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Harm Reduction: A Model for Social Work Practice with Adolescents

Harm Reduction: A Model for Social Work Practice with Adolescents



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presents the case for harm reduction in working with youth
presents the case for harm reduction in working with youth

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Published by: katherine stuart van wormer on Mar 01, 2009
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Harm Reduction:A Model for Social Work Practice with AdolescentsKatherine van WormerTHE SOCIAL POLICY JOURNAL 3 (2), 2004, 19-37.ABSTRACT. A practical antidote to the war on drugs, the harm reduc-tion approach seeks to meet clients where they are, establish rapport andhelp them modify or give up their risk-taking behavior. This article pre-sents the case for harm reduction techniques for work with youth whoserisk-taking behavior is problematic. Emphasis is on drinking, drug use,and high-risk sexual activity.KEYWORDS. Harm reduction approach, client-centered approach,strengths perspective, adolescents, high-risk adolescent behaviorINTRODUCTION“Meet the client where the client is,” the popular slogan of socialwork practice, sums up harm reduction philosophy in a nutshell. Fromits origins as a way of addressing the negative consequences of druguse, the harm reduction concept has grown considerably in recent years(Hill, 1998). An international public health movement, harm reductionjoins client and therapist in the realistic pursuit of reducing the harm inKatherine van Wormer, MSSW,PhD, Professorof SocialWork, Universityof North-ern Iowa, Cedar Falls, Iowa 50614 (E-mail: vanwormer@uni.edu).The Social Policy Journal, Vol. 3(2) 2004http://www.haworthpress.com/web/SPJ2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J185v03n02_0319Page 2one’s life. Typical strategies include: helping clients substitute a lessharmfuldrug for alifethreateningdrug;recruitmentof clientsintometha-done maintenance and needle exchange programs; giving women re-turning to their battering husbands a safety plan for self protection; andan after-school program to help gays and lesbians “talk through” prob-lems of internalized homophobia that might otherwise seek self-de-structive channels of expression.Although social work and the harm reduction approach are a naturalfit and widely integrated in Europe (see van Wormer, 1999), the U.S.social work literature is remiss in terms of describing the utilization ofthis practice/policy perspective. A search of Social Work Abstracts on-line as of August, 2003 reveals ten listings for harm reduction, only fourof which are in American social work journals–from Health and SocialWork are articles by Brocato and Wagner, (2003); Reid (2002); andMacMaster, Vail, and Neff (2002); and from Social Work Research anarticle by Burke and Clapp, (1999). (Actually, this is a big improvementover one year earlier when only one article from a U.S. journal of socialwork was listed.) For point of comparison, PsycInfo lists 388 at the timeof this writing. In substance abuse texts written by American socialworkers, as well, the harm reduction model is relatively absent. Excep-tions are Abbott (2000) and van Wormer and Davis (2002). Abbott pro-vides a two page description of the model and includes a chapter byDunn (2000) that utilizes the stages of change model consistent withharm reduction and strengths-based principles. The van Wormer andDavis volume, similarly, is strengths-based and utilizes a harm reduc-tion conceptualization throughout. One can expect to hear much moreabout harm reduction and its practice counterpart, motivational inter-
viewing, in the future, however. The prestigious Journal of Social WorkEducation recently published “After the War on Drugs Is Over: Impli-cations for Social Work Education”by McNeece (2003). I believe, indi-rectly, the empirical research in the federally funded Project Match(1997) which confirmed the effectiveness of a variety of treatment ap-proaches but which showed that motivational strategies worked welland especially well with angry clients, has brought a belated effect tobear on treatment offerings. At the same time, there is a general consen-sus that prevention is preferable to treatment and that harm reductionstrategies, like the public health model, are geared toward preventingthe development of addictions problems in the first place.A further promising development is the endorsement by the NationalAssociation of Social Workers (NASW) (2003) in their handbook ofpolicystatementsof acomprehensivepublichealthapproachfor thepre-20THE SOCIAL POLICY JOURNALPage 3vention of alcohol, tobacco, and other drug problems and harm reduc-tion strategies aimed at persons affected by such problems. In this arti-cle we will examine the principles of a harm reduction or public healthframework, relate these precepts to the strengths perspective of socialwork practice, and explore work with adolescents as just one of the ar-eas of social work for which the harm reduction model has special rele-vance. Emphasis will be on adolescent risk taking in the areas of sex-uality and substance abuse.HARM REDUCTION Versus TRADITIONAL APPROACHESWhat is the harm reduction approach? To define this term, we need totake into account the two aspects of harm reduction that are often poorlydifferentiated in the literature–these are the policy and practice aspects.As policy, harmreductionis anoutgrowthof theinternationalpublichealthmovement. Its most familiar representation is as a philosophy that op-poses the criminalization of drug use and views substance misuse as apublic health rather than criminal justice concern. The goal of the harmreduction movement is to reduce the harm to high risk takers and to thecommunitiesinwhichtheylive,includingtheharmcausedby criminal-ization of the substances (Jensen and Gerber, 1998). Proponents of thismodel generally oppose laws against drinking by young adults underage twenty-oneand harsh punishmentsfor drug use and possession. Thewar on drugs, from this viewpoint, exacts a deadly toll. This toll is gen-erated in terms of: use of contaminated, unregulated chemicals; thespread of hepatitis, tuberculosis, and AIDS through the sharing of dirtyneedles; the social breakdown in America’s inner cities; and politicalcorruption elsewhere (van Wormer and Davis, 2002). In Europe, in fact,it was the AIDS epidemic of the 1980s which catapultedharm reductionpolicies into prominencein several countries, including Britain (Abbott,2000). Drug use was medicalized, and the behavior of drug use closelymonitored at methadone and other clinics where a safe drug supply wasprovided under medical supervision. SeveralU.S. cities including Balti-more and Seattle have moved in the direction of such progressive poli-cies.Because harm reduction measures are diversified and highly prag-matic (as opposed to moralistic), scientific research plays a key role inconvincing legislators and other policymakers to sponsor the establish-ment of such strategies. Proof is essential, moreover, to establish whichprograms are truly harm reducing, as Canadian public health specialist,Eric Single(2000), reminds us. Fortunately, despite the U.S. federal gov-ernment’s reluctance to publicly endorse non-abstinence based pro-grams for youth, there is much grant money available for experimental
treatments, as, for example, the Cannabis Youth Treatment Series de-scribed at the National Clearinghouse for Alcohol and Drug Informa-tion and unveiled by the Substance Abuse Mental Health Services Ad-ministration (SAMSHA, 2000). This series compared traditional withalternative approaches, including motivational therapy, in which cli-ents, in individual sessions, are given the message that the decision tostop smoking marijuanais up to them.Results with a large sample showedthat there was substantial reduction in marijuana use with the variousmethods that were applied. Consistent with the principles of harm re-duction, note that in the research literature today, the measure of treat-ment success relevant to substance misuse is a reduction in use and inharmful consequences;the traditional measure was always complete ab-stinence from the drug (van Wormer and Davis, 2003).At the practice level, harm reduction is an umbrella term for a set ofpractical strategies based on motivational interviewing and other strengths-based approaches to help people help themselves by moving steadily inthe direction of reduction of high-risk practices. As practice, harm re-duction entails removing barriers such as lack of childcare or bureau-cratic constraints that impede people from getting treatment. Typicaladvice given to clients is of the order of, “Don’t drink on an empty stom-ach,”or “Don’t drink and drive.”Duncan, Nicholson, Clifford, Hawkins,and Petosa (1994) describe how they confronted an epidemic of paintand solvent “huffing” after two boys died from inhaling paint fumes inplastic bags. Educational presentations to youth groups emphasized thedangers of huffing and warned them if they did do it,to at least use paperbags instead of plastic bags which could be lethal.In this client-centered approach, use of negative labels such as “anti-social”and“borderline”in mental health,“criminal personality”in crim-inal justice, and“alcoholic/addict”in substance abuse treatment is avoid-ed; clients provide the definition of the situation as they see it. The tradi-tional message imparted to kids, such as in educational programs, is thetotal and immediate abstinence from all dangerous, risk-taking activi-ties such as no sex before marriage and don’t drink until you’re 21. Pe-terson, Dimeff, Topert, Stern, and Gorman(1998) warn against the“boom-erang” effect of these absolutist approaches as alienating of youths andlessening adult’s credibility. An approach stressing choice in decisionmaking, in contrast, empowers youth to make practical decisions abouttheir own lives. Given the obvious reluctance of drug users to volunteerfor treatment under the old, police-dominated system, new and very dif-ferent forms of intervention must be developed (McNeece, 2003).PUNITIVE TRADITIONS ON THE AMERICAN CONTINENTForcing young unwed mothers to carry their babies to term; returningparolees who have relapses to prison; mandatory sentencing; zero toler-ance in the schools–such practices commonly supported by the Ameri-can public and policy makers reflect a punitive ethos that has its roots inColonial times.Like the very language that shapes our every thought and deed, thepresent day American value system is rooted in the New England expe-rience, in the foundation laid down by the colony of religious zealots inMassachusetts Bay. The essence of this foundation was the holy experi-ment known to the world as Puritanism. In his classic, Wayward Puri-tans: A Studyin theSociologyofDeviance, Kai Erikson (1966) provideda colorful portrait of this society and of the dissenters among them.Theirs was a society run by the clergy whose role it was to interpret thescriptures for guidance in all matters of living. Indeed, back in England,the English had found their narrow liberalism and lack of humor baf-fling. To Puritans who reached Massachusetts, the truth was perfectlyclear: God had chosen an elite few to represent Him on earth. It was

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