Harm Reduction Therapy Groups for Substance Misuse

By Cynthia Hoffman 06/22/16

An experienced harm reduction practitioner offers guidelines and protocols for using harm reduction concepts in group therapy.

Harm Reduction Therapy Groups for Substance Misuse
Support in harm reduction.

Groups for people suffering from addictive disorders have always tended to fall into two categories: Self Help groups such as AA and other 12-step programs that are engaged in either as the primary intervention for substance misuse or based on a recommendation of a treatment program, or group therapy as part of a treatment program that uses 12-step concepts—particularly abstinence—as a model. As Harm Reduction continues to gain support as a treatment modality for addictions, many providers are interested in incorporating harm reduction techniques and principles into their group treatment programs. Cynthia Hoffman has been offering harm reduction treatment for over a decade, including in the groups that she runs in her practice. Responding to the interest from providers on this topic, she offers here an overview and guide to using harm reduction practices in group settings…Richard Juman, PsyD

A Latina, lesbian firefighter who binge drinks. A white, female software engineer who vapes cannabis every weekday evening and throughout weekends. An African-American woman working as a high-level administrator who binges on alcohol and cocaine. A white, stay-at-home married mother who drinks a bottle of wine while her kids are at school. A transgender Asian man who uses ketamine daily while attending graduate school. These are composites of a few clients who have attended my Harm Reduction Therapy groups over the last six years.

Who seeks Harm Reduction Therapy?

Clients come to my group because they’re either looking for a way to manage their substance use or they’re trying to decide if abstinence is the right choice for them. Some have been to a 12-step program, others have been to rehab, and for some, this is their first experience with therapy. I also work with young people who have not yet learned to moderate; they come in to get their use under control, as the only way they’ve learned to use to that point was to binge. 

Whether or not group participants have attempted sobriety previously, most participate in the group because they’re looking for a way to better manage and more deeply understand their substance use. They want to improve their lives and feel better.

Abstinence-based programs are not for everyone

Because the 12-step approach has permeated the culture, 12-step treatment is commonly recommended to those struggling with substance use. While 12-step programs work for some, they don’t work for most. Often, people walk away from the programs feeling ashamed as a result of the harsh language and concepts that don’t appeal to them, such as needing to eliminate one’s “character defects” or the notion that substance misuse is a moral failing. While some of the individuals who leave 12-step programs seek lesser known forms of treatment, such as Harm Reduction therapy, most suffer alone. 

Many of the clients I see for Harm Reduction Therapy have already tried a one-size-fits-all program, such as 12-step, that didn’t work for them. They experienced feelings of anger and frustration after being told that, despite the non-clinical structure and low rates of retention, these programs were the only answer. 

Harm reduction meets the needs of people who don’t want to participate in abstinence-based programs. In Harm Reduction Therapy, treatment is individualized. Often, the clients I see have been rejected by other therapists, even before those therapists have met them. They’re asked “Have you tried AA?” Clients who were previously unaware of group or individual Harm Reduction Therapy are often excited to have discovered the process, while also apprehensive about what it will entail. Harm Reduction Therapy is respectful, client centered and individually tailored. 

Why harm reduction?

A basic tenet of Harm Reduction Therapy is that the substance users themselves are the agents of change in their own lives, rather than their families, partners, a higher power, or a 12-step group. The therapist and client work in collaboration to explore the reasons and implications behind the use, while developing strategies for safer use and reducing the stigma associated with the use. 

To be clear, Harm Reduction Therapy does not disregard the obvious fact that out-of-control substance use can be dangerous. The harmful or unsafe ways in which a client uses substances—as well as potential negative, even fatal possible outcomes associated with continued use—are not ignored but rather discussed openly and in an exploratory manner.

Benefits of harm reduction groups

I have been facilitating Harm Reduction Therapy groups and educating professionals about harm reduction for 16 years, both in agency and in private practice settings. For the last six years, I have been facilitating these groups via my private practice in San Francisco. What I hear from my clients—and what I have the privilege to observe—is that these groups are extremely helpful. 

Participating in a group both reduces isolation and helps broadens perspective. People who drink and/or misuse substances often believe that they’re the only one with this problem, and they often experience shame and guilt about their use. Seeing others who are also functioning well in many parts of their life but struggling with substances can alleviate this shame and help to change the negative self-image they have developed. Feeling less isolated and less ashamed can in itself lead to lasting change in substance use.

Running harm reduction groups

I run two different types of groups: an 8-week group and an ongoing support group. I provide the following descriptions of my groups in the hope that those who run groups for substance mis-users will become excited about Harm Reduction Group Therapy and be able to draw from the curriculum. I noticed a growing need for this knowledge in 2014 when I attended the Harm Reduction Conference in Baltimore, Maryland. There, I ran a workshop called “Running Psychoeducational Harm Reduction Groups.” Attendees, including therapists, case managers, administrators and social workers, shared their desire to run Harm Reduction groups in their agencies but weren’t sure how to initiate or design them. After the workshop, many requested copies of my presentation so that they could take it back to their agency and begin facilitating groups. My groups are strongly facilitated and structured. This is intentional, as it helps reduce the anxiety that clients feel when they enter the groups and the focus seems to increase retention.

8-week group

In my 8-week psychoeducational group, I introduce different harm reduction topics for discussion. These topics derive from the work of many harm reduction experts, including Dr. Alan Marlatt, Dr. Patt Denning, Jeannie Little, LCSW, Ken Anderson, and Dr. Andrew Tatarsky. The curriculum is designed to raise clients’ awareness and consciousness about their substance use and help them develop strategies for safer use.

Examples of group discussion topics:

● “What is Harm Reduction?” is the introductory group session where various examples and basic tenets of harm reduction are discussed. Often in this initial group, as the concepts and philosophy behind harm reduction are explained, clients start to relax. They realize they’re not going to be judged or shamed in any way. They’re often relieved that they don’t have to identify themselves as an addict or alcoholic.

● “Using a Decisional Balance” is an exercise where clients look at their goals for use and identify the pros and cons of making a change in the way they use. They also look at the pros and cons of not changing. Oftentimes, what is uncovered are feelings and reasons for misuse that may surprise or enlighten participants.

● “Drug, Set, Setting” is an exercise where participants look at the interaction of the drug itself, their mindset when using and the settings in which they use. This helps participants identify and explore the situations in which mis-use or over-use might occur

● “Urge Surfing and Mindfulness” is an exercise where clients learn how to use mindfulness to navigate the feelings that arise during cravings. This may include using mindfulness to help lower anxiety

● In “Goal Setting; Short Term and Long Term” we discuss short-term goals. I use the tenets of Motivational Interviewing to help the client identify what benefits they want to maintain from their use and how they want it to look for the next week. We also keep in mind the longer term goal they might have.

● In “How to Identify and Pay Attention to Feelings,” there is a discussion of the various feelings that arise in the weeks, days and hours before a drinking or drug-using session. Often, people who misuse are unaware of the feelings that can cause over-use. 

Group meetings always open and close with a familiar practice. At the beginning of each group meeting, the following takes place: 

● Clients check in, identifying two prominent feelings that occurred during the previous week. This is done in an attempt to help participants better identify their feelings and learn to spot any patterns where the experience of certain feelings leads to increased or decreased use. 

● Participants re-state the two goals they had set for themselves the previous week and discuss their progress toward those goals. Whether they achieved their goals is not the focus. Rather, the focus is on the process of working toward them. Often, people will say that substance misuse takes them by surprise. However, it’s actually a choice that an individual makes. If there’s a way to slow down the process and take a moment to stop and think about whether or not they want that drink or hit, they will see that they make a decision.

At the end of each group meeting, clients set two goals:

● The first is directly related to their substance use. For example, the goal might be to count how many drinks they consume or how much pot they smoke during a period of time. Or it might be to have a day or a period of abstinence. 

● The second goal is focused on wellness. It might be to add in physical exercise, or to make sure to eat food and drink water while consuming substances. Or, it could be about finding alternative activities to focus on during the times one typically uses. Often when people start using substances more and more, they put aside hobbies they’ve enjoyed in the past. Or, they may discover they’ve never learned ways to unwind and relax, other than by using substances.

One very important aspect of group therapy is that clients learn to cultivate and express compassion and kindness for one another. In turn, they learn how to treat themselves with the same compassion and kindness.

Ongoing support group

For those who have completed the 8-week group or who already have familiarity with harm reduction, I also run ongoing support groups.

In these groups, clients check in, again stating the predominant feelings they experienced during the previous week. They re-state their goals from the previous week and share how they were able to achieve the goals or explore why they may not have been able to achieve them. Clients consistently report how they benefit from the accountability factor that occurs in the group.  Setting weekly goals helps to keep substance use top of mind. Openly discussing these goals and trying to set varied goals in the group session helps normalize the process. Participants support each other and may offer one another suggestions—first establishing whether or not the advice is wanted. 

After the check-in, participants suggest a topic which might include: 

● Getting back on track

● How to talk with family members about their use

● Sharing worries about attending an event that can cause cravings for use

The collaborative nature of Harm Reduction Therapy continues in the group setting. As people with substance mis-use issues often focus on what went wrong during their use, group participants and I work together to help identify what they did well.

As the facilitator, I practice various motivational interviewing skills helping clients to:

● Focus on and finetune their goals

● Identify and resolve ambivalence about changing their patterns of use

● Identify the ways in which they are self-efficacious

● Practice non-judgmental compassion during the group process

This allows the group members to learn to give this type of support to one another and, most importantly, to themselves. 

Outcomes for Harm Reduction Group Therapy participants

Group member outcomes are varied. Specifically, I have had clients achieve the following:

● Put more days of abstinence into their week or participate in planned periods of abstinence ranging from one week to six months, until they feel they are ready to reintroduce their substance of choice

● Reduce the amount of times they smoke cannabis during their day

● Reduce the number of hours they use methamphetamine from 24 hours each weekend to 12 hours once a month

● Limit the use of cocaine or other party drugs to special occasions

● Learn coping mechanisms for managing use more effectively or for abstaining during difficult situations

● Add healthy activities like making sure they consume water between drinks, increase the amount of physical exercise they get, or include meditation or other stress-relieving practices into their life

Participants may also decide they need an extended period of abstinence or additional, more intensive help such as individual therapy, an outpatient program, a period in a rehab or medication. Medication might include an opiate replacement like Suboxone or a craving management medication like Naltrexone. It might include medication for the anxiety or depression one might be trying to address during their substance use.

This is far from an all-inclusive list but, hopefully, it offers some idea of what practices people can change when they participate in a Harm Reduction Therapy group. I am able to see people change their relationship to alcohol and other drugs and make lasting change in their lives while developing a higher regard for themselves.  

Cynthia Hoffman, MFT is a psychotherapist in private practice. She has been practicing and teaching Harm Reduction Psychotherapy in San Francisco for over 16 years in both private practice and agency settings. She runs Harm Reduction Therapy Groups in private practice as well as seeing individuals and couples. She provides clinical supervision and training in various agency settings. She also runs Harm Reduction Study/Consultation Groups for clinicians.

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Cynthia Hoffman.jpg

Cynthia Hoffman, MFT is a psychotherapist in private practice. She has been practicing and teaching Harm Reduction Psychotherapy in San Francisco for over 16 years in both private practice and agency settings. She runs Harm Reduction Therapy Groups in private practice as well as seeing individuals and couples. She provides clinical supervision and training in various agency settings. She also runs Harm Reduction Study/Consultation Groups for clinicians. Cynthia can be found on Twitter, as well as Linkedin.