Rivkah Lapidus, a member of NSGP since 1984, is a member of the SAGE Task Force and a former member of the NSGP Board of Directors. She has a private practice in Somerville, is a visual artist, and is a member of Mayor Curtatone’s task force in establishing a safe consumption site in Somerville.
Before I get into the clinical and controversial aspects of Harm Reduction, I want to ask: Do you wear a mask? A seatbelt? A bicycle helmet? Good -- whether you knew it or not, you are already on board with a Harm Reduction stance. I would like to offer the simplest possible definition of Harm Reduction so that you can see where you fit into the approach. Harm Reduction is just that -- reducing the harm that may come from specified behaviors and situations, even ones we find distasteful, even when the affected person doesn’t want to change, or expectations of complete change are unrealistic. Have you referred a woman to a Safe House? Discussed averting suicide with a struggling patient? Started seeing a patient twice a week? Have you practiced psychotherapy in any form? These are all the ways we have of averting harm -- not eliminating harm completely, but reducing the possibility of worse outcomes.
History The Harm Reduction movement was a paradigm shift born of necessity: people were dying of HIV and related diseases. A full history of the decades that formed the Harm Reduction paradigm (Roe, 2005) is beyond the scope of this small article. In brief, various social movements coalesced in the 1980s during the AIDS epidemic. Harm Reduction was a life-saving alternative to the abstinence-based Disease Model that was preeminent in the field at the time (Peele, 1985). International Harm Reduction conferences presented the research from those years, including Best Practices medication trials, methadone treatment, and needle exchanges programs (NEPs). In addition, social movements challenged racially biased drug policy introduced in President Nixon's War on Drugs and that were aggressively enforced during the 1980s.
The Harm Reduction Model Integrated Harm Reduction Therapy for problematic substance use (Marlatt, 1996; Tatarsky, 2002) is a decades-old paradigm, but hasn’t become a fully integrated part of clinical teaching. The major principles of Integrated Harm Reduction Therapy are: 1) accepting that substance use is part of our world; 2) understanding drug use (or harmful behaviors) operate on a continuum; 3) establishing improved quality of life, even without abstinence (many users do not wish to stop); 4) non-judgmental and non-coercive treatment without stigma; 5) ensuring users have a voice in the creation of programs meant to serve them; 6) affirming and empowering People Who Use Drugs (PWUD) to support each other; and of course, 7) real engagement in the treatment setting.
The Stages of Change model (Prochaska & DiClemente, 1986) is critical to a Harm Reduction approach. Among People Who Use Drugs there is a wide range of users who fit somewhere on the Stages of Change Model. Harm Reduction allows people to set their own agenda, and the clinician to meet them at whatever part in the cycle of readiness they are in, without judgment or enforcing an agenda. The stages of change are: Precontemplation, Contemplation, Preparation, Action, and Maintenance. The stages don’t need to proceed linearly. Interventions must be attuned to where the individual “is at.” For example, a precontemplative user is not thinking at all about change. This might be a time to do a “cost-benefit analysis” (e.g. Denning & Little 2017) or a personal values assessment. A contemplative user feels conflicted and uncomfortable about the target behavior. This is a great opportunity to address ambivalence. It would be a misattunement to convince a precontemplative user that it is time for an abstinence program.
Contemporary Harm Reduction Challenges At this moment in history, and during a pandemic, public health is more or less a sacred mission. During the pandemic, people who use drugs are in danger of slipping off the radar. Worldwide, the Harm Reduction community is engaged in establishing Safe Consumption Facilities for PWUD. There is an urgency about bringing these sites, a.k.a. Safe Injection Facilities (SIFs), a.k.a Overdose Prevention Sites, from out of the shadows and into the light of day as an effective, evidence-based, and sane approach to the ravages of a drug supply increasingly laced with fentanyl, leading to a sharp rise in overdose deaths.
In a safe consumption space, users would have their drugs checked for deadly fentanyl, be given clean equipment, and have their vital signs and mental status monitored after dosing. Emergency services would be supportive and respectful of peer services and called in if there is a situation that peers cannot handle. Users would have a place to relax, shower, read materials for multiple treatment options (not “one size fits all”), and enjoy conversation for as long as needed. Perhaps a “warm” referral could be made to a therapist or program.
SIFs have often operated underground, peer to peer (Remembering Aubri Esters, n.d.; Dooling & Rachlis, 2010). Such sites already operate in Montreal and Vancouver (Small et al, 2012). In Portugal, legalization of opioids combined with SIFs have basically ended the overdose epidemic there (Vogel, 2014). There has never been an overdose death at any of the operating sites. Numerous studies show there is no “honeypot” effect -- people are not induced to use substances by the presence of a safe facility. These sites are effective, but our country has lagged in establishing them. This writer is pleased to be a member of Somerville, MA Mayor Curtatone’s original task force on establishing a SIF by the end of this year (we were waylaid by the pandemic).
Other challenges to Harm Reduction remain linguistic, therefore conceptual. Our language about substance users has needed to change to avoid stigma and “othering.” We need not identify people by their behaviors in a negative way. Language such as “co-dependence,” “enabling,” “powerlessness,” and labels like “an addict” come from another paradigm. Often clinicians aren’t sure what to recommend to their client who uses substances, and the 12-step model is a strongly rooted standby.
Harm Reduction Applied to Group Therapy In applying the Harm Reduction model to group therapy, some ideas to keep in mind are: 1) Just as you create an environment in which it is encouraged to talk about feelings, also make it acceptable to talk about behaviors that are usually kept hidden; 2) Cultivate an atmosphere of non-shaming and curiosity; 3) If you feel out of your depth, consult with someone familiar with this field, and the many possible approaches; 4) Appreciate the effort it takes for a group member to talk about substances, and encourage the topic as it arises.
Back to What This Has to Do with You Many of us may say “fine -- but I don’t work with these populations. How is this relevant?” I would like to assure you that it is relevant, and that you do work directly or indirectly with these “populations” whether you are aware of it or not. For example, one person NOT in treatment with you may alter an entire family system. It may or may not be something that turned up in a clinical interview with the client(s).
Clinicians are often woefully under-trained in critical health psychology and contemporary substance use theory. I have already deemed you Harm Reductionists by virtue of the work you do in general. But getting into the specifics of sex work, drug use, and other “choices” may feel sordid and not your metier. It doesn’t have to be. With every empathic treatment intervention you make with any “population,” you are practicing Harm Reduction in the broadest sense. Adopting the language of People Who Use Drugs and becoming aware of Harm Reduction programs in your local area are important first steps to working empathically with clients who use substances. You are providing a space to help people feel safer, and to carry that into their world.
If you would like to know more about harm reduction and how it relates to your practice, or for more references, please email the author at email@example.com.
References Denning, P., Little, J. (2017). Over the Influence, The Harm Reduction Guide to Controlling Your Drug and Alcohol Use. The Guilford Press.
Dooling, K. & Rachlis, M. (2010, September 21). Vancouver’s supervised injection facility challenges Canada’s drug laws. CMAJ, 182(13), 1440-1444. https://doi.org/10.1503/cmaj.100032
Marlatt, G.A. (1996, February). Models of relapse and relapse prevention: A commentary. Experimental and Clinical Psychopharmacology, 4(1), 55-60. https://doi.org/10.1037/1064-12126.96.36.199
Peele, S. (1985), The meaning of addiction: Compulsive experience and its interpretation. Lexington, MA: Lexington Books.
Prochaska, J.O. & DiClemente, C.C. (1986). Toward a comprehensive model of change. In W.R. Miller & N. Heather (Eds.), Treating Addictive Behaviors (pp. 3-27). Springer.
Roe, G. (2005, September). Harm reduction as paradigm: Is better than bad good enough? The origins of harm reduction, Critical Public Health, 15(3): 243–250.
Small W., Wood E., Tobin D., Rikley J., Lapushinsky D., Kerr T. (2012, April). The Injection Support Team: a peer-driven program to address unsafe injecting in a Canadian setting. Subst Use Misuse. 47(5), 491-501.
Tatarsky, A. (Ed). (2002). Harm Reduction Psychotherapy: A new treatment for drug and alcohol problems. Jason Aronson.
Vogel, L. (2014, July 8). Decriminalize drugs and use public health. CMAJ, 186(10). https://doi.org/10.1503/cmaj.109-4820
Zinberg, N.E. (1984). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press.