Being a Harm Reduction Therapist Involves...
by Peter Goetz, MFT
.....taking a broad view of what drug and alcohol mis-use, abuse and addiction treatment includes. That may or may not include setting sobriety as the desired outcome goal.
It includes a perspective that drug and alcohol use and mis-use - and any step in between - is rooted in the interweaving effects of a drug, the individual’s lived experience and the social, cultural, and living environment in which the individual is using the drug.
Practicing from a harm reduction perspective means that your own values around drug and alcohol use may be radically different from those of your client. And that does not make any difference in how you listen to your client.
Harm Reduction thinking is less focused on the drug or alcohol being used and more on the over-all functionality of the person who is using. How does their drug use impact on how they live their life, their interactions with their families, their communities?
Practicing harm reduction psychotherapy involves a reminder-to-self that despite protestations, bad behavior, forgotten appointments, projections of blame and other obfuscations from clients, there’s just about always a part of them that wants help. Otherwise, why would they be there? Therapist reminder-to-self: access that part.
Being a harm reduction therapist requires that the therapist manage their own anxiety about potentially disastrous consequences that clients’ behaviors may be setting into motion. A theorist of years ago called this ‘witness at an execution.’ The job of the therapist may be that of predicting problems but not forestalling them. Framing choice and widening the range of possibilities is always useful; mandating behavior usually is not. The client seeking counsel always has agency.
Harm reductionist thinking does not require the therapist to have all the answers about drug and alcohol use and their effects but it does require that therapist to collaboratively open an inquiry with their client to find the information needed to help them make informed choices.
People use and mis-use drugs and alcohol for reasons. It’s useful to find out what those reasons are. And to keep asking. Reasons change, as we all do, over time and changing conditions.
One rhetorical harm reduction question is: Why do people drink or use drugs?
Answer: Because they work.
That’s where it gets interesting. What works, what’s being worked and how does that happen?
Being a harm reductionist invites you to hold a wide angle lens of time; events, relationships and conditions change and unfold over time. Change is rarely straight forward. For a therapist, best to get out of the way enough, maybe just enough, to allow change to happen.
In the aftermath of every narrative of bad experiences coming from drinking or drugging, the harm reductionist should always ask: and then what happened?
Never ever underestimate the presence of shame when people describe their problems with drugs and alcohol. Unnamed shame takes the air out of the room; naming it creates space, psychological space between behavior and the person experiencing it.
Practicing harm reduction psychotherapy holds a perspective that drug and alcohol mis-use may be acting as compensations, modulators, enhancers, and denials of events that have actually happened to people. Much of that experience is traumatic, held in memory and re-enacted in actions taken. Though rooted in history, coded repetitions of significant trauma are re-lived every day. In the words of William Faulkner: “The past is never dead. It’s not even past.”
Even addicts can make informed choices in their lives. Not all parts of a drug abuser or alcoholic may be on board with their mis-use, the rationales surrounding using or the problems stemming from it. In this sense, harm reduction offers an optimistic perspective on people, their problems and their potentials for change.
Harm reduction thinking involves, at core, reducing the harm that people create and sustain in their lives. They may think it’s one thing, you might think it’s another. Talk about that.
Practicing from a harm reduction perspective includes the very real possibility that the drug or alcohol use your clients describe may well kill them. The work can be risky for all involved.
And finally, harm reduction psychotherapy is most decidedly not ‘anything goes’. Its an active engagement in the lives of people seeking help with the very real problems and conditions they experience with drugs and alcohol use and the choice points at play for change to happen. Harm reduction may be about naming the elephant in the room, framing actions being taken to jump up on the back of the elephant or get trampled by it. Harm reduction might be about how we’ve made friends with the elephant or walked off in another direction away from it.
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