Harm Reduction Psychotherapy

Background

In the late 1980s, with the advent of the HIV/AIDS epidemic, harm reduction gained a foothold throughout the world. Once it became apparent that substance users, particularly intravenous injecting heroin-using individuals, were not only likely to get the disease, but also were at risk for transmitting it to others, the stage was set to shift the focus from drug-use cessation to stopping the spread of HIV. Needle exchanges and low-threshold, easily-accessible methadone programs became frontline actions in efforts to stop the spread of the disease. The focus was on strategies to help patients change their behavior in a positive direction to reduce the harmful consequences of their substance use. In short, as Earnest Drucker and colleagues have pointed out, AIDS took precedence over addiction.

Harm Reduction Philosophy

Out of the incorporation of this public health perspective, a new clinical philosophy emerged that Marlatt has called compassionate pragmatism. Tatarsky, in his book, has outlined six core ideas that characterize the harm reduction model:

• 1.
  Meeting the client as an individual: This idea reflects a belief that patients come with different internal worlds, strengths, needs, vulnerabilities, biologies, social backgrounds, and use histories; consequently, their patterns of use and the meanings that they hold will be unique for each user. For treatment to be successful, it must be tailored, as best as possible, to the patients' specific needs.
• 2.
  Starting where the patient is: This idea means accepting the patients with whatever goals and level of motivation for change that they come in with.
• 3.
  Assuming the client has strengths that can be supported: Patients are more than their problems. In many respects, to have survived in a world of active users and drug dealers speaks to deeper inner resources. The goal here would be to use these to help the patient move forward in a positive way.
• 4.
  Accepting small incremental changes as steps in the right direction: For most people, change will involve small steps, steps that may take time to integrate before the person can move on.
• 5.
  Not holding abstinence (or any other preconceived notions) as a necessary precondition of the therapy before really getting to know the individual: The belief is that the goals of the treatment will emerge out of the therapist-patient relationship and dialogue. This practice enables patients to begin where they are motivated to begin and have a therapy that is shaped to their needs.
• 6.
  Developing a collaborative, empowering relationship with the client: In line with psychotherapeutic traditions, there is an emphasis on egalitarianism, on a teamwork approach to clarifying issues, choosing goals, developing strategies, and implementing actions.

Understanding Drug Use

From an HRP perspective, people use substances to meet a variety of psychological, social, or biological needs. The psychological reasons incorporate the view that substance use can be adaptive, a view embodied in Edward Khantizian's self-medication hypothesis. For example, substances may be used to quell the pain of anxiety or depression, help block intrusive traumatic memories, overcome a sense of inner deadness, increase the ability of those with attention deficit hyperactivity disorder to focus, and reduce the symptoms of psychosis. Leon Wurmser, in turn, has looked at the role of the inner critic, or the harsh, punitive superego, in the use of substances. For many, alcohol or drugs serve as a kind of revolt against or escape from this experience of internal tyranny.

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