Steve’s story is not unique. His life typifies those of hundreds of thousands of people who are in jails and prisons today. For many, difficult childhoods led to drug use or misuse and a whole host of other emotional and behavioral problems. A large study conducted by the Centers for Disease Control and Kaiser Permanente examined the association between drug use and eight types of childhood trauma (emotional abuse, sexual abuse, physical abuse, neglect, violence between parents, absent parents, parental substance use, and a parent in prison) in a large sample of adults and found that the presence of adverse childhood experiences contributed to earlier initiation of drug use and increased the probability of lifetime drug use. People with four or more adverse childhood experiences are five times more likely to have an alcohol use disorder, and those with six or more are forty-six times more likely to be an injection drug user. When the data are analyzed another way, 67 percent of all intravenous drug misuse is related to trauma, with the figure rising to 78 percent for women.1
Researchers estimate that 50–60 percent of women in the criminal justice system have a history of physical and sexual abuse in childhood and/or adulthood; some studies estimate that the rate is as high as 90 percent.2 Men with a history of incarceration also have experienced multiple traumas (e.g., emotional and physical abuse) and experience more traumatic events while in prison. Additionally, incarceration can result in being abandoned and rejected by family members, increasing the risk of anxiety, depression, and substance use issues.3
People with substance use disorders also have very high rates of other mental health disorders—approximately 50 percent of respondents with a substance use disorder also met criteria for at least one mental health disorder in their lifetime, according to a major national survey.4 Individuals with co-occurring disorders tend to have more severe and enduring symptoms. They are less likely to engage in treatment, more likely to be homeless, and at greater risk for being victimized.5 A 2006 Bureau of Justice Statistics report on mental health problems in prisons found high rates of mental health problems: “state prisons: 73% of females and 55% of males; federal prisons: 61% of females and 44% of males; local jails: 75% of females and 63% of males. Nearly a quarter of both state prisoners and jail inmates who had a mental health problem, compared to a fifth of those without, had served 3 or more prior incarcerations.”6
People who use and misuse drugs are extremely complex, and the challenges facing incarcerated people make matters worse. Focusing only upon whether or not a person is using or misusing drugs does not allow providers to adequately explore underlying causes of drug misuse or to discover and facilitate the development of motivation to change. Instead of turning to prisons and jails as a first line of defense against drug use, we must utilize a treatment approach that focuses more on underlying causes of substance use than on substance use alone.
Harm reduction therapy was developed to treat substance misuse as a health concern—not as a legal matter. It simultaneously addresses all of the complex issues facing people who use drugs. While abstinence is one possible goal of harm reduction therapy, it is not the only way to resolve drug problems. As a client-centered and motivational treatment approach, harm reduction therapy encourages people to identify their own needs and goals and the strategies they feel will best help them reach those goals. Harm reduction prioritizes safety first and employs strategies to keep people alive and healthy. Once people have reduced their risk-taking behaviors, they are in a better position to stabilize mental, emotional, and socioeconomic conditions. Only then are they likely to be ready to consider changing their relationship with drugs in more profound ways.
Limitations of Existing Substance Use Treatment Models
At present, drug addiction is conceptualized by the National Institute on Drug Abuse as a “chronic relapsing brain disease” requiring formalized treatment.7 While the paradigm of care is changing, most treatment is dominated by the Twelve Steps of Alcoholics Anonymous, which promotes lifelong abstinence as the only way to “recover.” It is estimated that 86 percent of treatment facilities utilize drug testing and 74 percent use Twelve-Step facilitation.8 This one-size-fits-all approach is too narrowly focused on elimination of substance use rather than on treating the many co-occurring problems that substance users suffer. Only 10 percent of people who need treatment even go, and most of those who need treatment state that committing to abstinence as a precondition for treatment is a major deterrent.9 Outcomes of abstinence-based treatments and of twelve-step groups are mixed at best—most people do not succeed at maintaining abstinence upon completing treatment.10
It is estimated that 46 percent of people in substance abuse treatment are mandated to be there, many by the criminal justice system (33.6 percent) or as a condition of other community agencies or services (12.1 percent).11 Because of this, substance use treatment and coercion are inextricably linked. With the proliferation of drug courts and alternatives to incarceration, in which a person who is convicted of a drug offense may choose or be remanded to treatment rather than jail, we have only replaced one coercive situation with another. Externally imposed mandates and punishments actually reduce individual motivation, and confrontational approaches are more likely to create resistance and drive people out of treatment.12 For people with multiple challenges and interlocking problems, we need client-centered treatment that offers a variety of interventions and a menu of options for change, based on an extensive assessment of each client’s needs. Our job as treatment professionals is to facilitate healthier choices and change by offering treatment options that respect autonomy, show empathy, and invite collaboration.
Harm Reduction Therapy: An Alternative Treatment for Substance Misuse
Harm reduction therapy is a very different paradigm for the treatment of substance use disorders. It offers a significant alternative to the various “disease” models of addiction and abstinence-only treatment. It was developed by mental health professionals who were working with people with co-occurring substance use, medical issues, and mental health disorders. They were frustrated by fragmented treatment systems, concerned about the high threshold imposed by abstinence-only treatment, and alarmed by confrontational approaches that caused harm to fragile clients.13
Grounded initially in the public health approach to the HIV and hepatitis epidemics in the 1980s, harm reduction therapy emphasizes reducing the harms associated with substance misuse, both for the individual and for society, without necessarily eliminating the consumption of drugs.14 The goals of harm reduction are pragmatic: address the immediate threats of drug use to life and health, engage people in a compassionate and supportive relationship, and then build motivation to make larger changes. The most well-known of all harm reduction interventions, needle exchange, has been very effective in reducing the transmission of HIV and hepatitis without increasing the use of drugs.15 Other important harm reduction interventions include distribution of naloxone to reverse opiate overdose; supervised injection facilities that reduce overdose and have shown success at increasing access to drug treatment;16 Good Samaritan laws that protect drug users from arrest when they call emergency medical services; and the ending of discrimination in employment and housing for people with drug convictions.
Harm reduction therapy is a welcoming and low-threshold approach that simultaneously addresses substance use, mental health disorders, unhealthy relationships, and socioeconomic problems. It facilitates the transformation of identity from someone whose life has been dominated by the criminal justice system to someone who has real choices—personally, socially, and economically. Harm reduction therapy does not require abstinence as a condition or goal of treatment. The selection of interventions, the goals, and the intensity of treatment are determined by each client in collaboration with his or her therapist. Goals might include complying with the terms of the criminal justice system. Harm reduction therapy integrates a wide array of evidence-based models and interventions from motivational interviewing;17 cognitive-behavioral, psychodyn
amic, experiential, and mindfulness therapies; self-help models; case management; and psychiatry and addiction medicine. It is practiced in many community-based and private settings and has been adapted to work with families and groups.18
“Come as you are” is one of harm reduction therapy’s core values. By starting where the client is, not requiring change as a condition of treatment, and moving at the client’s pace of change, harm reduction therapy engages people who avoid or are excluded from traditional abstinence-only programs. Harm reduction practitioners accept that we live in a society where people will use drugs; our focus is on reducing the harmful effects of substance use rather than on coercing people to stop using drugs.
Any positive change is another guiding principle of harm reduction therapy. This means that many outcomes—ranging from controlled use to moderation to abstinence (which can mean abstinence from some substances but not from others)—are considered to be forms of success in harm reduction therapy. For some people, using sterile syringes and adopting safe injection practices can be the initial stages in a process that leads to reduction in intravenous heroin use. Other clients may benefit from alleviating PTSD symptoms and increasing their ability to form relationships in order to become less isolated. Gradually, the need to use substances to cope with anxiety, hyperarousal, and other symptoms or with trauma, depression, and loneliness decreases.19
While it is true that harm reduction therapy, with its embrace of active drug users and its broad array of options for change, is philosophically at odds with the top-down mandates of the criminal justice system, including its requirement for total abstinence from all drugs, in practice the two can work in tandem. Harm reduction therapy is pragmatic and flexible enough to help people comply with the conditions of early release at the same time as it helps people develop the motivation and skills to change their relationship with drugs and transform their lives. The result of this delicate balance is that people are more likely to feel understood and respected, and they are more likely to engage in and stay in treatment. With its flexibility and sophisticated understanding of interlocking issues, harm reduction is an ideal treatment model for reentering individuals.
Understanding Why People Use Drugs
People use drugs for many reasons—relaxing, increasing feelings of pleasure, reducing feelings of physical or emotional pain, connecting with other people, and coping with social oppression.20 As one user put it: “After a lifetime of depression and long bouts of self-medication with alcohol, cocaine, and whatever else was available, heroin was a godsend. In fact I can truly say that junk is one of the best things that’s ever happened to me.”21 There are many drivers of substance misuse, and it is important to understand them, rather than judge, if one is to truly help someone to change his or her behavior. Edward Khantzian’s self-medication hypothesis helps to explain why many people use substances.22 The use of alcohol and other drugs may also serve as a vehicle for identity and group membership. It may be culturally sanctioned or a response to one’s environment. In addition, problematic substance use may serve as a way of coping with social oppression. As Carol Draizen put it: “The vast majority of the addicted poor living on the streets have life histories of severe, cumulative trauma, made worse by the inhuman conditions homeless people face. Getting high is also one way to have a little privacy—at least in your own mind.”23
Not all substance use is misuse. Most people use drugs with no problem, and this is true both of alcohol and of other drugs. For example, only 23 percent of people who try heroin go on to develop an opiate use disorder.24 All substance use (not just alcohol use) occurs on a continuum from experimentation to occasional, regular, or heavy. Only some use spirals out of control, which harm reduction practitioners call chaotic use. While most people’s alcohol and other drug use does not rise to the level of misuse, harms can and do occur at any level. For example, most people who drink and drive, most college students who participate in drinking games, and some people who contract HIV when they first experiment with injecting drugs do not have a substance use disorder, yet they can suffer and cause great harm. Harm reduction focuses on the actual harm each person’s substance use causes to him or her and to others, not on whether or how much a person is using.
Harm reduction practitioners believe that people have a relationship with drugs. As with all relationships, an individual’s relationship with drugs might be more or less harmful at different points throughout the life span. Problems with drugs develop out of a unique interaction between an individual (including his or her state of mind, health, and motivations), the physiological effects of the drug as well as the method of use (swallowing, smoking, or injecting, for example), and the sociocultural environment in which substance use occurs (including whether a drug is legal or illegal, which affects quality and dangerousness as well as the risk of arrest and incarceration). This evidence-based model, developed by Norman Zinberg in the 1970s, involves three components: drug, set (that is, a person’s mind-set), and setting.25 Based on his research, Zinberg came to understand that the use of legal drugs is governed by a set of cultural norms, whereas illegal drugs live underground. While drug-using subcultures have their own rules and customs, stigma and fear keep many people using in secrecy, which drastically increases the risk of harmful consequences. Imprisonment only complicates matters further.
We might expect that many who are coming out of prison and who also have histories of substance misuse, poverty, trauma, and social deprivation will emerge demoralized. Assessing past and current use within this framework helps to understand the complexity of drug misuse rather than simply pathologize it. By paying very close attention to the reasons, manner, and circumstances of each individual’s use, we can understand each person’s relationship with drugs, accurately assess harm, and find solutions that fit both the circumstances and the individual.
Motivation and Change
Harm reduction therapy is a client-specific and client-directed treatment approach grounded in the values of self-determination and the facilitation of client motivation.26 The therapist works with a client according to the client’s readiness and willingness for change, based on the client’s definition of the problem and the client’s perception of what is needed. The client’s motivation for change is the primary focus unless there are urgent safety issues requiring immediate attention. But harm reduction understands that motivation is not a simple matter. When challenged to change important relationships or long-held habits, people are often ambivalent. Broadly speaking, the forces that favor ongoing drug use are centered on ways that substances bring pleasure and life enhancement as well as the ways that drugs and alcohol reduce pain and suffering. The forces within the person that seek change are two-fold. The first is the fear of loss; the other is a desire for a better life. Given the reality of these forces, the job of the harm reduction practitioner is to help people discover and enhance their motivation for healthy change and mourn the loss of a loved object or habit.
Motivation that is driven by internal desire is enhanced in contexts that foster competence, relatedness, and autonomy.27 Encouraging clients to select their own treatment goals leads to improved substance use outcomes regardless of severity of symptoms at the onset of treatment.28 This is a contrast to the traditional substance use treatment system, which emphasizes abstinence as the primary goal and has historically been more directive and authoritarian rather than collaborative and client-centered.29
Harm reduction therapy is an integration of four core components. The most important element is a strong therapeutic alliance, one that meets people where they are and accepts and honors their choices.30 The good therapist also holds the future and the sense of possibility for those having difficulty doing so.31 As Goethe said, “If I treat you as though you are what you are capable of becoming, I help you become that.”32 Second, harm reduction therapy is trauma-informed—it recognizes that the client’s history and other issues are often more critical than substance use. Third, it
utilizes a three-dimensional assessment approach, based on Zinberg’s drug/set/setting model, that helps the client and therapist to work simultaneously with multiple issues.33 Finally, harm reduction offers people a menu of options to change their substance use. Substance use management is the technique of helping people change in the direction of safety, moderation, or abstinence.34
From a harm reduction perspective, the term “recovery” does not mean abstinence from psychoactive substances. Rather, it means those steps that enable drug users to develop, often for the first time, a meaningful and satisfying life. Recovery should include the autonomy to guide one’s own choices; positive relationships that support those choices; feelings of well-being, competence, and confidence; optimal health; and a sense of purpose in life. Recovery also means having a non-problematic relationship with drugs: the ability to use in a responsible manner with a minimum of risk. For some, recovery occurs most easily in the absence of alcohol and other drugs. For others, safer or moderate use is sufficient (even helpful) to live healthily and well. There is no single path to achieving a sense of well-being and optimal health. There is no such thing as “the program.” Each person’s journey is unique, and harm reduction therapy is designed with enough flexibility to help each person discover and develop his or her unique way of changing.
Success Is Any Positive Change
Steve’s therapist began working with him while he was homeless, treating his mental health and substance use problems concurrently. A nonjudgmental attitude toward his drug use enabled him to explore personal issues and to access other services without fear that he would be mandated or pressured to quit using as a condition of getting help. During the first year a strong therapeutic alliance developed, and Steve became open to the idea of housing. Because he was in treatment when a housing opportunity became available, he was able to take advantage of it, and his aggressive behavior diminished somewhat.
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