Is Harm Reduction the New Narrative?

By Juliet Elisabeth 10/08/15

The Fix Q&A with Andrew Tatarsky about alternatives to abstinence-based treatment.

Dr. Andrew Tatarsky
Dr. Andrew Tatarsky

Dr. Andrew Tatarsky is a pioneer in the psychotherapy of addictive disorders, having discovered that meeting clients “where they are at,” showing compassion, and empowering them resulted in clients achieving their goals through self-directed change. His approach to harm reduction builds upon the legacy of pioneers like Dr. Alan Marlatt, who wrote the introduction to Tatarsky’s book, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, published in 2002. He is also the founder and director of The Center for Optimal Living in New York.

Dr. Tatarsky’s book introduced Integrative Harm Reduction Psychotherapy (IHRP), a counseling method developed by Tatarsky and utilized at The Center for Optimal Living. A book review from Moderation Management stated: “The approach blends a psychodynamic emphasis on the multiple meanings of substance use and the importance of the therapeutic relationship with a more strategic focus on the process of changing behavior.”

A seasoned advocate for harm reduction worldwide, Dr. Andrew Tatarsky has appeared at many conferences, is a founding board member of the Association for Harm Reduction Therapy, founding member and past president of the Division on Addiction of New York State Psychological Association, a clinical advisor to the Office of Alcoholism and Substance Abuse Services of New York State, and a member of the Board of Moderation Management Network. 

I spoke with Dr. Andrew Tatarsky after his return from delivering trainings on Integrative Harm Reduction Psychotherapy in the Philippines and Indonesia.

What is the history of harm reduction and how is it applied to the counseling and treatment of addicts?  

Harm reduction is a general philosophy and set of strategies that was essentially born in Europe. It started in Amsterdam, then in England and Switzerland, as public health strategies that helped people stay alive and safe—like needle exchanges. It became more widely accepted in the midst of the HIV/AIDS crisis, where the epidemic threatened to move out into broader society and steps were needed that could contain and end the epidemic. This was the late 1980s.

In the U.S., two important voices were heard. The first was that of Edith Springer, a social worker and an “ex-junkie” (her term), the person that many consider the “Godmother of Harm Reduction.” The other was that of Alan Marlatt. He wrote the first major book on harm reduction, Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors, in 1998. Largely as a result of their efforts, in the mid-1990s, a growing group of primarily American psychotherapists began to see the value of applying harm-reduction principles to the psychotherapy of addiction. 

Meanwhile, I’d been in the field since the '80s, my first years in the traditional “abstinence-only” field. At the time, it was the only ideology, but as the clinical director of a treatment program I began to see that it wasn’t helping enough people. Most people didn’t want what we were offering and most people didn’t get better from what we were offering. Frequently, if they didn’t abstain, we would have to discharge them from treatment. I began to wonder why this model wasn’t helping most people with substance abuse problems.  

The basic problem with the model is the “tyranny of abstinence,” the view that abstinence is the only acceptable goal. I wondered, “What if we just relax the abstinence requirement? What if we get rid of the whole abstinence idea?” I had just begun a private practice and began to accept patients who were actively using substances. I was breaking all the rules. At the time, I was sort of afraid that I was committing blasphemy. But nonetheless, people were doing really well; they became meaningfully engaged in therapy, many cut back their substance use, many stopped and they made positive changes in other important life issues. And that led me to begin talking with colleagues. Why is it that by breaking the traditional rules of treatment people were making positive changes? I told that to Alan Marlatt in 1994 and he said “you are doing harm reduction.” I’d never heard of that before, but that introduced me to harm reduction as an alternative philosophy. 

Where did the idea for Integrative Harm Reduction Psychotherapy, the method of psychotherapy you designed, come from?

In 1998, Alan Marlatt edited a professional journal called In Session, Psychotherapy in Practice, to which I, along with Patt Denning, Debbie Rothschild and others submitted papers. In my paper, I coined the term "Harm Reduction Psychotherapy," where it was formally established as a distinct type of therapy. 

What I’ve gone on to do since then is develop my own version as Integrative Harm Reduction Psychotherapy (IHRP). 

You are the founder of The Center for Optimal Living. What is the purpose of the center and how is it different from other treatments?

A little over four years ago, I thought there should be a kind of home here in New York, a home base for advancing this work, educating people and professionals, advocating for integrating this work into the treatment system and having a comprehensive treatment center that would showcase this work. We are the only private center based on IHRP, but we have been training and consulting to several other organizations on using this approach in different settings.  

On your website, it states “addiction treatment has been limited to approaches requiring abstinence as a precondition of treatment.” Is one problem with traditional treatment an Abstinence Violation Effect?

That was coined by Alan Marlatt. The Abstinence Violation Effect is a really important idea, one of the problems with abstinence-only treatment. To my way of thinking, abstinence is one possible harm-reduction goal. If that works, it’s a self-affirming choice that falls under the HR umbrella. But what I call the abstinence-only ideology is the presumption that abstinence is the only acceptable goal, the only acceptable measure of success. From that standpoint, anything short of complete and total abstinence is considered failure, not valued, or worse, it’s considered relapse. That is what sets up the Abstinence Violation Effect: Any violation of abstinence becomes failure and, potentially, an occasion for blaming the patient for still struggling with their addiction.

After Philip Seymour Hoffman died, I saw some comments on social media that were just horrible, to the effect that “obviously he didn’t work his program well enough.” The notion that “if you’re working the program then it’s going to work for you,” that assumption is the Abstinence Violation Effect, which leaves people feeling guilty, demoralized, like failures, hopeless. All of those feelings make people more helpless, desperate, overwhelmed and more vulnerable to misusing substances.

One of the beautiful and powerful things about the HR shift is that any positive change is affirmed, is valued. Just taking a closer look at your substance use is a step in the right direction. You’re not sure what change to make, but you are interested in looking closely at it and making a personal exploration of your relationship to substances. The abstinence-only program can’t do that because of its basic assumptions. So the disease model frequently contaminates smart, well-meaning psychotherapists. We have a treatment system that is dominated by the idea that abstinence and AA are the only way, and mental health professionals have been taught that you can’t see someone in psychotherapy if they haven’t accepted the disease model and achieved abstinence in AA. It’s not a system that serves the public well. 

Basically, Integrative Harm Reduction Psychotherapy changes the traditional narrative of hitting rock bottom, forced abstinence, and relapse until one accepts they have a disease and abstains. Instead, IHRP is client-centered and gives the person seeking help an opportunity to share their own story and find meaning in it? 

I want my clients to become experts about themselves, to get an empowering education about their problematic, addictive behavior and to understand what they need to do to change. It’s a completely transparent process.

Another important problem with the disease model of recovery is the stigma about addiction that people just take for granted. That people struggling with addiction can’t think for themselves, can’t be trusted. That "they’re infantile." I think of that as social countertransference. And it impacts a lot of mental health professionals, which is really unfortunate, because people need to have a safe place to think about their substance use—to delve into it—and, often, it’s while people are engaging in these behaviors. IHRP invites people in on their terms, wherever they’re at in relation to their substance use. Then we have the material, we have the experience, we have the whole person in the room rather than limiting what can be talked about. It seems so simple and obvious, sometimes I wonder should I even be having to say this: the key to any kind of helping relationship is listening.

You’ve discussed in your writings the importance of empathy, listening actively, and asking questions without judgment.   Are these the vital roles of a counselor practicing IHRP?

The first principle of IHRP is listening—listen to the patients’ experience, listen to what they have to say, get out of your own head. When you find your own voice it’s inherently empowering. And when a therapist says “this is what you have to do,” that is inherently disempowering. In IHRP, we think disempowering authoritarian help, as I was saying before, requires people to submit or provokes a sense of rebelling. IHRP is not authoritarian. We set up a relationship that’s going to support people to find their own truth. And this collaborative part is what is very empowering to people. Together, we try to figure out a path that’s going to really serve you. IHRP is diametrically opposite to that disempowering system out there. And we think that’s how it works.  

We’re finding that more and more people are seeking this therapy out. The so-called “treatment resistant drug user” resists bad therapy, but when they hear that there’s an option out there that’s on their own terms, many become motivated to seek help. This treatment accepts that we are all human, and struggling, and that there is something universal about that. The therapist’s empathy gives the client the experience of being “worthy of being empathized with”; “I’m worthy of respect and I can adopt that attitude towards myself.” Clients start feeling more compassionately toward themselves and start taking better care of themselves. Research empirically supports that.

The therapist’s ability to empathize is a very powerful tool to support the process of self-discovery. Reacting to that empathy, clients can explore why they would get drunk or do something that is self-harming: "What was going on with me that led me to react that way?” That’s where positive change and growth around the substance use occurs. If I can care for myself more effectively in another way, maybe I don’t have another drink.

I especially related to not being able to express my real feelings and question authority, including my former rehab counselors, those in AA “with more time,” which mirrored the relationship I had with my own domineering mother. You’ve written about “treatment trauma” before, can you explain it further?

If you don’t listen, and try to inject your ideology into the other person, that is inherently or potentially re-traumatizing them. It is reminiscent of having a narcissistic parent who wasn’t listening but was trying to inject their feelings and demands on you, and you were just supposed to submit. But if you rebel to save your sense of autonomy, then you get blamed for it. You’re being a rebellious “resistant” person and you live with that label and that can further confound those feelings, cause self-esteem issues, contribute to greater hopelessness and I think in many cases an increased vulnerability to overdose. It can become like a self-fulfilling prophecy. 

Having that kind of early experience makes people vulnerable to similar relationships later in life. And unfortunately that’s one reason why some people can be extremely vulnerable to abusers, narcissists, and some of them wind up in AA. Another complicated piece to this trauma is the dissociation that can occur when you grow up with trauma. One of the ways we deal with trauma, and with not having our feelings affirmed about these overwhelming experiences is that we tune it out, we shut down. If our parents don’t recognize how we’re feeling then maybe we don’t. That’s tuning out. Maybe not connecting to how we’re feeling is one of the consequences of trauma. It makes us vulnerable to falling into self-defeating relationships.  

How can one work IHRP on their own?

You may have seen that on our website there is a 6-step guide that applies the integrated HR psychotherapy to a self-guided process, that helps people clarify their positive change goals regarding substance use and other potentially risky behaviors and develop personal plans for change. It hits on creating an inner attitude that is conducive to change, developing skills that support positive change and working with ambivalence about change. This is something people can do on their own, for free, and it includes a lot of the basic elements that we work on in therapy. People can take advantage of the guide on their own, and if they run into difficulty they can check in with us. Or we can help them find a therapist able to work with them. We are committed to using compassion, empathy, collaboration and empowerment to change the narrative of addiction treatment. 

Train with Dr. Tatarsky at “Integrative Harm Reduction Psychotherapy Training” at the New School, November 6-8, geared towards graduate students, social workers, and other professionals working in the harm-reduction field. Clients, the public, and clinicians are also invited to “Psychedelic Education and Continuing Care Program Launch Event,” on November 12, for discussion about psilocybin, MDMA, and ayahuasca. Details and how to register appears on the Center for Optimal Living’s website.

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Juliet Elisabeth is a freelance writer and independent contractor as a research analyst focused on the healthcare field; also an artist and mother of two. Activist for choice in recovery treatment. Her blog is AarmedWithFacts.