So Glad You Came! Harm Reduction Therapy in Community Settings 

Jeannie Little and Perri Franskoviak 

Harm Reduction Therapy Center 

Harm reduction therapy was originally developed as a nonabstinence based method of treating people with drug and alcohol problems. In this article, we describe and apply the principles and practices of harm reduction therapy in community settings, places where people congregate for nontherapeutic reasons—street corners, community drop-in centers, needle exchanges, and primary care clinics. Low threshold welcome and flexible session arrangements are defining characteristics of this community-based approach. We have been instrumental in developing several programs, three of which are described here. These programs work with more than 1,000 clients per year, with varying levels of intensity. The programs offer drop-in or sidewalk sessions, drop-in support groups, regular therapy appoint ments, and psychiatric medications. Many impressive outcomes, such as reduction of harmful drug use, stabilization of psychiatric problems, and permanent housing, are found each year. & 2010 Wiley Periodicals, Inc. J Clin Psychol: In Session 66: 175–188, 2010. 

Keywords: harm reduction therapy; engagement; dual diagnosis; homeless; psychotherapy; mental health; substance abuse 

By the time I reached the bottom of the stairs, I had already heard the moaning coming from the bathroom at the back of the building. ‘‘I’ve been trying to help her out but she’s having trouble pulling herself together,’’ said Joe, one of the Community Center staff. That she needed something was his on the spot assessment, and I nodded, concurring with his judgment. I asked her name, but Joe didn’t know. She’s been coming in fairly regularly, he said, often in a state of chaos, but never this bad. 

After several more minutes, during which I introduced myself through the closed door, the door flew open, revealing a woman with wet hair, 

Correspondence concerning this article should be addressed to: Jeannie Little, Harm Reduction Therapy Center, 423 Gough Street, San Francisco, CA 94102; e-mail: jeanglittle@gmail.com 

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 66(2), 175–188 (2010) & 2010 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20673

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missing a front tooth, flinging herself against the walls and screaming ‘‘Don’t look at me, don’t look at me,’’ and then apologizing for her outburst in the next breath. A pair of wet pants lay crumpled on the floor. She picked them up only to throw them down, then picked them up again and lifted the hem of her flimsy, delicately flowered shirt to reveal her naked backside. 

I looked away as she screamed that she was moving as fast as she could, following this outburst with another apology. She pulled the pants up her legs in a series of jerky movements, and then flung her head back as she kicked first one leg then the other straight out in front of her. 

As I followed her through the Community Center, I wondered how I could get her to slow down long enough to speak with her. But talking was not on the agenda as she hurled herself out the front door and onto the sidewalk. She began flailing, her face contorting first into a grimace, then relaxing, and then crumpling into a worried frown. After a quick glance toward the oncoming traffic, she made her way across the street and into the corner market. I watched the erratic dance of her limbs as she crossed the threshold and disappeared into the store. 

How had this woman come to this moment in her life, here in San Francisco’s Tenderloin district, clutching a plastic bag of wet clothes and the crumpled pack of cigarettes that I’d picked up off the floor and handed to her as she left the center? Her brain was being propelled by a combination of chemicals, some no doubt endogenous, some ingested, that had created a war of impulses inside her. She’d be vulnerable on the street, a woman in a neighborhood where manipulation and violence are primary forms of interaction. It was no accident that she’d come to the Community Center, to a place where people reached out when she showed up, no matter what kind of state she was in. She knew, even if unconsciously, that she was welcome here. 

This vignette illustrates one of the fundamental principles of harm reduction in the community: Flexibility is the key to beginning a therapy relationship. This means meeting and engaging individuals on the street, in the waiting room, or outside a bathroom door to begin the process of developing a trusting relationship in which people can, over time, bring themselves to the therapeutic encounter and begin to see that relationship as a resource rather than an intrusion. This woman eventually became a client of the second author and has been in psychotherapy, steadily improving, for 3 years. 

Developed during the 1990’s by several practitioners (Denning, 1998, 2000; Little, 2001, 2002; Springer, 1991; Tatarsky, 1998, 2002) and a researcher (Marlatt, 1998), harm reduction therapy has grown over the last 18 years as an alternative approach to treating people with drug and alcohol problems. Harm reduction therapy is based on the understanding that drug and alcohol problems are multidetermined, and that each individual has a unique and idiosyncratic relationship with his or her drugs. Any resulting treatment should be entirely individualized, with a different course and different outcomes for each person. Harm reduction and harm reduction therapy principles of respect, collaboration, incremental client-driven change, and offering a menu of options for behavior change all support an individualized approach and especially support an approach that encourages clients to make their own decisions about whether to come or not come to treatment. 

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A unifying principle of harm reduction therapy is that drug users do not have to quit to reduce harm or to resolve their problems with drugs. Although it recognizes and supports abstinence as a worthy goal of treatment, it is not by any means the only goal, and it is only a legitimate goal if proposed by the client. The ultimate goal of harm reduction is not abstinence. At the risk of stating a redundancy, the goal of harm reduction is harm reduction! 

To date, with notable exceptions discussed below, harm reduction therapy has developed in clinics and therapy offices, settings that have a structured frame in which the therapeutic encounter takes place. We have been instrumental in developing several community-based programs that utilize harm reduction therapy to treat individuals with a dual diagnosis of mental illness and substance abuse. 

In this article, we describe an application of harm reduction therapy in three community settings where the Harm Reduction Therapy Center (HRTC) partners with two community-based organizations (CBO’s), whose mission is to serve homeless residents of San Francisco with a variety of community, social service, and healthcare programs. We will highlight the particular ways in which harm reduction therapy has been adapted beyond the therapy room to attract and engage alcohol and drug users in treatment, particularly those individuals, like the woman in the opening vignette, who have been overlooked and considered untreatable by most programs. 

Harm Reduction Therapy in Community-Based Settings 

We consider a community-based setting to be a place where people congregate that is not designated as a formal therapy office, mental health clinic, or drug or alcohol treatment program. It may be a public health or any helping setting that belongs to the community of people in which it is located and/or is significantly driven by the needs of that community. Public health settings include medical clinics, outreach programs, needle exchanges, and HIV, hepatitis, and STD prevention programs. Helping settings include drop-in centers, community centers, housing with colocated support services, food pantries, and employment resource centers. 

Our programs are not the only ones in the United States that have developed and documented harm reduction programs that include mental health treatment. The harm reduction groups at the VA’s Comprehensive Homeless Program in San Francisco began as dual diagnosis treatment and support groups (Little, 2002). The New York Harm Reduction Educators and St. Ann’s Corner of Harm Reduction began as syringe exchange programs in 1990. Through the years, they’ve all developed a full spectrum of public health and psychosocial support, focused on disease prevention, mental health, and ‘‘recovery’’ from the worst ravages of drug abuse, illness, and homelessness (Majoor & Rivera, 2003; Rogers & Ruefli, 2004). 

The Harm Reduction Therapy Center 

The Harm Reduction Therapy Center (HRTC) operates seven community-based programs, all in partnership with CBO’s that serve homeless and/or low-income or indigent people. Three of these programs are located in the Tenderloin and the Sixth Street corridor, two neighborhoods adjacent to one another in the central city of San Francisco. These two neighborhoods contain the greatest number of single-room occupancy hotels (SRO’s)—residential hotels that were once respectable but slowly decaying dwellings, providing a home for itinerant workers, musicians, artists, and in the 1960s, for those residents who were displaced by San Francisco’s program of 

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urban renewal. Later, as the mental hospitals were emptied and inmates were released from prison, those who were discharged found these places to be affordable places in which to live. 

Today, these same hotels, and the neighborhoods that contain them, are home to many of the city’s most marginalized residents. They are home to the highest concentration of mental illness, drug abuse, and dual diagnosis in San Francisco. The Tenderloin neighborhood holds 10% of the city’s population but has 46% of the homeless within its bounds (U.S. Census, 2000). Although the fastest growing groups in the Tenderloin are Latinos and Asian/Pacific Islander individuals, the homeless or unstably housed adults in the Tenderloin are more likely to be African American men (San Francisco Digital Library). Above all, they are all poor. The number of Tenderloin residents living in poverty is 27.4% compared to 11.3% of residents in the whole of San Francisco (U.S. Census, 2000). 

HRTC’s longest running community-based program is located at Tenderloin Health. Funded largely by the San Francisco Department of Public Health, Tenderloin Health provides a variety of medical and social services to extremely low income individuals who are homeless or marginally housed and who have comorbid psychiatric, substance abuse, HIV, and other medical illnesses. Tenderloin Health houses a large homeless HIV clinic, with which HRTC partners. Tenderloin Health serves approximately 6,000 clients per year in its multiple programs. HRTC had been providing clinical consultation to Tenderloin Health’s staff and in 2003, began treatment services for clients. 

HRTC has steadily developed its treatment services at Central City Hospitality House, San Francisco’s oldest continuously operating drop-in center since 2005. In operation for more than 40 years, Hospitality House prides itself on being a peer based agency whose mission is to build community and to empower its participants to become more self-supporting and to lead healthy and productive lives. The programming at Hospitality House focuses on providing basic services, such as access to bathrooms, the telephone, a bed in a shelter, and a place to sit and get a cup of coffee. Hospitality House also operates an employment center, an art studio, and a shelter. Hospitality House sees more than 20,000 people per year at its two sites. 

HRTC’s programs serve adults who, although they might have partners, running buddies, and associates, are by and large disconnected from family or social and economic structures within which the majority of Americans function. We think of these individuals as exquisitely complex, as they present a multiplicity of priorities, both for themselves and for the therapists working with them. Our attempts to refer clients to other mental health or substance abuse programs, and the clients’ previous attempts at treatment, have been largely unsuccessful. Many of these individuals are unable to meet the high threshold requirements of other clinics, such as sitting quietly in a clinic waiting room, having the attention span or comprehension skills to fill out intake paperwork, or possessing the trust to enter an office with a staff person with the door closed. HRTC requires none of these things; HRTC expressly developed its community-based programs to enable people to receive mental health and substance abuse treatment without having to satisfy any program criteria. 

A total of 1,100 individuals were seen at the three programs over the last year. One third of the individuals seen are African American, just under half are white, 8% are Latino, 8% identify as ‘‘other’’ with very small numbers of Native Americans, Asians, and Pacific Islanders. Women comprise less than a quarter of the individuals presenting across all three sites, while men make up almost three quarters. Three and a half percent identified themselves as transgender, although this number is much 

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higher (6%) at Tenderloin Health, which has made an effort to attract transgender residents, the majority of whom are African-American transgender women. This outreach has been quite beneficial to bringing some of the city’s most marginalized citizens into care, as African-American transgender women have the highest rate of HIV infection and new infection in San Francisco. Like biological women in the Tenderloin, transgender women are also more vulnerable to experiencing violence (Heslin et al., 2007; Lombardi et al., 2001). Some transgender women, like their biological counterparts in the Tenderloin, also engage in survival sex, making them more easily exploited and subject to violence in the midst of these transactions. 

HRTC’s clients have a range of Axis I and II disorders: one quarter of them have been diagnosed with schizophrenia or other psychotic disorders, one third have major depression or other mood disorder, 11% meet criteria for bipolar disorder, and 17% have posttraumatic stress disorder. In addition, 21% meet criteria for a personality disorder and 76% are diagnosed with one or more mental illnesses and one or more substance use disorders. Despite only 17% having a formal diagnosis of PTSD, almost all have histories of personal trauma: almost 100% have histories of institutional trauma in foster care and the criminal justice system, 100% have experiences of racism and poverty, 100% live in neighborhoods that have high levels of violence and abuse. Finally, many of the adults that we see also have medical comorbidities, including hypertension, asthma, HIV, hepatitis C, and soft tissue infections, which are woefully undertreated. Many deal with chronic pain, and most have had at least one trip to the county hospital emergency room in the past year. 

Fundamental Principles of Community Harm Reduction therapy Low Threshold 

A fundamental characteristic of community-based treatment is that the frame of the treatment is informed by the needs of the members of the community in which the program is located. In a community whose members are dealing with survival needs, such as finding a place to sleep for the night or getting something to eat, a program that required appointments to access its resources would not be an example of community-based treatment. Such a program might fit in a community whose members have access to instrumental needs such as food, clothing, and shelter, but its high threshold would be a barrier in a community whose members struggle to meet those needs on a daily basis. 

Before HRTC begins to set up a new community program, we spend time observing participants in the settings where our programs are colocated, watching how the staff interact with participants, noting participants’ functioning, needs, and capacity to use resources. This allows us to mindfully create a treatment structure that maximizes access by minimizing requirements for both the client and the clinician. Clients do not need to fill out paperwork to initiate a treatment relationship with our programs, and our documentation database is designed in such a way so as to streamline the input of information for the therapist. 

Creating a low threshold means offering as many points of entry as possible so that community members can choose how they may access services. Providing an array of options for engagement, from brief encounters on the sidewalk to individual sessions with a therapist to drop-in group participation, gives participants a choice about how they would like to engage. All services are offered on a drop-in basis so 

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that clients can move in and out or vary the intensity of treatment, depending upon their needs. In other words, they can regulate the ‘‘dosage’’ of treatment in the same way that they dose themselves with their drugs (Little, 2002). 

Creating a menu of voluntary options and a treatment system that can be managed by each client, including whether to show up or not on a given day, is a powerful way to communicate that we acknowledge the inherent autonomy of the people who come to us, and our willingness to engage with them wherever they are. Autonomy is the expression of one’s authorship of one’s own actions (Ryan & Deci, 2000). It is one of the three components, along with relationships and a sense of competence, that support self-determination, which is, in turn, correlated with well being and health. 

Integrated 

Just as most harm reduction therapy is integrated, so is HRTC’s treatment. We pay equal attention to drug problems, mental illness, and other psychosocial problems. It is the client’s hierarchy of needs that determine the focus of therapy on any given day. Our programs are staffed by psychotherapists, psychiatrists, psychiatric nurse practitioners, and addiction medicine specialists, and our partner agencies offer case management and peer counseling. We work seamlessly as multidisciplinary teams that are able to provide the client whatever he or she needs—medication, counseling, a housing referral, accompaniment to an appointment, a support group. Finally, HRTC integrates several therapeutic approaches: motivational interviewing (Miller & Rollnick, 2002), cognitive-behavioral skills training (stress reduction, mindfulness, substance use management (Bigg, 2001), life coaching (money management, nutrition, other life skills), and nonverbal approaches such as drumming (Schultz, 2006) and somatic experiencing (Levine, 1997). All of these approaches and interventions take place in a context of relational psychodynamic therapy (Rothschild, 2007) and of modern analytic processes of emotional communication and joining (relational alternatives to analytic interpretation; Ormont, 1992) that recognize the primacy of transference and countertransference and that values the relationship as the primary therapeutic tool. 

Takes Into Account the Impact of Past Experiences on the Present 

Each client has both a real and a transferential relationship with his or her therapist, with HRTC, and with the context in which our programs are held. The real relationship is based on the actual encounters each client has with staff and structures. How accommodating is the schedule? How accessible are the rooms? Are they decorated with comfort and warmth in mind? Does the staff greet prospective clients with a big smile and a warm welcome or with a rote ‘‘What do you need today?’’ Is the staff interested and curious or anxious to get on with the business of the encounter? These factors, and many more, trigger responses in each client and influence the subsequent course of the work. 

Each client also approaches the agency and its staff with expectations. These expectations are formed by prior experiences of treatment at the hands of other institutions, social service agencies, and treatment programs. Given the clients’ multiple problems, and given that most have been in the foster care and/or criminal justice system, these experiences have been largely negative. The job of the harm reduction therapist (and others) is to undo negative expectations by repeatedly 

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expressing welcoming affect, making affirming statements, and offering a respectful and collaborative relationship. 

Trauma Informed 

Because so many of HRTC’s clients have histories of personal and institutional trauma, and their lives are fraught with danger now, harm reduction therapy in community-based settings must be trauma-informed. Important elements of trauma include coercion, intrusion, loss of control, powerlessness, loss of trust, often an element of surprise, and physical and emotional attacks. Trauma survivors have great difficulty developing trust. They are hypervigilant. They doubt the safety of their surroundings. Enormous numbers of trauma survivors abuse alcohol and drugs (Goetz, 2001; Little, 2006). 

Program structures and therapist expectations must avoid replicating any of the above characteristics. HRTC’s drop-in programs give people the freedom to learn to set their own boundaries, which is essential to recovery from trauma. Our fidelity to the stages of change (Prochaska, DiClemente, & Norcross, 1992), whereby we honor the wisdom and experience of the client and do not impose our expectations on clients, allows for a profoundly non-coercive treatment experience. 

Welcomes People in Crisis Who Present Difficult Behaviors 

The harm reduction therapist, if practicing truly client-centered treatment, is called upon to tolerate and to understand all behavior rather than to control it. We adapt treatment to the client, rather than the reverse. Our clients, being predominantly homeless, bring a lot of difficulty with them. They carry with them their belongings, which harbor bugs that sometimes crawl into our offices. They are unkempt, their hygiene is poor, and crowded group rooms can be intensely smelly. They have been known to defecate on the floor if they can’t get to a bathroom. If intoxicated or actively psychotic or just plain angry, they shout and sometimes even threaten the therapist. 

Under the guise of creating ‘‘safety’’ for both clients and staff, programs frequently create rules and systems to prohibit these and many other ‘‘disruptive’’ behaviors. Often this is more about staff comfort than actual safety. The harm reduction therapist’s job is to explore behavior and to reframe it as understandable, even adaptive. Our job is to believe that behaviors are expressions of our clients’ lives. Although we do not allow anyone to be hurt (and so far no one has been) and we do have express rules against physical assault or threats, we emphasize defusing situations by exploring the underlying problem rather than prohibiting the behavior. For example, when ‘‘Dude’’ starts shouting in group and insisting that he must use the copy machine for his drawings (if unstopped he will make hundreds of copies!), the therapist intervenes by saying, ‘‘Dude, you must be so mad at me. Tell me what I did to make you so mad.’’ In this way, we also draw clients’ anger toward us rather than let it be expressed toward other clients, where it might do someone harm. 

At some point, most of our clients have crises. All staff are trained in crisis evaluation and are authorized to commit clients to an involuntary hold if absolutely necessary, which it is not often. Crisis prevention is our priority; however, because emergency hospitalization is rarely therapeutic and is often traumatizing, we might spend hours talking with and settling a client who is in crisis to avert a dangerous situation. Of the 1,100 clients that HRTC worked with in the past year, we hospitalized 25. 

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Community Treatment at HRTC 

How are these fundamental principles implemented in community settings? The most important ingredient of harm reduction therapy is the therapist’s attitude: implementing harm reduction therapy in community requires, first and foremost, the practice of radical acceptance. 

Relationship 

Above all, we view everything that we do as treatment, from the briefest hello to an ongoing therapy relationship. We view all interactions as in the service of building and maintaining the therapeutic relationship, knowing that relationship is the key to all behavior change. We build relationships by providing the space and time for people to move toward us or for people to invite us to move toward them in their time, not ours. We practice radical inclusion of all people, and all behaviors that they bring into our programs. We understand that behavior serves a purpose, and despite sometimes self-destructive aspects, it communicates essential information about a person’s history, feelings, and response to the present environment. We cultivate the ability to listen and be present with what Freud called ‘‘equally hovering attention’’ to the needs and agenda of the client, as well as to the thoughts and feelings that are generated in us when we interact with them. Finally, we practice neutrality: putting our own wishes and agenda(s) aside in favor of discovering and exploring the client’s. We constantly remind ourselves, ‘‘Whose life is it anyway?’’ 

Engagement 

Treatment begins with an encounter. At HRTC, we have created a model of engagement that is tailored to each individual’s capacity for interaction, and moves at a pace that feels comfortable to him or her. We walk around the agencies in which our programs are located, greeting folks, smiling, making eye contact when invited, and stopping to chat when it seems clear that someone has something to say. For some, we may spend months saying hello on the sidewalk outside the drop-in center, or perhaps offering a daily cup of coffee to a person sitting alone in the midst the agency’s drop-in center. For others, outreach might mean asking permission to sit with them as they wait to see the doctor to have an abscess treated, letting them come forward, listening closely to what they want to share, and expressing interest in hearing more, so that treatment becomes a conversation, and not an appointment or a session, with the expectation inherent in those contacts. 

We work with the staff at our host agencies, making ourselves available for consultation if there are clients with whom they don’t know how to work. We assist in de-escalating stressful, chaotic, or emergency situations. We also offer daily drop in group and advertise them by walking around the agency and announcing each group, answering any questions that folks might have about what happens in a harm reduction drop-in group. 

Our best publicity is word of mouth. Lenny mentions to his running buddy Cowboy that he’s been going to a drop-in group where there’s coffee and people can talk freely about their drinking and using and whatever else is on their mind. No one tells them what to do. Pretty soon Cowboy starts to show up, as does Sandra, who goes everywhere that Cowboy goes. Sean drops by and says he doesn’t like groups, but he’d like to talk to a therapist alone. In this way, HRTC’s five therapists and two part-time psychiatric and addiction medicine staff saw 1,100 clients in the last year. 

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Drop-In Groups 

We offer what we call harm reduction drop-in groups, 12 per week across the three programs. These groups are an hour in length, and participants are invited to come whenever they’d like and for as long as they’d like. No one is ever late to a drop-in group. Group members may talk about their relationship to their drugs, or they may talk about what it’s like to be homeless, or how hard it is to be out of touch with their children. The group therapist works to make everyone feel welcome, which is often challenging when you’ve got Joe in the corner muttering under his breath in response to the voices in his head, Esther shrinking back into her chair wishing she could disappear, and Monty who just walked into the room is high-fiving some of his friends, all the while Bruce is talking about the devastating recent loss of his mother. We manage to maintain this level of diversity most of the time, with as many as 20 people attending each group (in rooms that are generally comfortable for only 10), coming and going, standing, and sitting on the floor. In the words of one participant, ‘‘This is the only group where you can think what you want and say what you want and you’re always accepted.’’ Of the 1,100 people who sought out HRTC last year, only 300 attended groups. 

Assessment 

Harm reduction therapy is an interdependent system, continually generating feedback that both our clients and we use to modify our ongoing interactions and the treatment goals. Denning (2000) has described this phenomenon as ‘‘assessment as treatment’’: the therapist’s continual curiosity, observation, and inquiry into the client’s experience, past and present, that never stops throughout the course of treatment. We typically conduct a formal assessment over a long period of time. Some clients prefer a formal interview that occurs over a few sessions; others cannot tolerate formal questioning and we gather information organically as we get to know them. We offer our insights and recommendations to clients, but only after we have gotten their permission to do so. We also pay attention to body language and the way people hold themselves and move, as many do not yet have words for the experiences they have undergone. We do not engage in the gathering of collateral information that is so common to other substance abuse programs. Only if a client expressly wishes it do we meet with and gather information from spouses, partners, parents, children, friends or other loved ones, and only then with the client present. 

Individual Therapy 

Approximately two thirds of clients come on drop-in basis and sessions last for a few minutes every day or perhaps a half an hour a couple of times a week. Sometimes these encounters occur with the door open, as the level of suspicion and fear that a person holds inside may need many moments of building trust. Others may never step into the treatment room. Treatment for them takes place on the sidewalk, in the hallways between the bathroom, and the clinic rooms. These sessions often focus on current crises and involve evaluation, problem solving, and de-escalation. Sometimes the focus is light conversation or banter as clients get to know the therapist. 

Harm reduction therapy in community settings usually involves at least some mental health case management, most often Social Security reports and advocacy. This service is critical, as many of the individuals we see in both sites are unable to 

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follow the structure of appointments and exams that typically are required in support of obtaining benefits. 

Eventually, some clients (about a third at any point in time) move from drop-in visits to regular appointments. When this happens, and clients have access to one or two regular individual therapy sessions per week, the therapy tends to deepen and becomes focused on earlier life trauma and its relationship to present drug use and other behaviors and circumstances—relationship status, relationships with children, health, criminal activity, violence (either as victim or perpetrator), housing, and the many other life issues that we all contend with as adults. Although the sessions are usually less crisis-ridden and more predictable, they are intense and often painful for both client and therapist—these are among the hardest lives in America. 

Medication Evaluation and Monitoring 

HRTC’s community programs offer medication evaluation and management for both psychiatric and addictive disorders. HRTC is a site for San Francisco’s Office-Based Opiate Treatment program, providing buprenorphine and group and individual counseling for opiate-dependent individuals. The psychiatric and addiction medicine staff prescribes psychotropic medications to people who are active drug users. To date, we have observed no dangerous interactions. Our harm reduction values— particularly that drug users can get better without having to quit—inform our desire to provide symptom relief with medications in the hope that this will support change in drug use. 

Case Illustrations 

The stories of four clients who have worked with HRTC at Tenderloin Health and Hospitality House are described as follows. 

Karen 

Karen is a 68-year-old Caucasian native San Franciscan. She suffers from schizophrenia. Most of her life she has been in state hospitals, board and care homes, and acute diversion units. She spent more than 10 years living on the streets in the Tenderloin after running away from a group home; it was here that Karen was introduced to crack and experienced exploitation and abuse as many people took advantage of her kindness and lack of personal boundaries. 

Eight months ago, Karen began coming to the Sixth Street Self-Help Center, which is only a few doors down from the SRO she calls ‘‘home.’’ The center is open from 9–5, and Karen is generally the first one in and the last to leave. Because of her paranoia, Karen can’t tolerate large crowds and avoids many of the larger agencies where people eat and receive services. When she started coming to the Self-Help Center, she was receiving services through a community mental health agency on the other side of town. Because she frequently presented with lice and bed bugs, she was asked to not participate in the ‘‘socialization room’’ there, and so her main interactions with other people involved hanging out on Sixth Street, which is a haven for drinkers and crack smokers. Most days she comes to the Sixth Street Self-Help Center, attends the drop-in harm reduction group, and checks in briefly with her therapist. It is through this relationship that her therapist is able to work with Karen in small doses. 

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Karen has made great strides in the last 8 months. Although she still smokes crack, she has remained bug free and her hygiene is good most days. She has made friends since coming to the Center, especially in the harm reduction group. Her case manager from another agency reports that Karen is doing the best she has ever seen in many years of working with her, and contributes this to Karen coming in for treatment. Karen reports, ‘‘I’m feeling the best I have in 20 years!’’ 

Jorge 

Jorge is a 23-year-old Salvadoran American male who was referred to HRTC at Tenderloin Health in 2006 for help with anxiety and opiate addiction. Jorge began work with an individual therapist after approximately a 3-month engagement period, during which time his therapist provided mostly crisis management services to him. Once he developed trust with his therapist and had stable housing, he began to attend regular sessions. During therapy, it became clear that Jorge not only was struggling with depression, anxiety, and opiate addiction, he also had a history of severe childhood trauma and a problem with crack. His therapist diagnosed him with PTSD. 

Homeless for 4 years after a brief stint in college, Jorge worked as a sex worker to help finance his drug use. He had become dependent on heroin, which he reports worked well to contain his severe anxiety as a teenager. He suffered severe head injury and multiple traumas, including assaults, during his homeless years. Jorge credits books with giving him relief during this time. He reports that even when he had no place to stay or keep his things, he always had a book. 

Currently, Jorge is on opiate replacement therapy in HRTC’s Office-Based Opiate Treatment program and is largely managing his drug use well. He sees his therapist weekly, takes all his psychiatric medications, has been approved for social security, and has begun an internship program in social services. He continues to struggle with relationships, he reverts to out of control drug use occasionally, and his traumatic past haunts his waking life and his dreams. He reports, however, ‘‘if you asked me four years ago if I’d ever have a job, I’d have laughed you outta there. Now, everything isn’t a crisis anymore, and I’m doing ok.’’ 

Ethel 

Ethel is a 44-year-old African-American woman who approached HRTC staff while waiting to see her medical doctor. Ethel has HIV, as well as schizophrenia and a crack problem. She is also legally blind. Although she requested ‘‘some time to talk talk’’ with a therapist, she had difficulty making it in until she found out that the therapist had candy in her office. Ethel loves candy. And fried chicken. 

Ethel has been homeless for many years, likely since her first psychotic symptoms surfaced. She is playful, engaging, and usually talks about things that make her happy. It can be hard to understand Ethel as she sometimes speaks in garbled sentences; she can tolerate only short visits before leaving her therapist’s office. Because she is so disorganized, she is not able to make appointments or follow through with securing income or health insurance to pay for needed medicines. She is in and out of jail due to her crack use and to multiple thefts to support her habit. 

Ethel displays many symptoms of having lived through traumatic events—she is often inappropriately sexual, rageful, and quick to fight and yell. She says she has a hard time sleeping by herself and that ‘‘sometimes I can’t forget thingsyI want to forget.’’ 

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Engagement is ongoing for Ethel: every time she is released from jail, the process of engaging her and helping her manage her many needs begins again. 

Dude 

‘‘Dude,’’ as he calls himself, is a 37-year-old African-American man who presented to HRTC during a drop-in support group for those who want to talk (or not!) about drugs. He brought with him three well-worn bags of belongings, sat down, and began talking to himself. That was 18 months ago. Dude has been a regular group member ever since. Occasionally he is willing to meet individually, but he says ‘‘I like the classes. They are my sociology.’’ 

Dude is a musician and professional wanderer who was adopted by a San Francisco family and raised here. He attended college and consistently shares his love of learning with the group. Dude also suffers from schizophrenia. He is disorganized and smelly, and other group members find it hard to understand him. He often communicates through drawings, which he calls ‘‘chess games’’ and gives these to other group members. 

Due to his paranoia and difficulty being around others, Dude has made a life of avoiding services. Although he has been approved for Supplemental Security Income (benefits, his disorganization has made it almost impossible for him to secure the required payee. At this point, he has been unwilling for the group leader to assist him with his money, homelessness, or other primary needs, always saying, ‘‘I’m gonna be hitchhiking out of here tomorrow anyways.’’ 

Outcomes 

Although HRTC does not conduct formal outcome research in our community programs at this time, we do maintain electronic recordkeeping systems that allow us to track client progress. Over the past year, many people who have engaged in treatment in HRTC’s community programs have gotten much healthier. Approxi mately one-third attend regularly scheduled appointments, the rest see a therapist for at least brief encounters, and more than half attend drop-in groups regularly. At the time of writing, about 60% are successfully managing their substance use, 50% no longer present in crisis, 70% have more stable mental health, 60% are taking psychiatric medications, and 60% are more stable in housing. 

We also consider the care of our therapists a critical ‘‘outcome’’ of our program. Therapists must embody flexibility and responsiveness to 100 different crises and stories in any given day. Just as the harm reduction therapist prioritizes the development of the therapeutic relationship, the same is true for supervisors supporting harm reduction therapists as they offer their full attention to the many participants in our community-based programs. Therapists receive individual clinical supervision and administrative supervision and support from onsite program coordinators each week. Team meetings take place weekly and are used in part to check in and support staff. HRTC’s therapists also participate in weekly program meetings and case conferences convened by each host agency. All staff in their first two years attend weekly in-service training and group supervision, and all HRTC therapists take part in a monthly supervision group on group psychotherapy. Finally, we support staff in seeking out additional training to enrich their work, support professional growth, stimulate continued interest in our clients, and support career growth. 

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At HRTC, therapists are expected to absorb what their clients share and not act unless the client is in imminent danger. Because of the intensity of the material that therapists hold, an important focus of supervision is on identifying counter transference responses to clients, and how those thoughts, feelings, and sensations in the body can be understood as information about the client as well as about our own development as therapists and ability to manage difficult clients. We highlight the importance of self-reflection and processing the work in supervision. We believe that it is not so much a lack of technical expertise that impedes work with complex clients, but rather countertransference, which needs to be continually studied and brought into greater awareness. Finally, we pay attention to signs of burnout and vicarious traumatization, and encourage time off and other self-care activities. 

Clinical Issues and Summary 

We believe that harm reduction therapy is crucial to the care of dually diagnosed individuals, particularly those who are homeless, poor, and otherwise relegated to the fringes of American society. For two decades, case management has grown as the ‘‘treatment’’ of choice for community mental health patients. Although enormously helpful and harm reducing, it is not psychotherapy. Case management does not allow the time or space for people to sit with no other goal than to talk about the horrors of their pasts, the difficulties of day-to-day life, their dreams and hopes, and their relationship with drugs and alcohol. Harm reduction therapy does all of these things. It encourages people to explore their relationships with drugs, with depression, anxiety, or internal voices, with other people, with their pasts, and with their futures. It facilitates gradual behavior change using many techniques: motivational interviewing, substance use management, and relational psychother apy. Harm reduction therapy is the lowest threshold and most comprehensive treatment for working with the most complex individuals in the country. It is our hope that this article will inspire others to adopt the fundamental principles and treatment methods of harm reduction therapy in community settings. 

Selected References and Recommended Readings 

Bigg, D. (2001). Substance use management. Journal of Psychoactive Drugs, 33(1), 33–38. Denning, P. (1998). Therapeutic interventions for people with substance abuse, HIV, and personality disorders: Harm reduction as a unifying approach. In Session: Psychotherapy in Practice, 4(1), 37–52. 

Denning, P. (2000). Practicing harm reduction psychotherapy: An alternative approach to addictions. New York: Guilford. 

Denning, P., Little, J., & Glickman, A. (2004). Over the influence: The harm reduction guide for managing drugs and alcohol. New York: Guilford. 

Goetz, P. (2001). Trauma and alcohol use. Retrieved August 1, 2009, from www. petergoetzmft.com 

Heslin, K.C., Robinson, P.L., Baker, R.S., & Gelberg, L. (2007). Community characteristics and violence against women in Los Angeles County. Journal of Health Care for the Poor and Underserved, 18(1), 203–218. 

Levine, P. (1997). Waking the tiger: Healing trauma. New York: Random House. Little, J. (2001). Treatment of dually diagnosed clients. Journal of Psychoactive Drugs, 33(1), 27–31. 

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Little, J. (2002). The sobriety support group: A harm reduction group for dually diagnosed adults. In A. Tatarsky (Ed.), Harm reduction psychotherapy: A new treatment for drug and alcohol problems. New Jersey: Jason Aronson. 

Little, J. (2006). Why harm reduction therapy? Trauma, oppression, and self-determination. Presentation at the 1st National Harm Reduction Therapy Conference, Seattle, Washington, May 2006. 

Lombardi, E.L., Wilchins, R.A., Priesing, D., & Malouf, D. (2001). Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality, 42(1), 89–101. 

Majoor, B., & Rivera, J. (2003). SACHRL An example of an integrated, harm reduction drug treatment program. Journal of Substance Abuse Treatment, 25, 257–262. Marlatt, G.A. (1998). Harm reduction: Pragmatic strategies for managing highrisk behaviors. New York: Guilford. 

Marlatt, G.A., & Tapert, S.F. (1993). Harm reduction: Reducing the risks of addictive behaviors. In J.S. Baer, G.A. Marlatt, & R.J. McMahon (Eds.), Addictive behaviors across the lifespan: Prevention, treatment and policy issues. Thousand Oaks, CA: Sage Publications. 

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford. 

Ormont, L. (1992). The group therapy experience: From theory to practice. New York: St. Martin’s Press. 

Rogers, S.J., & Ruefli, T. (2004). Does harm reduction programming make a difference in the lives of highly marginalized, at-risk drug users? Harm Reduction Journal, 1(7). Online: www.harmreductionjournal.com 

Rothschild, D. (2007). Bringing the pieces together: Relational Psychoanalysis and harm reduction therapy in treatment with substance abusers. Psychoanalytic Perspectives, 5(1), 69–94. 

Ryan, R.M., & Deci, E.L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. San Francisco Digital Library, http://shapingsf.ctyme.com 

Schultz, S. (2006). Drumming as a healing tool for working with African Americans in a therapeutic setting. Unpublished manuscript presented to John F. Kennedy University. Springer, E. (1991). Effective AIDS prevention with active drug users: The harm reduction 

model. In M. Shernoff (Ed.), Counseling chemically dependent people with HIV illness (pp. 141–158). New York: Harrington Park Press. 

Tatarsky, A. (1998). An integrated approach to harm reduction psychotherapy: A case of problem drinking secondary to depression. In session: Psychotherapy in Practice, 4(1), 9–24. 

Tatarsky, A. (2002). Harm reduction psychotherapy: A new approach to treating drug and alcohol problems. New Jersey: Jason Aronson. 

Journal of Clinical Psychology DOI: 10.1002/jclp