Duncanian Approaches to Therapy
The harm reduction paradigm rejects the presumption that abstinence is the best or only goal for all problem drug users. It sees non-medical drug use as bein on a varying continuum from harmless – even benficial – to seriously harmful in its consequences for the user and the community. Harm reduction therapy for drug abusers accepts small, incremental steps in reducing risk as being legitimate goals of treatment. As commonly stated, any positiuve change is harm reduction.
A number of harm reduction approaches to therapy for the addict or abuser have been developed. Miller and Rollnick’s motivational interviewing has been adopted as a treatment model by many harm reduction practitioners. Patt Denning has developed an approach rooted in Rogerian client-centered therapy and drawing in elements of cognitive-behavioral therapy and motivational interviewing. Adam Tatarsky has developed a harm reduction psychotherapy that incorporates elements of the psychoanalytic tradition of Sigmund Freud. The earliest and most respected practitioner of a harm reduction approach, however, was David Duncan. It is for this reason that harm reduction psychotherapy in general is often referred to as Duncanian Therapy.
A fundamental concern of his approach is that of distinguishing between psychoactive drug use and misuse. It is a common error to use terms such as drug abuse or addiction to refer to any use of an illegal or socially disapproved of drug. Neither abuse nor addictioon is a property of any particular drug or group of drugs, they describe patterns of use and consequences that can apply to any drug. Legal drugs are often abused and there are many more persons addicted to the legal drug nicotine or to alcohol, which is legal in most states of India, than are addicted to all illegal drugs combined. Furthermore, just as the great majority of alcohol drinkers are not alcoholics, the majority, perhaps the great majority, of uers of prohibited drugs are neither abusers of nor addicted to those drugs.
Drug abuse has been defined as the use of a drug at such doses or under such circumstances that it seriously impairs the user’s ability to function in their family, job, school, and community or to cope with circumstances. Addiction refers to compulisive use of a drug that persists in the face of negative consequences. In physical addictions, the user’s body has become so accustomed to a continuous state of suppresssion by a depressant drug, that failure to take the drug results in physical symptoms that are essentially a rebound effect due to release from the drugs depressant effects. Thus withdrawal of an opiate, which relaxes muscles, suppresses thesexual drive and calms the digestive tract, causes an opiate addict to experience muscle cramps, hypersexuality, nausea, vomiting and diarrhaoea.
Dr. Duncan, and those who follow his approach, have always refused to accept a politically imposed diagnosis of drug abuse or addiction. Non-addict users of illegal drugs were accepted for counseling regarding ways to minimize any risks associated with their drug use, including the risk of arrest or other punitive actions for their drug use. But Duncanian therapists reject convincing them that they must or should abstain from use of their socially disapproved drug of choice. Dr. Duncan likened this to an ethical surgeon’s refusal to amputate a healthy limb.
Even in the patient with a drug abuse disorder, it is still up to the patient whether or not to seek treatment for that disorder. Just as a patient with any physical disorder is free to forego treatment, the addict may not be ethically compelled to seek treatment. The addict or abuser who chooses not to seek treatment for his drug problem will only be offered assistance with harm reduction by a Duncanian therapist.
If the abuser or addict seeks treatment for his drug problem, it is still up to him whether the goal of treatment will be abstinence from further use of the drug or a return to the earlier stage of nonproblematic use of that drug. The role of the therapist in the Duncanian approach is to focus therapy on achieving the ends the patient prefers and to further allow the patient freedom to select from an array of treatment options those that he prefers. This is an empowering approach, which emphasizes the patiient’s strengths and abilities arther than his weaknesses and disabilities. It is also an approach that places responsibility on the patient, who must choose what goals are to be sought and what options are chosen in seeking those goals, and thus is resposible for the outcomes that result.
The Duncanian approach rejects the a priori assumption of many approaches to addictions treatment that a prson who has once lost control of their drug use can never regain control. Rejection of this concept is consistent with a growing body of community research that has shown that many addicts do return to non-addicted and nonp[roblematic use of the drug they were formerly addicted to.
In treating a drug abuser, the Duncanian therapist assesses the purpose the drug taking serves in the abuser’s life. Dr. Duncan was the originator of the “self-medication hypothesis,” which holds that drug abuse and addiction results from the abuser’s use of the drug in an ill-advised attempt to find relief from emotional pain or distress. When a behavior results in relatively immediate relief from such a preexisting aversive state, the behavior is said to have been negatively reinforced. There is a large body of research on the effects of negative reinforcement. A behavior that has been negatively reinforced is likely to recur at a high frequency and intensity, to crowd out competeing behaviors, to be highly resistant to any attempt to eliminate it, and to return again after it seems to have been eliminated – in brief, all that we expect of an addiction.
Opiates are often used to provide an escape from aggressive impulses that have proven difficult to manage or from unwanted sexual desires. Opiates can also be effective in suppressing psychotic symptoms in schizophrenic persons. Amphetamines and other stimulants can be effective in providing short-term relief from depression. Opiates and sedatives can provide a welcomed respite from chronic depression. Use for self-medication in any of these situations can serve as negative reinforcement of drug taking, resulting in addiction.
Once the patient has, with the aid of the Duncanian therapist, identified the sources of reinforcement for continued excessive drug use a major thrust of treatment is on developing alternate means to achieve those ends. This often involves learning and practicing skills in such areas as stress management or anger management. It may also involve referral to a psychiatrist for the prescription of appropriate antidepressant or similar medications. Finally, it may involve the therapist assisting the patient in values clarification and problem solving activities aimed at making changes in the patient’s life situation either to reduce sources of distress or to enhance the patient’s social resources. The bulk of the time in therapy, thus, is spent on issues other than drug use per se.
Related links
Rollnick and Miller's Motivational Interviewing approach click here
Denning's Practicing Harm Reduction Psychotherapy click here
Tatarsky's Harm Reduction: The New Paradigm for Treating Drug and Alcohol Problems click here
Duncanian Thory of Addiction click here
Duncan's self-medication hypothesis click here
Duncan's explication of the concept of responsible drug use click here
