Harm Reduction

Psychological Treatment for Substance Use Disorders

Spring 2015
Nancy A. Haug, Ph.D.
Harm Reduction
—  Denning & Little:
—  “An approach to working with drug users that aims to
reduce drug-related harm to individuals, their families and
communities without necessarily reducing the consumption
of drugs and alcohol.”
—  Goal is decreasing negative consequences vs. reducing the
prevalence of drug use.
Harm Reduction Principles
1.  Clinician should work with stated goals of the client.

2.  Access to treatment should have few barriers to entry.

3.  Success is any reduction of harm in a drug user’s life.

History of Harm Reduction
—  Coined in 1980s to describe public health approaches
—  Netherlands (hepatitis and HIV)
—  Needle exchange programs
—  Mersey Clinic in Liverpool (1989) pharmaceutical opiates
and clean equipment

—  U.S. 1960s à methadone programs in San Francisco

—  Needle exchange in New Haven, CT (1986) & Tacoma, WA
(1988)
—  Needle exchange banned by federal government until 2009

—  Medical Marijuana legalized in 1996 in California

What is Harm?
—  Personal à physical and mental health, infectious
diseases, premature death, relationship disruption,
unemployment, loss of income, incarceration

—  Family à physical and emotional violence, breakup of

families, child abuse and neglect, loss of income

—  Community à crime, injuries, death, gang violence,

street drug sales

—  Societal à loss of productivity, health care cost, drug

treatment, social services, policing, incarceration,
interdiction
Harm Reduction Movement
—  Public Health à needle exchange, overdose prevention,
pill testing in clubs, housing

—  Advocacy à drug policy and laws (e.g., medical

marijuana, crack and powder cocaine sentencing,
treatment over jail, pregnant women)

—  Treatment à harm reduction psychotherapy

Harm Reduction Psychotherapy
—  Philosophy and set of strategies

—  Attitude of acceptance toward drug use and drug users

—  Interested in the individual’s relationship with drugs and

reasons for using

—  Open, flexible, client-centered

—  Understands the client in the context of cultural experience

and identity

—  Collaborative

—  A purely client-driven model

Harm Reduction Therapy
—  Integrative Model:
—  Developed to treat dual diagnosis
—  Integrates model and interventions from a variety of
therapeutic traditions
Harm Reduction Therapy:
The Nature of Drug Use
—  Not all drug use is abuse à drug use occurs on a
continuum

—  People do not have addictions; they have a relationship

with drugs

—  People use drugs for reasons

—  Drug, set and setting: unique relationship with each

drug used (culture’s relationship with drugs influences
the drug experience itself)
Harm Reduction Therapy: The
Nature of Change
—  Change in addictive behavior is typically gradual and
different for each person

—  People do not have to quit using drugs in order to make

positive changes

—  Success is any movement in the direction of positive

change or reduction in drug-related harm

—  Success is related to self-efficacy

—  Abstinence is a harm reduction outcome!

Harm Reduction Therapy: The
Nature of Treatment
—  Active drug users can and do participate in treatment

—  Collaborative process model (not outcomes model)

—  Stay where the client is and stay with the client
What does it take to practice
HRT? (Denning & Little, p.292)
—  Willingness to practice radical neutrality

—  Willingness to grapple with ethical gray areas

—  Willingness to tolerate, accept, and understand difficult

behaviors

—  Willingness to be taught by our clients

—  Willingness to relinquish the role of authority, judge or

expert

—  Willingness to partner with clients

Harm Reduction (Miller, Ch. 23)

—  Screen for risk or harm that is occurring

—  Evaluate for substance-related problems

—  Infections (i.e., HIV, TB, STDs)
—  Child abuse/neglect
—  Suicide risk

—  Proponents: Pragmatic and humanitarian to reduce

harm to users and to society

—  Opponents: Condones and facilitates drug use

Harm Reduction
—  A form of tertiary prevention à reduce harm to user or
others.

—  See stonewallsf.org and andrewtatarsky.com

—  Internet-based interventions (tweaker.org)

—  Screening and services where people who use substances

already are:
—  HIV medication dispensed at methadone clinic
—  Needle exchange at public hospital
—  Free condoms distributed at a street fair
—  Pill testing or adulterant screening (dancesafe.org )
Preventing Harm
—  Is it ethical to have harm reduction as a goal rather
than abstinence?

—  Why might a professional reject attempts to prevent

harm?

—  See Box 23.4 (p. 385)

Arguments against
Harm Reduction
—  Prolongs addiction by removing natural consequences

—  Enables and condones illegal behavior

—  Leads to relapse, deterioration and death

—  Harm reduction is “foot in the door” for legalization

—  Not an evidence-based treatment