Dr. Jessica Katzman
3150 18th Street, Suite 207
San Francisco, CA 
(415) 570-4277
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Harm Reduction, Part Four: Treatment Considerations

3/23/2016

2 Comments

 
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.
Traditional substance use treatment programs tend to be purposefully confrontational in approach; this is in order to break through denial and give the person a hard look at the reality of their situation. 
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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:


REDEFINING SUCCESS
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.)

INDIVIDUALIZED GOAL-SETTING
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.)


SUPPORTING RELAPSE

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.


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Spatial Movements

2/23/2016

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After over a year of sharing space with some really wonderful colleagues in the ActivSpace building, I have finally moved into my own office! 

My new space is on the second floor, just off the building's sunny internal courtyard, and is one of the few vaulted-ceiling units in the building.

I've actually been waiting specifically for one of these units to become available, as I love how the dramatic height gives a spacious feel to the room. This is difficult to capture in pictures, but I still wanted to share some images with you:
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I've taken such immense pleasure in putting together my own little cozy room, and it feels so wonderful to invite folks in to a space that feels like me.

I'm also thrilled to continue to lay down roots in the ActivSpace community, and to be part of the ever-shifting, surreal, and still vibrant Mission district, in the city I adore above all others.

Thank you for reading, and for your continued support! I'm really enjoying this particular phase of my career development, and it's nice to be able to share that.
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Harm Reduction, Part Three: Substance Use as a Biopsychosocial Phenomenon

2/11/2016

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Greetings again to you all! I've recently been occupied by the project of moving into my own office (news about that to follow soon), but have been wanting to return to this topic.
In today's installment, I'm going to discuss substance use as a biopsychosocial phenomenon. This means that all substance use patterns are the net result of a complex interaction between a combination of biological, psychological, social, and spiritual determinants. ​
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Because the origins and progression of these use patterns are complex and variable, it then follows that a single-cause, one-size-fits-all approach to treatment can not possibly be sufficient for everyone.
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​Before moving on to further discuss treatment, I'd like to mention an important point that's related to the biopsychosocial model: people use substances for reasons.

These reasons can be viewed as pathological, or entirely normative within one’s culture and time.

Here are some examples:
  • Because they (especially initially) feel GOOD! Every living organism is organized around the hedonistic pursuit of pleasure and avoidance of pain
  • For religious ritual or shamanistic traditions (e.g. vision quests)
  • To aid in self-exploration and growth
  • To increase stamina during heavy work
  • To escape reality 
  • For sensory enhancement and sensual pleasure
  • To aid social bonding with other humans
  • To create or maintain an identity
  • To treat disease (i.e. self-medication)
  • To escape boredom and psychological despair
  • Pressure from one’s peers, or in the service of fitting into a social group
  • To stimulate artistic creativity
  • For celebratory purposes
  • To aid sexual connection and performance, or to enhance intimacy

(This is hardly an exhaustive list--can you think of any other ones to add?)

As we will see in future installments, exploring these reasons will heavily inform the direction treatment will take, and aid us in creating a compassionate frame for intervention.
​
That's all for now! I hope to have another installment for you coming up soon. Thanks for reading!
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Harm Reduction, Part Two: Moving Away from the Moral and Disease Models

12/17/2015

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Welcome back, and thank you for your comments on my first installment in this series of posts about harm reduction! This week, we'll take a look at the larger historical context of our belief systems concerning psychoactive substances and their misuse.​
The full history of drug and alcohol use in human society, obviously, lies way outside the purview of this post, since we would have to track back at least 10,000 years. Additionally, these substances are always inextricably bound up in the cultural, social, economic, political, religious, agricultural, and medical developments of a people.

(For fun, see A History of the World in 6 Glasses by Tom Standage f
or a pop-history take on the significance of fermented beverages in the evolution of human culture.)
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​The United States, in particular, has always struggled with a highly
 conflicted set of attitudes regarding drinking. The Puritanical roots of the colonial people, and later temperance organizations, had a hand in shaping the MORAL MODEL, seen in the 19th and early 20th centuries. This model can be characterized by these beliefs:
  • Addiction stems from a weakness of character, and is the result of poor choices.
  • It is naturally associated with crime, poverty, sin, domestic violence, and laziness.
  • The appropriate response should be punishment, not sympathy. (For an example of how this principle continues to impact our political policy, look no further than the War on Drugs.)


This was gradually (and perhaps only partially) replaced by the DISEASE MODEL, which has been viewed as our standard approach since the inception of Alcoholics Anonymous in 1935. The precepts of this model are:
  • Addiction stems from a biological disease, which follows an inevitable progression from use, to dependence, to extreme consequences, to death.
  • It is a black-and-white issue (either your're an addict or you're not) and is incurable (once an addict, always an addict).
  • This malady is marked by loss of control and powerlessness, as well as the addict's denial of the severity of the problem.
  • The only way to arrest the disease process is total abstinence, ongoing participation in 12-step community, and turning one's life over to a higher power.

​In contrast, the HARM REDUCTION MODEL of substance misuse holds that:
  • There is no one single cause—it is as complex as any human behavior, and often multi-determined (vs. a biological, inherited disease).
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  • It is not a black-and-white matter, but rather a continuum of use that flows from abstinence to dependence​​​.
        (Additionally, people may skip around on           this continuum, depending on their life             context and emotional state.)
  • There is actually a diversity of outcomes for substance misuse (vs. the “inevitable progression”). For example, it has been shown that most people stop using drugs by age 29 (and few start after this age), a process Peele calls "maturing out," which reflects how competing values and goals can have an effect on our choices.
  • The most common outcome of chemical dependency treatment is relapse, and continued abstinence the exception*. However, this typical over-focus on black-and-white treatment outcomes overlooks large amount of improvement in those who do not maintain perfect abstinence.
  • Many people are able to quit or stop using problematically without outside help (by some accounts, up to 35% recover with no help from others).
  • We are more likely to see positive outcomes from a focus on self-efficacy and the power to set one's own goals (vs. powerlessness and surrender).
     
​Thank you for reading! Next time, in Part III, I hope to discuss some treatment issues, such as redefining success, substance use as a biopsychosocial phenomenon, and looking at our complex relationships with our substances of choice.


* For example, Miller & Hester’s review of the literature on outcome studies regarding the efficacy of methods for treating alcoholism (from 1980 through 2002) concluded that, in the year following a treatment episode:
- 1 in 4 remained continuously abstinent
- 1 in 10 drank moderately and without problems
- Mortality during this period averaged less than 2%
- Even clients who DID drink in the year following treatment showed substantial improvement, abstaining on three out of four days, and reducing their overall alcohol consumption by 87% on average, with a 60% reduction in alcohol-related problems.
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Harm Reduction, Part One: Origins and Overview

12/10/2015

2 Comments

 
The remarkable progress made this year towards ending our disastrous war on drugs make this an optimal time to define and discuss the concept of harm reduction*.
I was trained in and practice from a harm reduction perspective (see my services for more information), so I'd like to provide some background and information about what this means, as well as invite some conversation around alternative ways to approach alcohol and substance use.
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So what IS harm reduction, and how did it begin?
​
Though we can trace its roots back for several decades, harm reduction largely became visible in the 1980s as an international public health movement that recognized HIV as a larger health risk than drug use in and of itself, and aimed to reduce transmission via the distribution of condoms and clean needles.

The primary principles of this health movement are an acceptance of the reality that people DO engage in high-risk behaviors, and a commitment to helping them reduce the harm associated with those behaviors, without requiring that the behaviors
themselves stop
.

Out of these principles grow many of our well-known public safety regulations and health education programs, such as seat belt and helmet laws, minimum drinking age requirements, nicotine replacements, safer sex practices, and designated driver programs.

General Philosophy
​Harm Reduction 
is a pragmatic stance, rather than one based in moral idealism, and is grounded in scientific research, human rights, compassion, and common sense.

It is consumer-oriented, maintaining a low threshold for participation; providers are committed to meeting people where they ARE, rather than requiring abstinence before treatment begins.

It is collaborative, rather than punitive; people are encouraged to participate in setting their own goals for treatment, and to work together with their providers towards those goals.


This stance represents a major shift in how we approach individuals with high-risk behaviors, opening the doors of treatment to many more people than ever before.


That's it for today--stay tuned for Part II: Moving from Away From the Moral and Disease Models! 


* Much of the information in these posts and my practice was gleaned not only from the excellent book Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol, but also via live trainings with Patt Denning, Ph.D., one of the authors. For those seeking further reading in this topic, I can not recommend this book highly enough.
​
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Solving the Procrastination Puzzle

10/21/2015

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After becoming aware of Canadian researcher Timothy A. Pychyl's blog Don't Delay, which discusses the science behind procrastination, I purchased Solving the Procrastination Puzzle: A Concise Guide to Strategies for Change, a short (by design) presentation of his team's research, formulated into practical advice on how to break our most entrenched task completion habits.
I’ve found this easily-digested (100 pages!) book very helpful in working with my own clients around habit change and goal-setting, and find many practical applications for my own life.*

In one of his often-referenced blog entries, Just Get Started, Dr. Pychyl describes their findings using pagers to track procrastination over time:

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​As expected, on Monday when participants were avoiding some task(s) in preference to others, we found that they typically said things like, "I'll feel more like doing that tomorrow" or "Not today. I work better under pressure." We rationalize the dissonance between our behaviors (not doing) and our expectations of ourselves (I should be doing this now). Later in the week few, if any, participants spontaneously said things like "I feel like doing that [avoided task] today" or "I'm glad I waited until tonight, because I work better like this."

More surprisingly, we found a change in the participants' perceptions of their tasks. On Monday, the dreaded, avoided task was perceived as very stressful, difficult, and unpleasant. On Thursday (or make that in the wee hours of Friday morning), once they had actually engaged in the task they had avoided all week, their perceptions changed. The ratings of task stressfulness, difficulty and unpleasantness decreased significantly.

What did we learn? Once we start a task, it's rarely as bad as we think. In fact, many participants made comments when we paged them during their last-minute efforts that they wished they had started earlier - the task was actually interesting, and they thought they could do a better job with a little more time.
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Given the large costs often involved, why, then, do we habitually procrastinate? A flash of insight occurred while reading Give in to Feel Good--another of his popular blog entries--which reframes task avoidance as an attempt at short-term mood repair. This also shed some light on the difficulty those struggling with depression and anxiety have with facing unpleasant tasks: if your mood is already low, avoidance will be a compelling short-term method to regulate your level of distress. 

Like many instant gratification techniques, however, the long-term consequences eventually become greater than the immediate rewards. 
​My clients have reported that applying the simple insight of "I don't actually have to be in the mood in order to get started on something," has been helpful in shifting their long-standing patterns of work avoidance, and thus reducing the costs of that avoidance.

Check out Dr. Pychyl's blog and his book for more great insights and tips, and please feel free to share your own!


* Just kidding! Therapists never procrastinate :)
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Inside Out

10/19/2015

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I greatly enjoyed* and have already reaped much therapeutic mileage from Pixar's summer film, Inside Out, with its reminder that exiling the experience of sadness can often leave our lives psychically poorer, and that the basis for human empathy and connection resides in our ability to have full access to our entire range of feelings.

I also appreciated the ability of this film to portray our core emotions as incredibly salient, caricatured personalities, as this directly mirrors the work that I often do with my own clients. Externalizing strong feelings, inner states, or critical voices into visible entities can be helpful in partially de-identifying with our impulses, allowing us to view ourselves with greater neutrality and compassion. It can also be helpful in facilitating much-needed conversations with these parts of ourselves while in a supportive therapeutic atmosphere.


I can't imagine that I was the only therapist or healer to get excited over the potential applications of this film, and I would be very curious to hear from others about how they have integrated this artful bit of pop culture into their practice. Please do feel free to reply back to me with any thoughts you might have on the matter!

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* Though I entered the theater expecting to cringe at least once over the portrayal of complex neuroscience and cognitive psychology concepts, I found that the only truly upsetting element was the highly size-negative/fat-shaming representation of Sadness (as held in contrast with Joy and Disgust). A less stereotypical approach at constructing their appearances would have been much welcome.
2 Comments

Expanding my Referral Network: A Request

10/12/2015

2 Comments

 

My focus during this next phase of my practice is to exponentially grow my referral network, and develop a strong base of professional colleagues. My main motivations for this are:

1) Clinicians moving from agency work into private practice face considerable isolation risks; these can not only threaten one's ability to practice competently, but also one's overall well-being and job satisfaction. Maintaining healthy ties to a professional community is essential, and as we no longer have access to the default network provided by the workplace, it is up to us to build our own.

2) I find that it is frequently necessary to refer folks to another therapist or service for various reasons (when I am full, not on someone's insurance plan, not in the right geographical location, am too personally close to the person seeking therapy, discover issues outside my scope of practice, etc.).

I also often seek referrals for my own clients to additional services that I do not offer, such as couples therapy, child/family therapy, support groups, psychiatry, bodywork/massage, personal organizers, or other specialized services.

To this end, I have reached out to as many colleagues as possible, and am pleased with my growing list of potential referrals (augmenting my Resources page).

I also 
recently joined both Open Minds and Gaylesta, which are local groups of therapists and students who affirm that sexual and gender diversity are natural expressions of the human experience, and who help clients connect with LGBTQQI-friendly and kink/poly-aware therapists. I am excited to welcome more queer-identified folks into my practice as a result of these connections. 

I have already found the support in these associations to be significant, and appreciate the immense pool of resources members provide each other. I volunteered at the Gaylesta booth for a few hours of the Castro Street Fair, which became a wonderful point of connection with other like-minded therapists and the community, and I plan to represent Gaylesta at the Transgender Health Fair in December.

Here, then, is my request to you:

If you know of another mental health/helping professional that is not currently within my network, please connect us!

To other mental health/helping professionals:

-If you would like to be in my referral network, please introduce yourself!


-If you have a consultation group that is accepting new members, or are attending a training I might be interested in, please let me know!

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If you work with another really strong/specialized clinician, please connect us!

-If you have a newsletter or mailing list, please add me to it, and if you would enjoy reading my quarterly practice newsletter, please add yourself here!


Thank you 
for your assistance with this project! I am loving the world of private practice, and intend on staying connected to a supportive and diverse community as I walk this new path.

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Practice Updates: Expansions and New Beginnings

10/5/2015

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Greetings! I'm excited to share some recent changes to my practice. The summer of 2015 brought major changes, as after almost a decade at PAES Counseling Services, I stepped down from my Clinical Supervisor position, and into my own practice full-time. It was indeed a bittersweet departure, as I will acutely miss all of my wonderful RAMS, Inc colleagues, as well as the wonderful clients this program serves. However, I continue to maintain strong ties to this community, and am also extremely excited to be able to devote my full attention to my private practice, fostering its growth over the months and years to come.  

I continue to supervise for Queer LifeSpace, a nonprofit providing long-term, low-fee mental health and substance use services to the LGBTQQI community. I have also taken on a postdoctoral intern from CIIS, as well as a trainee from Haight-Ashbury Psychological Services (HAPS), a sliding scale psychotherapy clinic. (HAPS was actually my initial practicum site--way back in 1999--and current collaborations with my very first supervisor has lent a wonderfully rich coming-full-circle feel to this phase of my career!)

In addition, I have a new contract with Episcopal Community Services, providing consultation and supervision for the case management team at the Navigation Center, the city's newest homeless shelter pilot program. Supporting their staff is a natural extension of my last decade within San Francisco's welfare-to-work program, and I am pleased to maintain a link to services for San Francisco's neediest populations.

Please feel free to update me on your professional developments, and thank you for your continued interest and support!
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FYI: SF Housing authority opens its wait-list to homeless residents for this week only!

1/14/2015

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San Francisco’s Housing Authority is now accepting applications for its public housing wait-list for the first time since 2010. Homeless adults and families may apply, as well as unstably housed families, and those who wish to move from a supportive housing unit into a public housing unit.

Beginning January 13, homeless San Francisco residents will be able to place their names on the public housing waiting list. Applications will be received online only, and the list is only open until January 17th at 11:59pm.

You may 
go to this page to apply, or to help someone with the application process.

Homeless residents throughout the City will be able to access the online application at libraries and select Housing Authority sponsored sites, where staff will be available to assist applicants with the online application process.  
Please see this flyer for information and locations.

You can learn a little more about background behind this current effort in the Examiner article. Please feel free to reach out to me if you have any questions about this process!


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    Jessica Katzman, Psy.D.

    I'm a psychologist with a private practice in San Francisco's Mission 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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    Photo credit: Tristan Crane Photography.

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