What's Under the Harm Reduction Umbrella? Part Three
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Traditional assessment and treatment planning in addiction treatment tends to be predicated on the client’s diagnosis and the types and amounts of substances being used. In contrast, a harm reduction approach focuses primarily on what individuals are motivated to change with respect to their relationship with substances. Such an approach requires courage, patience and skill. Last week, Jeannie Little and Patt Denning discussed their ideas about how much structure, containment, direction, and freedom clients need in Harm Reduction Therapy. Here, in the concluding article of the Harm Reduction Umbrella series, they review several complex cases where treatment demanded client-specific and flexible treatment recommendations. - Richard Juman
All good therapies and treatment plans are driven by the client’s diagnosis, with the goal of answering the question: “What treatment is needed?” Harm reduction therapy takes pains to consider also:“What will be helpful and not harmful?” We make determinations or recommendations based on the need for immediate safety and on other considerations discussed below. The first question we ask is WHO decides and the next question is HOW we decide.
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First, we ask!
Some people know what they want and need and, given free rein to be honest and choose their own goals, they will tell us. Self-determination theory (Ryan and Deci), an empirically derived theory of motivation, makes it clear that intrinsic motivation—that arising from within the individual—is developed in the absence of coercion, rewards, or punishments and in the presence of opportunities for autonomy, competence, and connectedness. In other words, people need to feel that they are in charge of themselves and their decisions, that they have the skills to make changes, and that they will be connected to important people throughout their journey. The literature on goal choice shows that the more people choose their own goals, the more successful they are. If the client does not have a clear sense of direction, and if we have an established therapeutic alliance, we join the client in teasing out what would be most helpful. In a discussion of pros and cons, the therapist brings to bear a number of pragmatic and clinical considerations.
Then we consider the need, or lack thereof, for structure, containment, direction and freedom based on criteria that go beyond ASAM.
Safety is our first concern, and we prioritize the safety of others above all else. Are others in danger? Children, others on the road, people the client is responsible for at work, people they are sharing needles with/having sex with? We might make a CPS report if we suspect that the client is a danger to children. This is tricky, though, and requires a careful, values-neutral assessment. Intoxication is not necessarily dangerous to children. A distracted parent is not providing optimal attention and support, but that in itself is not a reportable offense.
Beyond our obligations as mandated reporters, there are a number of circumstances in which we take action in our moral duty to reduce harm. We might encourage family members to make sure that drugs are out of the reach of children, and that they plan their drug use around the times they need to be actively involved with their children. We suggest having a supply of naloxone in case of an opiate overdose. We are uncompromising about drinking and driving and, if someone has driven to a session under the influence, we call a cab and, if needed, ask to hold their car keys until the next day. Sometimes, direction comes not from the therapist but from others—judges, bosses, or family; it can be better for the client/therapist working relationship when this is the case.
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Suzanne needed containment of dangerous behaviors and unstable affect. She and her partner had adopted children and her mother-in-law lived with them. She had not adapted well to these changes and was exhibiting considerable stress. She was drinking heavily, and she routinely drove while drinking, sometimes with her children. We knew that she was using alcohol as medicine for high levels of anxiety, but she was unable to manage her level of use, so alcohol ended up dysregulating her further. Containment had to be externally imposed. She refused our recommendation of an inpatient program. Rather than deny treatment until she was more cooperative, we developed a team approach. One therapist worked with her to provide reassurance, support, and emotional tolerance skills, while another worked with her extended family to help them provide the containment that she needed. They decided to install an alcohol ignition lock in all of their cars, and to ensure that she had no child-care responsibilities while she was drinking. After two years, she was sufficiently emotionally and physically contained that she was able to attend an inpatient program that specialized in working with trauma and substance use. With a couple of slips into heavy drinking, she has been stable for many years with the support of Moderation Management.
Safety vs. Comfort
Many programs use concern for safety as a rationale for imposing control. But they fail to distinguish between safety and comfort. Counselors or therapists often say that someone showing up intoxicated to a group session is “unsafe” for other group members. Let’s be clear - this is not unsafe. Unsafe means that someone is about to get hurt, or has been, and a call to 911 is needed! What is more often meant is that people are uncomfortable: they are feeling triggered by the smell of alcohol, or are developing cravings as a person talks about IV drug use. If treatment is meant to help people become strong and resilient, able to navigate the world of drugs and other stressors without resorting to unwanted substance use, treatment programs need to work with triggers and cravings, not eliminate them. What better place than in a group facilitated by a therapist who can help de-escalate intense feelings, provide emotional containment for other group members, and teach valuable relapse prevention skills?
Readiness to Change
Just because acuity is high does not mean motivation is.
Joey is 16 and lives in the park near a homeless youth program where one of our therapists works. He is extremely disorganized, is in constant conflict with the police and with other kids who live in the park, and uses large amounts of methamphetamine and alcohol. ASAM would certainly recommend a high-intensity program because of the acuity of his mental health and his aggression. If we tried that, we would never see him again. And even if needed, he would probably leave or get kicked out of a restrictive program, or any program for that matter. Instead, our therapist searches him out and offers food, conversation, and emotional connection. He joins with Joey’s experience and says things like: “Man, that sucks that he said that to you” and strengths-based praise such as “You only shouted at her? How did you manage not to hit her? I’m really impressed.” In this manner, the therapist is communicating that he understands how easily provoked Joey is, he admires Joey’s restraint, and he respects his autonomy. He is building Joey’s capacity for emotion regulation. After three years of gentle engagement and treatment, Joey’s emotional system has calmed down and he has been attending regular therapy sessions in the office and discussing changes to his substance use.
Co-occurring Mental Illness
The presence of a serious mental illness does not indicate the kind of structure or the level of containment or direction needed. Even people with active psychosis maintain strengths and abilities. They are often capable of making decisions, as well as taking steps toward health if, like all of us, they want to. Motivation to change should be the defining criteria unless immediate safety is at risk.
Luna had been diagnosed with schizophrenia at age 22, a year before coming to HRTC. At the time of intake she was stable on medications. A wild teenager, she had used alcohol, meth, and heroin for several years before her first break and had abstained from all after an extended hospitalization. She came to us because she had begun to drink again under the stress of a decision to go to college. Despite a serious mental illness and heavy drinking, she was actually a low-risk client who was willing to quit drinking again to avoid going back to the hospital. She needed a combination of exploration, skills-building, and direction – exploration to help her make sense of her history with drugs and to accept herself as a person with schizophrenia; skills to manage her life as an adult; and direction to manage symptoms when they arose. Given her interest in being abstinent and her enthusiasm for introspection, she benefited greatly from SMART Recovery meetings as a long-term support system.
In contrast to the traditional view that “addiction” is the same for everyone and that what works for one works for all, there are many complicated factors in the personalities of people who misuse substances that influence treatment recommendations. Various personality types—narcissistic, borderline, dependent, and antisocial—have unique characteristics that indicate the kind of program that would be most effective. However, particularly in the case of borderline personality, the diagnosis covers so many different kinds of people that it is imperative to have a truly individualized treatment plan. Just as with serious mental illness, the diagnosis does not, in and of itself, lend itself to guidelines about how much containment and direction would be helpful.
We pay particular attention to where a person is on the compliance/defiance continuum. Defiance is most commonly known as “problems with authority” and is considered a bad thing. Compliance, on the other hand, is generally viewed positively: “He is a good patient.” But both defiance and compliance should be understood as signs of immature personality development and not a “character defect.” (For example, both are quite normal in adolescence!) They could also be seen as clues to how a person has survived a difficult or traumatic life. Many programs activate an anti-authority response in clients by being overly directive and restrictive, and defiance or compliance might be indicators of an unsuccessful program fit.
Rhonda kept asking her therapist to give her homework in between sessions so that she could get better faster. She never actually managed to do it, or she forgot to bring it in if she had. We suspected that Rhonda had dependent characteristics or was exhibiting outward compliance and covert defiance. It was important not to confront her or attempt to expose the dynamic. Either intervention might arouse shame and decrease the likelihood that she would remain in treatment. So she continues to ask for homework and we continue to offer it. At some point we gently mused that, while she seemed to enjoy getting homework assignments, her enthusiasm waned when she got home. This intervention invited her to study her motivation and led to more authentic work at a pace that was right for her.
Benjamin, forty-eight, is often completely dysregulated. He exhibits many traits of borderline personality, rooted in a history of childhood neglect and abuse. He uses meth and heroin, has lost his housing for nonpayment of rent, and lives on the streets in a high crime part of town. His nutrition is poor, he is losing weight, he is prone to infections at his injection sites, and he is often in the emergency room. With others in the community, he is extremely argumentative, intrusive and rude, which puts him at risk for victimization. He has been in individual therapy with us for several years and attends many of our groups. Over a period of months he began decompensating, becoming paranoid and disorganized. He escalated in groups and was unable to be calmed, he could not follow through with appointments with our psychiatrist, and he got kicked out of most of the social service organizations he frequented. We wanted very much for him to be treated in a dual diagnosis hospital program but, given that group settings caused him to be more emotionally unstable, it seemed more therapeutic to loosen rather than tighten the structure. We began meeting with him in cafes or taking walks. It took several months of what Edith Springer2 calls “sidewalk therapy” for him to calm down, become more emotionally regulated, and come back to treatment indoors. We expect this to be the treatment for more years to come before he is able to stably manage his relationships and his drug use.
Cognitive Ability and Style
People vary in their ability to process information. Whether an issue of native intelligence, learning disabilities, substance-induced cognitive deficits, or traumatic brain injuries, it is important to recognize deficit rather than assume resistance. Some people can be very concrete and unable to self-reflect. Others don’t have an actual deficit, but because of painful emotions or memories they are focused outward, avoid introspection, and are said to “lack insight.”
Ramon is in his sixties and has a long history of heavy drinking to the point of blackout, with occasional episodes of drinking and driving. Prior to coming to HRTC he had made a few attempts to quit or moderate, neither of which were successful. He had had several DUIs, had been to three rehab programs, and had had several emergency detoxes. Even though he was coming to us for treatment (we think his wife sent him), he showed little interest in understanding his drinking or even discussing it. He called it recreational or social drinking despite several serious health problems. His memory was impaired, and he sometimes got confused about appointment times. Open-ended questions led to a lot of silence in sessions. He had no ideas about his triggers, and his strategy for change was “well, I just can’t drink.” His combination of low introspection, low readiness to change, and cognitive impairment called for greater direction but not necessarily greater containment. The benefits of a containing environment—offering a period of abstinence, intensive amounts of information, and the opportunity to learn about oneself in the absence of pressure to use—would likely not stick with him. Better to have long-term therapy, where he could get regular suggestions and reminders integrated into his life. Sessions were guided by therapist-generated questions about situations he might find himself in during the next week and recommendations for how to moderate or abstain. Each week he was asked to report on each situation and how he handled it. Over time, he developed new skills simply through rote learning and practice. He became willing to acknowledge himself as a person with an alcohol problem, and since he had attended AA in the past and found it helpful, we encouraged him to return to meetings. There, he can experience a similar routine and sense of accountability that will help him stay abstinent for the rest of his life.
Psychodynamics and the Inner Critic
Many people coming to substance use treatment are “high functioning.” They are able to work and maintain relationships; they are introspective and willing to take emotional risks: and they tend to be conscientious about the harm they have caused others and themselves. They might ask a therapist to “call me on my shit,” or “don’t let me get away with anything.” This is a red flag, an indication of someone who has been abused or is abusing himself by repeating critical voices from the past. We surmise, when we hear these requests, that substance use is actually a solution to an intolerable inner state. As the psychoanalyst Fenichel (1945) said so eloquently, “The superego is that part of the mind that is soluble in alcohol.”
Justin’s drinking was out of control. He had done extensive personal growth work, expressed a sense of responsibility to his family, and showed great capacity for introspection. Yet he responded to pressures at work, conflicts with his wife, and parenting challenges with intense self-criticism. He drank to relieve pressure, then was filled with self-loathing when he overdrank. Because of his sensitivity to pressure and criticism, he needed no direction and certainly no containment. Open-ended exploration and modeling praise for less-than-perfect efforts and outcomes were needed to relieve his internal critic. In only six weeks, he stopped driving after even one drink, reduced his alcohol intake to healthy levels, and decided to enter couples therapy to improve his relationship with his wife and reduce stress in the family.
Trauma and PTSD
Traumatized clients often require emotional containment to develop the capacity for emotion regulation. Sometimes this can occur through physical containment and direction, but that should never be coerced. One of the hallmarks of trauma is having one’s control taken away, often violently. In harm reduction treatment, we help clients maintain control over their treatment, and offer options for more restrictive settings with the clear caveat that they are free to refuse.
Derrick is an Iraq veteran in his twenties with a history of severe child abuse. He joined the service to escape his family and his heavy drinking and drug use. He was involved in combat operations and witnessed severe injuries but escaped any injury himself. He did not use any substances during his four years in the service.
He came to therapy because he had been drinking heavily every day since his re-entry into civilian life and was having periodic meth binges. He had been diagnosed recently with PTSD. His interpersonal relationships were volatile and he had poor impulse control. He was eager for help and asked for as much contact as we could offer. We met in individual therapy twice a week and he attended one of our groups.
Derrick was very fragmented, often starting a story in the middle as if he had already told us the beginning. He had difficulty remembering the goals that he set for himself, and rarely followed them. Derrick clearly needed a high level of physical containment; in addition to not remembering his goals, he would drink and drive and provoke fights. We referred him to a 30-day inpatient program where he loved everything he was learning in groups and classes. He did not like 12-step meetings however and, when he said this to his counselor, he was discharged (“kicked out”) after only three weeks. The counselor reported to us “There is nothing more we can do for him if he won’t go to AA. We’re wasting his and our time.”
Once out of the program he got into so many drunken fights that he ended up in jail. He was released on probation wearing an alcohol-sensitive ankle bracelet. This turned out to be an excellent, if somewhat humiliating, solution. He did very well, but when the bracelet was removed, he started drinking again and quickly spun out of control. It has become clear that, in the absence of external restraints on his drinking, he cannot manage himself. We believe he needs long-term residential treatment that can simultaneously treat his PTSD and is containing but non-directive. This may seem like an odd combination, but Derrick, while unable to contain his substance use, is able to engage as a cooperative and eager participant in exploring both his alcohol and drug use and its connection with his history of trauma and recent combat exposure.
A harm reduction therapist might recommend a variety of programs, including abstinence-based rehab and 12-step meetings. In our own programs, we pay attention to individual differences in the amount of structure, the amount of emotional containment, and the amount of direction needed by each client. When we make referrals to more restrictive programs, we make sure to recommend programs that understand the complex psychological and biological underpinnings of problematic substance use, programs that understand motivation and change and programs that are pragmatic about what is possible. Such resources are difficult to come by. The authors hope that this article inspires other programs to re-think and re-structure themselves in order to create a full continuum of programs that are harm reduction informed.
1 Safety First is the name of an excellent guide for teenagers and drug use authored by Marsha Rosenbaum, Director Emeritus of the Lindesmith Center and published by the Drug Policy Alliance.
2 Edith Springer brought harm reduction counseling to the United States and published its first paper here - "Counseling Chemically Dependent People with HIV Illness," Journal of Chemical Dependency Treatment, 1991, 4:2:141-157.
Jeannie Little, LCSW, CGP and Patt Denning, PhD, are the co-founders of the Harm Reduction Therapy Center in San Francisco. Both are primary developers of Harm Reduction treatments for alcohol and other drug problems. Their work at the Center has had an enormous impact on the understanding and optimal treatment of substance use disorders. They are the co-authors of Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol and the Second Edition of Dr. Denning’s groundbreaking Practicing Harm Reduction Psychotherapy. An updated and revised edition of Over the Influence is due out in Fall of 2016.