Integrative Harm Reduction Psychotherapy: A Call for National Dialogue

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Our Addiction Treatment System is in Crisis

We are losing the battle against addiction and its negative consequences in spite of the well-meaning intentions of most treatment providers.

The recent heart-breaking losses of Academy Award-winning actor, Philip Seymour Hoffman, to an apparent heroin overdose, and TV actor, Cory Monteith, to opiates and alcohol, have focused attention on the terrible reality of fatal drug overdose that befalls around 100 of our less well-known citizens each day. These numbers and every other measure of success disturbingly indicate that our addiction treatment system is failing to attract and help the overwhelming majority of people with substance use disorders in this country. What is wrong with addiction treatment in America and what needs to change?

What is wrong with addiction treatment in America and what needs to change?-Andrew TatarskyAs an addiction treatment psychologist with 35 years of experience helping people with these problems, I think it is high time for a serious national dialogue about what works in treating addiction and what does not. As a society, we need to “re-envision addiction treatment” (Kellogg and Tatarsky, 2012) to make it more appealing, effective and humane.

Here are some critical questions to consider: How can we make treatment more appealing to people struggling with these issues? Most don’t go to treatment willingly. Many, if not most, users do not want to stop using at the time they begin to become concerned about their use. Yet, most addiction treatment facilities require that people agree to stop in order to receive treatment. Does this “abstinence-only” ideology actually prevent many people who want help from getting it? What would help people seek and stay in treatment even when they continue to struggle with active substance misuse? What are the ingredients that should be part of a “re-envisioned” effective addiction treatment for people across the spectrum of severity and readiness to change?

Does this ‘abstinence-only’ ideology actually prevent many people who want help from getting it?-Andrew Tatarsky

A Scientific Revolution in the Addictions Field

  • Crises are unstable and potentially dangerous processes in which old systems are not working and there is a need for new solutions. When harnessed and directed in creative ways, the energy and feelings generated by crises, can generate new hopeful solutions. There are already new approaches to the treatment of addiction that can be the solutions we need, but they are not widely available or known about in the general public.
  • Drawing on my work with addicted people and my read of the research, I have gathered together a group of ideas and strategies for understanding and treating addiction that I use in my own treatment center and in which I train professionals internationally. I call it, Integrative Harm Reduction Psychotherapy (IHRP). I believe that this approach can improve our field’s effectiveness if adopted more widely. I offer below an outline of this work to spark a dialogue with my colleagues and the public at large. I will elaborate on the approach in future posts.

Integrative Harm Reduction Psychotherapy: A New Paradigm for Treating Addiction

  • This new model understands that addiction is a meaningful reaction to suffering. Biological, psychological and social factors are all correlated with addiction. Trauma and problems managing self-esteem and relationships are frequently present to some degree. A complex interaction of these vulnerabilities that is unique to each person gives rise to the reinforcing quality of the addictive behavior. In this context, substance use and other risky behaviors take on multiple personal and social meanings and functions that contribute to the addictive process. Common examples are self-medication of emotional pain and using a substance to confer group membership. People whose substance use serves important, often life-saving functions experience the substance as helpful; they are frequently in pre-action Motivational Stages of Change in which they are not ready or able to consider changing their behavior. Alternative solutions must often be discovered before people are ready, able and willing to change.

The New Model for Treating Addiction: Many Paths to Recovery

  • The new understanding of addiction described above suggests the need for integrative treatment in which addiction is treated concurrently with related physical health, mental health and social issues. The therapy combines psychodynamic, cognitive-behavioral, mindfulness, social and biological interventions in a way that is uniquely tailored to each person’s needs.
  • The Harm Reduction frame starts therapy “wherever the person is” in terms of their goals, motivation and unique personal and cultural qualities. The full range of positive change goals are seen as valuable, at least as starting points for the recovery process: reduced harm, safer use, reduced use, moderation and abstinence.
  • A comprehensive initial assessment will determine an initial personalized treatment plan based on substance use severity, the psychobiosocial factors, multiple meanings and functions of the behavior, motivation to change, and insight.
  • Effective treatment has a primary focus on engagement and therapeutic alliance throughout the therapy. IHRP “starts where the person is” with empathy, respect and acceptance, because creating safety and support are seen as essential to the therapeutic project. Teaching self-management skills to address urges and difficult emotions is often essential. An ongoing assessment throughout treatment deepens both client and therapist awareness of the addiction severity and its meaning and functions. Exploring the client’s ambivalence about change reveals the issues that need new solutions. As these issues are clarified, positive change goals around the substance use and these issues can be established. And, finally, a personalized plan for pursuing these positive changes can be developed collaboratively between client and therapist. The plan may include a variety of therapeutic modalities, lifestyle changes, health practices and medications depending on the client’s needs.
What Are Your Thoughts?

Side Note PictureI invite readers to agree, disagree, challenge, critique and offer your own ideas about what should go into a new, hopeful and effective addiction treatment. I will reference these responses and respond in future posts to this site. -Andrew Tatarsky

Image Credit: Justin Hoch [CC BY 2.0], via Wikimedia Commons

What Are Your Thoughts on this Topic?

  • Shaun Shelly

    Absolutely agree. I recently presented to professionals in the field in Cape Town on non-abstinence based treatment approaches – actually included references by both Scott and you.

    Personally I am doing my PhD (which is leading on from my MPhil research) on a cumulative continuum based treatment model for community based out-patient programs. The aim is to be able to engage the substance user while they are still using in a way that does not threaten the very real needs that substance use meets.

    To simply expect someone to stop using prior to understanding the needs that the substance use is meeting, and assisting them in developing other coping strategies, is asking someone to forsake their identity, to abandon the one consistent “relationship” they have formed. This is unrealistic and possibly cruel.

    Unfortunately many so called evidence based treatment modalities are highly manualised, short term, and allow little space for meaningful psychotherapy to take place.

  • Karen Kehler

    I agree with both Andrew and now Shaun. I’m not a “certified” addictions counselor (10% of clients) but glad over the years for having had a minor in my Master’s for it – it has proved to be a wise investment. Over the last 20 years I have seen both success and failures. I’m glad I’m in private practice where I can truly ‘custom fit’ for my clients and work through more carefully the complexity of addictions. I have been shocked repeatedly how the topic of grief is barely, if ever, touched – yet often the initial reason for the loss of control. In the National test for Counselors of 200+ questions -1 was for grief, 1 for addiction – 50-75 were for research design! SO my field is off track too- trying to compete with psychologists rather than embrace education and the art of psychotherapy.
    On the ‘front line’ I’m seeing the obvious uptake in real heroin abuse – as Opiate users find it easier to access – cheaper and more potent – and their 24/7 lifestyle of drug behavior that is so different from the other drugs, especially alcohol. The approaches and therefore training, should be very different but they’re not. The caskets are piling up – and we will have even more grieving to manage – how we do that will shape future lives. No one seems to be speaking about the impact of the deaths. Same for the gun violence deaths.
    I find that rehabs are too ‘nice’ in various ways that are not like ‘real life’ at all – so the addict doesn’t ‘get tough’ to manage the real stress of real life. If they have been using since teens – they have NO clue what that even is. But incarceration is the opposite – they’re safe (supposedly) but they don’t get comprehensive treatment – so its wasted time. Even requiring workbook completion would be an improvement! For opiate/heroin users we are taking away their ‘ecstasy’ and expect them to want living ‘real life’ with its nonstop struggles. We need to figure out how to improve their straight experience – so that it ‘feels good’ too – for that one day a time.
    Russell Brand said it best – they are ‘not well’ – the experience of that ‘perfect’ high is logged in the brain – the chase begins – but stopping it ‘for the rest of life’ is what most don’t understand – don’t want to sign up for and don’t ‘get’ why one minute – one hour – one day is the only way through – and only with a custom fit to the individual.
    We DO need to treat this as a CRISIS – it is. We as mental health professionals need to collaborate not divide and conquer – we need to embrace the complexity and open up conversations to treat not with both the science and the art of helping.

  • Juan Blea

    While I agree that harm reduction approaches to treatment can be effective, I’m more curious about ways to reduce the fear associated with addiction. For example, in my experience, I tend to be approached by people who want someone they love to change his or her life. I’ve recently had a man in his mid-sixties discuss his grand-daughter’s addiction to opiates break down in tears simply out of the fear he felt. Does your approach have an educational component for families? It appears they need almost as much help as a substance abuser (I don’t like or use the term, “addict.”)

  • Gunnar

    I am a clinical director at a small clinic where we have both straight up harm reduction practices and abstinence based programs. We view them as a continuum of care. We have always believed that meeting the patient where they are is the key to excellent treatment AND that for a proportion of people, abstinence is likely the best course of change for some patients. This plays out as follows. We often get folks who come in wanting off of heroin so they can stop stealing from grandma, but cannabis continues to help them with their daily living and are precontemplation with that. Our statement to them, is that while we are ok with where they are, and they don’t need to be completely clean when they start treatment, and in order to graduate, they must be clean for 30 days. We also say that if they feel like going back to their cannabis after treatment that is their decision. This gets them in the door and their therapist can MI them into action around their other substances.
    It is a nice idea to say that we can get folks off of one substance but not be hell bent on getting them completely clean. The problem with that is how that plays out in the milieu. We recently underwent a program evaluation, and one of the criticisms by patients was that we were too lenient on people being allowed to continue to use during treatment and that it felt like they weren’t there to get better, but to temporarily decrease consequences. This created a dissonance in the milieu that was not productive and demotivating for clients trying to create the kind of transformation for themselves that can heal their disorder.

    I would really like to see a debate by innovative practitioners who have the actual experience in the milieu with combined harm reduction/abstinence based programing to try and figure out how to best serve all clients, in all stages of change. I agree that much of the treatment system is out of date and needs a huge rethink, but theoretical does not match practical in much of what is being talked about academically.

    On a side note, I am 100% behind the comment about manualized interventions which don’t allow for the skilled clinician to operate at their potential, but they are easy to measure effectiveness, which isn’t a good reason to let go of the art of treatment.

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