Journal of Social Work Practice in the Addictions

ISSN: 1533-256X (Print) 1533-2578 (Online) Journal homepage: http://www.tandfonline.com/loi/wswp20

Harm Reduction in Substance Abuse Treatment:

Pragmatism as an Epistemology for Social Work
Practice
Viktor Lushin LMSW & Jeane W. Anastas PHD LMSW
To cite this article: Viktor Lushin LMSW & Jeane W. Anastas PHD LMSW (2011) Harm
Reduction in Substance Abuse Treatment: Pragmatism as an Epistemology for Social
Work Practice, Journal of Social Work Practice in the Addictions, 11:1, 96-100, DOI:
10.1080/1533256X.2011.546205
To link to this article: http://dx.doi.org/10.1080/1533256X.2011.546205

Published online: 23 Feb 2011.

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Date: 21 November 2015, At: 04:41

Journal of Social Work Practice in the Addictions, 11:96100, 2011

Copyright Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: 10.1080/1533256X.2011.546205

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Harm Reduction in Substance Abuse

Treatment: Pragmatism as an Epistemology
for Social Work Practice
VIKTOR LUSHIN, LMSW
Doctoral Student, Silver School of Social Work, New York University, New York,
New York, USA

JEANE W. ANASTAS, PHD, LMSW

Professor, Silver School of Social Work, New York University, New York,
New York, USA

Social work practice in the drug abuse field is closely tied to the epistemology of logical positivism. Most clinical decisions in this field rely on
a positivist disease model that broadly categorizes drug users, prescribes
standard abstinence-based treatments, and pays little attention to peoples
current needs and social contexts (Kirk & Reid, 2002; Wakefield, 1992).
Many studies suggest, however, that functional and contextual factors are
extremely important in understanding and treating drug and alcohol users
(Marsden et al., 2009; Perreault et al., 2007). Could our field benefit from
the use of a different, more flexible epistemology? One such approach is
pragmatism.
The philosophy of pragmatism was introduced in the work of three
great American thinkers of early modernity: Charles Saunders Pierce, William
James, and John Dewey (Browning & Myers, 1998). The main ideas of pragmatism are expediencepractical usefulnessas the main measure of truth,
guidance of action as top priority of science, and a communitarian or ecological view of knowledge. Pragmatists believe that knowledge is generated
in a community of fellow-knowers who share goals and agendas; and that
access to knowledge must be as broad as possible (Browning & Myers).
Pragmatists recognize that new knowledge does not have to always rely on

Address correspondence to Viktor Lushin, Silver School of Social Work, New York
University, 1 Washington Square North, New York, NY 10003, USA. E-mail: vb1206@nyu.edu

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preexisting theory, unlike positivists who require a theoretical background

for any research (Browning & Myers).
Contemporary pragmatists, such as Rorty (1982), articulate opposition
to broad generalizations, especially about people. Canadian philosopher Ian
Hacking (2006) describes it as making up people. He also speaks of looping effectsdamage to a persons self-image and personal growthas a
result of internalizing negative labels such as mentally ill, or drug addict.
Psychiatrist Bradley Lewis (2006) criticizes the tendency of medicalization
broadly applying medical diagnoses to individual psychosocial problems
that often have social roots such as inequality or power struggle, rather than
psychopathological ones. We suggest pragmatism as a more fitting framework for the field of substance abuse, offering harm reduction model as an
example of pragmatisms inspiring success.
To help those addicted, we need to precisely evaluate their social functioning, risks, and support mechanisms, and the essentials of their social
context (Marsden et al., 2009). To take account of all this information, we
need an epistemology more flexible, more open to the clients reality, and
less tied to preexisting theory, than logical positivism. Besides that, the
idea of value-free knowledge contradicts our professions ethically codified
call for social justice (National Association of Social Workers, 2000; Smith,
Whitaker, & Weismiller, 2006). Pragmatists value usefulness of knowledge
over its theoretical legitimacy, and avoid excessive generalizations (Lewis,
2006; Rorty, 1982). This worldview might also offer a protection against
harmful looping effects that were mentioned earlier (Hacking, 2006).
Harm reduction is an apt example of pragmatism at work in the area of
drug misuse intervention. The harm reduction idea works on several levels:
as a clinical practice theory, as an intervention model, as a policy framework,
and as a social movement (Toumbourou et al., 2007). It emerged as a theoretical perspective after gaining momentum as a grass-roots movement. (The
recovery movement in mental health has followed a similar path.) The first
harm reduction programs appeared in the Netherlands and other Western
European countries in the 1980s as a public response to the spread of the
AIDS epidemic. Starting with simple efforts like local needle exchange programs, the model evolved into many forms that now include supervised
injecting facilities, and widespread use of substitute medications for opioid drugs such as methadone and buprenorphine (Marlatt, 2002; Marsden
et al., 2009). In a truly pragmatist way, the first harm reduction programs
worked without a theoretical basis, which developed later (Marsden et al.,
2009).
The main principle of the harm reduction model is a belief that in dealing with such complex and harmful human behaviors as substance abuse,
the primary goal is to avoid or minimize further dangers such as contracting
HIV and hepatitis, or death due to drug overdose. According to harm reduction theory, there are ways to significantly reduce drug-related damage while

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the person is still a drug user, a notion supported by many studies (Marlatt,
2002; Marsden et al., 2009; Toumbourou et al., 2007).
From a harm reduction perspective, insistence on permanent cessation of all drug use early in treatment is recognized as unpragmatic, and
even as a potential client scare-off factor (Dobkin, Civita, Paraherakis,
& Gill, 2002). Achieving abstinence is a valid, but not necessary, goal for
clients receiving treatment, a pragmatic position that remains quite alien to
most treatment programs in the United States today (Marsden et al., 2009;
Toumbourou et al., 2007). Unlike the traditional positivist view of addiction
with its stigmatizing diagnostic labels (Hacking, 2006), harm reduction offers
a pragmatic way of understanding people: by carefully assessing risks and
protective factors (Tuchman, 2010), and with a view of immediate practical
needs of each individual client (Marlatt, 2002; Marsden et al., 2009).
Harm reduction was not initially an evidence-based approach to treatment, and in general pragmatism is more interested in what is useful than
what is true, which can be seen as a metaphysical position (Anastas,
2000). However, many pragmatists, especially those who follow Peirce (e.g.,
Buchler, 1955; Stout, 2007) as opposed to James (e.g., Rorty, 1982), find
empirical research to be a good way of deciding what is truly useful (Haack,
2006).
As the harm reduction approach gained momentum, a growing number
of studies have demonstrated the effectiveness of harm reduction interventions not only in minimizing hazards of drug abuse, but also in reducing the
actual consumption of drugs, in improving clients social functioning, and
even in achieving abstinence (Hartzler, Cotton, Calsyn, Guerra, & Gignoux,
2009; Marsden et al., 2009; Tuchman, 2010). There is also ample evidence of
much higher retention rates in harm reduction programs than in abstinencebased ones (Hartzler et al., 2009; Marsden et al., 2009; Toumbourou et al.,
2007).
The harm reduction model does not depend on diagnostic categorization of people, and does not prescribe the same treatment to people
with the same diagnosis (Marlatt, 2002). It advocates for careful attention
to the clients immediate social context and priorities, which might not
currently include achieving sobriety or total abstinence (Marlatt; Tuchman,
2010). For example, harm reduction interventions and studies draw systematic attention to the unique drug-related problems and treatment needs
of women (Tuchman). The enormous rates of physical and sexual abuse
of drug-using women, their socioeconomic powerlessness, and tremendous
difficulties with childrearing responsibilities seem to be beyond the scope of
a positivist-minded disease-model system of thinking (Tuchman).
The harm reduction approach has won many proponents in Canada,
Western Europe, and many other countries around the world, but is still
largely viewed with suspicion in the United States (Marlatt, 2002; Tuchman,
2010). However, a more effective and humane antiaddiction effort in this

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country might, in part, depend on whether social workers and other professionals in the field will be prepared to use a pragmatic epistemology and
harm reduction practices. This might help us all to develop and successfully use contextualized, client-centered approaches to addiction treatment
instead of relying on obsolete positivist worldview and the outdated disease
model.

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