Wednesday, March 26, 2008

Introduction to Harm Reduction Psychotherapy

Ideas have different meanings at different moments in history. Ideas that once appeared crazy, dangerous, or incomprehensible later become so much a part of accepted truth that society temporarily forgets the time when these ideas were dormant. New ideas arise in response to current conditions as an attempt to make sense of and help guide us in responding to these conditions. Ideas determine our view of reality both expanding and limiting our possibilities. As history marches on and conditions change, ideas that were once progressive and useful can become stale, empty, regressive barriers to change. When the dinosaurs of outmoded ideas die, the ideas that have been hiding in the hinterlands creep back into the mainstream to repopulate the field, New ideas once again arise that attempt to explain the limitations of those that came before. This is as true for individual psychology as it is for scientific paradigms.

Within the drug and alcohol treatment field, there have been a number of great ideas that have represented new paradigms for understanding problematic substance use. The application of these ideas to clinical treatment led to revolutionary changes in practice that resulted in dramatic improvements in the care available to people with substance use problems. The addiction-as-disease concept (Jellinek, 1962) challenged the moral model of drug misuse which blamed the problem on the inappropriate values or immoral character of the user. The disease paradigm opened the way to treatment rather than punishment, for these problems. The self-medication hypothesis (Khantzian, 1985) pointed out that for many, drug use is a form of self-care that reflects an attempt to cope with painful feelings. This idea highlighted the important dimension of the meaningfulness of drug use and the necessity to recognize and address the under- lying issues the user is trying to heal through drug use. Relapse prevention (Marlatt and Gordon, 1985) pointed out that, rather than viewing a return to problematic drug use after a period of abstinence or diminished use as failure, relapse should be seen as a common natural part of the process of changing behavior, which can be an opportunity for learning that might decrease the possibility of future relapses.

Harm reduction is the most recent of these important new ideas in the substance use treatment field. It heralds a paradigm shift in the way we understand and respond to problematic drug and alcohol use. Harm reduction rejects the presumption that abstinence is the best or only acceptable goal for all problem drug and alcohol users. Harm reduction sees substance use varying on a continuum of harmful consequences to the user and the community. In doing so, harm reduction accepts small, incremental steps in the direction of reduced harm with the goal being to facilitate the greatest reduction in harm for a given person at this point in time. Inherent in this change in the treatment focus is a radical redefinition of the relationship between the client and the clinician, a departure from the paternalistic model associated with more traditional substance use treatment. Harm reduction places respect for the client's strengths and capacity to change as the starting point for developing egalitarian relationships in which clients are encouraged to collaborate in setting up the treatment and choosing goals and strategies that they find useful. This shift in basic assumption is actually consistent with psychodynamic and behavioral models of drug misuse and has many beneficial implications for treatment that will be discussed in this book. A growing group of clinicians, researchers, and public policy makers have recognized that the philosophy of harm reduction has a critically important role to play in our efforts as a field and in the larger society to improve the treatment of people struggling with substance use problems.

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