Mainstream abstinence-oriented treatment of alcohol and drug users in the United States today continues to have poor success by anyone's criteria.

Clinical observations and empirical studies typically report that a majority of clients seen initially do not successfully complete treatment or maintain their gains after treatment.

These poor outcomes are evident ill residential and outpatient programs and across different theoretical approaches. The Substance Abuse and Mental Health Services Administration reported that between 1992 and 1997 only 47% of patients completed American drug and alcohol treatment programs with another 12% referred to other programs (SAMHSA, 1999).

Several treatment outcome studies suggest that only 20-40% of patients who complete treatment achieve long-term success even when abstinence and moderation are both considered as successful outcomes (Keso & Salaspuro, 1990; Nordstom & Berglund, 1987).

For example, Helzer and colleagues (Helzer et al.. 1985) looked at three-year outcomes of four abstinence-oriented programs of patients who met D.S.M. III criteria for alcohol dependence. They found only 15.1% reported total abstinence and 18.4% reported some form of problem-free drinking.

Ditman et al. (1967) did a one-year follow up of 301 "chronic drunk offenders" who were randomly assigned to no treatment, Alcoholics Anonymous, or clinic treatment as a condition of probation. Using re-arrest for a drinking- related offense as the primary outcome measure, they found that 68% of the clinic group, 69% of the AA group, and 56% of the no treatment group were re-arrested; the differences were not statistically significant.

And, more recently, a large scale controlled study, Project MATCH (Project MATCH Research Group [1997]) was funded by the National Institute on Alcohol Abuse and Alcoholism to compare patients' responses to different treatment approaches. 1,726 people with alcohol use problems were randomly assigned at sites across the country to twelve sessions of 12-Step Facilitation Therapy (TSF), Cognitive- Behavioral Therapy (CB11, or Motivational Enhancement Therapy (MET).

Using complete abstinence during the year after treatment as the measure of success, 24% of individuals in the TSF group were abstinent, 14% of those in the CBT group, and 15% of those in the MET' group.

Standard approaches are not equipped to address serious emotional or socioeconomic problems accompanying substance use problems. These statistics for failure in substance abuse treatment do not include people with drug and alcohol problems who never seek traditional treatment, a group that represents the majority of problem users in this country.

The United States Department of Health and Human Services (USDHHS, 1997) estimated in 1997 that about 15 million adult Americans are alcohol dependent or abusing. SAMHSA ( 1999) estimated that there were 2,207,375 admissions to 15,000 American in- and outpatient treatment facilities in 1997.

Assuming that some of these were multiple admissions by some people, it is likely that approximately two million people were treated in that year. These data suggest that close to 85% of individuals with alcohol problems in 1997 were untreated in this country.

This is supported by the Institute of Medicine's (1990) estimate that 80% of American alcoholics have never made contact with self-help or professional treatment and by the National Institute on Alcohol Abuse and Alcoholism's (1999) estimate of 10 million untreated American alcoholics. I think it is safe to assume that the statistics for other drug users are comparable.

For example researchers at SAMHSA (Woodward et al. .1997) estimated that 48% of the need for drug treatment, excluding treatment for alcohol problems, is not being met. If the helping profession of addiction treatment was a Fortune 500 company, it would have gone out of business long ago.

Tom: Harm Reduction to Moderation by Andrew Tatarsky

Tom called me four years ago because he was concerned about "drinking too much and at the wrong times," and he wanted "to get it under control." He called me specifically because he had heard of my reputation as an alcohol treatment specialist who will work with problem drinkers who do not want to stop drinking.

Tom appeared at my office for our first meeting looking scared and shaking. The faint odor of alcohol accompanied him as he entered my office. I found myself feeling somewhat anxious and wondered if this would interfere with our work.

As it turned out, this first meeting ended with us feeling optimistic about the possibility of doing some valuable work together, a feeling that has grown and strengthened over the past four years of weekly psychotherapy.

Tom is a somewhat heavy man, at that time looking his 43 years of age, wearing a neatly trimmed mustache and a hoop earring in his right ear. Along with his neat, casual style of dress, he projected the image of a hip, downtown, arty man trying to look younger than he was.

His initial wariness and guarded manner melted quickly in response to my interested, accepting stance. He seemed painfully lonely and hungry for contact, and he expressed intense gratitude for my willingness to help him on his terms, that is, while he continued to drink.

This also seemed to reflect a desperate need for validation of his adequacy as a person. He was exploring whether I might be able to offer that to him.

As Tom talked, I also quickly formed the impression that he was a very bright, honest, emotionally-vulnerable, and talented man. I immediately liked him and felt optimistic about embarking on a psychotherapeutic journey together.

Tom described himself as''!, 43-year-old single Italian-American gay man who-lived alone in New York City. He said that he was glad to be gay, although there were certain changes in the gay world that had become increasingly problematic.

While he was vague at this point, these problematic changes would become clear over the course of our work together; they were powerfully related to his drinking problem and a number of other emotional and lifestyle problems.

During the next few meetings, Tom revealed himself as sensitively attuned to the nuances of my reactions to him, belying both a keen attention to detail and a particular sensitivity to the emotional responses of others. He expressed a strong need for emotional support and reassurance, frequently asking if I thought he was "doing it right," showing me things that he had done to address his problems and asking for my approval.

He didn't actually want my opinion but rather my approval for the decisions that he had already made. These aspects of him revealed a very fragile sense of self and an intense reliance on the approval of others to maintain a positive self-image.

I felt as if I was being invited to play the role of mother, applauding and feeling proud of his baby steps toward learning to take better care of himself in the world. Not only did it seem to me that he wanted my approval to maintain a good feeling about himself, but as a kind of mother /father, he wanted me to help him to construct a more firm and more effective self.

I wondered if this vulnerability in his sense of self might be directly related to his drinking, a suspicion that was to be supported in several important ways.

Tom said that he indeed saw his drinking as a problem, though the most important factor motivating him to seek treatment was pressure from his job. Tom had a responsible position as curator at an art museum. Prior to his visit, Tom's supervisors had given him an ultimatum: go in for alcohol treatment as the condition for keeping his job.

Tom was in a crisis in his workplace. He was extremely disturbed by the way his coworkers had responded to his excessive drinking and felt that he was being misjudged and misunderstood. Our session was Tom's second attempt at seeking help for alcohol use. His first experience was a coercive intervention that occurred nine months prior to our meeting.

Tom's colleagues had staged a semi- theatrical intervention to get him into an intensive treatment program, assuming for him that he had no other options. As Tom spoke, he was controlling strong feelings of anger and sadness.

Without warning, his colleagues had confronted him publicly, at the start of the workday, and told him that they had made arrangements for him to be evaluated by a well-known alcohol treatment program that morning and that a car was waiting just outside to take him there.

At that moment Tom realized that he had no choice but to go unless he wanted to risk losing his job of twenty-three years......

Outcome

Because the focus on alcohol receded into the background at this point, I will end the detailed description of Tom's treatment here. The treatment is still alive and productive at the time of this writing. During this period, he has generally maintained his moderate drinking with a few minor slips similar to those discussed previously.

These occurred around emotionally charged interpersonal situations and were used as opportunities for further learning that deepened Tom's work in therapy. The central focus of therapy has been on strengthening Tom's ability to maintain his self- esteem in more autonomous ways.

He thinks differently about these insecurities and is able to take constructive actions in the world that give him direct feedback about his value as a person. A related focus has been on working through the threatening fears and fantasies that have kept Tom from freely expressing his emotional needs in relationships.

Therapy has helped Tom to feel more confident about and successful at pursuing satisfying relationships in his life. During this period his depression has not returned.

Tom has" demonstrated an ability to cope without alcohol with many challenging situations that had been triggers for excessive drinking in the past. These strategies have become familiar tools in his repertoire of coping skills.

This, in conjunction with his awareness of his emotional vulnerabilities and continuing commitment to his emotional growth, suggest a very good prognosis for the future.

>From Chapter 1 of the book Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, by Andrew Tatarsky.