Harm reduction is a frequently misunderstood approach to working with substance users. As a result, many therapists may not use this approach, and thus miss an excellent opportunity to have an impact on clients who are not yet ready for change.
In this article, I will examine three misconceptions about harm reduction and set the record straight. Let me begin by saying that, just as there are variants among how practitioners address substance use issues, there are variants among harm reduction practitioners in their philosophies of treatment and in how they think about their work. Harm reduction is not a monolithic entity. Rather, there are three threads within harm reduction as it has emerged over the course of more than 20 years.
Three Threads of Harm Reduction
- Policy: Most broadly, and at the societal and governmental level, there is harm reduction policy. This focuses on reducing the harm created by how societies and governments address the issues surrounding substance use in their laws and social practices. Examples of the policy focus are attempts to decriminalize certain substances or increase regulation of others.
- Public Health: A second thread in harm reduction is public health. This focuses on large scale interventions designed to reduce harms associated with the ways in which substances are used by individuals. Examples include syringe exchange and condom distribution programs, but also programs such as designated driver campaigns.
- Clinical: Finally, there is clinical harm reduction, also known as harm reduction therapy (HRT), which focuses on helping individuals reduce the harms resulting to themselves from substance use and other life problems.
Harm Reduction Psychotherapy
The first use of the term harm reduction psychotherapy (HRT) to describe clinical applications of harm reduction was by Andrew Tatarsky, Ph.D., in his seminal book Harm Reduction Psychotherapy. This book was followed closely by the publication of Practicing Harm Reduction Therapy by Patt Denning, Ph.D. and Jeannie Little, L.C.S.W., now in its second edition. These two books are essential reading for practitioners.
Against this background, I want to address several misconceptions about HRT I have encountered among treatment providers.
- HRT is Anti-Abstinence: The most prominent of these misconceptions is that HRT is anti-abstinence. Nothing could be further from the truth! While non-use is a highly effective way of reducing the harms associated with substance use, abstinence lies at one end of a continuum of use that results in harm, with the other end being highly harmful use. Therapists who practice HRT are very happy when their clients choose abstinence as a means of addressing issues related to their substance use.
Where HRT therapists differ in their approach… is that they do not insist on abstinence (or even substance use) being the focus of treatment.-Frederick RotgersWhere HRT therapists differ in their approach from traditional practitioners is that they do not insist on abstinence (or even substance use) being the focus of treatment. Rather, in HRT, and consistent with such empirically-supported approaches as motivational interviewing where clients are the ultimate decision makers about goals, the focus and goals of treatment are decided by the client, not the therapist. HRT therapists are not at all opposed to abstinence, provided that is the goal chosen by the client.
- HRT Therapists Enable Substance Use: A second misconception is a belief that HRT therapists condone and enable substance use by their clients. This is an illusion that grows out of the approach just mentioned—where the client chooses the focus and goals of treatment, not the therapist.
Anyone familiar with Prochaska and DiClemente’s Stages of Change model recognizes that clients enter treatment in various stages of readiness to change. In fact, Prochaska’s own research has suggested that as many as 60 percent of clients in action-focused programs, are actually still in one of the earlier stages of change (Pre-contemplation, Contemplation or Preparation).
Insistence on a particular change by the therapist does not result in motivation to change on the part of the client.-Frederick RotgersWith this in mind, it becomes clear that therapists need to recognize and meet their clients where they are at in order to help clients motivate themselves to make changes. Motivation ultimately originates in the client, and the job of the therapist is to help clients who may not yet have decided to change consider the pros and cons of doing so. Insistence on a particular change by the therapist does not result in motivation to change on the part of the client. In fact research has shown that such insistence likely engenders resistance! Thus therapists are faced with a dilemma—insist on change to abstinence and possibly engender resistance, or meet the client where they are and use empirically-supported approaches, such as motivational interviewing, to help the client move to a less harmful place in their lives.
- Are HRT Assumptions Ethical?: The last misconception I want to discuss is whether or not HRT is ethical in assuming that clients are capable of making effective choices about their substance use. Traditional thinking insists that addicts, by virtue of the actions of substances in their brains, somehow lose the capacity to make effective decisions about their lives. If this is true, then ethically to allow such impaired clients to choose their own substance use goals could be considered unethical.
Research shows quite definitively that the vast majority of problem substance users, including persons who would now be diagnosed with Substance Use Disorders, Severe, change on their own, making the decision to do so, at times, while intoxicated. Gene Heyman, in his book Addiction: A Disorder of Choice discusses this research extensively. A more concrete example is the founding of Alcoholics Anonymous (AA). AA began shortly after a period of intense drinking by Bill W. during which his brain surely was altered in its functioning by alcohol. Nonetheless, he was able to not only make the decision to stop drinking, he did so and founded an important support organization for others making the same decision!
I have addressed several common misconceptions about harm reduction in the clinical arena. Space prohibits a full discussion of all of these misconceptions and their counter-evidence. I plan to do so in future articles on Pro Talk. In the meantime, don’t hesitate to contact me about harm reduction, HRT or any other clinical questions, and consider joining the Harm Reduction Forum coming soon on Rehabs.com.
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