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©2014, ALL RIGHTS RESERVED ISSN: 1555–7855

INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY 2014, VOL. 9, NO. 2

Using mindfulness in a harm reduction approach to substance abuse treatment: A literature review Corliss Bayles Walden University

Abstract Harm reduction, a modern post-2000 form of treatment for substance use behaviors, provided a public health and disease model for the reduction of the spread of the human immunodeficiency virus in the early 1980s. Different from the traditional choice of treatment, abstinence, harm reduction is designed to meet people “where they are at”. The traditional 12-step treatment for substance use disorders does not allow the individual to relapse, lest it is considered the treatment has failed. Harm reduction focuses on the reduction of negative consequences of substance use and allows the substance user to accept moderate and safer use, thereby, reducing the harmful effects of the disorder. The inclusion of mindfulness with harm reduction places the individual in the present state of awareness, the here and now, making them aware of cues that trigger the desire to use substances. This article will compare the use of harm reduction treatments combined with mindfulness techniques as an alternative treatment for substance abuse when the 12-step substance abuse program does not work for everyone.

Keywords harm reduction, relapse, substance abuse, mindfulness, 12-step program, schema, mode deactivation

A ddicted people are a vulnerable population. They face many psychological and emotional problems which have a negative impact on their

quality of life. In addition to the psychological and emotional problems, there is also an adverse impact to the health and well-being of addicted individuals, which have a significant effect on the social and eco- nomic influence on a global level (Nooripour, 2014).

The outbreak of the human immunodeficiency virus (HIV), in the early 1980s, rapidly spread from the homosexual community to the heterosexual population through the shared use of needles and syringes during intravenous drug use. The result of HIV became Acquired Immunodeficiency Syn- drome (AIDS) and spread throughout the world. Lee, Engstrom, and Petersen (2011) reported that this pandemic disease gave birth to the idea that in order to decrease the spread of HIV / AIDS, a new alternative to assist in the treatment of people who suffer from drug use was developed. This new form of treatment was known as harm reduction (Lee et al., 2011). Harm reduction was an intervention de- signed to reduce the problematic effects of addictive behavior (Logan & Marlatt, 2010). In an attempt to reduce the blood-borne diseases associated with HIV and hepatitis, harm reduction was a supporter of the needle exchange program that provided substance abusers with new needles, education on safe use, sharing needles, safe injection sites, and allowed them the ability to inject themselves in the presence of medical personnel (Logan & Marlatt, 2010).

The harm reduction concept

Marlatt’s Buddhists beliefs had a profound influ- ence on his research in addictive behavior. Buddha teaches that enlightenment should be sought by seeking the middle way, which is analogous with harm reduction. Marlatt believed that a middle path between the extremes of asceticism and gluttonous self-indulgence led to moderation in behavior. Moderation in behavior became the principal focus of his research related to the understanding and intervening in addictive behaviors (Blume, 2012).

The “compassionate pragmatism”, as Dr. Marlatt called it, of harm reduction provides an important public health alternative to moral and disease model of substance abuse (Lee et al., 2011). Lee et al. argued that harm reduction opened the eyes of public health to multifaceted programs and policies that reduced harm associated with drug use. Harm reduction focused on meeting people “where they were at”, and identifying client-driven individualized goals. Although open to abstinence, advocates for harm reduction recognized that (1) this goal may not be the most appropriate goal for every client, and (2) emphasizing abstinence as a goal may prevent some of the clients from seeking help or staying in the program (Lee et al., 2011).

Realizing that any and all positive changes re- garding substance abuse were valuable, addressing substance abuse would be just one part of helping clients make positive changes in their lives (Lee et al., 2011). Programs that were effective in helping people change were needed in order for this change to take place. Positive indications of effective programs are improved individual, and community well-being (i.e. reduced needle sharing, discarding needles in public areas, reduction in deaths from overdoses, increased enrollment in detoxification and treatment centers) (Logan & Marlatt, 2010). By reducing the harmful effects of substance abuse, communities are able to see a reduction in the need for medical care due to drug overdoses, reduction in the number of arrests and court costs, and increase in participation in tax payer contributions, due to an increase in an employed population Larimer, Malone, Garner, Atkins, Burlingham, Lonezak,…Marlatt, G. A. (2009).

Recognizing that substance use had become a problematic coping strategy of disadvantaged neigh- borhoods was a step toward helping make a positive change and this would call for an alternative coping mechanism (Lee et al., 2011). In efforts to reduce harm from substance abuse, there arose a need for explicit consideration of the way in which social injustices and trauma contributed to the use of substances. To address this need was another step toward positive

change for substance users. Lee et al. (2011) suggested that if efforts were made to de-stigmatize substance use and substance users by investing in the “bottoms up” approaches that emerged from grassroots, such as people empowering approach efforts (Blume, 2012), it would be particularly beneficial for those who used substances.

Logan and Marlatt (2010) reported, that in 2006, alcohol and substance abuse was associated with trauma and emergency room visits. Over one million people screened positive for substance use, and substance-related risky behaviors, abuse, or depen- dence with no previous sought out substance abuse treatment. Basically, these people did not recognize that they had a problem with substance use, so there was no motive to seek treatment.

In addition to using substances, many of the people had co-occurring mental disorders (Logan & Marlatt, 2010). Traditional treatment practitioners usually required substance users to be abstinent of drugs, before they could be treated for their mental disorders. In some cases, this was not a feasible treatment plan. Harm reduction allowed the patient / client to reduce the use of drugs while simultane- ously receiving mental health treatment (Logan & Marlatt, 2010).

Harm reduction goals

Instead of viewing abstinence as the only option for intervention for substance use, harm reduction focuses on reducing the negative consequences of substance use, accepting goals of moderate use or use in safer conditions (Dimeff, Baer, Kivlahan, & Marlatt, 2003). Harm reduction interventions target different populations and have three main goals. The first goal is to stay alive. The second goal is to maintain one’s health, and the third goal is to get better. The strengths of harm reduction include flexibility and the ability to individualize both the goals and the strategy to achieve them.

The differences in these strengths make it difficult for various stakeholders to define, implement, and assess harm reduction approaches (Lee et al., 2011). Opponents of harm reduction saw the program as

“making peace with genocide”, “giving up on people” (Lee et al., 2011, p. 1153) rather than reducing the harm and minimizing the destruction. In cases where clients are not willing to stop substance use, abstinence is only a system that is set up for those people to fail. Those who oppose the use of mini- mizing the effects of substance use through various interventions, that do not include abstinence, believe that harm reduction misleads the addict and allows him / her to deny the seriousness of their problems (Dimeff, Baer, Kivlahan, & Marlatt, 1999).

Buddhist teachings about mindfulness

In addition to Dr. Marlatt’s use of mindfulness in his approach of harm reduction in treatment (Blume, 2012), there have been other psychologists whose practice was based on the principles of Buddhist teachings of mindfulness. For example, Dr. Jack Apsche (2014) uses mindfulness as part of Mode Deactivation Therapy (MDT) in his practice with adolescent males to treat Conduct Disorders (CD), Oppositional Disorders, reactive and proactive

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USING MINDFULNESS IN A HARM REDUCTION APPROACH TO SUBSTANCE ABUSE TREATMENT: A LITERATURE REVIEW 23

©2014, ALL RIGHTS RESERVED ISSN: 1555–7855

aggression, and PTSD. Drs. Jennings and Apsche (2013) confirmed that mindfulness, along with MDT also proved to be an effective treatment for sexual abusers. Already in 1969, German-born psychiatrist Fritz Perls realized the benefits of mindfulness and the therapeutic effects of staying in the present moment (Bayles, Blossom, & Apsche, 2014).

Because human beings commonly have many negative mental traits, observing the five precepts is one of the very basic ways to counteract the negative traits. The five precepts are: (1) refrain from harming self or others, (2) do not steal, (3) do not practice sexual misconduct, (4) speak truthfully, and (5) do not use drugs / alcohol that cause carelessness and loss of awareness (Faxun, 2011). As such, the five precepts help guide physical actions, speech, and mental attitude via a systematic means aimed at actualizing the purification of the body, speech, and mind. The individual will eventually gain wisdom little by little, and with wisdom, comes awareness of thoughts and behaviors (Faxun, 2011).

The concept of the five precepts is essential to any mindfulness-based recovery program. The five precepts are similar to a harm reduction program, and when coupled with mindfulness, they can be- come relapse prevention tools. These tools are like a

“karmic compass” pointing an individual away from self-harm and suffering by teaching the individual to develop a good heart and true happiness (Faxun, 2011). By adopting the five precepts, one adopts the principles of harm reduction. They learn to cultivate self-respect, self-trust, and eventually learn to move away from guilt and remorse.

Relapse prevention treatments

Relapse, which is often associated with a medical con- dition, is the return to a previous set of behaviors or mental state. It is considered a larger part of an issue that is specifically related to the individual. Relapse prevention (RP) is related to relapse as a naturally occurring event that is address through treatment. As such, relapse is not considered bad, rather it is con- sidered to be a part of the overall treatment process (McGovern, Wrisley, & Drake, 2005). RP in this case, refers to the re-occurring event of a substance user to return to previous treatment states of substance use. The relapse prevention model has been well documented, with a large data base to support it (Hendershot, Witkiewitz, George, & Marlatt, 2011). The benefit of relapse prevention is that it does not consider a lapse in behavior as a treatment failure. The lapse is considered a normal part of the recovery process and is a learning experience where the client learns to work through the lapse and understands the pattern or cues that are associated with the lapse (Hendershot et al., 2011). One disadvantage of the relapse model is that it is difficult to measure because if the individual lapses, he or she is very likely to hide the incident out of fear of sanctions (Babor, Steinberg, Anton, & Del Boca, 2000).

Bowen, Chawla, Collins, Witkiewitz, Hsu, Grow,… Marlatt (2009) estimated relapse rates following substance abuse treatment at over 60% and are de- scribed as chronic relapsing conditions. Twelve-step programs or mutual support groups are still the most common form of treatment. Mutual support groups

/ 12-step programs are highly organized groups de- signed to help those recovering from substance use by having them be accountable to others in the group. The purpose of the program is to help the individual refrain from substance use all together. The goal is abstinence and that should be accomplished at the end of the 12-step process. As mentioned earlier, 12- step programs are not appropriate for everyone. This program is discussed further later in this article. By combining skills training with cognitive interventions and a cognitive behavioral treatment that focuses on response to high-risk situations, RP with a harm reduction approach is an alternative to the 12-step program that prevents or limits relapse.

Although RP has empirical evidence of promising advancement in treatment, significant problems remain. Firstly, relapse is difficult to define as it varies according to the treatment approach, and to measure as it is largely a self-reported condition. Relapse rates also vary significantly depending on the specific approach and treatment goals. Bowen et al. (2009) reported a 44% to 70% relapse rate of standard RP approaches, i.e. without integration of further efficacious treatment components such as mindfulness and acceptance. Furthermore, with the exception of a few long-term studies such as that of American psychiatrist, Harvard professor, and trustee of Alcoholics Anonymous (AA), George Vaillant (2003), hardly any long-term follow-up relapse data is available. Besides, as the AA, the main champion of the 12-step program for substance abuse, places a high premium on anonymity and privacy of its members, conducting research is not easy nor encouraged. At this time, it is interesting to add that Vaillant’s study found that just as many treated alcoholics are abusing alcohol at the end of a two-year follow-up period as are the untreated sample through spontaneous remission. Similarly, another comparative study by Brandsma, Maultsby, and Welsh (1980) concluded that abstinence approaches such as the 12-step program had the highest drop-out rate, 68% at the 6-month follow-up compared to an average of 42% for the other methods. Almost none of the subjects remained totally abstinent after treatment, and neither were there significant differences between groups on this variable. Here, a meaningful pattern seems to emerge. Abstinence is not reasonably achievable as a substance abuse treatment goal. There- fore, scientific and evidence-based harm reduction models with integrated cognitive and mindfulness elements have become viable alternatives, despite the continued controversy of the appropriateness of harm reduction goals by controlled substance use compared with abstinence-only treatment scenarios of the disease model.

Using mindfulness in the treatment of substance abuse

Mindfulness is considered to be awareness in the present moment, which is approached in a non-judg- mental manner in the treatment of substance abuse. This form of treatment is gaining more attention in scientific literature. Mindfulness is an added element that is sometimes used in third wave treatment programs, and has been used by many therapeutic orientations, such as Cognitive Behavioral Therapy

(CBT), Mindfulness-Based Stress Reduction (MBSR), Acceptance and Commitment (AC T ), Mindful- ness-Based Cognitive Therapy (MBCT), and Mode Deactivation Therapy (MDT) (Bowen et al., 2009; Jennings, Apsche, Blossom, & Bayles, 2013). By com- bining mindfulness with traditional cognitive-be- havioral relapse prevention (CBRP), research suggest that mindfulness may help develop a detached and decentered relationship to thoughts and feelings, preventing escalation of thought patterns that may lead to relapse (Bowen et al., 2009).

Although mindfulness has existed in practice for centuries, it was never applied as a stand-alone therapy until psychiatrist and psychotherapist Fritz Perls used it in an attempt to unify mind, body, and spirit with Gestalt Therapy. Using what he learned from Zen Buddhism, Perls emphasized the principle of enhanced awareness in the present moment. He recognized and understood that all forms of imme- diate awareness – sensation, perception, emotion, thought, behavior, and bodily feelings, were the natural therapeutic effects of staying in the here and now experience (Jennings, Apsche, Blossom, & Bayles, 2012). Jennings and Apsche (2013) described mindfulness as “being fully aware of your immediate present experience and accepting yourself as you are in this moment without judgment” (p. 17).

While cognitive behavioral therapy (CBT) has become the most common standard approach among psychotherapies, the explicit effort to integrate mind- fulness and acceptance into traditional CBT therapies has revolutionized the field of psychology (Jennings, Apsche, Blossom & Bayles, 2013). Traditional CBT uses four main strategies to change thinking and behavior: skills training, exposure therapy, cognitive therapy, and consistency management. Exposure therapy is the equivalent of immediate awareness because it contains the essential elements of intense focus on immediate awareness by including mental, physical, and emotional experiences that produce acceptance of the immediate discomfort and irratio- nality (Jennings, et al., 2013). Through the process of identifying and challenging the validity of cognitions, the process of CBT can be seen as a degree of mind- fulness that systematically and repeatedly exposes the client to his or her disturbing and dysfunctional thoughts, emotions, and behaviors. It is hopeful the client will increasingly be able to tolerate and accept disturbing cognitions without negative self-judgment (Jennings, et al., 2013). However, this was considered a shortcoming upon which third wave approaches such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT ), and Mode Deactivation Therapy (MDT) were conceptualized.

Beck’s (1996) development of the concept of Modes or core beliefs impacted psychological functions when he posited that people learned from un- conscious experiential components and cognitive structural processing components (Bayles, Blossom, & Apsche, 2014). Harmful behaviors are maladaptive due to dysfunctional modes or schemas and in order to change a person’s behavior, the experiential compo- nents have to be restructured. Once the dysfunctional behaviors and habitual responses have been removed, they are replaced with self-awareness, acceptance, and regulatory skills (Bayles, Blossom, & Apsche,

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2014). Non-judgmental acceptance is the key to the process of challenging negative cognitions (Jennings, et al., 2013). Since the intent of harm reduction is to reduce the negative consequences of substance abuse, the goal is to accept moderate use and use in safer conditions as an alternative therapy for substance abuse (Dimeff, Baer, Kivlahan, & Marlatt, 1999).

Mindfulness is just beginning to be introduced into the treatment of substance abuse. Research in the use of mindfulness in substance use programs is finding its way into scientific literature (Bowen et al., 2009). Mindfulness is achieved through a series of awareness and observation exercises that helps develop trust, reduces anxiety, and increases commitment to treatment. Mindfulness has become a key factor in overcoming limitations of traditional CBT (Bayles, Blossom, & Apsche, 2014). CBT is limited in the area of validation. Where CBT challenges the validity of the individual’s core belief, Mindfulness and MDT validates the individual’s belief as having a grain of truth. Once the belief is validated, clari- fication of what the individual perceives as truth, is clarified in order to understand the belief system. The perceived views of the individual is redirected to an alternative possibility that the individual currently holds. Validation, Clarification, and Redirection (VCR) uses unconditional acceptance and validation of the individual’s unconscious learning experi- ence (Bayles et al., 2014). Avoidance of openness and honesty in interactions with others is another major problem with interpersonal relationships; mindfulness-individuals are encouraged to be open and honest with others, thus overcoming avoidance (Bayles et al., 2014).

Other uses of mindfulness

Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) has been used to treat depression (Bowen et al., 2009). Mindfulness-Based Relapse Prevention (MBRP) is an aftercare approach that integrates RP with practices from MBSR and MBCT. The core principle of the treatment is to recognize and identify high-risk situations. By recognizing the early warning signs of relapse, this increased awareness of internal (emotional and cognitive) and external (situational) cues, previously associated with substance use, allows the individual to develop effective coping skills, and improve self-efficacy (Bowen et al., 2009). The pilot efficacy trial study, conducted by Bowen et al., showed significant decrease in the number of days substances were used by the participants, while cravings, awareness and acceptance also improved.

The mindfulness part of MBRP aims to raise awareness of the triggers, monitor internal reac- tions, and foster more skillful behavioral choices by focusing on increased awareness, acceptance and tolerance of positive and negative physical, emotional, and cognitive states (e.g. cravings), in the present moment, thereby decreasing the need to engage in substance use (Bowen et al., 2009). It is evidenced that cravings is a significant predictor for substance use, substance use disorder (SUD), and relapse following substance use disorder treatment (Witkiewitz, Bowen, Douglas, & Hsu, 2013). By using mindfulness to increase awareness of regulation and

tolerance of potential events that cause relapse, the substance user may improve the ability to cope with relapse triggers by interrupting the previous cycle of automatic substance use behaviors (Bowen et al., 2009). From a mindfulness perspective, cravings may be effectively reduced by increasing awareness and acceptance of the triggers that lead to relapse, while helping the individual recognize and minimize the blame and / or guilt and the negative thinking that increases the risk of relapse (Bowen et al., 2009; Witkiewitz et al., 2013).

Mindfulness-based relapse prevention vs. treatment as usual

Bowen et al. (2009) conducted a randomized con- trolled trial (RCT) to compare the feasibility and initial efficacy of MBRP with the 12-step treatment as usual (TAU) among individuals with substance use disorders. The effect of treatment outcomes, as well as key secondary processes (cravings, mind- fulness, and acceptance) were assessed. Bowen, et al. hypothesized that those treated with MBRP would realize greater reductions in substance use and increased awareness associated with mind- fulness and acceptance than those receiving TAU. The reduction in substance use that was realized with MBRP was due primarily to the mindfulness approach since the participants, through increased awareness, were cognizant of the cues that led to substance use. They were accepting of their behavior, non-judgmentally. Through harm reduction, they learned to use moderately and in safer conditions, thereby reducing the need to abuse the substances.

MBRP is conducted using an 8-week, 2-hour group sessions following protocol in the MBRP treatment manual. There are usually 6 to 10 clients and two therapists participating in the group sessions. Each session has a central theme with meditation practices and related RP discussions and exercises (Bowen et al., 2009). Some of the themes included in the sessions are automatic pilot and its relationship to relapse, recognizing thoughts and emotions in relationship to triggers, integrating mindfulness practices into daily life, practicing the skills in high-risk situations, and the role of thoughts in relapse (Bowen et al., 2009). Sessions begin with a 20 to 30 minute guided meditation involving experiential exercises and intermittent discussions on the role of mindfulness in relapse prevention. Participants are given daily exercises to do between sessions and a meditation CD to use for practice outside the group. During the sessions, homework that the group has worked on throughout the week is reviewed (Bowen et al., 2009).

The TAU group remained in the 12-step program designed to maintain abstinence. The TAU groups met weekly and their themes included rational thinking skills, grief and loss, assertiveness, self-esteem, goal setting, and effects of alcohol and other drugs on interpersonal relationships and experiences (Bowen et al., 2009). Some of the groups included the RP skills, based on the disease model of addiction. The TAU group did not have regularly scheduled homework assignments, met once or twice a week (depending on the clinical need) and the meetings lasted 1.5 hours. Therapists facilitating the MBRP groups held master’s degrees in psychology or social work while

therapists facilitating the TAU groups were licensed Chemical Dependency Counselors with varying levels of experience in outpatient clinical aftercare services (Bowen et al., 2009).

When comparing why the outcomes of TAU and mindfulness / harm reduction programs differ in outcome, it is clear that mindfulness works much better with harm reduction than with TAU for the fact that TAU lacks acceptance of the substance abuse behavior. TAU teaches the substance user grief and loss techniques (Bowen et al., 2009), where mindfulness therapy teaches acceptance of one’s behavior without judgment (Jennings, Apsche, Blossom, & Bayles, 2013; Bayles, Blossom, & Apsche, 2014). Harm reduction allows moderate use of substances while the individual is in treatment while TAU insists on abstinence with no tolerance. If the individual relapses and uses a sub- stance one time, the treatment is considered a failure (Logan & Marlatt, 2010). Harm reduction considers relapse as a part of therapy and a learning experience to increase awareness (Hendershot, Wikiewitz, George, & Marlatt, 2011). Mindfulness therapy provides regularly scheduled homework assignments for the substance user to continue with while he or she is not in a therapy session, where TAU does not provide regularly sched- uled homework assignments. Training for mindfulness programs / harm reduction programs differ from the training for TAU. Therapists facilitating mindfulness therapies hold Master’s Degrees in Psychology while therapists facilitating TAU therapies are licensed as Chemical Dependency Counselors with various levels of experience in outpatient clinical aftercare services (Bowen, 2009). Further research would need to be conducted to determine whether the difference in training may be factor in the different outcomes of the programs, however, the difference in overall structure of both programs has a definite impact on the outcome of the treatment. All in all, mindfulness will not work as well with the 12-step program because the outcome goals of the mindfulness / harm reduction programs (moderate use of substances) are in opposition of the 12-step programs to obtain abstinence.

The overall results of the study supported the author’s hypothesis. Evidence was provided that the feasibility and initial efficacy of MBRP was supported as an alternative to the standard 12-step based related care programs. Outcome scores suggested significant improvement in the number of days of substance use, awareness, acceptance, and judgment mediated the relationship between those receiving MBRP and self-reported cravings (Bowen et al., 2009; Witkiewitz et al., 2013).

More recently, Kelly, Stout, and Slaymaker (2012) conducted a study consisting of 303 emerging adults. The participants consisted of 26% females, 95% white, and 51% presented with comorbid Axis I disorders, ages 18 - 24. The study was conducted at a residential treatment center for effectiveness of a 12-step program for Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Effectiveness was assessed on intake, 3, 6, and 12 months on 12-step attendance, involvement, and outcomes for percent of days of abstinence and percent of days of heavy drinking. The authors conducted a lagged hierarchical linear model (HLM) to determine whether attendance and involvement played a beneficial part in recovery.

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USING MINDFULNESS IN A HARM REDUCTION APPROACH TO SUBSTANCE ABUSE TREATMENT: A LITERATURE REVIEW 25

Kelly et al. (2012) discovered that at the 3-month time period, attendance rose 36% to reach its highest at 89% and maintained at 82% for 6 months. By the end of the 12-month period, attendance and involvement declined to 76%. During the initial phase (3 months) meetings were attended 3 times a week, but declined to once weekly by the 12th month. In conclusion, a comparison of the study conducted by Kelly, Stout, and Slaymaker (2012), against the study conducted by Bowen et al. (2009), measuring TAU against mindfulness-based treatment programs, it can be concluded that mindfulness-based treatment performed at a level that assured its place in society as an acceptable alternative treatment program to 12-step programs (Kelly et al., 2012).

Conclusions

As we have illustrated, the broad adoption of re- lapse approaches in the various treatment contexts challenges standard definitions, measurements, and consistent findings of comparative outcomes. However, it is apparent that there are strategies that are integral to substance abuse interventions that have proven to be more effective in terms of achieving progress when measured by treatment perseverance, frequency and amount of usage, and associated societal costs compared to traditional 12-step programs.

In particular, it is argued that mindfulness-based cognitive behavioral therapies is appropriate and effective as a Behavioral Self-Control Training (BSCT)

method. By promoting awareness and acceptance rather than disputing core beliefs and shaming the client, a stronger therapeutic alliance is possible to support behavioral goals and commitment. Accord- ing to Saladin and Santa Ana (2004), the literature on BSCT, old and new, is unequivocal with regard to its efficacy, and it is argued that the principles of mindfulness cultivate and enhance the positive potential of cognitive-behavioral approaches that are focused on harm reduction rather than a disease model perspective on substance abuse treatment.

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f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .