophy is not a new idea. It has been long implemented in the public health world (mandatory vaccinations) and through legislation intended to make consumer products more safe (e.g., seat belt laws) and the environment less polluted (e.g., clean air and water legislation). Few of these harm reduction efforts have ever been thought of as controversial, but the application of this treatment philosophy to addictions has been controversial, Dr. Denning thinks because of the zero-tolerance mentality towards substance abuse and the "War on Drugs" that has come about in the United States over the last thirty years. Useful harm reduction programs like needle exchanges (where an injection drug user can learn about the risks of sharing needles and obtain clean needles so as to avoid serious disease) are difficult to implement when the public's first impulse is to see such drug users as a menace that should be imprisoned.

Links Relevant To This Podcast:

• Dr. Denning's non-profit Harm Reduction Therapy Center has a website you can explore.
  
  
• Dr. Denning recommends the book Alcoholics Anonymous: Cult or Cure? by Charles Bufe.
  
  
• Dr. Denning's book Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions is intended for clinicians who are interested in offering Harm Reduction to their patients.
  
  
• Dr. Denning's book Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol is intended for consumers who are looking for a self-help guide and workboook for coping with their substance abuse issues.

About Patt Denning, Ph.D.

Patt Denning, PhD, is Clinical and Training Director of the Harm Reduction Therapy Center in San Francisco and Oakland, California. Dr. Denning worked in San Francisco Community Mental Health as a clinician and program director from 1978 to 1993. She completed her Ph.D. in Clinical Psychology from the Professional School of Psychology in San Francisco in 1985. In 1993 she left public mental health and founded a private practice, Addiction Treatment Alternatives (ATA). She completed the Diplomate-Fellow training in Psychopharmacology in 1997, and as well, was named to the Drug Policy Resources Directory for the Media in the area of Dual Diagnosis. The Harm Reduction Therapy Center, a non-profit therapy and clinical training program showcasing harm reduction therapy for substance abuse, was opened in 2000 and started seeing patients and training therapists in 2002.

Dr. Denning has written several books and multiple articles on the subject of harm reduction. Her book, Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions (Guilford Press, 2000) is aimed at helping mental health professionals understand how to implement the Harm Reduction therapy approach she has synthesized based on her own experience and other's research work. Another book, titled Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol (Guilford Press), co-authored with Jeannie Little, LCSW and Adina Glickman, LCSW, was released in the Fall of 2003 and is intended to be a self-help workbook and reference guide for laypeople interested in harm reduction.

Dr. Denning is a specialist in differential diagnosis, psychopharmacology, psychotherapy with seriously disturbed patients, HIV, and substance use disorders. She is a certified addiction specialist through the American Psychological Association's College of Professional Psychology. She is a well known speaker and consultant for issues relating to drug policy, chemical dependency treatment, dual diagnosis, HIV, and the organizational development of alternative treatment settings to meet the needs of a drug using population.