Mar 20 - Harm Reduction Treatment, -
A Harm Reduction Treatment Model – Part 2
By Patt Denning, PhD
Based on the principles outlined in Part 1 and on empirically validated approaches, harm reduction psychotherapy (HRP) uses multiple interventions, depending on the precise problems (harms) suffered by each individual and the goals agreed upon by client and clinician. Most individuals want to rid themselves of the grip of compulsive drug use. All want to eliminate the harms from drug use. Our methods are as varied as the individuals we are trying to help. HRP is a unique therapist-client collaboration that combines substance abuse treatment and psychotherapy, so that a client can address both their substance use and the factors underlying it.
Following is an overview of the HRP treatment approach:
Low-threshold entry: We assume that when someone calls us, they want to change something. We welcome them and do not demand any changes as a precondition of treatment. Come as you are is the attitude we take.
Biopsychosocial assessment: We base our assessment on a biopsychosocial model in order to determine with the client the full complexity of the problems that brought them into treatment. A substance use disorder is not a brain disease. Rather, it is an interlocking condition that has many factors, of which neurobiology is only one.
Challenging dangerous behaviors: If it becomes clear that any drug-using or other behavior poses an acute risk to the client or others, we challenge the client to change those behaviors immediately. The focus of treatment remains on those behaviors and on resistance to changing them until immediate danger is alleviated.
We treat co-existing psychiatric problems simultaneously, often with medications.
We conduct a cost/benefit analysis of each drug in order to help the client understand the complexity of their relationship with substances and to understand what gains and losses s/he will incur by changing and/or giving up any or all of them.
We work extensively with ambivalence, or a person’s mixed feelings about changing. We view ambivalence and its companion, resistance, as normal human reactions to change.
Setting goals: It is important to make specific and realistic decisions about change in order to minimize failure and maximize success. One change can lead to another, so any change in a positive direction is more important than determining the ultimate outcome of treatment at the outset.
Skill-building is an important part of treatment for many people, in areas such as stress reduction, coping skills training, and relapse prevention.
Trauma work, nutrition, psychiatric medication, family therapy, and medication-assisted substitution therapies are essential for many people.
Substance Use Management (SUM): For clients who are not considering abstinence, SUM helps people to manage drug use by increasing safety and control or decreasing negative consequences. SUM also helps to determine whether a client will be able to manage his use of drugs or will need to eventually consider abstinence as the best way to ensure safety and successful functioning.
Redefining success: Since successful actions lead to improved self-efficacy, and since self-efficacy is a predictor of further success, we congratulate any positive change, knowing that it is the start of a life-changing cycle of events. “Any positive change” is the harm reduction version of “one step at a time.”
The Development of Harm Reduction Psychotherapy: Conceptual and Empirical Underpinnings/Support
In this model, substance use disorders are viewed as biopsychosocial phenomena, Treatment design, then, necessitates a sophisticated blend of research and clinical wisdom in many areas. There are several concepts that support the general principles of harm reduction and form the foundation for clinical treatment of alcohol and drug disorders.
The Continuum of Drug Use: Drug use is not necessarily progressive and a person’s use of each drug may be at a different point on this continuum. Recreational use and habitual use do not necessarily constitute a problem.
Drug, Set, and Setting: The effect that a person gets from drug use, and the harms that may be associated with it, is a combination of these three elements: Drug = the class of drug, its cut and the route of administration; Set = the person and her unique physiology, psychology, as well as motivation and expectation of drug effect; Setting = the environment in which the drug is used-alone or with others, in what context culturally. Set or setting may, in fact, be a larger contributor to drug effect than the drug action itself.
Motivational Interviewing (MI): Motivation is not a stable trait that exists in the person. MI redefines motivation as a flexible state existing within an interpersonal matrix. Increasing motivation to change and decreasing resistance is the job of both parties, but especially the therapist. We do not have to wait for someone to get motivated or hit bottom. The stereotype that drug users routinely lie about their drug use is based on our habit of punishing or shaming a person. As long as there are punitive sanctions in our practice for drug use, our patients will feel the need to lie to us.
The Stages of Change: Specific clinical interventions can be tailored to wherever the person is in this stage model. A major source of resistance comes from a therapeutic intervention that is not congruent with the stage the client is in. For example, for a client who is still ambivalent about quitting drinking (contemplation stage), suggesting that they “just give it a try” is a mismatch of technique and will likely increase resistance. This is true for any behavior, not just drug use (looking for work, starting an exercise program, etc.)!
The Decisional Balance-a list of the specific pros and cons of changing: People are not in denial about their drug use, they are ambivalent, and ambivalence is the work of psychotherapy, not an impediment to it. Both client and therapist need a clear picture of the potential gains and losses that might accrue to any change, because the treatment must focus on these specifics if the client has any chance of maintaining a change. Below is an example of a decisional balance. The therapist should pay close attention to the “con” side and resist the urge to overly reinforce the “pro” side.
Change My Drinking
It might help my hypertension & I can stop taking the medicine
I could lose some weight
Might have more energy
Would look better on dates – not so puffy.
I like to drink with my buddies. They’re the only ones I have and I’d be lonely.
I’d have trouble going to sleep
Not sure I could handle the withdrawal
A Hierarchy of Needs: People often come to treatment with pressing needs other than their drug use. They may need assistance with housing or financial planning, better child care, or medical care. They may need medications to treat severe depression or anxiety. Traditionally, if a person comes to drug treatment, these other needs go unattended or are seen as signs of resistance to treatment. In HRP, we develop this hierarchy with the client and actively help in securing what they need without linking it to changes in drug use.
Psychodynamic Model of Attachment: A person’s attachment style is often similar to their relationship to drug use. Doing HRP is often similar to doing couples therapy in that the relationship has to be understood both in terms of behaviors, but especially the meaning of the person’s relationship with drugs.
Affect Tolerance and Trauma: Psychodynamic theory and clinical experience indicate that one of the primary difficulties in people with significant drug problems is their early childhood experiences which led them to be easily overwhelmed by affect. Drugs provide a way to manage affect. Knowledge of the neurophysiology of early childhood and the relationship between these experiences and the development of brain reward centers is crucial to our understanding of the vulnerability to drug abuse.
The key mission of HRP is to start wherever the client is-and stay there. The first part may not be particularly difficult for a psychotherapist once they get used to not requiring abstinence as a condition of treatment. The hard part, though, is staying with the client as they navigate the difficulties of change. We can easy underestimate the effort required for a person to change and become impatient with their process. It is also hard to sit and watch a person make decisions that we know can be disastrous. It is harder still to see the damage their alcohol or drug use may be doing to others. Other than bona fide child endangerment, however, people do have the right to make their own decisions-even bad decisions-about how to live their lives. Our job is to hold on for the ride and to not become overly anxious or angry. Dealing with our own sense of powerlessness, anxiety, worry, or disgust, is the hardest part of doing this work. And it is the most crucial element of it. Regular consultation is a must for anyone conducting HRP.
This is a brief overview of the background for harm reduction psychotherapy. The model that I have developed is intended for use by psychotherapists and chemical dependency counselors. I planned it in such a way as to point out specific areas of attention and specific techniques that I think are essential in the work. In terms of ongoing treatment, clinicians are free to use their own particular theoretical orientations. In this way, each one of us can find a way of incorporating people with drug or alcohol problems into our practice.
Suggested Readings (see also part 1):
Denning, P. & Little, J. (2012). Practicing harm reduction psychotherapy (2nd Ed.). New York: Guilford.
Denning, P., Little, J,, & Glickman, A. (2004). Over the influence: The harm reduction guide to managing drugs and alcohol. New York: Guilford Press.
Patt Denning, PhD
Director of Clinical Services and Training
Harm Reduction Therapy Center
San Francisco and Oakland
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