The following are excerpts from Dr. Tatarsky's book. Chapters are not presented in their entirety due to space limitations, but the reader will have an opportunity to get a sense of the content of each chapter including case material.
Introduction: Harm Reduction Psychotherapy: A New Treatment for
Drug and Alcohol Problems
Tom: Harm Reduction to Moderation -Andrew Tatarsky
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
2 HARM REDUCTION PSYCHOTHERAPY
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
Introduction 3
in the larger society to improve the treatment of people struggling with
substance use problems.
This book represents what I have learned in my twenty years in the field
of substance use treatment as a psychotherapist, psychologist, supervisor,
program director, and teacher. I will share with you some of the experiences
that led to my coming to embrace harm reduction as a clinical principle
essential to effective treatment of substance misuse. This book presents
harm reduction psychotherapy as treatment that works psycho therapeutically,
and it examines how and why.
The practice of harm reduction is a needed corrective to the limitations
of our current professional and public policy response to drug use problems
in this country .I will present my perspective on harm reduction psychotherapy
and why I think it has great promise for dramatically improving our success
at helping people struggling with substance use problems. Each chapter
focuses on a specific aspect or application of harm reduction psychotherapy.
The stories in this book demonstrate how harm reduction psychotherapy
is rooted in the basic principles of good psychotherapy practice and is
consistent with psychodynamic and cognitive-behavioral models of substance
misuse. I will discuss how harm reduction psychotherapy specifically lends
itself to effectively addressing several important emotional dynamics
commonly associated with substance use problems.
Additionally, each chapter contains a detailed story describing the psychotherapeutic
process with a client experiencing a substance use problem. All but one
of these stories were contributed by other psychotherapists in the field.
The stories were chosen to illustrate the particular topic of each chapter,
but each is like a multifaceted gem containing much more than I am able
to address. As a collection, the stories show the range of treatment approaches
that fall under the harm reduction umbrella as I understand it. They differ
in theoretical bias, psychotherapist style, and outcome; some result in
moderation of substance use and others lead to abstinence. I discuss how
I see them each falling within the continuum of treatment linked by the
harm reduction principle.
4 HARM REDUCTION PSYCHOTHERAPY
Each story can also be read as a window through which to
view the very unique interplay between client and clinician that characterizes
all good psychotherapy. We witness how successful therapeutic relationships
are established, how goals emerge as problems are clarified. We discover
that the general ingredients for the successful psychotherapy of drug
use problems are hard to distinguish from those of effective psychotherapy
with other kinds of clients.
The following stories humanize the diversity of faces of individuals
with unique drug and alcohol problems, a group of people generally stereotyped
by their drug use. They reveal the wide range of people who can develop
drug and alcohol problems and enable the reader to identify and empathize
with their struggles and respect their efforts to change and grow.
The stories also demystify the work of psychotherapy, bringing the reader
into the consulting room like a fly on the wall witnessing some of the
actual processes. The stories humanize the psychotherapists as they reveal
what the therapists thought and felt about their clients as they worked.
To my mind, the basic principles and ingredients of successful psychotherapy
with clients with drug and alcohol problems are essentially the same as
those used with other groups of people. The argument can be made that
the term "harm reduction" really stands for the reintroduction
of basic principles of good clinical practice into an area where they
have often been absent. I hope this book will contribute to that effort.
WHY HARM REDUCTION?
I got my first job after completing my internship in clinical psychology
as a psychotherapist at the Division of Drug Abuse Research and Treatment
at New York Medical College in the fall of 1982. This was a research-oriented
"multimodality" outpatient substance abuse treatment clinic
in East Harlem, New York City. I had no way of knowing at the time that
this job would be the start of a twenty-year journey through the world
of substance use treatment that would bring me to embrace harm reduction
as the most effective approach to helping the broad spectrum of people
with substance use problems.