Welcome back! In the last three parts of this series, we’ve looked at the basic principles of harm reduction, the shift away from the Moral and Disease models of addiction, and substance use as a biopsychosocial phenomenon.
Today, let’s look at how this paradigm shift translates into treatment.
The assumption is that once confrontation has broken down the addictive personality, one can then be taught humility, and the personality rebuilt around sobriety.
Another assumption is that addiction is the primary disease, which means that it MUST be addressed first, with total sobriety required before any other life or mental health issues are addressed.
Relapse--or any deviation from total sobriety--is often grounds for discharge from the program or treatment, and the person is deemed “not ready” for treatment.
Some people respond well to this structured treatment approach, and credit it with saving their lives. However, many others (especially those with severe mental health concerns or trauma histories) find this too aversive, and require alternative strategies.
In contrast, let’s look at some of the defining features of harm reduction treatment:
In this model, any step in the right direction towards health, any reduction in substance-related harm, ANY POSITIVE CHANGE is seen as a success.
(For example: if you generally have five drinks each night, and you then are able to bring it down to four, THAT is viewed as a step in the right direction, and recognized as a valuable accomplishment in treatment.)
In contrast to the “one-size-fits-all” model of abstinence, harm reduction recommends a thorough investigation of all internal and external factors that contribute to the current situation, and the co-creation of an individualized treatment plan, based on the person's unique goals and needs.
(For example: one person might have a preference for a long “warm turkey” phase of reduced use, with an eventual goal of abstinence, whereas another might just need assistance in creating a safer using plan while addressing a recent trauma.)
One thing to notice here is that the wide range of possible harm reduction goals actually includes abstinence! The difference is that abstinence is not held out as the only possible goal of treatment, and it is presumed that there might be multiple and gradual ways of getting there.
The emphasis here is on respecting each person’s autonomy over their life and choices, and empowering them to “run their own experiment” to determine their own optimal levels of use.
FOCUS ON THE HARM, NOT THE SUBSTANCE
The therapist/helper's focus is on reducing the potential harm of these substances, and not necessarily on reducing the use itself. They may provide psychoeducation about adverse medical or social consequences, along with a "menu of options" about how one might avoid those consequences.
(For example, one might choose to access clean needles in order to avoid disease transmission, or to drink a glass of water for each alcoholic drink in order to avoid dehydration, or to choose a designated driver to avoid a DUI. None of these choices involve reducing one's use, but greatly enhances the safety of the situation.)
Additionally, any sort of "relapse" behavior is viewed compassionately; treatment is often re-focused here, not terminated, as this is when people are often in greatest need of support. It can serve as both a potential warning sign (were initial goals too ambitious? are there new stressors to consider?) and an opportunity for learning about one's triggers and treatment needs.
Next time, we'll continue our exploration of treatment considerations with a discussion of how a person's relationship with their substance of choice affects treatment.
Stay tuned, and stay well! Thanks for reading.
Jessica Katzman, Psy.D.
I'm a psychologist with a private practice in San Francisco's Castro District. I'm interested in harm reduction, LGBTQQIAAP issues, psychedelic integration, social justice conversations, size acceptance, and any intersections of the above. I welcome your comments!
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