I Want to Be a Harm Reduction Counselor

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As in many other arenas, it can take a long time, often years, for evidence-based findings in addiction medicine to “trickle down” to the practitioner level. That means that there is frequently a disconnect between what researchers know, what clinicians believe and what they are actually able to implement in their clinical practice. Does the harm reduction approach to addiction treatment fit this paradigm? Here, a young clinician, The author struggles with the disconnect between what he finds intuitively valid and the abstinence-oriented treatment philosophy that is often mandated by referral sources and government entities…Richard Juman

Yes. I want to be a harm reduction counselor. There, I said it. You should try it; it feels good. After all, who among us does not want to reduce harm? The problem is, for many in our field, these two words are a dogwhistle for something other than abstinence. There are places where uttering these words is verboten, blasphemous, or even professional suicide. I worked for one agency in which the lead counselor would have run into the director’s office, waving this article and demanding my immediate termination. I am a graduate student and a novice in the field of substance use counseling, and as such, I am in the process of forming my style and approach to the helping profession. At this moment, I am convinced that harm reduction is the future of our field. I am not going to explain what harm reduction is, or why its time has come; Debra Rothschild does a fine job of that here. I am not going to explain how abstinence is included under the “harm reduction umbrella”; Jeannie Little does that beautifully here. I want to explain in my own words why I am inclined to view my work as part of the harm reduction paradigm.

In a harm reduction approach, all stages of substance use disorder are treatable, all treatment modalities are useful, and all pathways to recovery are valid.

Like many of us, I work for an agency which embraces an abstinence-based approach to treatment, and I am also a person in long-term abstinent recovery. I enjoy my work in this segment of our field, and I believe that abstinence is the best possible outcome for many individuals with substance use disorders. However, I have seen with my own eyes the need for a wider range of treatment approaches, successful outcomes and diverse pathways to recovery. There has been a false dichotomy drawn between harm reduction and abstinence. For many who believe that abstinent recovery is the only indicator of successful treatment, there is an us-and-them, all-or-nothing mentality that greatly restricts the treatment options available to individuals. This is most noticeable in the spectrum of referrals; but it also influences public policy, stifles innovation in the treatment field, and perpetuates stigma among those we serve.

Recently, Hazelden Betty Ford endorsed medication-assisted therapy as a viable treatment option. Who saw that coming? What they have realized is what many of us in the trenches are slowly coming to terms with: different treatment approaches are not mutually exclusive. The choice is not abstinence or harm reduction. The choice is harm reduction or death. I have had many clients in my office who might greatly benefit from medication-assisted therapy; but, as the saying goes, “You can’t get there from here.” At the residential facility where I work weekly, patients “complete” treatment and return before my next shift rolls around. What was that definition of insanity again?

A good deal of what I bring to the table is leftover from my brief career as a special education teacher. There is actually a significant overlap in the fields, and some of the latest neuroscience is pointing to a new model of addiction as a learning/developmental disorder. Not only is much of the underlying psychology useful, but specialized training in working with diverse populations and the spirit of working on behalf of the oppressed are present in both fields. The practices and documentation are very similar. A treatment plan is really just an IEP (Individualized Education Plan). A case consult is (ideally) a multi-disciplinary team meeting. Instructional media skills come in quite handy, and the developmental-learning model of substance use and treatment aligns well with behavioral psychology. Most of all, respect for the individual and the eschewing of labels are vital to the education and treatment of individuals.

“People-first” thought and language, now becoming fashionable in substance use treatment and recovery advocacy, were pioneered 30 years ago in the movement for people with disabilities. One of the most important ideas in special education is the idea of individually defined success. Individuals with differing abilities can define success in their own ways, and receive the same educational merits for doing so. Benchmarks are measured, taking into account the individual’s abilities, goals, and a host of bio-psycho-social factors. Sound familiar? In special education, the first thing we had to concede was the idea that all students should reach a bar that is uniformly set. The need for true individualization, not just of instruction, but of success, is paramount. Every improvement is celebrated; all progress is valid. Success must exist on a continuum; otherwise, failure is rampant. The other important takeaway from special education is the idea of adaptations. Imagine if every child with cerebral palsy was expected to climb the rope in gym class, or every auditory learner was expected to acquire knowledge by silently reading. Adaptations based on an individual’s unique abilities and circumstances level the playing field, and increase the likelihood of success and further development. This is now common sense in the field of education; but at first, there were many who cried “foul.”

I believe that this principle has been borne out in the field of substance use treatment, and the evidence is all around us. Just as learners have diverse learning styles, those in treatment have diverse recovery styles. There is no panacea, and conversely, throwing the kitchen sink at the individual in the hopes that something might stick may not be the best way to go about treating people. We have the assessments to determine people’s abilities, strengths, needs and preferences; these are often touted in sparkling testimonials by agency spokespeople as “adapting treatment to the individual.” But after the assessment, it is critical that the individual and her preferences are not then shoehorned into the agency’s philosophy. Why not go all the way and truly individualize treatment? Why not expand the continuum of success?

SAMHSA’s latest working definition of recovery has a distinctive harm-reduction feel:

“A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

One of the principles of harm reduction is the acceptance that substance use will never be completely eradicated. This perspective keeps me grounded and eliminates the need for me to quixotically crusade against substance use, and focus on helping people in a sensible way. I have often observed that pro-recovery does not equal anti-drug. While abstinence may be the best possible outcome for a person with substance use disorder, the reality is that very few achieve it, and it is rarely achieved in one treatment episode. Working from a harm reduction-informed approach allows me to use a supportive, empowering response to substance use and relapse, helping the individual to take stock of his success as well as his mistakes, rather than a cynical, shame-based response that drives the individual to “rock bottom” in order to find motivation.

When “Joe” came to me after a relapse, he was crestfallen, saying that he had “thrown away his clean time.” His experience with treatment and recovery had been heavily influenced by the 12-step model, which requires that the individual start counting over again with each use of substances. I told Joe, as I do all my clients who relapse, that the abstinent time he had amassed before his relapse still counted for something, and I elicited from him the strengths and skills he used to stay abstinent for that long. I then affirmed Joe’s commitment to recovery, and his effort thus far, before asking him what he might do differently to reinforce and maintain his change. Rather than being a gatekeeper to recovery, I want to be what motivational interviewing describes as “a benevolent witness to change.”

The main attraction, for me, to harm reduction is that it is all-inclusive. It really is irrelevant that harm reduction includes approaches to treatment and recovery that are traditionally non-inclusive. Given the current epidemic of substance use and death in our society, and the less-than-impressive outcomes we are seeing with traditional approaches, I can’t see the rationale for ruling out any treatment modality that works for any segment of individuals. In a harm reduction approach, all stages of substance use disorder are treatable, all treatment modalities are useful, and all pathways to recovery are valid.

As Debra Rothschild put it, “Clinicians working this way recognize that all people are individuals with their own histories, needs, fears and desires and that substance use exists on a spectrum. It is not a disease that either exists or does not. Treatment is not a one-size fits all model. Everyone is different, every treatment is different and for each, we do what we can to reduce harm and increase happiness and health.”

I cannot think of a nobler calling.

The author is a substance use counselor.