HARM REDUCTION FOR DRUG AND ALCOHOL USE
Harm reduction is a flexible approach to drug and alcohol use, where abstinence is only one of many possible goals. It evolved as a response to needle sharing during the AIDS crisis, but it can be applied to almost anything where harm may happen: airbags, stoplights, and brake signals for instance, can be called harm reduction devices to make driving safer, though for at least for as long as humans remain behind the wheel, not completely safe.
I came to harm reduction completely by accident. I was in the last semester of my social work degree at NYU in the mid-nineties, when and an old friend of mine who had once been my boss in an audiovisual design company (yes I know, go figure) called me on the phone one day and said, “I left that job too, and now I’m an episcopal priest running a needle exchange, want to come join?” I gave her an emphatic no, and I then a few more no’s, mainly because the commute to the South Bronx from where I was in Brooklyn would be horrible. Oh, and I knew absolutely nothing about needle exchanges. Finally, I did the math and noticed that I hadn’t earned money for nearly two years, and it might be nice to get an income again. And so, I gave it a try.
You can imagine what a learning curve it was, me, a kid from East London, moving into the offices of New York Harm Reduction, where, as people told me with hugely significant looks, we were near Fort Apache, from the movie Fort Apache, the Bronx. Myself, I had never heard of the movie, but when I saw it years later, it was all about riots in the streets, crime, corruption and murder around a Bronx police station, the one across the ballfield from where we were on Dawson Street. The only training in substance use that I had was one excruciating class NYU, where, when at one point I asked the teacher if surely there were some alternatives to the abstinence-only model, and she said, “No there are none.” I think that came out of a dogmatic loyalty to her position, rather than sheer ignorance.
People were so kind to me in the Bronx, which was a world I could only have imagined before I got there. There was the worker there who one day casually dropped that since her son was now 17, he had reached that age, where “they either go to rehab or to jail.” Obviously his school was not stressing the boy out with an onerous college application process. There was the homeless man who told me that sometimes he had dogs set on him when he tried to sleep in empty lots, and no one had spoken to him by name for many years. There the guy who was so stoned one night that he broke into an apartment that some fool had left open, only to find that it was his own. And everybody knew about “Sweep Day.” Sweep Day was the day in the month when the cops busted everyone on the street they could grab order to make the arrest quotas they officially denied having; and there was the more celebratory Pay Day, when everybody got their welfare check. Pay Day was a quiet day in the agency.
As time went by and I moved into low-threshold streetside counseling (the threshold was basically, “will you sit down and talk to me?”) Gradually I learned some harm reduction theory, and eventually I got to teach it myself. Here are some greatest hits of this method:
The idea of the continuum of use: In this, the degree of use of a substance is seen on a continuum from chaotic and out of control at one end to zero use at the other with moderation, obviously, in the middle. In harm reduction the goal is not necessarily to reach zero, but to go anywhere that is safer than where you are now.
The stages of change model, that looks at readiness for change. Some people are ready for change right now and looking for help with the practical action steps, others are just thinking about change and not yet ready to make a move, and some are in “precontemplation” – not even thinking about it. For each stage of change there is an appropriate intervention. Like when hardcore users come to the needle exchange, they don’t want a lecture or a sermon, they want their needles and maybe a cup of coffee and a friendly smile. That is precontemplation, and the intervention is having the coffee and the smile ready, and letting them know that we can give you treatment referrals if ever you are interested.
The counseling model of motivational interviewing, where you ask people pertinent questions about their lifestyle, goal and wishes, until they figured out more clearly what it is that they want, not what I, their benevolent and clever middle-class counselor imagines would be good for them.
Drug treatment has always had a harsh edge to it, and the love, if there is any there, has always been on the “tough love” side. Harm reduction goes out of its way to be respectful, collaborative and compassionate. To put it simply, it recognizes that the therapist is not a different order of human being because they took a two-year master’s degree and some training afterwards.
In my private practice, it would be very fair to say that the cast of characters is very different, and many of the personal issues are different, but the harm reduction approach is pretty much the same. There are more people with a lower intensity of use, such as a person who “kills” time by having a few drinks too many at airports or hotels; drinking in order to make it easier to socialize, drinking because it is part of a social culture or a job culture, or taking Adderall at work to stay on point. It’s the functional drinker or drug user who is frightened that they are losing hold of that “functional” part.
The methods don’t change either: where do you stand on the continuum of use? Are you a chaotic user, heavy, or moderate? Where do you want to get to, what are your goals? Where are you in the stages of change? Most often people would come to a therapist when they are in the “contemplation” stage of change – when they are undecided, or at least not fully resolved inside themselves, and need to tease out the pros and cons in a lot more detail.
You’ll never believe this, but it’s very easy to make great resolutions in the therapy office, only to get drunk anyway. Like, your resolve to not overdo it at a wedding dissolves in front of a couple of people saying, “Oh come on, chill out a little, it’s time to celebrate.” But there are many tricks and strategies to work with your human weakness: sharing your moderation plan with someone ahead of time so you will be more accountable; planning to start later in the day than usual; counting your drinks across the days and across the week; having a seltzer between each drink, or watering your wine down with seltzer; staying away from liquor; eating before you drink, the list is probably endless. If you are drinking or using a drug to assuage difficult feelings inside, there are ways to tolerate those feelings better, so that the substance use becomes more of an option and less of a compulsion.
Moderation can be harder than abstinence, like eating half of a meal or the sprinkles off the top of an ice cream cone. On the other hand, people do it all the time without recourse to any treatment, just so they can still have a glass of something with dinner when they feel like it. The twelve-step approach has saved countless thousands of lives, has given a precious level of community probably to millions in a world that doesn’t have much community, and it offers a beautiful and definable spiritual path where there might otherwise not be one. So, it’s not the enemy; harm reduction simply works with the people who are not going to go that route. What’s important is that on that continuum of use, you find the address where you can safely be at home.