Canaan, N.Y.—Henri Williams thinks this article may upset you.
That’s because he uses two words that routinely set off alarms among people working with adolescent substance abusers: harm reduction.
Many critics equate harm reduction with legalizing drugs, or at least shrugging off drug use. Government and private agencies dealing with youth drug use generally won’t touch the subject. “Harm reduction is a political lightning rod,” says William Miller, a professor of psychiatry at the University of New Mexico and a specialist in the treatment of addictive behavior.
But Williams, program director of substance abuse services at the Berkshire Farm Center youth facility in rural upstate New York, believes strongly in harm reduction, or at least his version of it. He says it’s the most effective strategy for dealing with teenage drug and alcohol users who don’t think they have a drug or alcohol problem.
For Williams, “harm reduction” means not using scare tactics with those youths, not insisting that you have all the answers, not preaching that any drug use at all is the end of the world and not kicking kids out of a treatment program if you discover that they’ve been drinking or smoking pot when they’re away from the program. You keep trying to educate them.
“The problem for us,” says Williams, “is how do we make incremental gains … until a client of our program can demonstrate the desire and capacity to abstain?”
And here’s a surprise: The idea is quietly catching on in the mainstream of adolescent substance-abuse education and treatment.
To be sure, many programs for adolescent drug abusers deal with relapse as part of the process of helping some kids get off drugs. But more and more treatment providers endorse the strategies that Williams outlines, even though they avoid labeling them “harm reduction.”
“It’s starting to become more accepted that abstinence doesn’t have to be the first and only goal,” says Ken Winters, associate professor of psychiatry and director of the Center for Adolescent Substance Abuse Research at the University of Minnesota.
Nevertheless, plenty of people are suspicious of any approach that signals to kids that they can use drugs without penalty.
“You’re saying that substance abuse is OK with us,” says Howard Simon, spokesman for the Partnership for a Drug-Free America. “Or you’re saying, ‘We know you’re doing something illegal – but that’s OK.’”
“It’s an absurd situation,” says Joyce Nalepka, president of Drug-Free Kids: America’s Challenge. “People pushing harm reduction, they’re saying, ‘Oh, a little bit [of drugs] won’t hurt.’
“Good programs hold kids accountable for their behavior. If you let them run wild, they’ll take advantage of you. … The harm reduction system is doomed to failure, and we’re going to live to regret it.”
For all the controversy, Williams and harm-reduction advocates claim they’re merely looking at teenagers and drugs realistically.
A 2001 study by Partnership for a Drug-Free America found that 48 percent of U.S. teens had tried illegal drugs, including 37 percent in the previous year and 24 percent in the previous month. Last year, the Monitoring the Future study from the University of Michigan put the number of high school youths who have tried drugs at 53 percent.
So when participants in Williams’ Berkshire Farm program continue to use drugs, he wants to keep them engaged in learning more about those drugs and how they affect the users’ lives. Williams believes that teens who choose abstinence because of science-based drug education – rather than fear of adult retribution – are far more likely to remain drug-free in the long run.
“We’re meeting kids where they’re at,” Williams insists.
But does it work? Early indications suggest that Williams’ program could be as effective as other strategies for drug users, including some abstinence-only programs.
Williams says that of the 290 kids in the Berkshire Farm program in 2000, 61 percent abstained from drug use during the year. A more complete study is under way to ascertain long-term results.
Yet research has yet to demonstrate one right way to treat adolescent drug abuse. Programs using a variety of strategies – including the traditional 12 steps of Alcoholics Anonymous, behavior modification and other forms of group therapy – all encounter difficulties when applied to adolescents.
For instance, a 1999 survey of substance abuse treatment programs by the University of Minnesota’s Winters found dropout rates running from 20 to 50 percent and adolescent patients relapsing into drug use during treatment at a rate of 16 percent to 54 percent (with a median of 39 percent).
But the controversy over harm reduction often seems more centered on philosophical or political concerns than on research.
“From our view,” says the partnership’s Simon, “when you hear the term ‘harm reduction’ bandied about, it seems to imply that drug use is inevitable and we can’t stop it, so it’s better to reduce the damage to those who use drugs. We believe that’s a flawed premise. If you truly want harm reduction, the best way is to reduce the number of people who expose themselves to the harm of using drugs.”
While this debate goes on, harm reduction stands as the cornerstone of some public health strategies aimed at adult substance abusers. Examples include methadone treatment for heroin addicts or needle exchange programs to cut the spread of HIV through infected syringes. One harm-reduction strategy is widely promoted with no controversy: the designated driver.
Such strategies qualify as “harm reduction” because they seek to reduce some harm from drug and alcohol use, while accepting the fact that steady use continues.
More oriented toward youth is Dance Safe, a self-styled harm-reduction group that claims 26 affiliates across North America (www.dancesafe.org) and promotes, for example, sales of “adulterant screening kits” for Ecstasy users. The kits help to determine if Ecstasy pills contain more harmful elements, such as PCPs.
Another drug policy reform group, the Drug Policy Alliance, describes harm reduction as its “guiding principle.” Backed by financier George Soros’ Open Society Institute, the alliance supports “realistic alternatives to the war on drugs,” such as needle exchanges, methadone maintenance and “ending criminal penalties for marijuana, except those involving distribution of drugs to children.”
While critics of harm reduction say it represents a softening of moral resolve, the alliance says it would prefer that kids avoid drugs, but get-tough stands and sloganeering about abstinence don’t work.
“I love abstinence,” says Marsha Rosenbaum, director the alliance’s San Francisco office and author of its Safety First booklet for parents. “I think abstinence is the best choice.
“But what do you do when kids refuse to say no? What do you do when they don’t listen? We believe that any positive reduction in drug use is good.”
Berkshire Farm’s Williams agrees. Others do, too, but not many say so out loud. Miller, the University of New Mexico professor, says that two years ago he was told to remove the phrase “harm reduction” from a paper he was publishing in a National Institutes of Health newsletter. And he did.
As the strategy that Williams calls “harm reduction” becomes more mainstream, observers need to look beyond labels at what a program does to see what’s really going on.
An Unusual Setting
The rural, tree-covered Berkshire Mountains might seem an unusual setting in which to test an “outpatient” drug program for teenagers.
Berkshire Farm Center, founded in 1886, is home to 250 boys, many placed by New York state family courts – some for delinquency, others as “persons in need of supervision.” Some of the boys come from a background of abuse, neglect or substance dependency. About three-quarters of the residents are classified as “severely emotionally disturbed.”
The boys live under 24-hour supervision in cottages and attend Berkshire Junior-Senior High, also on the campus. They get to go home on weekends and holidays, totaling up to 10 days a month – where they often have opportunities to drink or use drugs.
(Berkshire Farm also serves 3,000 boys and girls and their families at 40 community-based programs across New York. Most of these youth have been identified as being at risk for out-of-home placement.)
Approximately 70 percent of the boys at Berkshire Farm are recommended for participation in Williams’ Adolescent Chemical Dependency Intervention Program, which is licensed by the state as a voluntary outpatient program. All the clients are boys in residence at the farm.
Since the drug program began in 1995, almost all boys recommended for the program have chosen to participate, which Williams cites as a mark of success. The boys attend individual sessions once a week and group sessions two to four times a week.
“We accept that the concept of total abstinence is difficult to achieve the moment a kid walks into the program,” Williams says. Early on, he considers it a plus when a kid decides to use alcohol or marijuana less often, or in less dangerous circumstances.
(If a client is found to have been using heroin, crack cocaine or other more dangerous drugs – and it’s only happened a few times – he is put under medical supervision for detoxification. Williams says it then becomes a medical decision as to whether inpatient care might be a more appropriate. In those cases, boys have eventually returned to the outpatient program.)
Are the strategies here really all that controversial? From a political standpoint, maybe, but such strategies appear less questionable among public health professionals.
“It’s well understood in the field that you’re going to have kids who come into a program who may be using drugs and alcohol – or they have families who are – and you can’t just say that all these people are bad,” says Zili Sloboda, senior research associate at the Institute for Health and Social Policy at the University of Akron in Ohio.
Under a grant from the Robert Wood Johnson Foundation, Sloboda helped to develop a new, less authoritarian approach for the Drug Abuse Resistance Education (DARE) program. The changes, coming after studies found that DARE’s elementary school program had limited or no impact on later drug use, were designed to encourage kids to think for themselves rather than listen to lectures by authority figures, such as police officers.
“It’s very interactive and less didactic,” Sloboda says.
The change also seems in line with general trends in drug treatment and education, and even with the educational component at Berkshire Farm.
The University of Minnesota’s Winters looks at some current treatment trends as “New Age approaches.”
“These days,” Winter says, “the two buzzword phrases in chemical dependency treatment are ‘nonconfrontational’ and ‘adjusting goals that better fit the client’s interest.’” But Winters insists that total abstinence is the only approach for truly addicted adolescent drug users. “Older teenagers who have four to six years of heavy drug use under their belts – I’m a proponent of abstinence for them,” he says.
Nevertheless, he notes, “Other young people are at a developmental stage when it’s pretty tough to sell abstinence.”
That’s a dilemma in treating adolescents.
The University of New Mexico’s Miller is a leader among those pushing nonconfrontational counseling styles. “Getting into confrontational power struggles [with adolescents] doesn’t work,” he says. “The authoritative approach – saying, ‘I know reality and you don’t’ – is still out there, but kids don’t take well to that, either.”
Miller promotes “motivational interviewing,” which he describes as “letting people find within themselves the motivation for change.”
Berkshire Farm uses that technique, and also draws from a theory called “stages of change.” That theory divides the process by which individuals decide to change their lives into six stages: precontemplation, contemplation, preparation, action, maintenance and termination.
According to the theory, desired changes such as stopping drug use don’t happen until the middle stages. So what do you do until then?
Tripping Over The First Step
Kevin Walsh, Berkshire Farm’s director of clinical services, says the center’s program – and its focus on harm reduction – is designed with an understanding of adolescent development. “There’s been a tendency to take models that have been used for adults and apply them to adolescents, as if adolescents were smaller adults,” Walsh says. “Adolescents have different developmental needs.”
For many adult alcoholics and addicts, the classic 12-step, total abstinence approach of Alcoholics Anonymous seems the only workable strategy. Most AA members believe they can’t recover by using drugs or alcohol just a little bit – that for addicts, a “little bit” leads to a lot.
Recovery in the AA model begins with Step One: “We admitted we were powerless over alcohol [or drugs] – that our lives had become unmanageable.” But adolescents who don’t sense they have a problem are even less likely to think they’re out of control.
“A 16-year-old may readily admit he smokes marijuana,” says Williams, “but not that he’s powerless over it.”
“Adolescents think they’re immortal,” says New Mexico’s Miller, “and that’s a long way from Step One.”
The Berkshire Farm program is broken into phases, beginning with drug education that includes a detailed study of the physiological and psychological effects of drug use. Youth learn about how chemicals affect the brain – effects, Williams says, that youths often relate to their own experiences. Then they fill out and discuss pages of worksheets on which they identify goals, problems and barriers to attaining their goals.
Then they plot strategies, such as what to do when friends urge them to use drugs or when they see their own “personal warning signs” that signal a risk of relapsing.
It can take six months or more to complete the program.
“The idea of abstinence speaks to behavior,” says Williams. “We want to see changes in attitude and belief systems about substance abuse.”
Sounds Like …
The possibility remains that the Berkshire Farm program is unique not in its approach but in its willingness to describe that approach as harm reduction.
Officials at the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), with its $2 billion-plus annual budget for substance abuse treatment programs and grants, insist the agency does not use harm reduction approaches, although it supports methadone maintenance for adult addicts.
SAMHSA officials point out that the controversial two words do not appear in its most recent (1999) treatment protocols for “adolescents with substance use disorders.”
But the following paragraph does appear:
“If an adolescent in treatment experiences relapse, it is best viewed not as a failure of the treatment or the client, but rather as a common part of the early recovery process that needs to be factored into the treatment plan. As in chronic physical diseases such as leukemia or diabetes, relapse is an indication not for punishment or discontinuation of treatment, but for additional or intensified treatment. Relapse (or the lesser version, known as a minor slip or lapse) should be viewed by treatment professionals as an opportunity for learning; for example, it can help teach young people that they do not have control over their substance use.”
“It sounds like something I could have written,” Williams says. “That’s a harm-reduction approach.”
SAMHSA officials insist the protocol has nothing to do with harm reduction. But some other harm-reduction advocates can’t help but crow that their point of view is quietly gaining acceptance.
“It’s like a whispering campaign,” says the Drug Policy Alliance’s Rosenbaum. “We’re quietly saying, ‘We’re not supposed to say this, but the only way we can go is harm reduction. Don’t tell anybody, but we’re veering off from Just Say No.’ ”
Berkshire Farm Center
P.O. Box 13640, Route 22
Canaan, NY 12029
Department of Psychiatry
University of Minnesota
2450 Riverside Ave.
Minneapolis, MN 55454
William Richard Miller
Department of Psychology
Logan Hall 122
University of New Mexico
Albuquerque, NM 87131-1161
Partnership for a Drug-Free America
405 Lexington Ave., Suite 1601
New York, NY 10174
Drug-Free Kids: America’s Challenge
P.O. Box 60865
Washington, DC 20039