arm reduction in substance abuse treatment

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Journal of Social Work Practice in the Addictions

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Harm Reduction in Substance Abuse Treatment:Pragmatism as an Epistemology for Social WorkPractice

Viktor Lushin LMSW & Jeane W. Anastas PHD LMSW

To cite this article: Viktor Lushin LMSW & Jeane W. Anastas PHD LMSW (2011) Harm

Reduction in Substance Abuse Treatment: Pragmatism as an Epistemology for SocialWork Practice, Journal of Social Work Practice in the Addictions, 11:1, 96-100, DOI:10.1080/1533256X.2011.546205

To link to this article: http://dx.doi.org/10.1080/1533256X.2011.546205

Published online: 23 Feb 2011.

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Journal of Social Work Practice in the Addictions , 11:96–100, 2011Copyright © Taylor & Francis Group, LLCISSN: 1533-256X print/1533-2578 onlineDOI: 10.1080/1533256X.2011.546205

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Harm Reduction in Substance Abuse Treatment: Pragmatism as an Epistemology

for Social Work Practice

VIKTOR LUSHIN, LMSW Doctoral Student, Silver School of Social Work, New York University, New York,

New York, USA

JEANE W. ANASTAS, PHD, LMSW Professor, Silver School of Social Work, New York University, New York,

New York, USA

Social work practice in the drug abuse eld is closely tied to the episte-mology of logical positivism. Most clinical decisions in this eld rely ona positivist “disease model” that broadly categorizes drug users, prescribes

standard abstinence-based treatments, and pays little attention to people’scurrent needs and social contexts (Kirk & Reid, 2002; Wakeeld, 1992).Many studies suggest, however, that functional and contextual factors areextremely important in understanding and treating drug and alcohol users(Marsden et al., 2009; Perreault et al., 2007). Could our eld benet fromthe use of a different, more exible epistemology? One such approach ispragmatism.

The philosophy of pragmatism was introduced in the work of threegreat American thinkers of early modernity: Charles Saunders Pierce, William James, and John Dewey (Browning & Myers, 1998). The main ideas of prag-

matism are expedience—practical usefulness—as the main measure of truth,guidance of action as top priority of science, and a communitarian or eco-logical view of knowledge. Pragmatists believe that knowledge is generatedin a community of “fellow-knowers” who share goals and agendas; and thataccess to knowledge must be as broad as possible (Browning & Myers).Pragmatists recognize that new knowledge does not have to always rely on

Address correspondence to Viktor Lushin, Silver School of Social Work, New YorkUniversity, 1 Washington Square North, New York, NY 10003, USA. E-mail: [email protected]

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preexisting theory, unlike positivists who require a theoretical backgroundfor any research (Browning & Myers).

Contemporary pragmatists, such as Rorty (1982), articulate oppositionto broad generalizations, especially about people. Canadian philosopher Ian

Hacking (2006) describes it as “making up people.” He also speaks of “loop-ing effects”—damage to a person’s self-image and personal growth—as aresult of internalizing negative labels such as “mentally ill,” or “drug addict.”Psychiatrist Bradley Lewis (2006) criticizes the tendency of medicalization— broadly applying medical diagnoses to individual psychosocial problemsthat often have social roots such as inequality or power struggle, rather thanpsychopathological ones. We suggest pragmatism as a more tting framework for the eld of substance abuse, offering harm reduction model as anexample of pragmatism’s inspiring success.

To help those addicted, we need to precisely evaluate their social func-

tioning, risks, and support mechanisms, and the essentials of their socialcontext (Marsden et al., 2009). To take account of all this information, weneed an epistemology more exible, more open to the client’s reality, andless tied to preexisting theory, than logical positivism. Besides that, theidea of value-free knowledge contradicts our profession’s ethically codiedcall for social justice (National Association of Social Workers, 2000; Smith, Whitaker, & Weismiller, 2006). Pragmatists value usefulness of knowledgeover its theoretical legitimacy, and avoid excessive generalizations (Lewis,2006; Rorty, 1982). This worldview might also offer a protection againstharmful “looping effects” that were mentioned earlier (Hacking, 2006).

Harm reduction is an apt example of pragmatism at work in the area of drug misuse intervention. The harm reduction idea works on several levels:as a clinical practice theory, as an intervention model, as a policy framework,and as a social movement (Toumbourou et al., 2007). It emerged as a theo-retical perspective after gaining momentum as a grass-roots movement. (Therecovery movement in mental health has followed a similar path.) The rstharm reduction programs appeared in the Netherlands and other WesternEuropean countries in the 1980s as a public response to the spread of the AIDS epidemic. Starting with simple efforts like local needle exchange pro-

grams, the model evolved into many forms that now include supervisedinjecting facilities, and widespread use of substitute medications for opi-oid drugs such as methadone and buprenorphine (Marlatt, 2002; Marsdenet al., 2009). In a truly pragmatist way, the rst harm reduction programs worked without a theoretical basis, which developed later (Marsden et al.,2009).

The main principle of the harm reduction model is a belief that in deal-ing with such complex and harmful human behaviors as substance abuse,the primary goal is to avoid or minimize further dangers such as contractingHIV and hepatitis, or death due to drug overdose. According to harm reduc-

tion theory, there are ways to signicantly reduce drug-related damage while

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the person is still a drug user, a notion supported by many studies (Marlatt,2002; Marsden et al., 2009; Toumbourou et al., 2007).

From a harm reduction perspective, insistence on permanent cessa-tion of all drug use early in treatment is recognized as unpragmatic, and

even as a potential client “scare-off” factor (Dobkin, Civita, Paraherakis,& Gill, 2002). Achieving abstinence is a valid, but not necessary, goal forclients receiving treatment, a pragmatic position that remains quite alien tomost treatment programs in the United States today (Marsden et al., 2009;Toumbourou et al., 2007). Unlike the traditional positivist view of addiction with its stigmatizing diagnostic labels (Hacking, 2006), harm reduction offersa pragmatic way of understanding people: by carefully assessing risks andprotective factors (Tuchman, 2010), and with a view of immediate practicalneeds of each individual client (Marlatt, 2002; Marsden et al., 2009).

Harm reduction was not initially an evidence-based approach to treat-

ment, and in general pragmatism is more interested in what is useful than what is “true,” which can be seen as a metaphysical position (Anastas,2000). However, many pragmatists, especially those who follow Peirce (e.g.,Buchler, 1955; Stout, 2007) as opposed to James (e.g., Rorty, 1982), ndempirical research to be a good way of deciding what is truly useful (Haack,2006).

As the harm reduction approach gained momentum, a growing numberof studies have demonstrated the effectiveness of harm reduction interven-tions not only in minimizing hazards of drug abuse, but also in reducing theactual consumption of drugs, in improving clients’ social functioning, andeven in achieving abstinence (Hartzler, Cotton, Calsyn, Guerra, & Gignoux,2009; Marsden et al., 2009; Tuchman, 2010). There is also ample evidence of much higher retention rates in harm reduction programs than in abstinence-based ones (Hartzler et al., 2009; Marsden et al., 2009; Toumbourou et al.,2007).

The harm reduction model does not depend on diagnostic catego-rization of people, and does not prescribe the same treatment to people with the same diagnosis (Marlatt, 2002). It advocates for careful attentionto the clients’ immediate social context and priorities, which might not

currently include achieving sobriety or total abstinence (Marlatt; Tuchman,2010). For example, harm reduction interventions and studies draw sys-tematic attention to the unique drug-related problems and treatment needsof women (Tuchman). The enormous rates of physical and sexual abuseof drug-using women, their socioeconomic powerlessness, and tremendousdifculties with childrearing responsibilities seem to be beyond the scope of a positivist-minded disease-model system of thinking (Tuchman).

The harm reduction approach has won many proponents in Canada, Western Europe, and many other countries around the world, but is stilllargely viewed with suspicion in the United States (Marlatt, 2002; Tuchman,

2010). However, a more effective and humane antiaddiction effort in this

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country might, in part, depend on whether social workers and other profes-sionals in the eld will be prepared to use a pragmatic epistemology andharm reduction practices. This might help us all to develop and success-fully use contextualized, client-centered approaches to addiction treatment

instead of relying on obsolete positivist worldview and the outdated diseasemodel.

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arm reduction in substance abuse treatment

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