Valery Shuman
An Introduction
to Harm Reduction
A web-based seminar for
SHPA
November 30, 2012
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
MISSION
• Increase understanding of harm reduction
• Build skills necessary to implement harm
reduction
• Strengthen harm reduction leadership across
disciplines and communities
• Explore and challenge common beliefs that
contribute to discrimination against drug users
and other marginalized groups
Midwest Harm Reduction Institute
Why harm reduction?
• Associate Director, Midwest Harm
Reduction Institute
• Heartland Alliance for Human Needs &
Human Rights, www.heartlandalliance.org
• 773.334.7117 x.1021
• [email protected]
Midwest Harm Reduction Institute
Training Objectives
You will:
• Be able to describe the core principles and
values of Harm Reduction
• Begin to explore how your personal values and
beliefs may impact your efficacy when working
with people engaging in high risk behavior
• Become aware of available resources to learn
more, including books, websites, training, and
consultation opportunities
Midwest Harm Reduction Institute
Poll
What is Harm Reduction?
• If Housing First is to succeed, substance use
can no longer be a barrier to accessing housing
• Homeless individuals with substance use
problems must be offered the same options and
rights as other people who are homeless
• Homelessness is not a cure for addiction…
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
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Harm reduction
• Is a set of practical strategies that
reduce negative consequences of
drug use and other high-risk
behaviors
• Incorporates strategies that range
from safer use to managed use to
abstinence
• Meets and accepts drug users on
their own terms
– Harm Reduction Coalition
Midwest Harm Reduction Institute
HR & Other High-Risk Behaviors
Examples of Harm Reduction
Interventions
• Seat belts
• Needle Exchange
• Free CTA on New Year’s eve
• Designated driver programs
• March of Dimes - Reduce premature birth
& birth defects by encouraging women of
childbearing age to take folic acid
• Condoms!!
Midwest Harm Reduction Institute
Harm Reduction
• Medication Adherence
Working with people where they are
rather than where they should be
– Physical
– Psychiatric
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Self-Injury
Sex Work
Domestic Violence
What else?
Midwest Harm Reduction Institute
Elements of Harm Reduction
Programs
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User involvement
Any positive change
Supportive agency policy
Collaboration with other providers
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
Principles of Harm Reduction
(Denning, 2000)
• Drug addiction is a biopsychosocial
phenomenon
• Drug use is initially adaptive
• Drug, set, and setting are central to
understanding an individual’s drug
use
• There is no inevitable progression
from use to dependence
Midwest Harm Reduction Institute
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Principles of Harm Reduction
(Denning, 2000)
• Users have the right to sensitive
treatment, and to not be expelled for the
very behavior that brings them to
treatment
• Treatment should be based on the
development of a needs hierarchy
• Active drug users can and do participate in
treatment
• Success is related to self-efficacy
• Any reduction in drug-related harm is a
step in the right direction
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
Harm reduction values
• Normalize conversations about drug use
• Be nonjudgmental, including avoiding
potentially judgmental labels
• Value the individual’s information and input
& emphasize their strengths
• Be aware of power differences
• Build rapport and trust
Midwest Harm Reduction Institute
Harm reduction values
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Recognize ambivalence as normal
Avoid having preconceived goals
Provide choices
Emphasize personal responsibility for
outcomes
Midwest Harm Reduction Institute
Recovery = Any positive change
• Harm reduction values the development
and maintenance of a nonjudgmental
partnership that enables the consumer to
make well-informed, empowered choices
• Recovery is envisioned as a process—the
consumer sets the pace and parameters
of that process, and any steps forward are
valued
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
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Isn’t harm reduction…
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In favor of drug use?
Tacit consent to use drugs?
“Don’t ask, don’t tell”?
Simply a masked bid for drug
legalization?
• “Anything goes”?
• Anti-abstinence?
Expectations and responsibilities
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Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
Harm Reduction and
12-Step Recovery
Harm reduction and abstinence
• Harm reduction and abstinence are
congruent goals
• Harm reduction expands the therapeutic
conversation, allowing providers to
intervene with active users who are not yet
contemplating abstinence
• Harm reduction strategies can be used at
any phase in the change process
Midwest Harm Reduction Institute
Behavior-based
Clear purpose and explicit rationale
“No rules without relationship”
Enforceable, legal
Less is more
Participant input
Keep current and revise
Clear, consistent consequences
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Keeping a bottle at home
“The only requirement for membership…”
“Attraction not promotion”
“Keep coming back”
“Progress not perfection”
“Sometimes quickly, sometimes slowly”
“If he doesn’t want to stop, don’t waste your time…never force
yourself upon him…Let him draw his own conclusion.”
“When all else fails…”
“Many roads to recovery…”
“We surely have no monopoly…”
“Simply lay out the kit of spiritual tools for his inspection.”
“…constant thought of others and how we may help meet their
needs.”
Midwest Harm Reduction Institute
Harm Reduction:
Three Arms (Rotgers, et al., 2005)
We found that…drinkers would not take
pressure in any form, excepting from John
Barleycorn himself. They always had to be
led, not pushed…We found we had to
make haste slowly.
Bill Wilson
• Public Health (“Staying Alive, Maintaining Health”)
– NEP’s, Overdose Prevention, MSIF’s
• Public Policy and Advocacy
– Addressing effects of discriminatory policies
on people with drug problems
• Treatment (“Getting Better”)
– MAT, BSCT, MM, SUM, MI, SOC, HRT
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
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The big question…
Is it okay to use
substances?
Midwest Harm Reduction Institute
Countertransference
“Sorting through our own beliefs about the
morality of getting high on drugs is
imperative if we are to avoid a
countertransferential mire of reflected
negative judgments and basic
misunderstandings of our patients.”
(Denning, 2000, p.15)
Midwest Harm Reduction Institute
Countertransference
• Narrowing of treatment options
• “Making the case”
• Rigidity with patients who do not fit or are “resistant”
to available options
• Belief that all substance users must have treatment
• Users reluctance to seek/accept treatment is
“denial”
• Provider seeking gratification that comes with
providing treatment
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
What Influences my Perception of
Alcohol and Drug Users?
• My family of origin
• My personal experience with alcohol or
other drugs
• My experience of alcohol or drug use by
those I serve
• My educational or professional training
• My society and culture
• What Else…?
Midwest Harm Reduction Institute
How do my values affect my
clinical decisions?
• I need to be “on guard” with alcohol and
drug users.
• Alcohol and drug users are unable to
make informed decisions about their lives.
• Alcohol and drug users need to be sober
before they can “get better.”
Midwest Harm Reduction Institute
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How does my language reflect
my values?
• Alcohol users: “drunks,” “alcoholics”
• Drug users: “dope fiends,” “crack heads,”
“drug addicts”
• Sex workers: “whores,” “prostitutes”
How can I be nonjudgmental?
• Recognize that being completely
nonjudgmental is impossible – look at how
you respond to your judgments
• Follow the participant’s lead – avoid
pushing him or her to a place that he or
she is unable or unwilling to go
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
How can I be a partner?
• Listen first
• The participant is the expert – let him/her
know that you recognize this
• Remind the participant that he/she makes
the final choice – and lives with the
consequences of that choice
• Ask, “How can I be helpful?”
Midwest Harm Reduction Institute
How can I provide choices?
• List all options – not just those YOU prefer
• Ask, “What do you think would be useful or
helpful at this point?”
• Ask permission to provide options: “Some
people who have been in a similar situation have
found a couple of things helpful – would you like
to hear what they are?”
• Always let the participant know that he has
the final choice
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
Trauma and Substance Use
• Physical and sexual abuse among women
in substance abuse treatment programs is
estimated to range from 40% to more than
90% depending on definition of abuse and
target population (Moncrieff, et al.;1996;
Najavits et al.: 1997; Rice et al. 2001;
Root, 1989)
Midwest Harm Reduction Institute
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Trauma and Homelessness
• Relationship between trauma and homelessness
is bi-directional
• Homelessness is traumatic
• Homelessness can be a risk factor for retraumatization and re-victimization
• In one study of the homeless population in
Washington, DC, 63% of homeless women and
33% of homeless men reported having been
abused by an intimate partner
Trauma and Mental Illness
• Virtually universal trauma exposure (well over
90% report at least one traumatic event)
• Childhood sexual abuse: 52% of women and
35% of men
• Adult sexual assault: 64% of women and 26% of
men
• Attacked with weapon in adulthood: 49% of men
and 37% of women
• Witnessed killing or serious injury: 43% of men
and 24% of women
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
How Drug Users can be
Involved in Service Delivery
Risky Behavior as Coping
Strategies for Trauma
• A trauma-informed model frames
survivors’ symptoms as that person’s best
attempt to manage what they have
experienced
• What helps someone survive is a strength
that person has learned and –in some
way-continues to help in the present
• Look at the FUNCTION of the behavior
Midwest Harm Reduction Institute
References
Bigg, D. (2001). Substance use management: A harm reductionprincipled approach to assisting the relief of drug-related problems.
Journal of Psychoactive Drugs, 33 (1), 33-38.
Denning, P. (2000). Practicing Harm Reduction Psychotherapy: An
Alternative Approach to Addictions. New York, NY: The Guilford
Press.
Denning, P., Little, J., & Glickman, A. (2004). Over the Influence: The
Harm Reduction Guide for Managing Alcohol and Drugs. New York,
NY: The Guilford Press.
Miller, W. R. & Page, A. C. (1991). Warm turkey: Other routes to
abstinence. Journal of Substance Abuse Treatment, 8, 227-232.
Weil, A. (2004). From chocolate to morphine: Everything you need to
know about mind-altering drugs. New York: Houghton Mifflin
Company.
Zinberg, N. E. (1984). Drug, Set, and Setting: The Basis for Controlled
Intoxicant Use. New Haven: Yale University Press.
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Outreach
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Engagement in services
Disease prevention efforts
Substance use management
Overdose prevention
Peer to Peer harm reduction
Advocacy
– Empowerment
Midwest Harm Reduction Institute
Web Resources
• Harm Reduction Therapy Center
– www.harmreductiontherapy.org
• Harm Reduction Coalition
– www.harmreduction.org
• Drug Policy Alliance
– www.drugpolicy.org
• Chicago Recovery Alliance
– www.anypositivechange.org
• Moderation Management
– www.moderation.org
• Harm Reduction, Abstinence, Moderation Support
(HAMS)
– www.hamsnetwork.org
• SMART Recovery
– www.smartrecovery.org
Midwest Harm Reduction Institute
Midwest Harm Reduction Institute
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Midwest Harm Reduction Institute
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