Since 1982, I have worked as a psychotherapist, clinical psychologist, supervisor, program director, and teacher in the field of substance use treatment. Coming out of the mainstream abstinence-oriented treatment community, I have learned from many different theoretical traditions about how to support people in moving toward achieving stable sobriety from drugs and alcohol. And I have evolved my own perspective that integrates psychodynamic, cognitive-behavioral, and biological theory in understanding and treating issues that are unique for each substance user. I am still in touch with clients that I worked with over ten years ago who have been able to maintain stable sobriety through some combination of psychotherapy, self-management, and self-help participation.
But the fact is that the overwhelming majority of substance users in this country either "fail" these treatments or are never effectively engaged in treatment. A major factor contributing to this is the abstinence-only philosophy that dominates the treatment of, professional training in, and government policy toward substance use problems in this country. While abstaining from mood-altering substances may be the most appropriate, self-affirming goal for many substance users to work toward, the abstinence-only philosophy states that abstinence is the only acceptable goal for most, if not all, substance users who are experiencing problems in connection with their use. According to this model, substance users are required to agree to work toward this goal in order to be accepted for treatment and they must effectively maintain abstinence in order to be retained in treatment. Substance users unwilling to accept this goal for themselves or unable to achieve it are routinely denied or "terminated" from treatment with no alternatives offered.
Substance users are a broadly diverse group of people who can't possibly all be treated effectively in the same one-dimensional manner. I met people with a wide variety of differences in the nature of their problems with substances, their personal goals regarding substance use, their emotional and personality difficulties and strengths, and social, economic, and cultural backgrounds. Many of these people were unwilling or unable to accept abstinence as a goal for themselves for a variety of different reasons and were not effectively engaged by the prevailing abstinence-only approach; many were hurt in the process. The need for more creative, flexible ways of working with active substance users became clear to me. Three years ago, I discovered harm reduction as a philosophy and a movement working to bring together a number of different attempts to meet this need. And I immediately realized that what I had been doing with many clients, often in isolation, was a form of harm reduction psychotherapy.
In this paper, I will discuss the relevance of harm reduction philosophy for psychotherapy with substance users and describe the approach to harm reduction psychotherapy that I have been developing in my practice and implementing with a group of colleagues at PsychologicA, a group practice in New York City. I will also discuss the reasons why many substances users have great difficulty giving up their use of substances even though their use has become problematic in some way.
The Role of Harm Reduction Psychotherapy with Active Substance Users
Harm reduction approaches to psychotherapy with substance users may be defined as those approaches that attempt to help substance users to resolve problems that they have in connection with their use of substances without having abstinence as the goal or prerequisite to receiving treatment. There are a variety of treatment approaches which have been developed and practiced for many years now which can be grouped under this umbrella. Examples are motivational interviewing, recovery-readiness programs, controlled drinking training, and moderation training for problem drinkers. Abstinence may emerge as a goal and outcome out of this work but is not necessary to these approaches.
My approach is to engage people in a therapeutic context that will support them in clarifying the problematic, or "harmful" aspects of their substance use and working toward addressing these problems with goals and strategies that are consistent with their needs, values, lifestyle, etc. Treatments must be individually tailored to who people are and where they are if they are to be acceptable to most people.
By contrast, the abstinence-only approach is ideologically-based and not individually tailored. Its ideology insists that abstinence is the only reasonable or responsible goal for problem substance users, and thus restricts users who are unwilling to embrace abstinence from receiving help for their substance use problems. Such an approach is not supported by clinical outcome research or scientific theories of how people change. Furthermore, it makes it difficult, if not impossible, for substances users to get psychotherapy or other health services they find that the only treatment available to them is one which requires that they accept something that they cannot accept: the commitment to work toward abstinence.
Harm reduction recognizes that there are active substance users who want help and are able to actively and effectively involve themselves in helping relationships despite the fact that they intend to continue using. In fact, an argument can be made that this is the overwhelming majority of substance users. Harm reduction accepts that people's use of substances must be accepted as a prerequisite to engaging in a therapeutic process that has a possibility of being useful to the client who is, after all, the consumer of services. From this perspective, the high failure rate of all standard substance use treatment is not due to the "cunning and baffling nature of the disease" as many claim but rather to the failure of most treatment approaches to really begin where the client is, lip-service notwithstanding.
The Clinical Rationale for Harm Reduction Psychotherapy
Harm reduction psychotherapy as consistent with good psychotherapy and counseling practice and based on a scientific understanding of how people change. Any psychotherapy or personal growth process requires the active commitment of the client. The commitment will grow from a treatment alliance between the client and clinician around goals that are mutually agreed upon. The treatment alliance is the cornerstone of all effective psychotherapy. So, the initial focus of the therapy must be on what the client defines as the problem and what goals the client is interested in pursuing; whether this is an interest in moderating one's substance use, stopping using altogether, or focusing on issues that are not directly related to substance use. These issues may be survival concerns such as housing, relationship crisis, etc. or emotional issues like hopelessness or self-hate. If the focus is not on the substance use, whether or how substance use impacts on the problem is an area of therapeutic exploration rather than something assumed a priori by the therapist.
Substance use is also seen as having positive, adaptive value for many people. This is another reason why harm reduction psychotherapy does not begin with the assumption that substance use is necessarily harmful to the user, but rather raises the question of its harmfulness as part of the therapeutic exploration. In this way, the clinician is not experienced as someone who wants to take something away from the client that is felt to be vitally important or someone who is like others in the user's life who have failed to adequately understand, empathize with, and respect what is important to the user. But rather, the clinician may more likely be experienced as an ally trying to support that person in discovering better solutions to the issues being addressed by the substance.
Harm reduction psychotherapy also recognizes that behavior changes incrementally. As small positive changes are made in the use of substances, e.g. a lessening in the intensity or frequency of use or greater openness about use with people in one's life, confidence in one's ability to make changes increases and motivation to work toward greater change grows. Any reduction of harm is a step in the right direction.
Psychotherapy can be successfully conducted with many, if not most, active substance users. The degree to which the use of substances interferes with the therapeutic process varies in the same way that it does with other defensive or potentially harmful behaviors. Substance users are the only group of clients who are typically required to give up their symptoms or potentially problematic behaviors before they obtain help for them!
To the extent that the substance is serving important coping or defensive functions, this requirement is likely to be experienced as impossible to comply with until the functions and difficulties with the substance use are recognized and better alternatives are discovered. Failing to meet a requirement for abstinence may be experienced as a personal failure and an assault on the user's self-esteem.
Plummeting self-esteem and frequently associated shame, guilt, and self-hate may in turn precipitate a binge of intensified substance use as a response to these feelings. That approach to "helping" is likely to increase the harm associated with the substance use rather than reducing it; what began as an attempt to begin working on one's substance issues turned into another reason to feel worse about oneself and intensify the substance use as an expression of these feelings.
In contrast, an approach that accepts active drug use while the reasons for using are clarified has a greater likelihood of engaging the user in beginning a therapeutic process that will lead to positive changes regarding the substance use. The initial engagement itself can reduce the pressure to use and increase the user's motivation to seek alternatives to using and to develop less harmful ways of using. The therapeutic setting itself, individual or group, can reduce feelings of isolation, shame, and hopelessness.
This may occur simply as a result of the relationship with someone who accepts and respects the user regardless of substances use status and is hopeful about being able to support the client in finding positive solutions to his or her issues. A reduction in these feelings may reduce the pressure to use and break into the vicious cycle often associated with intensified substance use. But this work can also address the reasons for using by a wide variety of active interventions which directly target the issues.
Reasons People Find Substances Compelling Even When Their Use Becomes Problematic
We might define substance use as problematic when it is in conflict with other important needs or values such as health, relationships, finances, or work. Substance use becomes so compelling that these other values are superseded when it addresses vitally important emotional or psychological needs, needs which may be conscious or unconscious.
Substances may be used in an attempt to cope with otherwise unmanageable feelings such as despair or rage or vague, uncomfortable, unnameable feelings which cannot be clearly identified. Using may also reflect an inability to soothe oneself effectively in other ways or turn to others for support because of feelings of shame or fears of depending on others. It may also reflect a profound hopelessness about ever being able to feel better or get one's needs met in the world. Substances may be used to bolster failing self-esteem, to feel alive and strong, to assert one's autonomy, to punish oneself because of guilt or anger at oneself, to feel part of a group, to strengthen one's identity, or to get some respite or brief pleasure in an otherwise painful reality. These motivations may be compounded by conditioning, habit, lifestyle, and the biological effects of using itself.
Thus, if the substance use continues to fulfill some of these important functions, the prospect of stopping or moderating one's use will be very threatening to the user. An appreciation of this threat must come before any work on modifying one's use can begin.
The Process of Therapy
The first phase of therapy focuses on assessment and engagement. People who have not thought about or decided to directly work on their substance use need to be engaged with the question of whether there is anything problematic about their use. Prochaska and DiClemente have called these people precontemplators and contemplators. People who come with other presenting issues who use substances fall into this group. We support them in self-assessing the nature of their substance use pattern and explore whether their use impacts on their presenting concerns or other important issues. As problematic aspects of their use are identified, it becomes possible to focus directly on the substance use. Now, as with clients who come initially with concerns about their use, it becomes possible to discuss goals and strategies for modifying their use that are in line with what is important to them
It is important to listen for and reflect the client's ambivalence about changing rather than just side with the concern about using. The ambivalence contains the often unspoken personal meanings and importance that the substance has for the individual. As people become aware of these meaningful aspects of their use, a plan for change can be developed which considers how people can modify their substance use while meeting or expressing these needs in other ways. This may include both more effective substance-free self-care strategies and less harmful ways of using substances.
The question of moderating one's use versus working toward partial or complete abstinence now arises for many people. It is important to support people in clarifying for themselves what they are ready and interested in working toward as they set goals. Whatever I or you believe is realistic for them is less important than what the client is ready to work toward. I feel free to share my opinions about how realistic I think their goal is for them based on my experience with other people but I freely admit that I have no way of knowing whether or not they can achieve their goal. I suggest specifically identifying and working toward their goals, whether to moderate or to stop using, with an experimental attitude. How realistic the goals and strategies are is assessed as the work proceeds and revised when necessary. We continue to clarify what issues need to be addressed as they arise as obstacles to achieving the client's goals.
The work has a supportive focus on modifying the substance use pattern with a combination of cognitive and behavioral self-management strategies. There is an exploratory focus on the emotional issues that are associated with the substance use and conflict with changing. As these issues become clarified, it becomes possible to work on achieving more effective ways of managing or expressing them. This last aspect then becomes about getting to know oneself better, learning to listen to and accept oneself more deeply and discovering more effective ways of caring for oneself.
I see this approach as supporting the user in a self-generated process of change in which the client is in charge of his or her own growth and change. Insights which are revealed can then arise from the client's own experience and are, therefore, more readily accepted than when they are imposed by others.
I suggest flexibly combining cognitive and behavioral with psychodynamic and medical interventions as appropriate to the needs of the particular client. Modalities must also be matched to the unique needs, vulnerabilities, and strengths of the client. Most importantly, these decisions are based on what the client finds most useful and acceptable.
Andrew Tatarsky is a clinical psychologist with a private practice specializing in the assessment and treatment of the spectrum of substance use problems from a harm reduction perspective. He is current President-elect of the Division of Addiction of New York State Psychological Association and a founding member of Mental Health Professionals in Harm Reduction. |
