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What's Under the Harm Reduction Umbrella?

By Phungushead, May 28, 2015 | | |
  1. Phungushead
    There has long been an unfortunate tension among treatment providers between harm reductionists and abstinence-based clinicians and programs. But in addiction treatment, stubborn adherence to a rigidly held treatment philosophy tends to do a disservice to our patients. Jeannie Little, a seminal figure in the development of harm reduction theory and practice, asserts that abstinence is one of many treatment goals that can rest comfortably under the harm reduction umbrella….Richard Juman

    Harm reduction therapy is poised to be the umbrella for treatment of substance use and co-occurring disorders in the 21st century. First developed in the 1980s as a response to hepatitis and HIV, it is the most accessible treatment for substance use and misuse to date. It lowers the threshold even further than Alcoholics Anonymous, previously the most accessible recovery support system: “All you need for membership in AA is a desire to stop drinking.” To belong in a harm reduction community, one need have no desire to change at all! A person can be curious, reluctant, determined to continue a lifelong relationship with substances, desirous of minimizing consequences, or desperate to find help that is not like what he or she has experienced before. Debra Rothschild aptly calls harm reduction “the third wave” of substance use treatment.

    A paradigm shift such as this one—from the disease model of addiction and 12-step programs which demand lifelong abstinence from all psychoactive substances, typically through surrender to a higher power, to harm reduction, which promotes empowerment, self-determination, and a wide range of options for change—is shaking the foundations of the last 50 years of addiction treatment. What is so revolutionary is not, however, the battle of opposing forces.

    Disease model proponents and harm reductionists alike have made the mistake of polarizing the two approaches. While disease model proponents often have difficulty with the idea of non-abstinent goals, harm reductionists have been saying all along, “Abstinence is a harm reduction goal, it just isn’t the only one.” We have been busy creating a very wide umbrella under which all goals are welcome and any positive change is considered success (with thanks to Dan Bigg of the Chicago Recovery Alliance). With a menu of options as a core value, harm reduction can hold abstinence and 12-step recovery models under the same umbrella as safer use, reduction of use, moderation, and variations on abstinence. Harm reduction moves the fundamental values of “recovery” from powerlessness and abstinence to empowerment and choice. As long as a person freely chooses a 12-step program of recovery, in a landscape of many options, that choice falls within the scope of harm reduction.

    Rather than posing a threat to 12-step programs, harm reduction offers a larger umbrella under which all people and all options for change can coexist. Because it explores the reasons that people use drugs, harm reduction covers more territory in understanding substance use and misuse. Because it is grounded in the principles of public health, it addresses all of the harms that can occur in a drug-using life, regardless of whether a person’s use rises to the level of a disorder (“addiction”). Because it combines psychotherapy with substance use treatment, it addresses both substance use and the issues that lie behind it. Because it embraces an infinite number of change and recovery options, it adheres to the highest medical ethics of client choice and self-determination.

    Many characteristics of harm reduction therapy make it the ideal umbrella for substance use treatment in the 21st century.

    Harm reduction therapy is non-polarizing.

    Until now, both the moral model (manifested in the War on Drugs) and the disease models of addiction have been predicated on prohibition— "Just Say No.” They have taken an all-or-nothing stance to substance use. Characterized by terms such as “clean,” “dirty,” and “in the program,” or “out there,” one is either an “addict/alcoholic” who will face “jails, institutions, or death” if she keeps using, or a “normie” who can drink without consequence. These terms trap the substance user in a binary identity dilemma and a dichotomous choice to belong to one community or the other.

    Harm reduction, by contrast, holds that people have a relationship with drugs that is more or less healthy at different moments in time. Substance use occurs on a continuum from no use to benign use to chaotic use, with many points in between. Harms can occur at any point and should be addressed, regardless of whether a person is “addicted.” I have seen many people who have problematic relationships with alcohol but not with marijuana, or who get in trouble with speed but drink moderately, including after they quit using speed. I have worked with people whose use is chaotic, then they learn to moderate, yet they still have the occasional binge. I have also worked with many people whose goal is abstinence from all psychoactive substances, and they work beautifully alongside others whose goal is non-problematic use.

    Harm reduction therapy is trauma-informed.

    The majority of people who reach the level of chaotic substance use have histories of trauma, and the first ethic of harm reduction therapy is to "Do No Harm." This means that we do nothing that could be re-traumatizing. Such things include exercising authority and control, asking intrusive questions, being unpredictable, or using shaming language or techniques. What we do is remain mindful of trauma and its effects, understand the medicinal properties of drugs, treat each person with sensitivity, use grounding techniques when a client is overwhelmed, and refer to trauma specialists when we assess that symptoms of trauma are dominating the client’s experience.

    Harm reduction therapy is a co-occurring disorders treatment model.

    Co-occurring mental health and substance use disorders are the rule, not the exception. And when harm reduction therapy is practiced by mental health professionals, all issues can be addressed at the same time by the same clinician.

    Harm reduction therapy is inclusive.

    "Come as you are" is the mantra of harm reduction therapy—anyone is welcome, regardless of their relationship with drugs, their goals for future use, and their motivation to change. Any route to change is supported, and every positive change applauded. In other words, harm reduction therapy meets people at their stage of change. Using the Transtheoretical Model of Change, harm reduction therapists understand that people are at a different stage of readiness to change for each issue that they bring into treatment. At the Center for Harm Reduction Therapy, we tend to start with the issues that the client is most motivated to address. For example, a man came to us with a major heroin habit that had caused him to lose his job and alienate his partner and children. His partner had kicked him out and he was sleeping at his mother’s house. His most pressing concern was to re-establish contact with his children because he foresaw that the damage to them would last longer than any other harm. We facilitated the beginning of a conversation by advising him not to make promises. Once he could visualize a realistic way to connect with his children, his thinking became less panicky and he began making small, sustainable changes.

    Harm reduction therapy educates everyone about drugs and safe use practices, thereby reaching far more people and preventing a great deal more harm.

    Harm reduction does not take a position on whether drugs are good, bad or indifferent. It depends. Some drugs (typically the legal ones!) are more toxic than others. The experience of the user, as well as the emergence of problems, depends on his or her physical, mental, emotional, relational, cultural, and environmental context. Being knowledgeable about the interaction of the drug, the user (set), and the setting (Zinberg), harm reduction therapists can respond appropriately to any substance using situation.

    Harm reduction therapy is client-directed.

    The client, not the therapist or counselor, defines the nature of his or her problems. Some people identify self-medication of physical or emotional pain as the main driver of their substance use; others believe that a spiritual journey, an enhancement of physical and emotional experience, or partying led to trouble; still others are most comfortable with the idea that they have a disease. Harm reduction also shifts the emphasis from program-directed to self-directed goals, steps, and outcomes. Finally, the client sets the pace and the intensity of treatment, with more or less input from the therapist.

    Harm reduction therapy supports three broad avenues of change: safety, moderation, and abstinence.

    Safety means reducing the harm to oneself and others. Not drinking and driving, sterile syringes and safe crack pipes, taking care of the kids, and loading up on condoms when one’s aim is to party, are but a few of the harm reducing possibilities that harm reductionists keep foremost in our minds. In regard to moderation and abstinence—some people moderate their use of all drugs, while others abstain from all; some abstain from some and moderate others, while still others abstain or moderate most of the time, and then enjoy the occasional episode of “determined drunkenness.” Ken Anderson (How to Change your Drinking) is promoting the idea that “absence of problematic substance use” should be the standard of “recovery.”

    Implications for Treatment

    During my 35 years as a social worker and 25 as a therapist working with substance users and people with co-occurring disorders, I have studied my clients to understand what is most helpful to them. I have concluded that the important question is not whether a person is or is not powerless, or whether he or she should or should not be abstinent from one or all of her drugs. The answers to these questions change over time.

    The crucial thing to assess is the extent to which a person needs containment, structure, and direction, versus needing to explore his relationship with substances free of outside influence. In other words, at times, people (and that includes all of us!) need someone to tell them what to do, at other times they need to work with someone who has the capacity for infinite flexibility and whose role is to facilitate their own exploration.

    In Part 2 of this article, Patt Denning and I will discuss how we go about helping each person find the right level of structure vs. flexibility, direction vs. facilitation. We will give examples of how this works with different clients. In Part 3, I will challenge harm reductionists, abstinence proponents, and 12-step advocates to join together and create a real menu of options for people who use and misuse alcohol and other drugs.

    Jeannie Little, LCSW, CGP is the co-founder and executive director of the Harm Reduction Therapy Center in San Francisco. She is a licensed clinical social worker and certified group psychotherapist. Since 1990, she has been at the forefront of developing the harm reduction treatment model for people with co-occurring substance use and mental health disorders. With a long background in homeless and housing services, she adapted harm reduction therapy as a community treatment model that has reached thousands of marginalized people with little access to mental health care. She is also considered one of the creators of harm reduction groups. She provides training and ongoing consultation to professional and peer staff in outpatient clinics, drop-in centers, and supportive housing. She is co-author of Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol and Practicing Harm Reduction Psychotherapy, 2nd Edition.

    28 May 2015

    Jeannie Little LCSW
    The Fix


  1. Phungushead
    What's Under the Harm Reduction Umbrella? Part Two

    [IMGL="white"]https://drugs-forum.com/forum/attachment.php?attachmentid=46984&stc=1&d=1448077487[/IMGL] One of the most critical aspects of harm reduction is the notion that people should be empowered to choose their own path to recovery. In HR treatment, a client’s relationship with substances is explored and, hopefully, understood, potentially leading to reduced harm or a reduction or cessation of use. This is in contrast to non-HR approaches, where abstinence from substances is more likely to be imposed on the client through the control and authority of the treatment provider. Here, in the first of the two articles that will conclude the "Harm Reduction Umbrella” series, two clinicians who have been of primary importance in the history and development of the harm reduction model of addiction theory and treatment, Jeannie Little and Patt Denning, describe their thought process around assessment and treatment planning. As will be seen, in contrast to certain aspects of the widely-used ASAM criteria for treatment planning, they argue that the clients’ motivation for change should be the cornerstone of decision-making.

    In a previous piece a critical question about assessment and treatment planning was put forth:

    “The important question is not whether a person is or is not powerless or whether she should or should not be abstinent from one or all of her drugs. The answers to these questions change over time. The crucial question is the extent to which a person needs containment, structure, and direction, versus their need to explore their relationship with substances free of outside influence. In other words, at times people (and that includes all of us!) need someone to tell them what to do, at other times they need to be with someone who has the capacity for infinite flexibility.”

    In this article, we will discuss how we understand structure, containment, and direction and the ways that we go about determining the right level of each for each person.


    When we refer to “structure” in substance use treatment, often what we mean is putting someone in a restrictive environment that will eliminate risk, regulate behavior and prevent any contact with psychoactive substances. We also assume that such programs will be directive. That is, they will tell their participants what to do and how to do it in order to attain abstinence and maintain “recovery,” often thought of as synonymous.

    But the true definition of structure is much simpler. Structure refers to organization or order that is coherent (i.e., it is clear, understandable, orderly, and consistent) and stable (i.e., it is predictable, stays relatively the same over time with changes occurring in a gradual rather than disruptive manner). No program or organization lacks structure, including harm reduction, the most flexible of all programs. Where they differ is in the level of restrictiveness and directiveness. To what extent do they exert control over one’s activities? Do they restrict contact with the “outside world” and activities within the program? Or are people free to come and go as they please? To what extent do they tell participants what to do? Do they prescribe the goals and direct the methods to achieve those goals? Or do they support the client’s choices (short of harm to self and others) and methods? To what extent do they impose punitive sanctions for failure to “comply” with program rules and expectations? Do they punish, humiliate, or dismiss? Or do they applaud the strength displayed by someone who resists?


    This term can be used to describe a variety of concepts in a variety of environments. Containment within a restrictive environment imposes external controls to restrict freedom, activity, and contact with both people and drugs. Physically containing environments fall on a continuum from most restrictive (locked facilities like prisons and psychiatric facilities) to least restrictive (mutual aid groups or harm reduction therapy). More than 50% of people in substance use treatment are there involuntarily under the mandate of the criminal justice system. Still, more are there as a result of a family intervention. Whether mandated by the legal system or by family, coercion is often the mechanism that gets an individual into a restrictive treatment environment.

    Containment can also extend beyond the confines of a treatment program; monitoring is another mechanism of containment. Urinalysis, breathalyzers, ignition-locking devices, and ankle-monitoring bracelets which are alcohol sensitive are all used to enforce compliance with abstinence requirements.

    Containment also refers to emotional containment. Winnicott’s concept of the “holding environment” refers to an emotional environment that provides care, nourishment, and understanding and that gives a person the feeling that she is secure. Emotion regulation, which is supported in part by a secure base, is the ability to experience a full range of feelings in response to people or events, to tolerate emotional arousal, to react both spontaneously and with restraint, and to recover one’s equilibrium after emotionally wrenching experiences. Khantzian theorized that poor affect tolerance is one of the core deficits that leads some people to self-medicate with substances. Though physical containment can assist with emotion regulation by controlling the amount and type of environmental stimulation, it is really a psychological process that involves the ability to evaluate and understand what is happening, to self-soothe, to focus one’s attention, and to act with consideration to both internal and external factors.


    Here we refer to the extent to which a program or therapist prescribes outcomes and/or dictates both outcomes and the methods to achieve them. The vast majority of programs (rehabs, outpatient treatment, and self-help groups) prescribe a lifetime of abstinence from psychoactive drugs. Most also prescribe a lifetime of membership in a 12-step group, a sponsor, and stepwork. Standard treatment tends to direct activities within programs, with the same groups and activities required for all participants, including timelines or stages that people move through based on behavior and program adherence. Often this direction comes with exhortations that failure to follow “the program” will lead to “jails, institutions and death.”

    The Continuum of Options

    The most restrictive programs—prisons, jails, therapeutic communities, other residential rehabs, and inpatient detoxes—offer, or impose, depending on your perspective, constant monitoring of activities and behaviors. Not only are they restrictive, but these programs tend to be highly directive. Less restrictive, but still typically directive are partial hospital programs, sober living houses and outpatient programs. They might also, to varying degrees, use monitoring devices, thus extending their reach beyond the physical bounds of the program. If participation is coerced, then the whole process is involuntary.

    Self-help groups, more properly called mutual aid, fall on their own continuum of containment and direction. While not physically restrictive, attendance is sometimes mandated. Reporting (e.g., the show of hands for people who are “newcomers” at 12-step meetings or sharing the number of drinks and drinking days one has had in the last week at Moderation Management meetings) is an accountability device that, if internalized and remembered while away from the group, provides a sense that the group is always present. This can be experienced by prospective members as helpful and emotionally containing or as intrusive and oppressive.

    In 12-step groups, goals and methods are clearly prescribed. Both Moderation Management and SMART Recovery (Self-Management and Recovery Training) have a clear direction or prescribed goal—moderation of alcohol use or abstinence, respectively, but the structure of meetings is not directive. They function as facilitated discussions where people can explore their relationship with substances, evaluate their individual risk situations and, to some extent, set their own goals. The HAMS (Harm Reduction, Abstinence, and Moderation Support) network is harm reduction’s mutual support group for alcohol. Rather than prescribe a particular goal, it encourages people to choose safety, moderation or abstinence, and to define moderate drinking for themselves.

    Harm reduction programs fall on the least restrictive and directive end of the continuum, with participants choosing not only their goals but also the pace and the intensity of participation or treatment. We refer to this as “dosing”—just as people dose themselves with drugs as they wish or see fit, they also dose themselves with treatment, coming and going as they need or want with no penalty. Harm reduction is multidirectional—safety, moderation, abstinence, and/or attending to issues other than substance use are all worthy directions for change. It is client-directed and empowering. Because a core value of harm reduction is self-determination, we see our role as facilitators rather than directors of a person’s change process. We make recommendations only after considering the strength of the therapeutic alliance and only after being invited by the client.

    Advantages and Disadvantages of Containment and Direction

    Physical restriction and direction can be desirable for people who desperately want to break habits or for people who need medical intervention and monitoring. It is also appealing to families who just want their loved one’s behavior to stop, to bring order to chaos. Lack of containment and direction can risk harm for people who are impulsive and whose substance use is potentially dangerous to self or others. In any of these circumstances, some restrictive environments are helpful and, at times, necessary. Just as a child who is about to run out in the street needs to be picked up and put indoors, adults sometimes need to be gotten out of harm’s way. And, for people who can retain the image of the breathalyzer, the urine sample bottle, or the ankle bracelet, these “Big Brother” devices can be effective deterrents of unwanted behavior.

    On the other hand, being restricted can retraumatize people whose lives have been arbitrarily controlled by others; who have been abused as children or as adults; who have been institutionalized; who have been terrorized in their families, neighborhoods, or countries; or who have been locked up in jails and prisons. Since most people who persistently misuse substances have trauma in their histories, anyone might have sensitivities that would render restrictive programs more harmful than helpful.

    All programs should offer emotional containment, but many use interventions that are emotionally dysregulating. Confrontation, the almost exclusive use of groups in most treatment, the steps that require one to conduct a “searching and fearless moral inventory,” and the assignment to write one’s autobiography can arouse fear, anger, and traumatic memories, in turn triggering the very behaviors that one is trying to help! The challenge is to provide sufficient structure to enable the change process without overwhelming the individual or arousing resistance and rebellion.

    How We Decide

    The ASAM (American Society of Addiction Medicine) treatment criteria recommend that placement be determined based on severity across six dimensions. In general, the higher the acuity of substance use, the more critical the medical or psychiatric complications, and the weaker the recovery environment, the higher the intensity of treatment recommended. An important dimension is readiness to change, which recognizes that, despite high acuity, if people are not ready to change, high intensity placements might be wasted. This modifies placement considerations, but only in the absence of moderate to higher severity in the other dimensions. In other words, when assessment indicates moderate to severe and co-occurring complications, higher intensity treatment is recommended regardless of a person’s motivation to change.

    We disagree. Motivation should always be the primary consideration, except in cases when safety concerns require immediate intervention. Since adults are not children (though they might be either metaphorically or literally running out into the street), it is important to take a more nuanced approach in order to build a therapeutic relationship that can influence positive change. In early harm reduction groups in the 1990s, we learned quickly that people vote with their feet. In those early groups, members often said, “People know what they need and when they need it. We trust that they are taking care of themselves in the way that they need to today.” They were telling us that respect for their autonomy was key to their cooperative and enthusiastic engagement. We use this language explicitly with our clients, and they appreciate it.

    Although radically client-centered and directed, harm reduction therapists do make recommendations for more restrictive treatment environments, including abstinence-based rehab. We also use targeted directiveness. We might recommend abstinence from certain drugs or from all drugs for a certain period of time. In fact, when practicing Substance Use Management (SUM), a specific practice that is part of the harm reduction continuum, the therapist routinely gives instructions regarding how to count, measure, control, and otherwise change a client’s drug or alcohol use. These instructions are based on the client’s unique psychology, biology, and level of self-awareness; the drug’s pharmacology; and therapist’s experience. And there are no negative consequences imposed by the therapist for failure to follow the instructions, rather we examine the reasons the client has not used them.

    The question is not just “What is needed?” It is also “What will be helpful and not harmful?” We make determinations or recommendations based on the need for immediate safety and on other considerations discussed in the second part of this article. The first question we ask is who decides and the next question is how we decide.

    In the next week's article, we review several cases of people whose complexity demands client-specific and flexible treatment recommendations.

    19 November 2015

    Jeannie Little LCSW and Patt Denning PhD
    The Fix
    Image: Shutterstock
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