12-step doesn’t work for everyone: why I love harm reduction
An alternative to 12-step
She comes in and sits on the edge of the couch, anxious. As she tells me why she’s sitting in my office, she looks over furtively, both fearful and defended. I ask personal questions, some that she hasn’t answered even for herself. For example, I ask her what alcohol does for her, how it helps her. I help her identify the ways in which she has already employed harm reduction. Maybe she takes nights of the week off, or tries to eat dinner before she starts drinking. We solidify what she wants for herself, maybe do a pros and cons list about her drinking. She starts to relax in the seat. She begins to realize that I’m not going to give her a prescription of 12 step meetings or rehab, that I’m not even going to suggest that she stop using. She realizes through our conversation that she can be honest with me, that I’m not going to judge her or talk down to her.
This is a common example of what can happen during an initial Harm Reduction Therapy session.
Oftentimes, people arrive in therapy full of shame and anger. They feel misunderstood or maybe no one has even tried to hear them out. According to 12 step they have some moralistic failing, ‘character defects’ that need to be removed. They’ve been told they have to relinquish what little power they feel they have. But what if they’ve been disempowered for most of their lives?
Harm reduction helps people move from debilitating shame to a greater acceptance of who they are and a discovery of what they really want from their lives.
This is done in a number of ways. First—harm reduction therapy is client-centered. The goals are derived from the client. For example, a client may not want to stop using cocaine, but he doesn’t want to spend as much money on it or he doesn’t want using on a Saturday night to waste his whole Sunday. So the goals the client might have could be ‘minimizing the amount used’ or to ‘stop using by a certain time on a Saturday night’. As the clinician, I help the client to focus on their own goals. It is different than traditional psychodynamic psychotherapy in that while I follow the client in the session I am also leading…leading based on what the client has identified they want. I help them to keep their goals at top-of-mind while also helping them if they decide to alter the goals they’ve initially chosen.
I also like to work with clients using Mindfulness to help them be able to identify and manage difficult feelings that arise. Mindfulness practices, such as noticing difficult thoughts, feelings or cravings, and being able to breathe through them and learn ways to let the difficult thoughts, feelings or cravings go, is essential. I also use Cognitive Therapy practices. I help clients identify the thoughts they might have, for example, “I’m worthless” or “this is hopeless” and help them see how they can change their thinking. This is often done by helping clients to see their worth and identify the times in which they were able to succeed in their lives.
Using motivational interviewing
Many of the practices I am describing come from my training in motivational interviewing. The four principles of motivational interviewing are expressing empathy, supporting self-efficacy, rolling with resistance and developing discrepancies.
Expressing empathy certainly seems like a no brainer! However, traditional substance misuse treatment often includes confrontation (‘You’re an addict in denial!’ ) and humiliation (‘You can see where your stinkin’ thinkin’ got you so you need to do what we tell you to’). Motivational interviewing (and common sense!) tells you that people who misuse substances are suffering. One of the most effective ways to relieve suffering is to express empathy. Being there to witness a client’s pain and help them through it so that they don’t feel alone, can help make significant positive change in a person’s life.
Supporting self-efficacy includes just that. The task in harm reduction therapy is to help clients identify the ways and times in which they were able to manage their substance use better or help them practice doing so by helping them set small goals. It also includes helping clients to recognize that while they might have a difficult time managing their substance use, there are many things that they do well. Feeling a sense of self-efficacy promotes change.
The term rolling with resistance refers to the fact that sometimes substance misusers, despite all the information they have about past behavior, resist change. Rather than saying that the client is in “denial” or blaming the client for not yet making a change, the therapy provides a space where a client can explore ambivalent feelings about making a change. One of the ideas I love about the concept of rolling with resistance is that it in it, resistance refers to an interaction that may be occurring between the client and the therapist and is not just ascribed to the client being ‘difficult’ or in ‘denial’.
Developing a discrepancy refers to the idea that as the therapist, I help a client identify the discrepancies between their actions (i.e. drinking so much that they can’t spend time with their partner) and what they want (i.e. to be closer to their partner). Bringing these discrepancies to light in a non-judgmental and gentle way can help the client more easily accept that they are not behaving in a way to get them what they want from their lives.
To be clear, Harm Reduction Therapy does not ignore the fact that out of control substance misuse can be dangerous. The ineffectual or unsafe ways in which it has been for a particular client or even predicting what might happen if the client continues to use the way they are is not ignored and is discussed.
These many practices I’ve described sum up the many reasons that I love harm reduction! I get to see change and watch people develop a higher regard for themselves when I work with individuals, couples and in my group work. Harm Reduction Therapy is respectful, open, client centered, tailored to the individual who is presenting for therapy, and most importantly, an effective way to work with people to help them change the way they misuse alcohol and other drugs.
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