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Alan Marlatt on Harm Reduction Therapy

Alan Marlatt on Harm Reduction Therapy

by Victor Yalom and Rebecca Aponte

The founder of Harm Reduction Therapy talks about meditation, college drinking, 12-step programs, and the limitations of abstinence-only interventions.
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Harm Reduction Defined

Victor Yalom: We're here to interview you today about your work with addictions, and specifically your contributions to the field of harm reduction. Just to get started, the name harm reduction gives a hint of what your approach is about, but maybe you could say a few words to introduce the concept.
G. Alan Marlatt: We are basically trying to support people that have addiction problems. If they want to quit, we'll help them do that. That's our relapse prevention program. If they would like to be able to reduce their drinking or drug use-harm reduction—we want to support them there too.

Many people with alcohol and drug problems are not getting any help, and I think part of the problem is they don't want to identify as drug users, or if they're using illegal drugs, they're afraid they're going to be arrested and put in jail or something like that. They're holding out. But if you talk about moderation, many people say that's an enabling strategy.
VY: Many professionals.
GM: And others. So it's a very controversial topic, but basically my position is, "We'll help you, whatever your goal is. You want to quit, we'll help you. You want to cut back, we'll help you. We're not going to shut you out."
A lot of the traditional treatment programs are saying, "Unless you're totally committed to abstinence, we're not going to work with you."
A lot of the traditional treatment programs are saying, "Unless you're totally committed to abstinence, we're not going to work with you."
Rebecca Aponte: If somebody wants help cutting back, is that something that they can work on with a harm reduction therapist for life?
G. Alan Marlatt: With some people it's for life. Let me give you an example of a case. This is a woman that was being treated by a psychiatrist for depression at the University of Washington. The therapist called me up and said, "I've been seeing her for about three months, and today I found out that she has this drinking problem. So, I said to her, 'I can't really help you or continue to treat you unless you go into alcoholism treatment, and I don't know how to do that.'"

... Continue Reading Interview >>
VY: He doesn't know how to do alcohol addiction treatment.
GM: Right. Most psychiatrists don't know how to do that; it's not part of their training. So he wanted me to do an evaluation of her. When she came in to see me, she'd already been to the alcohol treatment center that the psychiatrist referred her to. I said, "How it's going?" She said, "Everybody's telling me something different. The psychiatrist said I was probably drinking a lot to kind of self-medicate my depression." And that was partly true.

Then, when she went to the alcohol treatment center in Seattle, they said, "No, your alcoholism is causing your depression. Unless you are into our abstinence-based program, it's just going to continue. Are you ready?" She said, "No, I'm not ready. This is the only thing that works for me and I know it's causing other problems, but I'm not ready to give it up."

So she was stuck in the middle. For a lot of these kinds of people, harm reduction therapy is the best alternative. So I said, "Let's do harm reduction therapy. I can help you keep track of your drinking, and see what's going on." So she agreed to do that. A lot of people at that point will drop out. If all they have are abstinence-based alternatives, they're not going to do it.

But she agreed to do it. She worked with me for three months and we kept track of her drinking. She reduced her drinking significantly.
VY: What was her goal?
GM: Her goal was to drink more moderately and to figure out what was going on in her marriage about drinking, because her husband said, "You're a chronic alcoholic and unless you stop drinking altogether, I'm going to leave you." That made her more angry and depressed. She tried to stop drinking, and then when he would go out of town, she would get loaded—this kind of thing.

We finally figured out there was a lot going on in terms of the marriage and her anger. Then I taught her meditation, which was the most helpful strategy for her. Then, one day she was going shopping and she saw her husband in a car embracing another woman and it just made her start drinking again. She said, "I can't do this anymore."

She went to a meditation retreat center in France—Plum village, the Thich Nhat Hanh Center. You go there, you take these precepts. One of them is no use of intoxicants while you're here. She said, "I took that and I thought, 'That's it. I'm never going to drink again.'" She's been now abstinent for five years.

So harm reduction was the bridge to get her there. If you say, "You've got to stop now," a lot of people go, "I can't stop now." But if you start getting them into a harm reduction program and they realize they can reduce their drinking and begin to figure out what their triggers are, they feel a lot more confident that if they want, they could quit. That's what happens a lot of the time.
VY: Getting back to the basics of it, what do you mean by harm reduction and how did it originate?
GM: I did a sabbatical at Amsterdam in the early '80s. That's where harm reduction originally developed, because they were the first country to realize that injecting drugs can increase HIV and AIDS—so why doesn't the government provide needle exchange instead of [the addicts] sharing needles, which spreads HIV much more readily? This was when HIV and AIDS really broke out and a huge number of people died. So they said, "If people are going to use, we want to help them stay alive. We want to reduce the harm." The needle exchange program was really the first type of that.

In Vancouver, Canada, where I grew up, there are many homeless people living in the lower east side that are injection drug users, and a lot of them are overdosing and dying.

What did the mayor's office do? After some persuasion from harm reduction specialists, they opened a safe injection center. This is where, instead of shooting up in the alley and not knowing what you're getting, you can go to this site. They'll give you clean needles. They'll allow you to shoot up there. There are nurses and doctors available if they need help. Since they opened that, the fatality rate has dropped. Of course, many people say, "Why is this happening? You're just enabling them to continue using."
VY: Right. "This is illegal and the government is helping them do something illegal."
GM: Exactly. The second program in Vancouver that just started and is also having good results is basically prescription heroin from doctors. Of course, that started in England years ago. Physicians there called it the medicalization approach. If they were dealing with a heroin addict, they could say, "Look, we'll prescribe you heroin while you're doing treatment because we don't want you to overdose from buying it on the street where you don't know how potent it is." These are harm-reduction kinds of approaches.

Another example is methadone treatment; that's harm reduction because you're reducing the rate of potential for overdose fatalities.

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The Bar Lab

I was interested in applying it to alcohol problems, which means moderate drinking. Mainly we’ve been working with college students who are binge drinkers, because the NIH report has been showing about 1,400 to 1,500 college students die every year from alcohol-related problems—overdose drinking, car crashes.
 
At the University of Washington, there was a recent case of a student who died. A 19-year-old freshman was living in a dormitory, and a woman that was his friend just turned 21. What do you do when you turn 21? You want to have a party because you can drink legally—even though her friends were 19 or underage. So they go, “Where can we go and not be caught by the dormitory advisors and things like that?” If you catch you drinking and you’re under 21, you could lose your room. So one guy said, “Hey, there’s a balcony on the seventh floor. Let’s bring all our alcohol up here.”
 
 So they took their vodka and rum and everything else up. There were six of them. They said, “We’ve got to drink quickly just in case—otherwise we’ll get caught.” They all got loaded pretty fast, and the guy who died was sitting on the edge of the balcony telling a funny story, lost his balance—head-first down in the cement, killed on impact. His blood alcohol level was 0.26. In Washington state, 0.08 is the legal limit. He was triple that.
 
 We found out from his family and friends that he wasn’t a big drinker in high school. Once he got to college and all of his friends were drinking, he just went overboard.
 
 So harm reduction for college students means we’ve got to train you how to drink more safely, even if you’re underage—that’s when the highest risk occurs. We developed a program called BASICS—Brief Alcohol Screening and Intervention for College Students.
We’re teaching them, “Just like safe driving, this is safe drinking.”
We’re teaching them, “Just like safe driving, this is safe drinking.” Your blood alcohol levels, what’s going on, how alcohol affects you—we teach them all that. We bring them into our bar. We have an experimental bar on campus called Bar Lab. We give them drinks.
VY: This is like John Gottman's Love Lab.
GM: Yeah. This is the Bar Lab. It's a cocktail lounge on the second floor of the psych building. What we do there is bring students in and give them drinks. They can drink anything they want for an hour—usually about 12 to 15 students. They're usually getting pretty loose and playing drinking games. Then we tell them, "Guess what? None of the drinks that you had had any alcohol in them whatsoever. They're just placebos." They go, "What?"

We tell them, "Look, when you go drinking, three things are happening: what your actual drink is, number one; what the setting is, like a bar, there's music or whatever; and most importantly, what your set is—your expectancy about how alcohol's going to affect you. Those things make for big placebo."

So, people who go through this—we call it the "drinking challenge"—end up drinking about 30% less after they go through that particular program.
VY: How do you get them to agree to do the program?
GM: They get paid for follow-ups and assessments over a four-year period—only about $200, but still. We had an abstinence-based alcohol awareness program on our campus, and they would show car crashes and things like that—people who get killed. And they were trying to say to people, "You can't drink legally until you're 21." Who showed up for that program? Hardly anybody—maybe 2% of the students.

But if we go into the fraternities and the sororities and the dormitories and others and say, "Would you be interested in a program that would help reduce your hangovers and your driving, sexual problems and things like that?" They all go, "Yeah." So you bring them in.

So harm reduction is typically user-friendly. It's not saying, "You've got to stop or we won't talk to you." People with addictive behaviors—there's so much shame and blame and stigma. They don't want to show up. Instead, we're saying, "We're going to meet you where you are. We're not asking you to quit right away. We're just saying let's talk about what your drinking or drug use is like and see what you might want to do. We'll try and help you, whatever your goal is"—rather than confronting them and saying, "you've got to quit."
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Moral Objections

VY: Why do you think there's such vociferous objection to the harm reduction approach?
GM: Many people buy into the moral model of drug abuse, the war on drugs—it's called a black-and-white model. Either you're abstinent or you're using. You're an addict. There's nothing in between. So the door is pretty tight. Kurt Olkowski, the new drug czar that we just got under Obama, said that the war on drugs has failed. Thank God, because the previous administrations under Bush and Nixon said, "Lock them up. If they're using illegal drugs, punish them." We now have 2.3 million people locked up in this country, which is more per capita than any country in the history of the world. Sixty percent of them are there either directly or indirectly incarcerated because of drug or alcohol problems.
VY: It's clear you take issue with the moralistic approach.
GM: Yeah.
VY: Is harm reduction a countervailing philosophy?
GM: It's a public health approach.
VY: Is it a more scientific, research-based approach?
GM: Yes, it is based on research, and there are more and more studies coming out that show that it is really helpful. It's working. Our BASICS program for college students is now listed on the national registry for evidence-based practices. We've got about 2,000 universities that are now using it. That's really working. People don't like to call it harm reduction. They would call it an alcohol skills training program or something.

Alan Leshner, who's the director of the National Institute on Drug Abuse, published an article last year saying, "Drop the term 'harm reduction' because it creates so much controversy. Let's call it something else"—sort of like the word "communism" or something. Up until recently, if you were presenting a paper at the APA or any other conference where there was sponsorship from NIH, if you used harm reduction in the title, it was eliminated. They said, "No, we won't let you talk about it."

I've run into this a lot. I've given talks about harm reduction where half the people walk out of the room while I'm talking. Huge resistance.
VY: Why do you think that is?
GM: They're from the moral perspective and they think all the harm reduction technique is doing is enabling people. I received an award yesterday, and one of the people that gave me the award told me he remembered when I was first talking about harm reduction and people claimed I was murdering alcoholics and allowing them to die.
...when I was first talking about harm reduction...people claimed I was murdering alcoholics and allowing them to die.


What we’re doing, like in Housing First, is trying to keep these people alive. That’s what the research has shown. So I think harm reduction is going to take off under the new administration. Ninety percent of the people who have alcohol and drug problems aren’t getting any treatment unless they’re busted for something. How are we going to bring them in? We’ve got to allow harm reduction to be a middle way. 
VY: You're not against abstinence as a goal.
GM: No. We're for both. We're just trying to get more people in the door.
VY: You're for both abstinence and moderation.
GM: We're for whatever your goals are. We're going to help you do that.
VY: If someone has a goal of moderation, but is unable—some people apparently can't control their drinking—
GM: You've got to put them through a program, and then they finally get to realize that they can't do it even though they've had the best program. If it's not working, they're much more willing to consider abstinence. You've got to try something.
VY: Do you agree with this idea that there is a subset of addicts that just can't do moderation?
GM: It depends on the moderation program. Now there are more pharmacology treatments coming in to help people moderate drinking, and many more cognitive behavioral skills training programs. A lot of people can't achieve moderation if they just try and do it on their own. If they get into a good program that teaches them the skills, like how to use a blood alcohol level chart—if you're a male or a female, how many drinks over how many hours, what your blood alcohol level is going to be—what are you going to do instead of drinking? You want to keep your BAL lower. A lot of the young people that we work with that do binge drinking—they drink two beers in 15 minutes. They don't feel anything so they drink two more, and things like that. We tell them to slow down. Drink two beers and wait half an hour. Then they can actually feel the effects of these two beers. "I don't really need any more," this kind of thing.

We're not telling them that it's all bad. We're just telling them it can be harmful.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.You start losing your coordination. You have blackouts and other kinds of problems. What is your limit here, where one more drink is not going to make you feel any better? You learn that. You stick with it. That's been working very well.
RA: Do you see a lot of parallels between the opposition to the harm reduction approach and the opposition to anything other than abstinence-only sex education?
GM: Totally, yes. It's the same issue because they're saying, "If you teach people about safe sex and condoms and things like that, that will enable higher amounts of sexual activity, so we should promote abstinence." But those programs are not working.

It's just like the DARE program—the drug abuse resistance education—totally abstinence-oriented. Now they're finding that kids who went through the DARE program in school are doing worse in terms of alcohol and drug use. Harm reduction applies, I would think, to what we call the 3 Ds of adolescence-the three dangerous drives—drinking/drug use, dating (sexual behaviors), and driving. So if you teach people how to do those things more safely, whether it's sex, driving or drugs, you're going to reduce harm. There's plenty of research to show that it's true, but the political resistance has been amazing.

For example, one of the big harm reduction programs we have done in Seattle is for homeless alcoholics, people living on the streets who are drinking. We worked with the Downtown Emergency Services Center, which provides housing for homeless people. There was a program in Canada called Housing First where they give people housing and let them drink in their housing if they want. Compare that to what they tried in New York, in which people had to quit drinking or they wouldn't get the housing, so almost everybody got expelled or kicked out because they couldn't give up drinking.

So the Seattle program, which we received a big grant on, basically asked, "What's going on?" We wanted to compare people who got housing right away with the people who were under waitlist control. The people we looked at were selected by the King County and Seattle government; they were people that had the highest health costs over the last year. These were very sick people; the average life expectancy for them is about 42 years. So the government referred these people, who either got the housing right away or were on the waitlist. In our program, they were allowed to drink in the public housing and the opposition in the media was huge. "What? We're using taxpayers' money and letting them drink? What is that all about? You're just enabling them."

One year later, we found that the people who got the housing had reduced their drinking. For many of them, having housing gave them more reason to live. As we published in the Journal of the American Medical Association, the most important thing was the health cost savings of four million dollars over the first year. All of a sudden, people said, "Maybe harm reduction saves money compared to what we were doing before." We keep getting these flips in terms of reactions to harm reduction.
RA: I've heard you mention before that therapists can unwittingly enable their clients' addictive behaviors by ignoring the addictions that are going on: treating the emotional issues that they bring into their sessions, but not talking about their alcohol or cocaine use.
GM: Yeah. A lot of people do have both kinds of problems, and they're using alcohol or cocaine or whatever it is to self-medicate when they're depressed or when they're anxious. That's still a big split between the mental health and the addictions fields, even though many people have both kinds of problems. How are we going to approach them and teach more mental health folks to think, "Hey, there are alternatives here"?

Harm reduction is one of them, and brief interventions have become very popular now. For example, Tom McLellan, who is the associate drug czar/psychologist that everybody knows, was saying we should train primary health care physicians at general hospitals, so that when people come in with whatever their medical problem is, if they have an alcohol, smoking or drug problem, do a brief intervention. It doesn't mean confront them, but just say, "Hey, have you thought about doing something about this? I have some information for you. Try it out. See if it works."

They include harm reduction programs to cut back as well as programs to stop. That is very radical, but it has been happening in trauma centers around the country. In the Seattle trauma center, if people are brought in from a car crash that involved drinking or something, Larry Gentilello, a physician there, would do a brief intervention, meet with the person once their medical care is handled. "Hey, there are some programs that could help you cut back or quit drinking. Are you interested?" A lot of them said, "Yeah." The trauma center would give them the information, and provide the referral. That turned out so well that now all trauma centers around the country have to show that they utilize brief interventions in order to get their license. That includes harm reduction.

I think we're going to see more of it because, first of all, it works.
The research is very strong. It saves lives. It saves money.
The research is very strong. It saves lives. It saves money.It gets more people on board.

Right now, most people with these problems are just staying out. They go, "All there is is Alcoholics Anonymous. I went one time. I don't like it, and there's nothing else that I know about."
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Harm Reduction in Psychotherapy

VY: Let's get into the nitty-gritty of how a typical psychotherapist, who doesn't specialize in drug and alcohol use, may deal with a patient struggling with an addiction. How do you start applying these principles in the course of counseling and therapy?
GM: First of all, you're going to ask the person what's going on in terms of their alcohol or drug use. What are the risk factors? We adopt a bio-psycho-social model. Biologically, you want to know maybe the family history and alcohol or drug problems. You want to know about whether that's going to increase their risk. Then you would go on to psychological issues, what we call psychological dependency on alcohol or drugs. Why do they think it's helpful, and what are their outcome expectancies about drinking or drug use?
VY: So you ask why they think it's helpful.
GM: Or harmful. We want to look at both sides. We want to meet them where they're at, enter their world. We use a lot of motivational interviewing.
VY: Yes, it seems very similar to motivational interviewing.
GM: So we're trying to figure out whether this person is in pre-contemplation stages of change or contemplation, or looking at possible plans of action—and matching our intervention with that. You can determine that pretty easily. Have they thought of doing anything about this? What do they think of the pros and the cons [of their drug or alcohol use]?
VY: Can you give an example of how you match an intervention to where they are?
GM: If they're in pre-contemplation, we're just going to try to talk about, "Did you know that the amount of smoking that you're doing is going to increase your risk of lung cancer and emphysema? Are you aware of this?" We try and enhance awareness of the risks. And then if they're in contemplation—
VY: Which would mean they're contemplating quitting?
GM: Or they don't know quite what to do. They're going between the pros and the cons: "Maybe I could quit, but I don't know what's the best way to quit. Maybe this isn't the right thing to do." That's when we meet them and help them look at the reasons why they like drinking and what some of their concerns are about it, and then try and move them on to the preparation and action stage.

In the BASICS program with college students, we just meet with them twice, one on one. In the first session, we give them feedback about their risks. They've filled out all these questionnaires so we know about family history and expectancies. We know about their cultural factors. We give them feedback in a friendly way. We could say, "Hey, you said that 80% of the students at this university drink more than you—actually, you drink more than 75% of the students."
VY: You're giving them some data.
GM: Giving them feedback, but in a friendly way. So they're getting a lot of feedback and awareness. And in the second session, it's the action plan. "What are we going to do about this?" We don't tell them what to do. We collaborate with them. What have you thought about doing? One young woman said, "In my sorority we usually drink and get drunk Thursday, Friday and Saturday nights. I was thinking of maybe not doing it Thursday night." We would support that—something that they come up with.
RA: Although it's not something that's necessarily spoken to directly, it sounds like this approach has a high sensitivity to the shame around addiction.
GM: Oh, yeah—shame, blame, guilt, stigma, moral issues. We're trying to let people know what their level is, how many other people have this kind of problem, and what kinds of things could help them. If they would like to quit, we'll say, "Great, we can put you in an abstinence-based program." Most of them are saying they just want to cut back. They're very positive about these kinds of skills we teach them. After we bring them in a bar lab and give them placebo drinks, then we teach them about blood alcohol levels and give them charts. We have them keep track of their drinking for two weeks so that we can see which days and what situations, whether they drink by themselves—which is more dangerous than social drinking—things like that.
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
VY: You're not coming at it from a moralistic way, but you do have some stance. You have an idea that if people are drinking in a way that you define or you think is destructive, you would like them to change that.
GM: Sure, yeah. It's pragmatic. That's where we're coming from. It's not moralistic.
VY: One thing I noticed in the video I saw of you with this black male, you got into really nitty-gritty details. He said he wanted to quit, but you really drilled down into, "What does that mean, to quit? What's your first step?" He said, "I'd go to the program." "What do you have to do to go to the program?"
GM: Right—break it all down into different steps. Also, we found that what triggered his relapses was, whenever he had cash, he'd go down to "buy a pack of cigarettes," and, "There's my beer"—these kinds of things. We're trying to teach people cognitive behavioral strategies around things that can set you up for relapse. Whether you're doing harm reduction or abstinence, there can be occasions where you just do way too much. What are the steps that lead up to that? We're using a lot of mindfulness and meditation to get people more aware of their choices.

Victor Frankl wrote this saying: "Between every stimulus and response, there's a space. In that space is our power to choose our response."So we use this idea in our work, and it's turning out to be very helpful, especially for people trying to stay on the wagon.
VY: How have you integrated mindfulness? It seems like a hot topic that's integrated into many approaches these days.
GM: Yes, mindfulness-based stress reduction—Jon Kabat-Zinn's work inspired us. I'm a good friend of his. Zindel Segal's mindfulness-based cognitive therapy for depression is very effective. Ours is mindfulness-based relapse prevention. All these programs are group-based, outpatient weekly programs for eight weeks.

We've gotten funding from the National Institute of Drug Abuse to evaluate the program, and we're finding that it's working pretty well for people with chronic alcohol and mental health problems. Of course, it's voluntary, so if people don't want to do it, that's fine, but a lot of people, once they talk to their friends who have gone through it, they go, "Hey, I'd like to do that." It's relaxing. It's stress reduction. It also gives you a different perspective on craving.

In the last study, we found that people in the control group, the more depressed they were, the more their craving went up—this was in an abstinence-based program—but if they went through mindfulness when they were more depressed, craving did not go up. The depression and craving was kind of disassociated. We're very enthusiastic about that.
VY: How do you explain that?
GM: Because mindfulness gives you a little bit of a different perspective, so you don't over-identify with situations like when you're depressed or feeling like you have to self-medicate to feel better. It gives people more of a choice. It doesn't mean they always do it, but a lot of times they do.

If you think of addiction treatment, the 12-step program, which is very popular, is basically Christian-based. The word God shows up in six of the steps, although they say the higher power could be anything. But a lot of people don't connect with that. The mindfulness program is more based on Buddhist psychology. It's a whole different approach. It's also very consistent with harm reduction—the middle way and things like that. It basically tells people there is another way. Instead of the 12-step program, you could do the eightfold path in Buddhism—right mindfulness, right activity, all that kind of stuff. So I think it's an alternative.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state.
Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state. Many of them are hooked in the spirits in the bottle, where they're really looking for another spiritual approach. I think mindfulness is another pathway. A lot of people relate to that pretty well.
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The Disease Model of Addiction

RA: Do you have a problem with the disease model, from the standpoint that it classifies a person as an addict in a way that integrates into their self-identity?
GM: Yes. Phillip Brickman identified four models: the moral model, the disease model, the spiritual model and the cognitive behavioral model.

The disease model says, "You have a disease and it's due to factors beyond your control: your genetics and your physiology and it's all the same disease for everybody, so we're not going to give you any individualized treatment. We're going to put you in a 12-step program"—which also buys into the disease model. The theory is that there is no cure whatsoever. All you can do is arrest the development of the disease by maintaining abstinence. If you have one drink, it's a relapse. In AA, you have to go back to the beginning again.

In harm reduction, we take the attitude, "Hey, lots of people have slips. Let's look at what happened. You made a mistake. How can you learn from it?" We're not saying, "You've got to go back to the beginning."
RA: That's very shaming.
GM: It's very shaming, yeah. I asked a lot of the disease model people, "Why do you say that there's no cure?" They said, "If there was a cure, people could go back to drinking. We don't want them to do that."

Even though the research at NIAAA—the National Institute in Alcohol Abuse—shows that quite a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
... a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
They don't want to say that. The disease model says that's enabling. I'm much more in the cognitive behavioral model.
VY: So you don't buy into the disease model at all.
GM: I don't want to put people in jail and say that they're moral failures. Sure, they have a problem—but for me, the disease model is: if you're a heavy smoker or a heavy drinker, there are potential disease consequences. You could develop cancer. You could develop cirrhosis. Is what you're doing a disease?
VY: Is the act of reaching your hand out and picking up a drink caused by a disease?
GM: It's a habit with potential disease consequences. In one of my most recent books, The Complete Idiot's Guide to Changing Old Habits for Good, we talk about changing old habits for good. Habits are what's driving this. It has disease consequences, totally. We're talking a huge health problem. But just to say the whole thing is a disease—what's the point?
VY: You haven't convinced everyone, obviously.
GM: No, of course not. But we're out there. There are more and more people coming over to the cognitive behavioral model because, treatment-wise, that's what is most effective.
VY: So you consider your approach consistent with the cognitive behavioral model?
GM: Oh, yeah. Many people call mindfulness a meta-cognitive coping skill, so it's consistent with the cognitive behavioral approach. Plus lots of research shows that it's stress reducing.

The biggest trigger of relapse is negative emotional states. People are upset. They're angry. They're depressed. They're anxious. They want help from the drug. So meditation is an alternative way of giving them stress reduction. That's what a lot of the patients that we're working with are saying: "Wow, this is really helping. I'm meditating and giving myself a choice instead of giving into my cravings." We're showing a big reduction, as I mentioned before, between negative emotions and craving for relapse risk.
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Consumer Choices

VY: I know back in the days, they tried to study and come up with an alcoholic personality or an addictive personality, and it seemed like there wasn't too much success with that.
GM: The main kinds of personality factors that keep coming up are sensation seeking—people that crave the high, altered state—and self-medicating—what they call coping. Those are the two main personality traits. Some people have both. That does increase the risk.

There are personality models. Right now, NIDA and other people are saying, "Addiction is a brain disease. It doesn't matter what drug you're using—it's all releasing dopamine in the brain. The pleasure centers are lighting up. We need pharmacotherapies that can reduce the effects of these different drugs or replace them, whether we're talking about methadone or any of these other kinds of things."
VY: What do you think of that?
GM: It may be helpful. Some of the medications do reduce craving on the short run. I think if we combine that with mindfulness, maybe the two of them would work together.
My position is, if you think something is going to work for you, try it.
My position is, if you think something is going to work for you, try it.It could be a pharmacotherapy. It could be psychotherapy.

In the addiction treatment field, there was Project Match that came up a few years ago. They were saying therapists should match patients with a particular type of therapy that the therapist thinks would work. In Project Match, they assigned hundreds of alcoholics to get Alcoholics Anonymous, cognitive behavioral therapy, or motivational enhancement interviewing. Those were the three groups. They followed everybody up for two years. They found—guess what?—there was no difference. All three groups did equally well.

What really worked the best was therapeutic alliance: if there was a good relationship between the therapist and the client, it worked.
VY: This has been the finding in all of psychotherapy research.
GM: Yeah. So I think instead of doing treatment matching, we should switch to consumer choice. People come in: "Hey, I'm interested in getting some help. What have you got?" There are some programs that are saying, "We've got a lot of different programs here. I'll show you some videos. Here's what's happening with 12-step programs. Here's a cognitive behavioral program. Here's something on moderation management. Take a look and see what you think might work for you and have a backup." Give people a choice of pathways.
VY: Back to being pragmatic.
GM: Back to being pragmatic. "If the thing you're trying doesn't work, there are other things you can try. Don't give up." The average number of serious attempts that smokers make to quit before they are successful is twelve. Twelve attempts! So people that have tried to quit smoking and say, "I can't do it. I've tried it three times"—I tell them, "You're not even there yet. Each time you learn something."
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Therapeutic Mistakes

VY: What do you think are some of the typical mistakes that therapists make if they don't specialize in working with addicts?
GM: Like the psychiatrist I was telling you about earlier, a lot of them say, "I can't handle this so I'm going to refer you to alcohol treatment. Until you get that under control, I'm not going to see you anymore." That happens so much. It's the wrong thing to do. People just get stranded. They get caught. They don't know where to go.
VY: What would you tell the therapist to do?
GM: Integrative approach: look at addictive behaviors like any other behavior issue. Read about it, get some training, take some courses and things like that; don't leave these people stranded.
VY: If someone's having problems with anxiety, you don't say, "I don't treat anxiety. You've got to go to an anxiety program." You integrate that into the treatment
GM: Not being able to see how the addictive behavior and the mental health problem relate to each other—thinking they're separate diseases. In reality, they're often extremely interactive. One is relating to the other—like the person with depression is trying to self-medicate and he gets caught in between. I think that is the main thing.

Sometime after that psychiatrist called me, I asked him, "How much training in alcohol and drug problems did you get when you were in medical school?" He said, "One half day." Christ. Of course they don't know anything about it.
VY: That's amazing.
GM: Yeah. That's the biggest issue—even in psychology. When I was a graduate student in the late '60s, I said to my professor at Indiana University, "People are studying behavioral therapy and they're doing all this kind of work with different behavioral problems. What about drinking as a behavior problem?' He said, "You don't want to get into that field." I said, "Why not?" He said, "The addictions field is very low prestige. Why don't you get yourself a real problem like snake phobias?" That's what was going on then.
VY: As a social policy health problem, there are a lot more people with problem drinking than with snake phobias, let alone snake bites.
GM: I said to my professor, "I don't know anybody with a snake phobia, but I've got a lot of people in my family with heavy drinking problems. Why can't we do something about that?"

The disease model didn't really look at drinking as a behavior or as a habit. The big shift was to try to move it from strictly genetic into habits. [quote:Smoking is a habit. It's not a disease in itself, but it causes diseases.
VY: That is changing, that field.
GM: It's gradually changing. When I got into the field, people were saying, "Stay out."
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I Like to Drink

RA: There are some addictions that are considered controversial, like sex addiction. From your perspective, is it the object of the person's desire that is addictive, or is it the relationship between the person and what they're going after that's addictive?
GM: The new DSM-IV revisions have been including other kinds of addictive behaviors, like gambling, sexual addictions, shopaholism, things like that. From a cognitive behavioral perspective, there are a lot of similarities. There's a lot of craving, whether it's sex or gambling. There are differences in terms of the effects, of course, but I see there being lots of common issues.

One of the biggest things is the problem of immediate gratification. We call it the pig problem. "I want to hit the jackpot. I want to have a sexual experience. I want to get drunk." All these kinds of things are very similar in terms of the neuroscience of what's going on.

So I'm totally open to talking about addictive behaviors as including ones that don't involve drug or alcohol use.
VY: You've been doing this for a few decades now, and addictions has been a career-long interest for you. What are some things you've learned that have made you a better therapist?
GM: I think having these experiences myself. I like to drink. I have drinking problems in my family. I wouldn't consider myself an alcoholic. Many people in the addiction treatment field are in recovery so they're saying, "Don't use at all." I'm much more user-friendly to these people because I do it myself. I'm helping to teach them that there are better ways to do this.

Since I've been more of a Buddhist psychologist, I took the bodhisattva vow, which is to reduce suffering in people that have these kinds of problems. If I can relate to them and identify with them rather than saying, "I am abstinent and you're using," it works a lot better.
VY: Thanks for taking the time to meet with us.
GM: You're welcome. It's been a pleasure.


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G. Alan MarlattG. Alan Marlatt, PhD spent many years as a Professor of Psychology and Director of the Addictive Behaviors Research Center at the University of Washington. He has published over 200 articles and book chapters as well as five books, and his work on relapse prevention, assessment and harm reduction has had a wide impact on the treatment of addictions in the U.S. and abroad.
Victor Yalom, PhD is the founder, president and resident cartoonist of Psychotherapy.net. He also maintains a part-time practice in individual, group and couples therapy in San Francisco and Mill Valley. He has conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and also leads ongoing consultation groups for therapists.

Rebecca Aponte was the Operations Manager for Psychotherapy.net from 2008-2012. She earned her BA in Psychology from Holy Names University in Oakland, California and is currently working toward her PhD in Counseling Psychology at Colorado State University. She was heavily involved in research on cult behavior and apocalyptic beliefs that was presented at the 2012 Pacific Sociology Association Annual Conference, with several publications in the works.
A most intelligent and insightful interview. Marlatt has a perspective that is desperately needed in the addiction treatment field, a field filled with judgment and pre-conceived ideas blocking effective treatment. Marlatt's work challenges many of the commonly held beliefs of both treatment professionals, the general public, and addicts themselves. The stigma surrounding drug use is intense, knee jerk reactions whenever drugs, drug use or drug users are mentioned, preventing us from helping more people. The most damaging of all is the self-stigma of the addicts themselves. We can help people to overcome this self-stigma but, like family systems work, if you don't change the system, when they return to a society that damns them if they do and damns them if they don't. Our society also needs treatment and publishing this interview is a step in the right direction. Bravo for Psychotherapy.net and bravo for Alan Marlatt for speaking out and speaking openly. For once, someone willing to speak about addiction and its treatment without being paternalistic.
Howard Josepher
I have followed and enjoyed Marlatt's work for a long time, and your interview clearly brought out important concepts in a very concise way. A wonderful presentation of his ideas by excellent interviewing! Thanks to all three of you!
David Bullard, Ph.D.
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CE credits: 1.5
Learning objectives: 1. Describe the philosophy and origins of the harm reduction model.
2. Learn how to apply the harm reduction approach to working with clients who are abusing drugs or alcohol.
3. Identify differences between the abstinence-based model to addictions and the harm reduction model.
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