What's Under the Harm Reduction Umbrella? Part One

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What's Under the Harm Reduction Umbrella? Part One

By Jeannie Little LCSW 05/28/15

Can abstinence be considered a part of harm reduction?


There has long been an unfortunate tension among treatment providers between harm reductionists and abstinence-based clinicians and programs. But in addiction treatment, stubborn adherence to a rigidly held treatment philosophy tends to do a disservice to our patients. Jeannie Little, a seminal figure in the development of harm reduction theory and practice, asserts that abstinence is one of many treatment goals that can rest comfortably under the harm reduction umbrella….Richard Juman

Harm reduction therapy is poised to be the umbrella for treatment of substance use and co-occurring disorders in the 21st century. First developed in the 1980s as a response to hepatitis and HIV, it is the most accessible treatment for substance use and misuse to date. It lowers the threshold even further than Alcoholics Anonymous, previously the most accessible recovery support system: “All you need for membership in AA is a desire to stop drinking.” To belong in a harm reduction community, one need have no desire to change at all! A person can be curious, reluctant, determined to continue a lifelong relationship with substances, desirous of minimizing consequences, or desperate to find help that is not like what he or she has experienced before. Debra Rothschild aptly calls harm reduction “the third wave” of substance use treatment.  

A paradigm shift such as this one—from the disease model of addiction and 12-step programs which demand lifelong abstinence from all psychoactive substances, typically through surrender to a higher power, to harm reduction, which promotes empowerment, self-determination, and a wide range of options for change—is shaking the foundations of the last 50 years of addiction treatment. What is so revolutionary is not, however, the battle of opposing forces.  

Disease model proponents and harm reductionists alike have made the mistake of polarizing the two approaches. While disease model proponents often have difficulty with the idea of non-abstinent goals, harm reductionists have been saying all along, “Abstinence is a harm reduction goal, it just isn’t the only one.” We have been busy creating a very wide umbrella under which all goals are welcome and any positive change is considered success (with thanks to Dan Bigg of the Chicago Recovery Alliance). With a menu of options as a core value, harm reduction can hold abstinence and 12-step recovery models under the same umbrella as safer use, reduction of use, moderation, and variations on abstinence. Harm reduction moves the fundamental values of “recovery” from powerlessness and abstinence to empowerment and choice. As long as a person freely chooses a 12-step program of recovery, in a landscape of many options, that choice falls within the scope of harm reduction.  

Rather than posing a threat to 12-step programs, harm reduction offers a larger umbrella under which all people and all options for change can coexist. Because it explores the reasons that people use drugs, harm reduction covers more territory in understanding substance use and misuse. Because it is grounded in the principles of public health, it addresses all of the harms that can occur in a drug-using life, regardless of whether a person’s use rises to the level of a disorder (“addiction”). Because it combines psychotherapy with substance use treatment, it addresses both substance use and the issues that lie behind it. Because it embraces an infinite number of change and recovery options, it adheres to the highest medical ethics of client choice and self-determination.  

Many characteristics of harm reduction therapy make it the ideal umbrella for substance use treatment in the 21st century.

Harm reduction therapy is non-polarizing. Until now, both the moral model (manifested in the War on Drugs) and the disease models of addiction have been predicated on prohibition— "Just Say No.” They have taken an all-or-nothing stance to substance use. Characterized by terms such as “clean,” “dirty,” and “in the program,” or “out there,” one is either an “addict/alcoholic” who will face “jails, institutions, or death” if she keeps using, or a “normie” who can drink without consequence. These terms trap the substance user in a binary identity dilemma and a dichotomous choice to belong to one community or the other.

Harm reduction, by contrast, holds that people have a relationship with drugs that is more or less healthy at different moments in time. Substance use occurs on a continuum from no use to benign use to chaotic use, with many points in between. Harms can occur at any point and should be addressed, regardless of whether a person is “addicted.” I have seen many people who have problematic relationships with alcohol but not with marijuana, or who get in trouble with speed but drink moderately, including after they quit using speed. I have worked with people whose use is chaotic, then they learn to moderate, yet they still have the occasional binge. I have also worked with many people whose goal is abstinence from all psychoactive substances, and they work beautifully alongside others whose goal is non-problematic use.

Harm reduction therapy is trauma-informed. The majority of people who reach the level of chaotic substance use have histories of trauma, and the first ethic of harm reduction therapy is to "Do No Harm." This means that we do nothing that could be re-traumatizing. Such things include exercising authority and control, asking intrusive questions, being unpredictable, or using shaming language or techniques. What we do is remain mindful of trauma and its effects, understand the medicinal properties of drugs, treat each person with sensitivity, use grounding techniques when a client is overwhelmed, and refer to trauma specialists when we assess that symptoms of trauma are dominating the client’s experience.  

Harm reduction therapy is a co-occurring disorders treatment model. Co-occurring mental health and substance use disorders are the rule, not the exception. And when harm reduction therapy is practiced by mental health professionals, all issues can be addressed at the same time by the same clinician.

Harm reduction therapy is inclusive. "Come as you are" is the mantra of harm reduction therapy—anyone is welcome, regardless of their relationship with drugs, their goals for future use, and their motivation to change. Any route to change is supported, and every positive change applauded. In other words, harm reduction therapy meets people at their stage of change. Using the Transtheoretical Model of Change, harm reduction therapists understand that people are at a different stage of readiness to change for each issue that they bring into treatment. At the Center for Harm Reduction Therapy, we tend to start with the issues that the client is most motivated to address. For example, a man came to us with a major heroin habit that had caused him to lose his job and alienate his partner and children. His partner had kicked him out and he was sleeping at his mother’s house. His most pressing concern was to re-establish contact with his children because he foresaw that the damage to them would last longer than any other harm. We facilitated the beginning of a conversation by advising him not to make promises. Once he could visualize a realistic way to connect with his children, his thinking became less panicky and he began making small, sustainable changes.

Harm reduction therapy educates everyone about drugs and safe use practices, thereby reaching far more people and preventing a great deal more harm. Harm reduction does not take a position on whether drugs are good, bad or indifferent. It depends. Some drugs (typically the legal ones!) are more toxic than others. The experience of the user, as well as the emergence of problems, depends on his or her physical, mental, emotional, relational, cultural, and environmental context. Being knowledgeable about the interaction of the drug, the user (set), and the setting (Zinberg), harm reduction therapists can respond appropriately to any substance using situation.

Harm reduction therapy is client-directed. The client, not the therapist or counselor, defines the nature of his or her problems. Some people identify self-medication of physical or emotional pain as the main driver of their substance use; others believe that a spiritual journey, an enhancement of physical and emotional experience, or partying led to trouble; still others are most comfortable with the idea that they have a disease. Harm reduction also shifts the emphasis from program-directed to self-directed goals, steps, and outcomes. Finally, the client sets the pace and the intensity of treatment, with more or less input from the therapist. 

Harm reduction therapy supports three broad avenues of change: safety, moderation, and abstinence. Safety means reducing the harm to oneself and others. Not drinking and driving, sterile syringes and safe crack pipes, taking care of the kids, and loading up on condoms when one’s aim is to party, are but a few of the harm reducing possibilities that harm reductionists keep foremost in our minds. In regard to moderation and abstinence—some people moderate their use of all drugs, while others abstain from all; some abstain from some and moderate others, while still others abstain or moderate most of the time, and then enjoy the occasional episode of “determined drunkenness.” Ken Anderson (How to Change your Drinking) is promoting the idea that “absence of problematic substance use” should be the standard of “recovery.” 

Implications for Treatment 

During my 35 years as a social worker and 25 as a therapist working with substance users and people with co-occurring disorders, I have studied my clients to understand what is most helpful to them. I have concluded that the important question is not whether a person is or is not powerless, or whether he or she should or should not be abstinent from one or all of her drugs. The answers to these questions change over time.

The crucial thing to assess is the extent to which a person needs containment, structure, and direction, versus needing to explore his relationship with substances free of outside influence. In other words, at times, people (and that includes all of us!) need someone to tell them what to do, at other times they need to work with someone who has the capacity for infinite flexibility and whose role is to facilitate their own exploration.

In Part 2 of this article, Patt Denning and I will discuss how we go about helping each person find the right level of structure vs. flexibility, direction vs. facilitation. We will give examples of how this works with different clients. In Part 3, I will challenge harm reductionists, abstinence proponents, and 12-step advocates to join together and create a real menu of options for people who use and misuse alcohol and other drugs.

Jeannie Little, LCSW, CGP is the co-founder and executive director of the Harm Reduction Therapy Center in San Francisco. She is a licensed clinical social worker and certified group psychotherapist. Since 1990, she has been at the forefront of developing the harm reduction treatment model for people with co-occurring substance use and mental health disorders. With a long background in homeless and housing services, she adapted harm reduction therapy as a community treatment model that has reached thousands of marginalized people with little access to mental health care. She is also considered one of the creators of harm reduction groups. She provides training and ongoing consultation to professional and peer staff in outpatient clinics, drop-in centers, and supportive housing. She is co-author of Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol and Practicing Harm Reduction Psychotherapy, 2nd Edition.

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