Harm Reduction Psychotherapy

By: Garry Cooper, LCSW
 

 

What does harm reduction psychotherapy look like? In an article in the December, 2003 Journal of Substance Abuse Treatment, psychologist Andrew Tatarsky, author of Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, describes his integrative harm reduction psychotherapy model, a combination of psychodynamic, humanistic, and cognitive behavioral precepts and techniques.

Tatarsky begins by reviewing the rationale for harm reduction. First, many users do not want to stop, and if the only treatment available insists or even focuses on just total abstinence, many clients will never seek treatment. Or they may delay treatment until something horrific happens to them or to someone else.

Second, with such a wide diversity of substance users—(there’s differences, he writes, in the “severity of substance use, personal goals regarding substance use (i.e., safer methods of using, moderation, or abstinence), motivation and stage of readiness to change (Prochaska, DiClemente, & Norcross, 1992), emotional and psychiatric status (Carey & Carey, 1990), personality strengths and vulnerabilities”–that the notion that only one treatment or even treatment orientation works seems narrow- and short-sighted. Third, there are a variety of meanings people attach to their substance use, several of which are adaptive. People use substances for self-medication, as a defense against certain affects or feelings, a way to cope with negative emotions, as a personality or ego ‘‘prosthesis” (Weider & Kaplan, 1969), as part of their sense of identity (they may see themselves as a rebel or non-conformist for example), as something that helps them connect with split-off aspects of the self, as a liberator of their creativity, or as a source of pleasure. All of these uses considerably widen the traditional view of addiction as disease. Give these reasons, Tatarsky argues, it makes sense to try harm reduction. At the very least, if it doesn’t work, the failure to successfully self-moderate may act as a stronger incentive for the client to try abstinence.

Therapists who use a harm reduction treatment model should accept several overall principles. First, they must genuinely accept that many substance users do not want, at least initially, to stop using. “This,” Tatarsky writes, “is not a pessimistic acceptance that problem users cannot change, but rather a way to begin an ambitious process of change, the endpoint of which cannot be seen at the outset.” The goal, rather than completely extinguishing substance use, is to move as far as possible toward “optimal health, self-sufficiency, self-actualization and satisfaction in the world of relationships.”

Second, therapists must genuinely accept the notion that the relationship is the key toward actively, meaningfully engaging the user in the process of change. Rather than giving the user the narrow choice of using or not using, therapist and client work together toward a goal that the client chooses and that’s meaningful to the client. Tatarsky points to research showing that the majority of problem alcohol users want to establish their own treatment goals, and that when they’re given a meaningful role in doing so, they stay in treatment longer and are more likely to have a successful outcome.

The third principle is that any reduction in the harm associated with the substance is valuable. Thus, the success of treatment doesn’t rely on whether the user stops, but on reducing the harm. While some might see this merely as moving the goalposts closer, it’s both a valuable goal and ensures that many people who would not even walk onto the field join the game.

Finally, it’s important to de-stigmatize the user. That’s often easier said than done. Many users come into treatment already expecting to be stigmatized by their therapist. It’s part of the very orientation and language of some substance abuse treatment. A history of stigmatizing relatives, perhaps law enforcement officials, mental health professionals and their own failed attempts at dealing with their substance use, all feed into the stigmatization they carry into treatment. Therapists may have to work on themselves to adapt a non-stigmatizing orientation, in order to make certain their unconscious negative bias doesn’t affect the relationship.

Before explaining his own model of harm reduction psychotherapy, Tatarsky cautions that several other models may also work (Carey & Carey, 1990; Denning, 2000; Marlatt, 1998; Miller & Rollnick, 1991; Peele, Bufe, & Brodsky, 2000; Rotgers, 1996; Rothschild, 1998; Tatarsky, 1998, 2002). A good harm reduction therapist should have an awareness of other treatment modalities. This will prevent the therapist from falling into the same trap as therapists who insist on abstinence: a too limited repertoire that doesn’t always allow the therapist to assist their clients’ goals.

Substance-using clients who come to therapy are already in distress and, Tatarsky, says, already engaged in their own process of change. (They would most likely be in the stages of change which Prochaska and DiClemente call contemplation, when they’ve already begun to consciously think about change—as opposed to precontemplation, the preceding step—or preparation, in which they’ve actually begun to test the waters. Clients who come to therapy under court order, however, may be in precontemplation or in the final phase of the change model, relapse, the stage which starts the cycle all over again). The therapist addresses the client’s distress and readiness to change by “developing an empathic resonance between clinician and client, deepening the identification and understanding of what is distressing to the client (that is, what is harmful about substance use and other issues), and setting harm reduction goals.” Harm reduction is presented as something to try, a hypothesis to test, rather than as a solution.

Tatarsky’s integrative model combines skill-building with exploring the multiple meanings of the substance use. Through a positive, empathic, supportive therapeutic relationship, the client’s own motivation to change and his willingness and ability to explore his substance use is enhanced. The skills—the primarily cognitive behavioral part of the model–involve identifying the harm and setting goals. The therapist might ask people to rewrite their negative script and think about how their lives would be different if their substance use and negative script weren’t so pervasive. As part of that process, they look closely at their patterns of use—how much they use, how often, how they go about finding and using the substance, and the negative consequences. Some suggested techniques involve doing a cost/benefit analysis of their current patterns of use or exploring their ambivalence through a vigorous analysis of both the positives and negatives of their use (therapists steeped in stigmatization and/or abstinence may be prone to shortchange exploring the positive aspects of current use). Tatarsky himself uses “voice dialog” (Stone & Winkelman, 1988) to do this analysis. In voice dialog the therapist talks with different aspects of the client, somewhat like the gestalt empty chair or Richard Schwartz’s internal family systems model (see http://www.selfleadership.org/ for an explanation of Schwartz’s work).

Tatarsky also uses awareness and relaxation training, helping the client to learn to identify and sit with their impulses and experiences instead of impulsively leaping for the substance. It is the difference between learning to tolerate and calm negative impulses and experiences or trying to smother them with substances. With their eyes either open or closed, clients are taken through six stages: awareness, taking a reading of their tension, anxiety or discomfort, breathing slowly and deeply, identifying a word or phrase which captures a feeling they’d prefer to call upon, visualizing a safe space, and then practicing the steps.

Tatarsky believes that the psychodynamic, humanistic elements of his model, what he calls “the general aspects of a good therapeutic relationship,” are the necessary fuel for the cognitive behavioral parts to work well. “Empathic questions that support the client’s capacity to reflect with curiosity, and tacit encouragement of the client’s autonomy may serve as an antidote to the client’s ties to early figures who frequently did not support autonomous self-care (Krystal, 1977),” he writes. “Our caring anxiety [about] risky behavior may, under the right conditions, become internalized as healthy self-caring attention to danger.

Therefore, it’s crucial to engage the client. That involves several principles. First, it’s vital to establish the therapeutic alliance. The idea that the alliance is crucial for good therapy outcomes, no matter what therapy modality is used, has spread across the field of psychotherapy, but it’s been slower to seep into substance use therapy, which has been steeped in the language of confrontation and insistence of goals set by the therapist. Harm reduction therapy restores this notion to its primacy and brings substance use psychotherapy into line with the rest of therapy. The notion of starting where the client is at, Tatarsky writes, “is one of the core slogans of the harm reduction movement.” This, he says, is why the initial therapeutic focus must be around the client’s reason for coming.

The clinician’s attitude is crucial. The therapist “must meet the client without preconceived ideas about the client’s needs, strengths, and appropriate goals.” Therapists should be aware of their own prior assumptions about the client and clearly see those assumptions as countertransference reactions that put treatment in jeopardy. By making the harm reduction position explicit right at the beginning of therapy, the therapist soothes the client’s expectations of being treated coercively. In addition, he writes, by telling the client at the outset that he’s likely to be ambivalent about modifying his substance use because of its adaptive value, the therapist heads off the client’s shame, which can also sink treatment.

Sharing goal setting is also a crucial principle. Because so many clients who use substances have a variety of comorbid conditions. Opening goal setting into a collaborative process makes it much more likely that the client will bring these other conditions and their effects into the therapy focus. Again, increasing numbers of therapists recognize that comorbid conditions and substance use reinforce each other, and working on one without the other does not bring the whole person into therapy and is more likely to set up failure. Tatarsky does stress, however, the importance of getting a medical evaluation. That medical information provides essential information for goal setting. Again, he stresses the need for the therapist to be genuinely collaborative with the client in goal setting. “Moderating use as well as a wide range of other harm reducing goals are accepted,” he writes. “These latter include learning safer drug-using practices, utilization of clean syringes, taking drugs with others, being knowledgeable about overdose risk and prevention, switching to less dangerous substances, and having clear ideas about dose limits.”

Tatarsky’s aware of the hurdles facing wider acceptance of harm reduction therapy. He acknowledges the need for more outcomes research that proves its effectiveness. And given the paradigms of mandatory therapy as part of criminal justice referrals, welfare-to-work programs and employee EAP referrals, harm reduction therapy’s an uneasy and often impossible fit. But, he writes, “harm reduction therapy is part of psychological and psychotherapeutic approaches that are deeply connected to the mental health traditions. In many respects, HRP represents one more situation in which we see the ‘reclaiming’ of the problem of substance abuse and addiction by the mental-health treatment field.”

References & Resources

Carey, K. P., & Carey, M. P. (1990). Enhancing the treatment attendance of mentally ill chemical abusers. Journal of Behavior Therapy and Experimental Psychiatry, 21, 205– 209.

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

Krystal, H. (1977). Self- and object-representation in alcoholism and other drug-dependence: implications for therapy. NIDA Research Monograph, 12, 88– 100.

Marlatt, G. A., & Kilmer, J. R. (1998). Consumer choice: Implications of behavioral economics for drug use and treatment. Behavior Therapy, 29, 567– 576.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: The Guilford Press.

Peele, S., Bufe, C., & Brodsky, A. (2000). Resisting 12-step coercion: How to fight forced participation in AA, NA and 12-Step treatment. Tucson, AZ: See Sharp Press.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102– 1114.

Rotgers, F. (1996). Empowering clients with respect to drinking goals. Journal of Studies on Alcohol, 147, 33– 36.

Rothschild, D. (1998). Treating the resistant substance abuser: Harm reduction (re)emerges as sound clinical practice. In Session: Psychotherapy In Practice, 4, 25– 35.

Stone, H., & Winkelman, S. (1988). Embracing ourselves. New York: New World Library.

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

Tatarsky, A. (2002). Harm reduction psychotherapy: A new treatment for drug and alcohol problems. Northvale, NJ: Jason Aronson, Inc.

Tatarsky, A (2003). Harm reduction psychotherapy: Extending the reach of traditional substance use treatment. Journal of Substance Abuse Treatment, 25, 249-256.

Wieder, H., & Kaplan, E. H. (1969). Drug use in adolescents. Psychodynamic meaning and pharmacogenic effect. Psychoanalytic Study of the Child, 24, 399–431.s 239-302 (December 2003)