Harm Reduction Psychotherapy: Extending the Reach of Traditional Treatment

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Harm Reduction PsychotherapyExtending the Reach
of Traditional Treatment

• Andrew Tatarsky, PhD
• Harm Reduction Psychotherapy and
• Training Associates, New York
• October 8, 2005

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Harm Reduction Introduction

• One of the most important new ideas on the
  substance misuse scene
• Works on three levels
• Interventions
• Philosophy
• Clinical Movement

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Harm Reduction Interventions

• A set of practical actions that reduce negative
  consequences of drug use,
• Incorporating a spectrum of strategies from safer
  use, to managed use to abstinence.
• Harm reduction strategies meet drug users where
  they are at,
• And address conditions of use along with use
  itself (Harm Reduction Coalition, 2005)

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Harm Reduction Philosophy

• Starting where people are, with their concerns
• Trying to understand them within their frame of
  reference
• Small, incremental positive steps are considered
  successes
• Abstinence may be the best outcome for many,
• But not a prerequisite or requirement for
  treatment

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Harm Reduction A Movement

• Attempts to challenge the limitations of
  traditional treatment
• Engages new populations
• Utilizes more flexible models
• Emphasizes helping rather than punishing
  substance users

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Rationale for Harm Reduction

• Majority of problem users are not being treated
  effectively (SAMHSA, 1999 IOM, 1990 NIAAA,
  1999)
• Many users do not want to stop completely
• Broad diversity of users vary in every variable
• Co-existing psychopathology, socio-economic
  status, motivational stage of change, health
  status, personality strengths and
  vulnerabilities, cultural context, etc.
• Multiple meanings and adaptive value of
  substances
• Self-medication, self-soothing/care, sense of
  mastery, interpersonal expression, expression of
  autonomy, sense of belonging, rebellion against
  inner critic (Superego), personal integration
• Need for individualized, matched treatment

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Harm Reduction Psychotherapy
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Theoretical Foundation

• Biopsychosocial Process Model
• Addiction is the result of an complex interaction
  of biopsychosocial vulnerabilities (e.g.,
  genetics, trauma, poverty, co-existing
  psychopathology and psychodynamics)
• Which give substances an increased positive
  valence
• And the biopsychosocial consequences of chronic
  use (e.g., neurochemical depletion and social
  isolation) also contribute to increased desire
  and continued use

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Process Model of Addiction
Biopsychosocial Vulnerabilities Trauma, genetics,
poverty, access, culture, stress,
psychopathology, despair
Drug Use is Pleasurable Multiple personal
meanings, real and symbolic functions,
self-medication, escape, self-soothing, affect
management, self-sufficiency, defiance, pleasure,
freeing suppressed aspects of self (anger,
sexuality,playfulness), etc.
Biopsychosocial Consequences of Chronic
Use Neurochemical depletion, social
stigmatization and isolation, ego and
narcissistic regression, conditioning, physical
deterioration
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Theoretical Foundation

• Vulnerabilities or consequences may need to be
  identified or resolved before drug use can be
  addressed directly
• This changes ones relationship to substances
• Interventions can target any of these
  vulnerabilities
• Even if drug use is not the primary focus of
  treatment

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Principles of Harm Reduction Psychotherapy

• Engagement in treatment is a primary goal
• Many users are unwilling or unable to stop
• Meet people where they are
• Abandon the abstinence requirement
• Use a lower threshold for treatment

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Principles of Harm Reduction Psychotherapy

• Rather than as a binary disease state (e.g.,
  present or absent)
• Drug use is seen as varying along a continuum of
  risk
• Therefore, any reduction in harm associated with
  substance use is a sign of success
• Wherever you begin, you are starting a process of
  positive change

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Principles of Harm Reduction Psychotherapy

• Mobilize clients strength in service of change
• Client and provider in collaboration to negotiate
  goals
• Importance of destigmatizing substance users

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Treatment Implications

• Therapists can use these principles to work in
  ways that suit their theoretical orientation and
  clinical style
• Inform the therapy process from setting the
  alliance, assessment, goal setting and working
  toward positive change

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Treatment Goals

• Engage client in a relationship
• Identify what is distressing or harmful about
  substance use and related personal issues
• Clarify harm-reducing positive goals that are
  realistic for the client
• Working toward change with strategies that meet
  the clients unique needs and strengths

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Integrating Strategies for Positive Change

• The therapy works on two dimensions
• With each focus supporting the other
• Cognitive-behavioral strategies focus on the
  process of changing behavior
• Includes efforts to identify risky or problematic
  aspects of use, clarify goals for reducing harm,
  and developing strategies to achieve personal
  goals

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Integrating Strategies for Positive Change

• The psychodynamic, exploratory focus
• Centered on clarifying multiple personal and
  social meanings of use
• Reflects an understanding of substance use as
  being connected to underlying dynamics and issues
• As meaning is unwrapped, underlying triggering
  issues can be resolved in other ways
• A therapeutic relationship is the necessary
  context for change

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Engagement as Therapeutic Focus

• The therapeutic alliance anchors the client in
  therapy
• Active listening
• Empathy for their experience
• Collaborative inquiry keeps client and clinician
  on the same side

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Engagement as Therapeutic Focus

• Stay with clients process rather than have an
  agenda
• Client chooses goals -- this motivates them
• Supports client in finding him/herself
• Creates a safe space for identifying harm, goal
  setting, and working toward change
• Relationship allows reworking of interpersonal
  issues that have been expressed through drug use

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Countertransference Issues

• Manage personal and evoked countertransference
• Acting it out can derail treatment
• Challenge therapists preconceptions about
• Client needs
• Goals
• Therapeutic readiness

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Assessing Harm and Setting Harm Reduction Goals

• Identify problems using the needs hierarchy
  (e.g., Maslow)
• Whats most pressing to the patient?
• What bring them to therapy?
• This is the glue for treatment

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Assessing Harm and Setting Harm Reduction Goals

• Microanalysis of current use pattern
• When?
• How much?
• Under what circumstances?
• How does it fit in with other aspects of life,
  i.e., positive and negative impact

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Assessing Harm and Setting Harm Reduction Goals

• Explore mixed motivations/ambivalence
  (see also Miller, 1995)
• A molecular focus on the pros and cons of drug
  use
• Cost/Benefit analysis Decisional balance
• Empathize with both sides of the conflict
• Keep the conflict within the client
• Taking sides pulls the therapist into conflict
  with the patient

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Ideal Use Plan

• An exercise for identifying problematic aspects
  of drug use
• And what might be a healthy relationship to
  substances
• Create a plan with the patient
• If you were to create a plan for using your
  substance of choice
• That would provide the greatest amount of benefit
  with the lowest level of risk

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Ideal Use Plan

• What would that look like?
• How could we set that up in your life?
• Hypothesis-testing approach
• Is it realistic? Can it be implemented?

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Driving Metaphor

• The ideal use plan is like driving to a
  destination
• Where do I want to go? (Analogous to goal
  setting)
• What is the route? (Analogous to strategizing)
• What are good defensive driving skills?
• Important skills include
• goals
• strategies
• awareness, and
• affect management

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Working Toward Positive Change

• Identify event-thought-feeling-impulse-decision
  action habit pattern
• Think through the impulse
• What will happen if I act on my old tendencies?
• Crave surfing, i.e., sitting with feeling
• Stop technique
• Identify Triggers

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Capacities for change

• Certain skills are necessary for changing oneself
• It may be necessary to help the client strengthen
  these capacities
• Self-reflective awareness enables the client to
  identify events, thoughts and feelings related to
  substance use
• Affect tolerance enables the interruption of
  impulsive action with substances
• These are strengthened in the course of
  therapeutic dialogue and through direct teaching
  of techniques
• Awareness training, relaxation training,
  meditation,etc

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Research Support

• Offering clients choice of moderation or
  abstinence increases retention and positive
  outcomes for both groups (Rotgers, 1996)
• Positive expectations about therapy, greater
  session attendance, and a positive perception of
  the working alliance predict greater client
  satisfaction and more positive drinking-related
  outcomes (Dearing et al., 2005)

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Future Directions

• There is a strong need for effective research
  that is sensitive to and appropriate for the harm
  reduction model (Majoor Rivera, 2003)
• Current obstacles to harm reduction research are
  unhelpful

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Acknowledgments

• Skoun Lebanese Addictions Center