Addicted to moralism

Treatment for substance abuse in the US is mainly an involuntary, punitive process. In some areas non-judgemental harm reduction programmes are challenging this approach, says Katherine van Wormer.

Iowa is the corn-growing region of the United States. Visitors note the friendliness, beautiful bike trails and low crime rate. The University of Northern Iowa – where I teach – has an exchange with the University of Hull in the UK. Each summer we have several British students who do their field practice at substance abuse centres in Iowa.

More than 90 per cent of US substance abuse treatment is based on the 12-step approach of Alcoholics Anonymous. Most of our clients have been ordered into treatment by the courts (often because of drinking and driving, drug arrests, or family violence related to intoxication). Typically, these involuntary clients attend outpatient treatment at agencies in their communities. Total abstinence is required; sobriety is tested by means of random urine tests. Some clients have custodial sentences hanging over their heads; one relapse and it’s off to prison.

AA itself is not the same as AA-facilitated treatment. Whereas AA, a self-help group, regards relapse as a normal part of recovery and does not write people off, treatment centres often dismiss a client from treatment for manifesting the very problems that brought them into treatment in the first place.

If you think this sounds punitive, you are right. So ingrained is this mentality in North American life that it is pretty well taken for granted. The origins go back to the early Puritans who were fierce believers in good versus evil, salvation for the few, and hard work as the way to salvation.

The legacy of this belief system explains the confessional and work-oriented nature of the 12 steps.

Within this grim picture, the disease model offers a beacon of light, a means of alleviating guilt and of getting treatment paid for by the government or private insurance. In the absence of nationalised health care, if alcohol and other drug addiction were not regarded as a disease by the authorities, there would be no treatment programming and even more incarceration than we have now.

Treatment providers bolster their case for treatment today with reference to the new magnetic resonance imaging technologies that can show biochemical changes in the addicted brain. (For colour slides of the brain on cocaine, visit

I am a proponent of harm reduction: the client-friendly, non-judgemental approach that can attract people to undergo treatment at an early stage of their problem behaviour.

Harm reduction strategies save lives. Adolescents do not respond well to the kind of labelling forced upon them at most US treatment centres and the harsh confrontation to which they are subjected if “in denial”. “You are losing them,” as one of the visiting British students angrily summed up her observations.

Motivational interviewing, which research has shown to be highly effective, is beginning to catch on. This is evidenced in recent counsellor training guidelines. Well known in the UK, this client-centred approach matches interventions to the client’s readiness for change. Motivational interviewing is closely akin to the strengths perspective of social work, and it is also consistent with the whole harm reduction principle of pragmatism – better to save lives than to preach.

Still, we have a way to go before a focus on moderate drinking replaces the total abstinence thrust. In north east Iowa, the British connection has helped treatment providers realise there are alternatives to 12-step based treatment, while helping the visitors appreciate that this US approach, too, can be an option.

Katherine van Wormer is professor of social work, University of Northern Iowa, and is the author of Addiction Treatment: A Strengths Perspective, Wadsworth, 2003. Visit

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