What is Harm Reduction Therapy and How Do I Practice It?
SMART Recovery, for which Stanton serves on the international advisory council, is an abstinence-based program. Only Stanton doesn’t think that “abstinence-oriented” is a type of treatment. Harm reduction, which incorporates abstinence as one end of a spectrum of harm-reduction techniques, does represent a therapeutic approach, which Stanton explains in the SMART newsletter.
Harm reduction therapy is based on four principles:
- While absolute abstinence may be preferable for many or most substance abusers, very few will achieve it, and even that small group will take time to do so and may relapse periodically;
- Ordinary medical treatment readily accepts and practices ameliorative therapies, which preserve health and well-being even when people fail to observe all recommended health behaviors;
- Therapists should present accurate information to clients and may even express their own beliefs, but they cannot make judgments for clients;
- There are many shades of improvement in every kind of therapy—this improvement may be all that people are capable of and should be encouraged and nurtured.
In Europe, the concept of harm reduction is taken for granted. Except for the United States, every national government in the Western world endorses or provides needle exchange programs. And harm reduction has had a certain impact in the U.S. as well, where many cities and states tolerate, or even encourage, clean needle programs. Moreover, there are methods for counselors to deal with addicts and alcoholics which are consistent with the harm reduction ideology. These often require counselors to develop whole new ways of thinking about addictions, clients and the therapeutic relationship. These new ways of thinking offer important tools for reaching clients and for improving treatment outcomes.
Following are key harm reduction therapy attitudes and techniques in relation to addictions:
Accept and respond to improvement. The standard addiction treatment in the U.S. requires the individual to instantaneously and totally give up all use of the problem substance, and rejects anyone who fails to do so! This is cherry-picking of clients, by working only with those who are immediately able to get better. But who then will deal with the vast majority who are not capable of immediate cessation? Substance abuse counselors who wish to work with this large majority need to define intermediate goals, and to recognize such positive steps when these occur.
Improvement includes any lessening of harms the person experiences. What if a man regularly, while out drinking, got into fist fights or committed crimes? If, while drinking no less, that person stayed at home, he might significantly reduce the harms his drinking causes. Or, if another man got drunk at home and then fought with his wife, he might improve his life by simply drinking at a safe place outside of his home. It is a strange kind of perfectionism which says, “I won’t accept any kind of drinking or drunkenness, and if this man continues to drink this way, I wash my hands of him.” This is reminiscent of former New Jersey governor Christie Whitman, who rejected the recommendation of the AIDS Commission she appointed when it listed provision of clean needles as the top step the state could take to prevent new HIV infection. New Jersey now has the highest rate of injection-based HIV infection in the nation, many of them children of drug users.
Humility (versus perfectionism) is a clinical skill. When people say, “I will not tolerate any kind of drinking in therapy, and therapists who do endanger the lives of their clients,” their own patients must surely have perfect compliance. Not! It’s just that they insisted on abstinence, so that any failures were those of their clients, and not their own. While this may assuage therapists’ consciences, it is not effective therapy.
Anticipate and incorporate continued harms in therapy. Among the delusions of therapists is that clients depend solely on their therapists for any advances they make. In fact, most people get better on their own. In part, this involves experiencing and learning from the pain of their mistakes. When we consider that most alcoholics have spent years, even decades developing their habits, we may begin to understand that positive changes may likewise take some time (although hopefully not as long as it took to develop the problem), and trial and error. This means recognizing that continued drinking will occur, while continuing to work with clients towards fulfilling life goals and reducing harms.
Learning to take care of oneself is a skill, a value, and an attitude. To say one accepts that human beings are imperfect does not mean that you endorse their imperfection. You want to encourage those you are helping to greater heights and larger successes. But it is the recognition and encouragement of smaller successes that lead to such progress. In particular, helping people to think about how to take care of themselves, even if they continue to drink and take drugs, may be an entirely new attitude for some people. When they first start getting medical care for health problems, or eating well or avoiding infection, or staying out of legal trouble, or getting a place to live, or accumulating money, etc., this new attitude can grow so that it crowds out all problem drug use or drinking.
What we consider substance abuse therapy in the United States consists largely of exhortation—”quit drug taking and drinking!” Real therapists must know how to improve the conditions of a range of clients, from those who are ahead of the therapist in curing themselves, to those who merely need encouragement, to those who need help to avoid falling off the edge, to those who may have given up and who are waiting —or helping themselves—to die.
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