SOC8385 - SECTION 5: HARM REDUCTION
Some people who do not seek counseling or treatment for their problems do so because they are not willing, or they are unable, to accept the stated therapeutic or treatment goals. For example, studies of substance abusers show that there is some sort of self-recognition process that is tied to increasing substance use and to substance-related problems, but this recognition does not inevitably lead to help-seeking.
Most substance abusers do not voluntarily seek treatment or join self-help groups. Only about one in four people seek treatment for their substance use problems and only a minority of these people seriously engages in available treatment. The frequent reluctance of substance abusers to seek help, especially from formal treatment programs, seems to be rooted not in denial of their substance use problems, but in concerns about their privacy and the stigmatizing effects of being in treatment, concerns about the cost and time requirements, and concerns about the demands treatment or counseling will make of them (Marlatt, Tucker, Donovan, & Vuchinich, 1997).
If people enter substance abuse treatment it usually occurs late in the development of substance use problems. People usually seeks medical or other health care for substance abuse related problems before they enter a substance abuse treatment program or attend a self-help group such as AA/NA. Additionally, if a substance abuser enters treatment it is typically preceded by informal social pressures by family, friends, doctor, or co-worker.
Therefore, primary medical care settings may be early contact points for problem identification and possible referral. Studies that have compared treatment participation and outcomes among coerced (primarily by the courts or employer) and voluntary clients found similar outcomes across both groups and reduced attrition among coerced clients (Fagan, 2004).
Almost all substance abuse treatment programs have abstinence or the elimination of all substance use as their only officially endorsed treatment goal. This is a result of most programs' reliance on AA principles, where complete, life-long, abstinence is the only goal.
In practice, what this means is that some clients never enter treatment because they are not willing to accept abstinence as the only treatment goal, they are dropping out of treatment when they realize they are not meeting the total abstinence requirements of the program, or they are judged to be failing because they are not meeting those requirements.
This is especially true for young substance abusers and for substance abusers with long histories of substance abuse. One controversial approach that is being used with people that are unable or unwilling to completely stop their substance use or addictive behaviors, is called harm reduction.
Harm reduction is based upon the principle that substance use is a reality in our society. Although not condoning substance use, harm reduction emphasizes reducing the negative consequences of substance use (e.g., driving under the influence, using dirty needles, using particularly dangerous drugs) by employing practical, achievable goals aimed at the safe use of substances and minimization of the harmful effects associated with continued substance use.
Although this approach may lead to - or include the possibility of - complete abstinence, it does not require it. While abstinence may be the ideal for many individuals, the harm reduction approach expands the definition of success to include the many smaller steps that may precede or replace abstinence (Denning, 2000).
In harm reduction, counselors convey they are concerned about the person’s well-being and believe the person can make improvements. The counselor does not conclusively reject the person who continues to engage in the problem behavior so long as the person is showing long-range positive movement in terms of such things as not only fewer problem behaviors, but the person also shows improvements in other areas in their life such as with their friends and family, work or school colleagues, and reduction in other problem behaviors.
The goal is to move clients to a more secure footing in life, to help them to resolve other problems, and to encourage better physical, personal, and social functioning. Top priority is given to stopping behaviors that are currently causing, or could cause, harm to the client or the people around him/her (for example, driving while intoxicated, stopping any violence or abuse, using particularly dangerous substances).
The basic philosophy of the harm reduction approach, is that after people begin to gain some control over their substance use, they may be more open to the possibility of stopping their use altogether or at least stopping their use of more dangerous substances in more dangerous situations (Miller, Turner, & Marlatt, 2001). Harm reduction has the potential advantage of engaging high-risk substance users and motivating them to participate in programs designed to minimize or eliminate the negative consequences of their substance use (Denning, Little, & Glickman, 2004; Tatarsky, 2002).
Case Example: Harm Reduction
Jennifer, 32 years old, was referred to you by a colleague because of your expertise in treating substance abuse. At the first session, it was clear that Jennifer did not want to talk about whether or not she had a substance abuse problem, rather she wanted to talk about why she was having such a difficult time finding a long-term, meaningful, relationship with a man. Jennifer was first married when she was 24. She met her husband, Pete, at a gym where he was one of the trainers. They were married for four years, but she divorced Pete when she found out he was having an affair.
Jennifer works for a clothing manufacturer where she is in charge of sales. It is a very stressful job that pays very well and, despite the long hours and stress, she enjoys the challenges of her work. Jennifer is a very attractive, bright, and strong woman. Since her divorce she has dated a number of men, but few of the relationships lasted very long and most of them were emotionally unfulfilling. She feels that many of the men she dated were intimidated by her success and strong personality and few of them were interested in a long-term relationship. At the same time she wonders if she is attracted to the wrong type of man and if she is contributing something to the relationships that is discouraging men from making a commitment. This is what she wants to talk about in her sessions with you.
During the first session, after you initially attempted to talk about her substance use, you decide to not bring up the subject until Jennifer appears ready to talk about it. You decide, instead, to focus on learning more about Jennifer and her relationship concerns. During the end of the second session, Jennifer brings up the subject of her substance abuse. She acknowledges that she had always liked to drink and for about five years she has been using cocaine. She tells you that she primarily drinks and uses cocaine on the weekends, but in the last two years when she comes home from a particularly stressful day at work, she will occasionally snort some cocaine or drink a little too much.
She acknowledges that she is a little concerned about her increased alcohol and cocaine use, but she feels she is generally in control of it and she feels it has not significantly impacted her job performance or other areas of her life. The more you work with Jennifer, the more you feel that her substance use is one of the contributing factors to some of her relationship problems. She is increasingly turning to alcohol and cocaine when things are not going well at work and in her relationships. However, when you bring up these thoughts in your counseling sessions, Jennifer is very hesitant to acknowledge that she has a substance use problem and she quickly moves to another topic when you begin to explore this area.
At this stage, many counselors would conclude that Jennifer is in “denial” about her substance use, but in reality, Jennifer is ambivalent about her drug use. Jennifer’s ambivalence stems from a complex psychological interplay of her accurate insights into the positive benefits of her drug use (i.e., it helps her to relax and deal with some of the stresses in her life), her insights into her psychological make-up (i.e., she may be contributing to her relationship problems), her hesitation to be labeled as having a substance use problem (i.e., not wanting to be stigmatized by colleagues and friends), her assessment that much of her life is very successful, and her lack of awareness that her substance use may be contributing to some of the problems in her life.
From a harm reduction and motivational interviewing perspective, you do not feel it is the counselor’s job to tell the client what they have to work on in the counseling sessions, rather it is the client who should be setting the agenda. At the same time, you feel there might be ways to indirectly work on Jennifer’s substance use problem while working directly on her relationship issues. This can be done by trying to link some of her relationship problems and other goals in her life with her substance use.
For example, you learn from Jennifer that sometimes before she is going to go out on a date she will have a few drinks or use some cocaine to calm her nervousness. You develop a plan with Jennifer to try not to drink or use cocaine before a date. You teach her some other ways to relax before dates and in other stressful situations and ways other ways to relax when she comes home from a stressful day at work. The strategies appear to be working.
Tapping into Jennifer’s strengths as a person, she is learning how to deal with the stresses in her life without using AOD. Over time, Jennifer began to see the role that substance use is playing in her life and she starts to get more control over it which in turn helps her look at her relationship issues in some new ways. She is not yet willing to completely give up her AOD use, but she had gained considerable control over when, and how much, she uses. She is drinking much less and she is beginning to talk about quitting her use of cocaine altogether. She seems much happier with her life and the direction it is going.
A harm reduction approach cannot be used with all problem behaviors. There are problem behaviors such as use of substances in dangerous situations (e.g., substance impaired driving), criminal behavior, and some other types of illegal or dangerous behavior where the goal of harm reduction would not be appropriate. However, a harm reduction approach can be applicable to many other types of problems and it is consistent with the principles of motivational interviewing.
The principles of harm reduction reinforce the importance of working with clients to develop counseling and treatment goals that are applicable to their needs, goals that the client can be motivated to reach, and goals that can change as they client progresses toward their stated goals.