Alexander DeLuca, M.D.
Harm Reduction Psychotherapy: Extending the Reach of Traditional Substance Use Treatment
1. Introduction and overview
Harm reduction first emerged as a "public health alternative to the moral/criminal and disease models of drug use and addiction" (Marlatt, 1996). Originally geared toward active substance users who were unable or unwilling to stop using, harm reduction became accepted in the United States in the late 1980s and early 1990s as a set of public health strategies for reducing the spread of HIV and other risks associated with active substance use (Heather, Wodak, Nadelmann and O’Hare, 1993). These included syringe exchange, condom distribution, methadone maintenance, and the designated driver.
Marlatt (1998) has called the philosophy of harm reduction "compassionate pragmatism" (p. 277). The essence of this model is the pragmatic recognition that treatment must meet active substance users "where they are" in terms of their needs and personal goals. Thus, harm reduction approaches embrace the full range of harm-reducing goals including, but not limited to, abstinence. This means that small incremental positive changes are seen as steps in the right direction.
Over the last 12 years, harm reduction philosophy has been accepted by a growing group of researchers, clinicians, and policy experts who have developed applications for drug and criminal justice policy, medical practice (S. Stancliff, personal communication, December 4, 2002), substance use treatment (Marlatt, 1998; Rotgers, 1996) and psychotherapy (Tatarsky, 1998, 2002).
2. The rationale for harm reduction
2.1. Many users do not wish to stop The overwhelming majority of people in the United States with substance use problems are not being treated. Many, if not most, substance users are unable or unwilling to embrace abstinence for a variety of reasons I will discuss below. Some data suggest that many substance users avoid seeking help altogether because they do not have life-long abstinence as their objective (Rotgers, 1996), which is the only treatment goal offered by the majority of drug and By accepting goals other than abstinence as reasonable starting places for treatment, harm reduction opens the door to this group of people in a way that traditional abstinence-oriented approaches cannot.
2.2. The diversity of substance users and the need for individualized treatmentSubstance users vary widely on severity of substance use, personal goals regarding substance use (i.e., safer methods of using, moderation, or abstinence), motivation and stage of readiness to change (Prochaska, DiClemente, & Norcross, 1992), emotional and psychiatric status (Carey & Carey, 1990), personality strengths and vulnerabilities (Khantzian, 1985, 1986) and socioeconomic variables. This diversity of issues working against abstinence would explain why an abstinence-only, one-size-fits-all approach would run the risk of failure with the majority of users. It also points to the need for a flexible, inclusive, and comprehensive model that could embrace the myriad needs of this diverse group of people and be open to a variety of treatment goals aside from abstinence. Miller and Rollnick (1991) have written about the importance of addressing ambivalence about using substances and other motivational issues before it is possible to set behavioral goals and pursue behavioral change with many substance abusers. Within such a model, treatments can be matched to the unique needs of the individual to maximize overall success. Denning (2000) has written about the importance of matching interventions to the client’s current stage of change in relation to a specific behavior. Tatarsky (2002) has argued that many of the issues commonly associated with substance use problems, such as early trauma, severe superego-"inner critic" pressure, and (serious) Axis I and II disorders that substances are used to self-medicate, often must be identified and addressed before it becomes possible to consider modifying substance use patterns. Given these considerations, harm reduction may be considered an umbrella concept that encompasses the broad spectrum of treatment modalities that can be matched to the needs of this diverse group of problem users.
2.3. The multiple meanings and adaptive values of substancesSubstances may be thought of as multi-purpose tools often used in the service of adaptation. For many, the substances have important personal meaning or have come to serve life-sustaining functions and are believed to be vitally important as long as no better alternative solutions are identified or available. These include self-medication (Khantzian, 1985), affect/feeling defense (Wurmser, 1978), coping with negative emotions (Rotgers, 1996), personality or ego "prosthesis" (Weider & Kaplan, 1969), sense of identity (as a drug user/rebel/non-conformist/etc.), personality integrator (i.e., enables the user to connect with generally split-off aspects of the self; Krystal, 1977), liberator of creativity, and a primary source of pleasure. Whether these motivations are within or outside the person’s awareness, any consideration of stopping is frequently met with intense anxiety or is simply unthinkable. Given these important functions that substances play, it is often necessary for users to "unwrap" the multiple meanings the substance has for them and discover alternative ways of performing the functions while they continue to use before any consideration of modifying substance use patterns is possible.
2.4. The question of moderationGiven the positive roles that substances play in people’s lives, they often have the desire to moderate, or otherwise reduce the harmful consequences of their use, without stopping altogether (Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993; Rotgers, 1996). Whether this is realistic or possible for a given individual must often be answered before abstinence can beconsidered. A supported attempt at moderation is often the best way of discovering from within one’s own experience whether moderation is a realistic goal. Difficulties encountered in a guided attempt at moderation can lead to increased motivation for abstinence.
3. Principles of harm reduction: Matching the spectrum of needs
3.1. Accepting that many substance users do
not initially wish to stop
3.2. Engaging the active user in treatment is
the primary goal: Relationship is the key
3.3. Any reduction in the harms associated
with substance use is seen as valuable
Therefore, harm reduction accepts small, incremental steps in the direction of reduced harm as legitimate goals. These might be steps toward abstinence or moderation, what Miller (Miller & Page, 1991) has called "warm turkey", as well as the full range of other issues that motivate people to seek help including: clarifying personal goals regarding substance use, resolving ambivalence about substance use, using in a safer manner, preventing overdose, and resolution of the emotional and interpersonal issues intertwined with substance use. Joining the client around goals that the client is motivated to pursue lowers the threshold for entry to treatment. Small steps may lead to other small steps as people’s confidence in their ability to change (self-efficacy) increases, and they learn that positive change is possible.
3.4. Mobilizing the client’s strengths in the
service of change
3.5. Clients and treatment collaboration
3.6. The importance of de-stigmatizing
3.7. Treatment implications
4. Harm reduction psychotherapy
The specific approach that will be presented here is an integrative harm reduction psychotherapy model (Tatarsky, 1998, 2002). This approach draws on the valuable contributions of the psychodynamic and cognitive-behavioral traditions along with the affirming stance of the humanist approaches. While this approach builds on my own clinical experience as well as that of the increasing number of professionals who are working with patients in similar ways, to date there has been no empirical evaluation of these techniques and practices. With the publications of guides by Denning (2000), Marlatt (1998), and Tatarsky (1998, 2002), the field has probably reached the developmental stage in which this kind of research is both needed and desirable. The clinical perspectives and interventions described are a portrait of a way of working with, and being with, substance users. Whether they will be effective in other settings, with diverse patient groups, as administered by therapists with varying backgrounds and levels of experience, remains to be determined.
Clients who enter treatment come in a state of distress while being simultaneously engaged in their own process of change. Harm reduction psychotherapy aims to support this process of self transformation through developing an empathic resonance between clinician and client, deepening the identification and understanding of what is distressing to the client (that is, what is harmful about substance use and other issues), setting harm reduction goals that can be hypothesis tested to determine if they are realistic for the client, and working toward change with strategies that meet the client’s unique needs and strengths.
The integrative approach combines a skills-building/selfmanagement focus with an exploratory focus on "unwrapping the multiple meanings" of the substance. The skills that are involved in the identification of harm, in setting goals for reducing harm, in unwrapping the multiple meanings of substance use, and in working toward positive change are a set of capacities that can be learned and internalized in the therapeutic process. These capacities are developed or strengthened in a relational "space" in which the client feels recognized and empathically connected to the therapist through the therapeutic alliance.
The development of these capacities can be facilitated in several ways. The general aspects of a good therapeutic relationship are one arena. In addition, empathic questions that support the client’s capacity to reflect with curiosity and tacit encouragement of the client’s autonomy may serve as an antidote to the client’s ties to early figures who frequently did not support autonomous self-care (Krystal, 1977). Our caring anxiety at risky behavior may, under the right conditions, become internalized as healthy self-caring attention to danger. The direct teaching of such coping methods as assertiveness, relaxation, and substance refusal may serve the direct goal of skill transfer, while simultaneously, and through ongoing relational support, help the patient internalize a capacity to function more autonomously.
Harm reduction target goals represent the part of the person that wants to change, and these inevitably come into conflict with the parts of the person that are attached to the old ways of using drugs. The process of setting harm reduction goals brings this conflict more into the client’s awareness. The exploratory focus of HRP supports the client in becoming more aware of those aspects of self—the needs, wishes, feelings, attempts at coping, defenses against anxiety, symbolic expressions, and interpersonal communications, etc.—that are all embodied in the desire to use as before. As these motives are identified, it becomes possible to consider alternative solutions as modes of satisfying or expressing them.
5. Engagement as a therapeutic focus
5.1. Establishing the alliance
"Start where the client is at". This is one of the core slogans of the harm reduction movement. Its relevance to our work is that the alliance is fostered when clients feel empathically recognized and offered help that meets their needs as they experience them. Therefore the initial therapeutic focus is around the client’s reason for coming.
5.2. The importance of the clinician’s
5.3. Shared goals
6. Assessing harm and setting harm reduction goals
6.1. Assessment and goal setting as treatment The assessment of the nature of the client’s concerns and the setting of harm-reducing goals can be seen as both the initial focus of treatment as well as the ongoing focus of the therapeutic process. The alliance around addressing the client’s concern creates the context in which the harmful aspects of substance use and other relevant issues are assessed. Assessment is a therapeutic activity in that it is the process by which the client’s recognition of the harmful aspects of the substance use is facilitated. As the harmful aspects of the substance use are identified through the collaborative inquiry, it becomes possible to set harm reduction goals to address them.
It is always essential to have the client get a medical evaluation to assess the physical impact of substance use. This can also yield important objective information to add to the determination of the harmfulness of substance use (see also Miller, Zweben, DiClemente, & Rychtarik, 1995).
6.2. Goals Where substance use has become excessive, abusive, self-defeating, compulsive, addictive, or is, in some way, significantly threatening or compromising other important needs and values, a harm reduction approach would initially aim to support the user in modifying substance use to reduce the harmful impact. While abstinence is considered the ideal goal for many users, as are regular exercise, healthy diet, and a reasonable balance between work and play, harm reduction psychotherapy does not see the acceptance of abstinence as necessary to begin the process of change. Thus, moderating use as well as a wide range of other harm-reducing goals are accepted. These latter include learning safer drug-using practices, utilization of clean syringes, taking drugs with others, being knowledgeable about overdose risk and prevention, switching to less dangerous substances, and having clear ideas about dose limits.
7. Facilitating the capacities for change
7.1. The ideal substance use plan
7.2. Awareness and relaxation training
8. Integrating strategies for positive
As the multiple meanings and functions of substance use are identified, cognitive and behavioral strategies can be used to support the learning of more adaptive and drug-free coping strategies to deal with the issues currently being addressed by the substance. Behavioral strategies include relaxation training, anger management, and assertiveness training. Cognitive techniques that deal with the unrealistic beliefs that are often related to substance use include stress inoculation, rational disputation, and "thinking it through."
Psychodynamic techniques may be necessary to work through the symbolic attachments that clients have to these self-defeating solutions. There are often early relational ties that are being expressed through the use of the substance that must be recognized and grieved in order for the new solutions to be embraced. For many patients, the therapeutic relationship offers a new relational experience that can serve as an alternative to the early negative ones and can also provide a context in which the old ties can be identified and grieved in the presence of the therapist.
9. Implementing HRP
As is clear from the previous discussion, HRP is rooted in psychological and psychotherapeutic approaches that are deeply connected to the mental health traditions. In many respects, HRP represents one more situation in which we see the "reclaiming" of the problem of substance abuse and addiction by the mental-health treatment field (Lichtman, 2002; Rothschild, 2002). From the psychodynamic world, we see the revitalization of the idea that substance use is a symptom of, a response to, or a medication for underlying conflicts and issues. Perhaps to a lesser degree, we see the cognitive-behavioral emphasis on understanding that the same learning principles are in involved in addictive behaviors as are involved in other psychological disorders (Marlatt & Gordon, 1985). Given this background, it would seem logical that this is an approach most suited for those who have a primary training in the mental health field (i.e., social workers, vocational rehabilitation counselors, psychologists, and psychiatrists) rather than those come from the more traditional substance-abuse treatment backgrounds (i.e., counselors in therapeutic communities and credentialed alcoholism and substance abuse counselors).
Eventually, the issue of the efficacy of the treatment will need to be addressed if it is to expand beyond the offices of private practitioners and the occasional "lone wolf" counselor. To date, there have been no studies on the efficacy of this or related approaches. However, at least one of the core concepts in HRP, the centrality of the working alliance, has been supported in the psychotherapy research field. As Teyber & McClure (2000) have written, "The term working alliance was formulated by Greenson (1967), and it reflects the extent to which the therapist and the client agree on the goals of their work, agree on the tasks that facilitate attainment of these goals, and experience an emotional bond with each other" (pp. 70–71). This definition reflects the essence of the HRP philosophy. On a more empirical note, they point out that "the working (helping and therapeutic) alliance has emerged as perhaps the most important variable in predicting effective treatment outcomes" (p. 70). Again, since an empathic bonding between therapist and patient is understood to be the vital, life-changing mechanism in helping substance-using patients change their lives, there is at least a possibility that HRP could be effective.
To bring this to a more scientific realm, it would not seem to be impossible to create an HRP manual—despite the emphasis on individually oriented treatments. The two core components involved in training therapists would mostly likely include: (1) learning skills and interventions (i.e., decisional balance, risk assessment, ideal substance use plan), and (2) fully understanding the harm reduction philosophy and developing the ability to listen and act from this perspective. Interesting outcome measures might include assessments of the therapist behaviors outlined above, the strength of the therapeutic alliance, and a wide variety of outcome measures serving to measure the possibility of the reduction of harm and the improvement in quality of the individual’s life.
The integration of HRP into the mainstream substance-abuse treatment would, almost of necessity, involve the interplay of harm reduction approaches with mandated treatment; a combination that has the potential to be quite complex. Wild (1999) has explored some of the dynamics of this mixture, and, among the issues that he has delineatare the two very different perspectives on substance users that exist between the criminal justice institutions and the treatment facilities. For the former, drug use is a criminal behavior, while for the latter it is a disease. To some degree, abstinence-oriented treatment providers may see relapse as part of the recovery process (and even that may not be universal), but this is much less likely to be the case with law enforcement officials, who may be quick to the individual back to prison. As Wild points out, to some degree, the only place where these two groups can meet is the shared goal of abstinence. The introduction of harm reduction has the potential to destroy even this precarious balance.
The solution may require a mixture of the insights of HRP with the framework of gradualism (Kellogg, 2003). The first step would be for the criminal justice system and/or the mandating agency to understand and accept the concept that recovery is a process and that relapse is an element of it. Wild (1999) has suggested that mandating agencies should accept reductions in use as a viable outcome, and, in some cases, that may be appropriate. Patients should be allowed to be in treatment for a set period of time in which their drug and/or alcohol use is not reported to the authorities. Other than requiring reports on attendance, the referring agency should have no access to urine toxicologies and clinical data. In this way, the treatment could be a "real" therapeutic experience without the role complications that sometimes encumber therapists in mandated situations and which run the risk of having a deleterious effect on the treatment (Wild, 1999). If patients are given time to work through the issues that are at the core of their addictions, if they are allowed to learn through both successful and unsuccessful experiments what it will take to either control or eliminate their dysfunctional substance use, the long-term chances of success are likely to be good.
This paper has provided both an overview of the harm reduction vision, and the details of an active and engaged psychotherapy that draws from both the psychodynamic and the cognitive-behavioral traditions. Through the development of the therapeutic relationship, the affirmation of the client’s own goals and choices, the uncovering and resolution of the traumatic relational substrate underneath the substance use, and the empowerment of the individual throughskill-building and information sharing, the whole person has the opportunity to heal. It is my belief that this healing will help the individual, the family, and the community at large.
This paper is adapted from a presentation that was given on April 6, 2001, at a conference entitled "The Great Debate: Abstinence vs. Harm Reduction in Addiction Treatment" that was held at The New School University. This conference was conceptualized and sponsored by the New York State Psychological Association Division on Addictions Executive Committee whose members include: Julie Barnes, F. Michler Bishop, Lisa Director, Scott Kellogg, Robert Lichtman, A. Jonathan Porteus, Marlene Reil, Debra Rothschild, Suzanne Spross, Andrew Tatarsky, and Alexandra Woods. It was also co-sponsored by the Masters Program in Mental Health and Substance Abuse Counseling at The New School University. Further support for this work was received from the Division on Addictions of the New York State Psychological Association. I would like to thank the NYSPA Division on Addictions Executive Committee and McWelling Todman at The New School University. I also wish to give special thanks to Scott Kellogg for his thoughtful comments and helpful suggestions on drafts of this paper.
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