Coming to Harm Reduction Kicking & Screaming

Myth #4:  You can’t mix harm reduction and abstinence goals in treatment/harm reduction means that anything goes.

I thought I would combine these last two as I think they are related. First of all, I’ve often heard that we can’t mix goals in treatment: clients who want to abstain will be triggered by those who do not or who are under-the-influence in the meeting. I’ve also heard consistently that there are liability issues for agencies, which is why they don’t allow anyone who is under the influence of drugs to be on the premises, client or not. 

Realistically, if you walk into almost any 12-Step meeting at anytime, you’re likely to sit next to someone who is under the influence of some drug, including alcohol.  And, amazingly, no one tells them to leave, and no one gets upset that they’re being “triggered,” in spite of the abstinence-only message many receive in 12-Step meetings. In fact, members are often the kindest to those who come to meetings under the influence (perhaps we’re reminded of where we came from - and where we could be again?).  Sometimes the secretary of the meeting will suggest – not insist – that this person might just want to listen at that day’s meeting instead of speaking but, mostly, that person would simply be invited to “Keep Coming Back!” 

As for the oft-repeated statement that harm reduction means “anything goes,” that there is no structure to harm reduction-based treatment, I offer the following thoughts.  Harm reduction psychotherapy is a complicated combination of accurate education, different therapeutic models, medications, skill building, nutrition, support from family and concerned others, and more.  It is as comprehensive a treatment as any I know.  Again, it is a long held myth than harm reduction simply means the client does whatever they want, with no consequence.  No harm reductionist would want someone to drive a car under the influence of a drug that could impair the ability to safely navigate a road.  But we might advocate for treatment over jail time. We always hold people responsible for their actions.  In fact, that is the very point:  we harm reductionists don’t care as much about what or how someone uses a drug as we care about how you behave under its influence.  So, far from being an ”anything goes” policy or treatment approach, harm reduction is the gold-standard for holding people accountable.  So, what does this look like in an agency setting?

Good question.  As harm reduction is all about reducing harm not increasing it, we agree that facilities, agencies, workers and policy makers need guidelines - just not as many as we all may think we need.  Guidelines - safety tenets, rules, whatever you may call them – aren’t reasons for unilateral prohibitions such as discharging clients who use drugs or engage in other behaviors that led them to treatment. Let’s say that again:  we should not discharge clients for exhibiting the very behavior(s) for which they are in treatment!  Substance abuse and/or dependence is a mental health condition; it’s found in the DSM-IV-TR, the guidebook for mental health conditions and substance use disorders.  So how has it happened that substance use disorders get viewed differently from other disorders or medical conditions?  How is it that treatment for this set of illnesses – substance use disorders - does not allow people to show any visible signs of their illness (using drugs, resisting treatment options, ambivalence about making changes, yelling at staff, etc.) if they want to get treatment?  Think about it:  if you were having heart problems and you came to the emergency room in the midst of a heart attack, would someone suggest that you needed to just stop and “come back when you’re really ready to stop having heart attacks and take this seriously,” which might include giving up your job, your home, your family, and more in order to just get help, because we’re not even talking about solving the problem here yet.  Furthermore, once individuals do decide to enter treatment of some kind and change their relationship to drugs, if their symptoms return, why is it that, instead of looking at the treatment as possibly being ineffective, we instead so often first blame and punish the ‘patients/clients’ by discharging them, withholding treatments, punishing them, or labeling them as “resistant,”  “antisocial/borderline,” “in denial” or worse?  And more importantly, how is this not completely unethical behavior on our part?

So, to integrate these concepts into our definition, we can see that, far from a philosophy of “anything goes,” harm reduction is dedicated to treating an individual regardless of where on the spectrum of use (or change) that person is and does not withhold treatment based on some fixed and predetermined judgment having nothing to do with the unique circumstances of that individual. The final piece of our harm reduction definition, then, involves an ethical and compassionate acceptance of the whole person combined with a collaborative approach whose goal is to help individuals improve their lives, however they would define that, one step at a time.

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