Is harm reduction therapy too risky for a therapist to try?

 

Further Reading

Dear Stanton:

I am a counselor who finds you ideas on harm reduction very appealing and sensible. But I wonder about the liability issues involved. If I work with a client encouraging him to limit his drinking to a safer amount and perhaps a safer setting and he overindulges and makes a poor decision, resulting in harm to himself or someone else, I worry that a lawsuit would lead to my being held culpable for “encouraging” or at least giving him permission to drink, instead of preaching absolute abstinence as the only acceptable alternative.

Given the current climate in the legal system and treatment community fostered by AA precepts, I can foresee a very hostile, and possibly expensive to me, reaction to attempts to help a client limit the harm resulting from his use. And it seems to me more dangerous in the case of someone using illegal drugs, where I might be charged with aiding and abetting illegal behavior by encouraging someone to moderate his use or take steps to cut down on the fallout. I wonder about risking my career, and then I wonder if a career is worth saving if it forces me to subordinate my beliefs about what is best for the client to the prevailing Zeitgeist.

Steve

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Dear Steve:

A thoughtful question. “Harm reduction” therapy, as you indicate, means focusing with clients on obtainable improvement rather than absolute ideal outcomes, like complete and perpetual abstinence, which virtually never occur. Since standard practice is abstinence-oriented, as you point out, conceivably a malpractice, tort, or even some criminal action could point out that you departed from community professional standards in this regard, and you might be made legally responsible for any negative consequences involving your client (even if these occur jut as often, or more frequently, for those in standard therapy).

I approach this by identifying at the start of the therapy relationship the likely risks for the individual — usually things they have done recently or are currently doing. Examples might be driving while high or intoxicated, compromising children through parental drinking or use of drugs (thus raising custody issues), endangering a job by missing work or having the possibility of a positive urine screen, and so on.

But these then become part of your contract with your client and a focus of treatment goals. That is, you work with the client to identify the most likely and serious risks they are engaging in, and tackle these immediately. For example, you might indicate that you understand or tolerate that people will sometimes continue to drink. But you then work to highlight those circumstances where this is not acceptable, and where the client’s drinking entails unsupportable risks. You might even write these down and have the client sign the document. All of this work can then be documented and used in any legal action.

I recently witnessed a case in which a person (not my client) was forced from his home and daughter due to his neglect of her from his drinking to deep unconsciousness. He loves his daughter deeply and is a good parent; he has lived away from her for a year. His recent treatment has worked well, and he has drunk twice in the last four months — both without going on a bender as he used to.

Yet, one of these occasions involved drinking, not even to intoxication, before a supervised visit with his daughter. A social worker smelled his breath and had the man tested, revealing his alcohol consumption. The consequences were disastrous — he was just about to be permitted to move back with his family.

This case invites a psychological interpretation — why, given that he rarely drinks, would he drink on this occasion? But while a counselor could imagine the man drinking, good counseling would help him to avoid completely abandoned drinking (which he has avoided), but also drinking when the consequences will be so severe, as they were for him this time. Of course, such counseling might focus on his anxiety around his visits, developing alternative responses for his anxiety, and so on. It should also identify low- versus high-risk drinking (he might have come home and drunk in his room or at a bar he could walk to).

I hope this is of some assistance. Try to do the right things, things that make sense; document your actions and your reasoning; engage your client in this risk analysis and, where necessary, obtain releases, consent, or other signed statements of the client’s understanding of what the two of you are aiming for.

Stanton