Gradualism:  A New Term For Harm Reduction?

by Thaddeus Camlin, Psy.D.

from harm reduction to gradualismThere is a litany of terms in the addiction world – including addiction – that need to go.  Recently, noted author and leading thinker in the field of substance use, Anne Fletcher, M.S., R.D., L.D., wrote an article pointing out the flaws in the term ‘harm-reduction.’  I’ve been guilty of slinging the HR term around all over the place without questioning it, but Fletcher’s article gave me cause for pause.

Is the Term Harm Reduction Harmful?

Why is it that with any other “disorder” (another term that deserves the axe?) symptom reduction is considered success, but with substance use symptom reduction is described in the negative terms of reducing harm?  A harm reduction plan could just as easily be called a health improvement plan.  Once again, the normal rules of treatment – be kind, supportive, encouraging, compassionate – are not being applied to the treatment of substance use.

Fletcher points out that we don’t call improvements in blood pressure harm reduction.  Yet, it might as well be blasphemy in the world of addiction to call a switch from heroin to cannabis a success.  Debates continue to swirl about whether or not a switch from whiskey to non-alcoholic beer can be considered any progress at all…  really?  I tend to think that going from 80 proof to 0.8 proof is progress, seeing as how that is a 99% reduction in alcohol intake.  Fletcher highlights the work of Scott Kellogg, Ph.D, a psychologist at New York University, who proposes the term ‘gradualism.’

Changing Language: Harm Reduction to ‘Gradualism’

Gradualism stresses that abstinence, moderation, or non-addictive use are all viable end goals of treatment, and that the process of change moves at various paces and is rarely (if ever) perfect.  With gradualism, professionals are encouraged to embrace various treatment approaches and honor the goals of clients rather than adopting one-size-fits-all programs and imposing their own agendas.

“Meet the client where they’re at” is one of the most common refrains in the clinical vernacular, however, when it comes to substance use this useful reminder is often completely disregarded.  A client request to focus on anxiety management techniques before working on improving a relationship would scarcely be questioned.  However, if someone said they wanted to work on switching from hard liquor to light beer most professionals would likely feel compelled to confront, label the client’s goal as denial, and push an agenda of abstinence.  It is time for the double standards for substance use treatment to end.  Gradualism, rather than harm reduction, is a term that points us in the direction of ending the double standards in substance use treatment by continuing to refine our language to reflect quality and dignified care.

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