HARM REDUCTION ANY POSITIVE CHANGE

Gary Clark, LCSW

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Some Introductions… 

A little about me  A little about you – What does Harm Reduction mean to you? – What has been your experience with Harm

Reduction? – What do you hope to get out of this training?

What is Harm Reduction? 

Harm Reduction is a set of practical strategies that reduce the negative consequences associated with drug use, including safer use, managed use, and non-punitive abstinence. These strategies meet drug users “where they’re at,” addressing conditions and motivations of drug use along with the use itself. Harm reduction acknowledges an individual’s ability to take responsibility for their own behavior. This approach fosters an environment where individuals can openly discuss substance use without fear of judgment or reprisal, and does not condone or condemn drug use. Staff working in a harm reduction setting work in partnership with tenants, and are expected to respond directly to unacceptable behaviors, whether or not the behaviors are related to substance abuse. The harm reduction model has also been successfully broadened to reducing harms related to health and wellness as well as many other issues. (Harm Reduction Coalition)

Some Values of Harm Reduction  

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Not all drug use is abuse- but all drug use does need to be safe and based on accurate information about drugs. It’s not necessary to stop all drug use to stop harm- although, for some people, that is the most efficient way, whereas for others, quitting is an unrealistic and insurmountable task. Just say KNOW. Take care of yourself regardless of the status of your drug use. Receiving nondiscriminatory care from others, especially health care professionals, regardless of the status of your drug use. Getting mental health needs attended to, formally or informally, when you are suffering emotional pain or mental illness regardless of the status of your drug use. Getting adequate pre-natal care without fear of criminal sanctions, regardless of the status of your drug use. Still putting business before pleasure, especially if your business is taking care of others, even if you continue to use drugs. Being free of punitive sanctions for what you choose to put in your body. Being free of the fear, the stigma, and the shame that accompany your choices.

PERSONAL EXPERIENCES WITH MAKING CHANGES Think of an experience that you had with attempting to make a change in habit or behavior, such as giving up smoking, losing weight, or starting and exercise program. You may or may not have been successful with achieving your goal of making this change. Answer the following questions about this experience. We will then share some of our answer with each other.      

What contributed to your decision to make this change? When you decided to make this change, how confident were you that you would achieve your goal? Did you experience any changes in your levels of motivation and commitment as you embarked on making this change? How many attempts were required at making this change before it became enduring? If it was more than one attempt, what influenced your decision to try again? What kind of influence did other people have on your experience with making this change? Did you learn anything about yourself as a result of attempting to make this change that you did not previously know?

WHAT DOES OUR EXPERIENCE TELL US?  Feeling ambivalent about change is normal.  Change occurs in a space that feels safe and non-

judgmental.  There are costs and benefits to all behaviors…there are costs and benefits to all change.  We are more likely to change a behavior when we feel a certain level of control over how we make the change.  There’s more to change than just the behavior!

DON’T ABSTINENCE FOCUSED PROGRAMS UNDERSTAND THIS? 

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Mainstream abstinence focused programs in the United States have poor success by anyone’s criteria (especially for those with co-occurring mental health conditions). Standard (abstinence focused) approaches to treatment are not equipped to address serious emotional or socioeconomic problems accompanying substance use problems. Most abstinence focused programs are based on the assumption that unless substance users are willing to accept total abstinence from all drugs and alcohol, they are not suitable for treatment (especially for those with co-occurring mental health conditions.) The assumption of abstinence focused programs is that the substance user needs to “hit bottom”, that is, suffer more from the assumed negative consequences of their use in order for motivation toward abstinence to grow. Abstinence focused programs are based in the disease model…the “disease”is a permanent, lifelong condition, dormantly active even when the client isn’t using drugs (always in recovery, never recovered) Instead of supporting the individual toward the understanding of and recovery from drug use, abstinence focused programs tend to devalue, dehumanize and objectify drug users and often alienate them from seeking help.

THE ROLE OF THE CLINICIAN IN HARM REDUCTION Although our goal is to meet our clients “where they are at,” most clinicians enter into each encounter with a number of prior assumptions about the nature of that person’s problems and life experiences.  The challenge for the clinician is to set aside her prior assumptions about the client so that she can embark on a process of discovery with the client.  A collaborative relationship between the clinician and the client makes it possible to discover together the problems that need to be addressed and can lead to the co-development of goals and possible strategies for achieving those goals.  The work is done with respect, unconditional love, dignity and care.  The clinician sees the participant as an equal; each individual, regardless of the roles he or she plays in life, has to right to self-determination, autonomy and a good life.  The clinician must avoid being parental, judgmental, controlling and punishing.  The clinician should keep the focus of every interaction on supporting the client toward being as happy, healthy and contented with life as possible. As they define that! 

THE PRINCIPLES OF HARM REDUCTION PSYCHOTHERAPY 

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FIRST DO NO HARM….evicting a person from a housing program for people with mental health condition and substance use issues is counterintuitive to helping them. DRUG ADDICTION IS A BIOPSYCHOSOCIAL PHENOMENON…research indicates that there is no single cause of addiction, nor even that addictions are primarily biological diseases. DRUG USE IS INITIALLY ADAPTIVE…whether used for recreation, escape, or mental enhancement, the initial use of drugs is most often adaptive, that is, beneficial in some way. THERE IS NO INEVITABLE PROGRESSION FROM USE TO DEPENDENCE…drug users are an extremely heterogeneous group. THE RIGHT TO SENSITIVE TREATMENT…boilerplate treatments cannot take into account varying levels of interest in and motivation for treatment. DEVELOPMENT OF A NEEDS HIERARCHY…willingness on the part of the clinician to construct a hierarchy of client needs that reflects and addresses his or her most urgent concerns, longer term goals, and strategies toward those goals. ACTIVE DRUG USERS CAN AND DO PARTICIPATE IN TREATMENT…most people can take steps toward change if they have a caring, empathic, genuine counselor. SUCCESS IS RELATED TO SELF-EFFICACY… success in solving drug-related problems is a function of the client’s belief in his or her own power to effect change. DRUG, SET AND SETTING: THE CLIENT’S UNIQUE RELATIONSHIP WITH EACH DRUG USED…

ANY REDUCTION IN DRUG-RELATED HARM IS A STEP IN THE RIGHT DIRECTION…

THE ROLE OF THE CLINICIAN IN HARM REDUCTION 

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Although our goal is to meet our clients n”where they are at,” most clinicians enter into each encounter with a number of prior assumptions about the nature of that person’s problems and life experiences. The challenge for the clinician is to set aside her prior assumptions about the client so that he can embark on a process of discovery with the client. A collaborative relationship between the clinician and the client makes it possible to discover together the problems that need to be addressed and can lead to the co-development of goals and possible strategies for achieving those goals. The work is done with respect, unconditional love, dignity, and care. The clinician sees the participant as an equal; each individual, regardless of the roles he or she plays in life, has the right to self-determination, autonomy and a good life. The clinician must avoid being parental, judgmental, controlling and punishing. The clinician should keep the focus of every interaction on supporting the client toward being as happy, healthy and contented with life as possible. As they define that!

A FEW MORE THINGS TO KEEP IN MIND… Edith Springer, 1991 

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SHOW CLIENT UNCONDITIONAL REGARD AND CARING. BE A REAL PERSON. Allow the client to see you as a person and not just a professional. Showing genuine/real emotion is one of the most powerful tools.

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DON’T GET CAUGHT UP IN THE CLIENT’S URGENCY. Take your time, think, be rational.

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BE A CONSTANT OBJECT. Your personal issues should not affect your interactions with your client.

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BE NON-JUDGMENTAL ABOUT THE BEHAVIORS OF THE CLIENT. SET LIMITS FIRMLY. Consistently set the same limits. Reduce the use of “no” as much as possible. DO NOT TRY TO CONTROL THE CLIENT. Try to control yourself.

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EMPOWER, DON’T ENABLE. (Supporting vs. Enabling, a whole other discussion).

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YOU ARE NOT RESPONSIBLE TO RESUE THE CLIENT. And you are not responsible for their successes! The client is responsible for his or her own life. You are responsible for a process of intervention.

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NEVER TAKE AWAY DEFENSES UNTIL YOU ARE SURE THE CLIENT HAS A REPLACEMENT DEFENSE OR COPING MECHANISM. Help clients develop new means of coping and work on fixing up some old ways.

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NEVER STOP EXPLORING YOUR OWN ISSUES ON DRUG USE ASD OTHER POTENTIALLY HARMFUL BEHAVIORS. NEVER FORGET THAT HARM REDUCTION IS ABOUT ANY POSITIVE CHANGE!

THE STAGES OF CHANGE Originally developed in the early ’80s by Dr. Prochaska and Dr. DiClimente as a way of addressing a person’s readiness for change. The model was developed from research on the treatment procedures or techniques that people use in modifying a particular problem behavior. According to the Stages of Change Model, there are five stages of change. 1. 1. Pre-contemplation 2. 2. Contemplation 3. 3. Preparation 4. 4. Action 5. 5. Maintenance 

Some thoughts from dr. Prochaska and Dr. DiClimente 1.

1. The stages describe attitude, intentions, and behaviors about change. 2. The “change” sought after is in a specific target behavior, such as drug use or reduction of psychiatric hospitalizations. 3. The model is used to describe voluntary change processes rather than mandatory or coerced change. 4. Each stage refers to a time period and to tasks one must complete before moving to the next stage. People may differ in the amount of time they spend in a stage, but the activities and processes involved to progress from one stage to the next one are similar for everyone.

MOTIVATIONAL INTERVIEWING 

MI was first described in 1983 by Dr. William Miller in an article published in Behavioral Psychotherapy. The concepts and approaches were later elaborated by Dr. Miller and his colleague Dr. Stephen Rollnick in 1991. MOTIVATIONAL INTERVIEWING as defined by Miller and Rollnick: A directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. MI is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of firective ????? And client-centered components shaped by a guiding philosophy and understanding of what triggers change.

The Spirit of Motivational Interviewing:  Motivation to change is elicited from the client and not imposed     

from without. It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. The counseling style is generally a quiet and eliciting one. The counselor is directive in helping the client to examine and resolve ambivalence. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. The therapeutic relationship is more like a partnership or companionship than expert/ recipient roles.

THE STYLE OF MOTIVATIONAL INTERVIEWING 

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Although Miller and Rollnick warn against viewing MI as a technique or set of techniques that are applied to or worse yet “used on” people, there are specific and trainable behaviors that are characteristics of a motivational interviewing style. Seeking to understand the person’s frame of reference, particularly via reflective listening. Expressing acceptance and affirmation. Eliciting and selectively reinforcing the client’s own self motivational statements /expressions of problem recognition, concern, desire and intention to change, and ability to change. Monitoring the client’s degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client. Affirming the client’s freedom of choice and self –direction.

PRINCIPLES OF MOTIVATIONAL INTERVIEWING 

EXPRESS EMPATHY. Accept what the person tells you from his or her reality.

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DEVELOP DISCREPANCY. Point out the difference between what the person says he/she wants and what he/she is doing now. AVOID ARGUMENTATION. Avoid labeling. Avoid making the person defensive. One can’t explore all one’s feelings about the issue if one has to defend oneself. Resistance is healthy but worker-created resistance is counterproductive. Don’t take a position. It isn’t your life. ROLL WITH RESISTENCE. Gently steer things using the momentum of the participant. RESISTANCE IS A SIGNAL TO THE WORKER TO CHANGE THE STRATEGY.

SUPPORT SELF-EFFICACY. Hope, trust and believe in the

person’s capacity to change. Client has to believe in his or her ability to carry out and succeed in a task.

HARM REDUCTION AND HOW WE CHANGE

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In order for our clients (ourselves) to either reduce or change harmful behavior, they (we) must believe a few basic things about themselves (ourselves)… I’m changing because I’m worth it. I’m a good person (not I want to change because I’m no good the way I am). I want to be better and more comfortable with myself (not I hate myself the way I am). I’m not going to try to change all at once (slowly works better) If I decide not to continue, or to go back to what I did before, that’s okay. I’m changing for myself, not for you or anyone else. I love myself just the way I am; I’m changing to make myself better and happier. • What else?

REAL SITUATIONS, REAL CHALLENGES AND SOME NEW IDEAS…

A BRIEF BIBLIOGRAPHY AND SOME SUGGESTED READINGS (IN NO PARTICULAR ORDER)  

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COMPASSION IN ACTION, RAM DASS AND MIRABAI BUSH, BELL TOWER, NEW YORK, 1992 PRACTICING HARM REDUCTION PSYCHOTHERAPY; AN ALTERNATIVE APPROACH TO ADDICTIONS, PAT DENNING, THE GUILFORD PRESS, 2000 SUBSTANCE ABUSE TREATMENT AND THE STAGES OF CHANGE, CONNORS, DONOVAN, DICLIMENTE, THE GUILFORD PRESS, 2001 HARM REDUCTION PSYCHOTHERAPY, ANDREW TATARSKY, JASON ARONSON INC., 2002 MOTIVATIONAL INTERVIEWING: PREPARING PEOPLE TO CHANGE ADDICTIVE BEHAVIOR, WILLIAM MILLER AND STEPHEN ROLLNICK, GUILFORD PRESS, 1991 OVER THE INFLUENCE: THE HARM REDUCTION GUIDE FOR MANAGING DRUGS AND ALCOHOL, DENNING, LITTLE, GLICKMAN, GUILFORD PRESS, 2004

A FINAL THOUGHT…COMPASSION IN ACTION Compassion in action is paradoxical and mysterious. It is absolute yet continually changing. It accepts that everything is happening as it should, and it works with full hearted commitment to change. It sets goals but knows that the process is all there is. It is joyful in the midst of suffering and hopeful in the face of overwhelming odds. It is simple in a world of complexity and confusion. It is done for others, but it nurtures the self. It shields in order to be strong. It intends to eliminate suffering, knowing that suffering is limitless. It is action arising from emptiness…

THANK YOU!!