What is Harm Reduction? How is it Different from Traditional Addiction Treatment?
Journey to Harm Reduction: Facilitator and Member
Harm Reduction is an alternative treatment approach, and often thought of as radical. Harm Reduction does make some assumptions and operates on a belief system. What are these? In general, Harm Reduction assumes that clinicians can work with clients who are actively using substances, and that those clients can make positive changes in their lives regardless of their current relationship with substances. In fact, there is a spectrum of use in Harm Reduction, which covers anything from abstinence to chaotic use. In Harm Reduction, we believe that any client can improve their life no matter where they fall in the spectrum of use.
Why is Harm Reduction important? This belief is seen as radical because it goes against many of the principles of the dominant “Disease Model” of A.A.ddiction that is taught in the majority of substance use treatment centers. In the Disease Model, substance use must stop completely before any therapeutic benefit can be reached. In the Disease Model, it is assumed that all of the client’s problems stem from their substance use. Therefore, if the client stops using substances, their life will improve. Harm Reduction acknowledges that life’s problems and substance use can be independent. Since they are independent,it is possible to work on goals without necessarily changing the relationship with substances.
In this article, I will discuss the implementation of Harm Reduction in a group setting. I will write about how I became a true believer in Harm Reduction and started a Harm Reduction group in a supportive housing building in San Francisco.
My First Abstinence Based Group
After I left residential treatment in 2007 I was back to active drug use within a month. It was a huge disappointment for myself and my family, especially considering that my family paid over $10,000 to send me to residential treatment. My mother was considering selling her car to send me back to residential treatment, so I thought that I should try outpatient treatment first.
The outpatient program was at a major hospital in the city that I lived. It was three nights a week for a few hours at a time. It was made clear, in the beginning, that the program was abstinence based; meaning that they expected me to abstain from all mind altering substances (except for nicotine and caffeine, of course). Not only was I expected to abstain from substances, but if I did use a substance I couldn’t come to group within 24 hours of the last time I used.
I found not using drugs to be extremely difficult to accomplish. It’s ironic to require people who are seeking substance treatment, presumably because they can’t stop using substances, to abstain from substances before entering a therapy group. I continued to use substances during my short time in that program. With the consequences of being asked to leave the group, or being sentenced to more intensive treatment, I kept my relapses a secret and lied about my sobriety date. Obviously lying my way through treatment did little good for my immediate mental health.
Do I Really Have to Stop Using?
Again, with my mother considering selling her car, to pay for the exact same residential treatment that had just previously failed., I thought that I had one last option––12-Step meetings. I availed myself a sponsor before the meeting even started. After the meeting, he gave me very clear instructions. He told me that, if I didn’t use drugs that night or the next morning, I was to call him and he would take me to a 12-Step meeting. What he said next was unfamiliar; he said that if I DID use that night or the next morning, I was to call him and he would take me to a 12-Step meeting.
You mean to tell me that I don’t even have to stop using drugs to be a member of a 12-Step Group? This system was so much easier than the clinical treatment that I was used to. In 12-Step programs the only consequence to using drugs is getting loaded; a punishment that is far greater than any sanction given by a counselor.
Are 12-Step Programs Harm Reduction?
So, are 12-Step programs Harm Reduction? – Unfortunately not, technically.
There is only one reason, although it’s a significant one, that 12-Step programs are not Harm Reduction; which is because of something that we call the third tradition. This tradition states that the only requirement for 12-Step membership is a desire to STOP using drugs. It is that one word, stop, that makes the 12-Steps rooted in abstinence based ideology, and not Harm Reduction. To be a member of a 12-Step group, according to the third tradition, there is the assumption that the person’s ultimate goal is to be abstinent, as opposed to a desire to change, cutback, maintain, or reduce harm.
Other than that one substantial obstacle, I believe that everything else in the 12-Steps is very much in the spirit of Harm Reduction; at least it was meant to be in its conception. Alcoholics Anonymous was the original 12-Step group and its founders were the ones who wrote the 12-Steps. In A.A. literature, its authors advise drinkers to try some controlled drinking before attempting the drastic program of abstinence. Also, A.A.’s founders advised its members, throughout their writings, to treat the alcoholic with tolerance and respect which are foundational principles in Harm Reduction.
Although the founding principles of A.A. were in the spirit of Harm Reduction, there is scant evidence of a Harm Reduction foundation still visible in the culture of A.A. today. Abstinence of all substances, not just alcohol, is the “way or the highway” as far as many A.A. members are concerned. The definition of sobriety now includes all mind altering substances. This was definitely not the same concept of sobriety that A.A.’s founders believed, especially since Bill Wilson, A.A.’s cofounder, took LSD in the 1950s and didn’t change his sobriety date.
I believe that the disappearance of Harm Reduction in A.A. has followed the degeneration of their primary purpose and the integration of clinical treatment in A.A. meetings. The primary purpose of A.A., the fifth tradition, states that alcohol is the only substance that the program deals with. Far from being all substance inclusive, early A.A. only concerned itself with alcohol; defining sobriety as abstinence from alcohol only. This is ostensibly still true in theory but not in practice. This is because the ideology of “a drug is a drug, is a drug,” that clinical treatment centers propagate, has flooded into A.A.; washing away any hope of ever having a modified Harm Reduction paradigm.
My Introduction to Harm Reduction
After working in an abstinence based treatment program for seven years, I became disenchanted with The Disease Model of addiction. I left the field of addiction treatment to pursue a master’s degree in social work. Ironically, I went back to school to get out of substance use treatment, but in my first year of graduate school I was introduced to Harm Reduction and this has rekindled my passion for working within Substance Use Treatment.
Before graduate school I had only thought of Harm Reduction as methadone treatment and needle exchanges. The idea that substance users could be worked with clinically while they still used substances was a completely new concept to me. In that first year of my MSW program I had the privilege to intern at a supportive housing building in San Francisco. Supportive housing operates on a housing first paradigm, where basically people are housed as the first stage of their treatment. Once housed, social services attempt to use interventions on other aspects of life such as substance use.
During the time that I spent working in supportive housing, I saw things that directly contradicted every truth that I had come to believe about drug use. In supportive housing I was working with people who met the criteria for Substance Use Disorder, but they were still able to maintain their lives. In The Disease Model, I learned that addiction is chronic and progressive; meaning that it only get worse, never better. What I saw directly contradicted this theory.
Here I observed people who had been maintaining stagnant relationships with substances for many years and even decades. Their patterns of use did not always get worse over time; instead they went through cycles and even decreased over time. The cyclical nature of substance use usually negatively correlated with other positive life achievements. For example, when an individual was employed or maintained good mental health, their substance use went down or they used the same but the use didn’t carry as severe consequences.
The Harm Reduction Group Begins
The most rewarding experience of my time in supportive housing was starting and facilitating a Harm Reduction group. My supervisor at the building wanted to have some type of recovery group and gave me the project to get it started. Originally, I was going to co-facilitate a recovery group with another case manager, but she quit; leaving me and my project back to square one. At this point, I had been learning about Harm Reduction and had read several pieces of literature on the subject. Now it was time to put some of this theory into practice.
I decided that I wanted to have two components to the group. The first being an open support group for the residents of the building to come and talk about drug use in a nonjudgmental environment. The second component would be an educational piece where I would share some techniques and ideas about how to reduce harm while engaging in inherently dangerous activities.
Supporting the Member Where They are at
Creating and holding a safe place for substance users to come talk about their use was the most important piece to starting the Harm Reduction group. To do this, I had to recognize and acknowledge that all substance users are in different stages with their relationship to drugs; and they are also all in different stages of their motivation to change that relationship. Both addiction and recovery operate on a spectrum.
In my group I had people from all over that continuum of use and motivation to change. I had one member in an abstinence based outpatient program, a member on methadone maintenance, a member who had no desire to change their relationship with substances, and other members who were ambivalent. I could have one group member who was blackout drunk, sitting next to someone else who was shaking in their second day of detox. Group members came as they were, and came and went as they pleased.
The goal was not only for myself to become accepting of the variety of substance users, but also to have the members of the group acknowledge an individual’s right to choose their own relationship with substances, so that the group would have an nonjudgmental culture of support. Surprisingly, this happened organically with little effort from myself. I simply laid out some basic rules, so that people felt safe and respected, and the members of the group took the discussion in any direction they wanted.
Psychoeducation: Drug, Set, and Setting
I led the group in an education of “drug, set, and setting,” which means that how the drug itself (drug), the individual’s physical and mental being (set), and their environment (setting) play an interchanging role in how drug use affects a substance user’s life. The idea was to show the members that they could change any aspect of their drug, set, or setting to reduce the harm they get from drug use. For example, a drug user can reduce harm by making sure they eat before using (set), or only use in the company of others (setting) to be safer when they use.
Drug, set, and setting was the foundation of the Harm Reduction group. As members shared their experience with drug use, I pointed out how drug, set, and setting had played a role in their experience. For example, a member may have shared that they use less drugs when they are employed. I would have pointed out that the member is using less (drug) because they feel better about themselves (set) when they are spending more productive time at work (setting). As the group progressed through the weeks, members became more familiar with the terminology and were able to put words to the changes happening in their lives through this framework.
I have no empirical evidence that my Harm Reduction group had any positive effect on the member’s relationship with substances or mental health. What I do know is that the members said that they enjoyed coming to the group and the attendance and participation exceeded all expectations from myself and my colleagues. Most members voiced their appreciation to have had a nonjudgmental space to talk freely about substance use. The concept of being able to seek addiction treatment on their terms, without any expectations, was a new and refreshing paradigm for them.
Harm Reduction is NOT only a refreshing concept for clients but equally nice for clinicians. With no rules or negative consequences for using, Harm Reduction creates an environment that has the potential to be truly honest. I know that for me I became tired, working in abstinence treatment, constantly treating people like they were liars; policing their behavior and bodies through drug testing. By releasing ourselves from the bondage of dogmatic thinking, will free us to to the actual work that we are meant to do.