Challenges to Implementing the Harm Reduction Approach
1533-2578 1533-256X WSWP Journal of Social Work Practice in the Addictions Addictions, Vol. 8, No. 3, June 2008: pp. 1–39
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Michael A. Mancini Donald M. Linhorst Francie Broderick Scott Bayliff
ABSTRACT. The social work literature recently has supported greater use of the harm reduction approach in professional practice. Implementing this approach, however, presents its challenges. We explore how practitioners in a housing program for people with histories of psychiatric disabilities, substance use disorders, and homelessness perceived the harm reduction approach. Prior to the opening of this new program, agency staff completed a questionnaire and participated in focus groups designed to explore their perceptions and level of support of the harm reduction approach used in the program. The goal of this evaluation was to understand the challenges of implementing a harm reduction approach in programs serving people with dual diagnosis and the implications this has for program administrators, staff, and clients. We found that practitioners, overall, favored the
Michael A. Mancini, PhD, is Associate Professor, St. Louis University School of Social Work, St. Louis, MO. Donald M. Linhorst, PhD, is Associate Professor, St. Louis University School of Social Work, St. Louis, MO. Francie Broderick, MA, is Executive Director, and Scott Bayliff, MSEd, is Associate Director, Places for People, Inc., St. Louis, MO. The authors wish to thank the Emmett J. and Mary Martha Doerr Center for Social Justice, Education, and Research at St. Louis University School of Social Work for their support. Address correspondence to: Michael A. Mancini, Saint Louis University, School of Social Work, 310 Tegeler Hall, 3550 Lindell Blvd., St. Louis, MO 63103, USA (E-mail:
[email protected]).
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Journal of Social Work Practice in the Addictions, Vol. 8(3) 2008 Available online at http://jswpa.haworthpress.com © 2008 by The Haworth Press. All rights reserved. doi:10.1080/15332560802224576
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approach’s pragmatism and its focus on client engagement, but many were frustrated by its perceived ambiguity regarding long-term outcomes and client expectations. We conclude with recommendations for how program administrators can facilitate the effective implementation of the harm reduction approach.
KEYWORDS. Harm reduction, mental illness, substance use disorders, MICA clients, co-occurring disorders, dual disorders, homelessness
Individuals with substance use disorders face many challenges to achieving and maintaining abstinence from alcohol and other drugs. The challenges facing individuals diagnosed with serious psychiatric disabilities and substance use disorders are even greater—particularly for those who suffer from chronic homelessness. Individuals with dual disorders are often unable to negotiate the demands of highly structured, abstinenceonly programs due to a lack of environmental supports or skill deficits, resulting in low retention rates (Carey, 1996). With few external supports or resources, many of these individuals return to the street and continue to abuse substances, resulting in many negative outcomes. Given these challenges, recent articles in the social work literature are promoting greater incorporation of the harm reduction approach into social work practice (Bigler, 2005; Brocato & Wagner, 2003; MacMaster, 2004). The harm reduction model is an atheoretical approach (Brocato & Wagner, 2003) that is largely informed by the public health model that seeks to lessen the harm alcohol and drug users do to themselves and society (Denning, 2001; Erickson, 1995; Marlatt, 1996). Harm reduction approaches have predominantly been applied to substance use disorders, although they have also been used in the areas of HIV/AIDS, heart disease, and smoking prevention (Marlatt, 1996; Riley & O’Hare, 2000). In this article we use the term substances to include alcohol and other drugs and substance use disorders to include both alcohol and other drug use disorders. A concrete, universal definition of harm reduction does not exist. This model is best characterized as a constellation of interventions and approaches with the goal of reducing the negative effects associated with substance use through small achievable steps (Denning, 2001; Erickson, 1995; Marlatt, 1996). In this model, practitioners utilize assertive outreach and engagement and motivational strategies such as education, resource allocation, and client support to minimize the primary and secondary harmful effects
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of alcohol and drug use such as overdoses, spread of infectious diseases, victimization, criminal activity, homelessness, and violence (Marlatt, 1996; Riley & O’Hare, 2000). Although the most desirable outcome in harm reduction programs is the elimination of use (i.e., abstinence), programs that use harm reduction differ from traditional, abstinence-only programs in that these programs do not make abstinence or the desire to obtain abstinence the only treatment goal or a prerequisite to receive services. Rather, harm reduction programs focus on a continuum of outcomes that include helping clients switch to safer substance alternatives (i.e., methadone, nonintravenous drugs), educating clients about safer use practices to prevent overdose, prevention of victimization, reduction of health problems (i.e., using with trusted others, use of clean needles or bleaching kits, condom use), and motivating clients to reduce their alcohol or other drug use (Marlatt, 1996; Riley & O’Hare, 2000). The vast majority of research on the harm reduction approach has involved programs designed to reduce the harmful consequences of intravenous (IV) drug use. Although these studies have shown very positive outcomes, very few experimental studies have been conducted in the United States that focus on programs for non-IV drug users with dual diagnoses. It should also be noted that harm reduction approaches may have negative consequences for some individuals who are unable to control their use unless they are in highly structured environments. In addition, the dangerousness of some substances and the illegality of drug use in the United States leads some opponents of the harm reduction approach to claim that the approach “sends the wrong message” and that using the approach can lead to substantial legal, social, and health-related problems for individuals with substance use disorders (MacCoun, 1998). These conflicting views can often lead to substantial ethical and value-related dilemmas for social workers and other clinical mental health staff and therefore have implications for staff training and supervision for programs seeking to implement this approach. In addition, the various approaches that comprise harm reduction make it a versatile approach, but at the same time make defining harm reduction difficult. This ambiguity can also lead to problems with implementation. This mixed-method study attempts to explore these implementation issues by examining the attitudes and perceptions of community mental health staff implementing a harm reduction approach in a residential housing program for individuals dually diagnosed with serious psychiatric disabilities and substance use disorders. Admission criteria included a primary diagnosis of a severe and persistent psychiatric disability
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(major psychotic or mood disorder), a secondary substance use disorder, and a documented history of an inability to maintain housing due to issues such as breaking rules, an inability to maintain sobriety, and using or trafficking substances on the premises. The vast majority of residents in the program have had long histories of problems associated with alcohol, crack cocaine, marijuana, and polysubstance abuse. At the time of this writing, there are no known IV drug users enrolled in the program. This housing program was developed with the explicit goal of helping individuals maintain housing who historically have been unable to do so due to their inability to achieve and maintain abstinence. In this 18-unit apartment program, individuals’ housing is not contingent on abstinence. Rather, residents engage in service components that use support, motivational interviewing, and integrated treatment to help them move gradually toward reduced use or abstinence while maintaining their housing. The harm reduction approach used by participants in this study includes abstinence as a desirable and legitimate goal, but one that is considered the endpoint of a continuum of other goals such as reduced substance use, safer use practices, and the engagement of behaviors that reduce secondary risks to health, such as safer sexual practices, maintaining secure housing, receiving adequate nutrition, and developing support networks. While in the program, residents have time-unlimited access to comprehensive medical and psychiatric rehabilitation services. These services include integrated mental health and substance abuse treatment that uses education, resource allocation, motivational interventions, and social support to encourage residents to reduce or eliminate their alcohol and drug use and other harmful behaviors associated with their use (i.e., unsafe sexual practices) and adopt healthier lifestyle choices. The main harm reduction element in the program is that remaining in the housing program and being eligible for medical and mental health services is not contingent on working toward, achieving, or maintaining abstinence from alcohol or other drugs. This approach is similar to other programs for individuals with dual disorders that utilize a harm reduction approach to treatment (Tsemberis, Gulcur, & Nakae, 2004). Prior to the implementation of this program, administrators, supervisors, and staff received substantial in-service training in harm reduction philosophy and practices as well as practices associated with motivational interviewing, stages of change, and integrated treatment (Drake, Mueser, Brunette, & McHugo, 2004; Miller & Rollnick 2002; Prochaska, DiClemente, & Norcross, 1992).
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Two months prior to the opening of this new program, agency staff completed a questionnaire and participated in focus groups designed to explore their perceptions and level of support of the harm reduction approach used in the program. The goal of this evaluation was to understand the challenges of implementing a harm reduction approach in programs serving people with dual diagnoses and the implications this has for program administrators, staff, and clients. Our initial research questions included how staff perceives (a) the harm reduction approach in relation to their work with their clients and (b) the relative strengths and weaknesses of this approach. The following sections provide a critical examination of the harm reduction approach in general and in relation to its use with dually diagnosed populations. Next, a description of research methods and findings is provided, followed by a discussion of implications for program administrators and staff for future research and for practice.
HARM REDUCTION Harm reduction started in the Netherlands as a response to the rising prevalence of hepatitis and HIV among IV drug users (Inciardi & Harrison, 2000; Marlatt, 1996). Through assertive street outreach efforts, this program provided clean needles, bleaching kits, educational pamphlets that contained information regarding safe sexual and drug use practices, and opportunities to engage in low-threshold treatment programs, in which abstinence is a goal, but not a requirement (Marlatt, 1996). Following the dramatic reduction in hepatitis and HIV cases, the model quickly spread to the United Kingdom, Australia, Spain, and Switzerland. Research has found that this approach is associated with lower drug incidence and prevalence rates and lower rates of HIV and hepatitis cases (Inciardi & Harrison, 2000). Although accepted elsewhere, harm reduction represents a controversial approach in the United States due to a long policy history of drug prohibition that has largely viewed drug use as a moral and legal issue rather than a health issue, as has been the case in much of Western Europe. Opponents of harm reduction claim that the model condones the use of drugs and therefore “sends the wrong message,” which may lead to increased rates of drug use in the general population or that reducing the harm associated with alcohol and other drugs will enable alcohol and other drug users to increase the occurrence and intensity of their drug use and other high-risk behaviors (MacCoun, 1998; McCaffrey, 1998; Weingardt & Marlatt, 1998).
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Although these arguments against harm reduction are plausible, there is currently no specific empirical evidence supporting these claims. The most widely researched harm reduction approach is needle exchange. The World Health Organization (2004), after a review of more than 200 studies on needle and syringe exchange programs, found that increasing the availability and utilization of clean needles substantially reduces the rate of HIV transmission. There is also no convincing evidence of any major unintended consequences of programs providing sterile injecting equipment to IV drug users, such as initiation of drug injection by those who had not done so previously, or an increase in the duration or frequency of illicit drug use or drug injection. Although empirical research has demonstrated the usefulness of harm reduction, particularly needle exchange programs, in reducing the harmful sequelae of IV drug use, more empirical studies need to be conducted that compare the effectiveness of harm reduction to abstinence-only programs and how these two treatment approaches can be blended together.
UTILIZING A HARM REDUCTION APPROACH WITH DUAL DIAGNOSIS CLIENTS Individuals with dual disorders have complex needs and require intensive, well-coordinated, and comprehensive services. Approximately 50% of individuals with severe psychiatric disabilities, such as schizophrenia, schizoaffective disorder, and bipolar disorder, are dually diagnosed with a co-occurring substance use disorder (Regier et al., 1990). Individuals with these dual diagnoses experience a range of psychiatric, legal, and health problems that inhibit recovery (Drake et al., 2004; RachBeisel, Scott, & Dixon, 1999). They are more likely to have symptom relapse (Swofford, Kasckow, Scheller-Gilkey, & Inderbitzin, 1996); higher rates of hospitalization (Haywood et al., 1995); higher rates of physical and sexual victimization, especially among women (Goodman, Rosenberg, Mueser, & Drake, 1997); higher rates of incarceration (Abram & Teplin, 1991); and a higher risk of contracting HIV/AIDS and hepatitis B and C (Rosenberg et al., 2001). In addition, they are less likely to take prescribed medications, which may result in increased violence (Swartz et al., 1998). Finally, individuals dually diagnosed with psychiatric and substance use disorders are also at an increased risk for homelessness (Caton et al., 1994; Drake, Wallach, & Hoffman, 1989; Herman, Susser, Jandorf,
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Lavelle, & Bromet, 1998; Mueser et al., 2000). Despite advances in the treatment of psychiatric disabilities and substance use disorders, dually diagnosed homeless adults remain difficult to engage and retain in traditional residential substance abuse treatment programs (Brunette, Drake, Woods, & Hartnett, 2001). One reason for this difficulty is that most traditional residential substance abuse treatment programs require complete abstinence as a prerequisite to enter and remain in the program (Tsemberis, Moran, Shinn, Asmussen, & Shern, 2003). These high threshold programs have a zerotolerance approach toward substance use and view complete abstinence as the only relevant treatment goal (Barrett & Marlatt, 1999). Individuals with severe psychiatric disabilities, substance use disorders, and a history of chronic homelessness have low completion rates in these programs (Rothschild, 1998; Tsemberis et al., 2004). Residential programs for this population that mandate abstinence have shown dropout rates as high as 76% (Burnam et al., 1995; Nuttbrock, Rahav, Rivera, Ng-Mak, & Struening, 1997). Programs that have modified their structure (yet retain a zerotolerance approach to alcohol and drug use) to accommodate the needs of dually diagnosed homeless adults have shown better retention rates, but still experience dropout rates ranging from 44% (DeLeon, Sacks, Staines, & McKendrick, 2000) to 66% (Mierlak et al. 1998). Individuals with dual disorders often use alcohol and illegal drugs to relieve their psychiatric symptoms (Khantzian, 1997). In addition, they do not possess the behavioral and cognitive skills necessary to negotiate the strict rules and high structural demands of abstinence-only programs, nor do they possess the external resources (i.e., social support, money, housing) necessary to successfully achieve and maintain abstinence (Tsemberis et al., 2004). Because these individuals have trouble conforming to the strict abstinence-only policies of high-threshold programs, they often are unable to remain in these programs. Many critics of such high-threshold programs maintain that they are idealistic and unresponsive to the needs of individuals with dual diagnoses (Barrett & Marlatt, 1999; Marlatt & Roberts, 1998). In contrast, the harm reduction approach is seen as representing a flexible and pragmatic treatment alternative (MacMaster, 2004; Marlatt, 1996, 1998; Sorge, 1991). One feature of housing programs that use the harm reduction approach is that they do not require total abstinence to enroll or remain in treatment and view movement toward reducing the harm associated with substance use as a legitimate and desirable outcome (Marlatt & Roberts, 1998). Another feature is that these residential programs place a priority on
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providing residents with basic human needs such as shelter, safety, and belonging, and view the provision of these needs as necessary prerequisites to successful treatment (Tsemberis et al., 2003). A third feature of these programs is that they utilize a flexible, low-demand atmosphere designed to enhance retention through engagement and motivational techniques, strategies that have been supported by the literature as being especially effective for work with dually diagnosed adults who are homeless (Brunette, Mueser, & Drake, 2004; Carey, 1996; Drake et al., 2004; Miller & Rollnick, 2002). These techniques include: (a) education on the process of addiction and mental illness, (b) skills training on safer use practices, (c) motivational strategies designed to help residents recognize harmful and maladaptive patterns of behavior associated with alcohol and other drug use, and (d) social support designed to help residents take the necessary steps to reduce or eliminate their alcohol and drug use. The use of the harm reduction approach in housing programs for people diagnosed with substance use disorders and severe and persistent psychiatric disabilities is beginning to gain salience (Cat Le, 2002; Tsemberis et al., 2004). However, there are almost no studies that have compared the effectiveness of harm reduction programs with abstinenceonly programs. In fact, only one study was found that compared a program using a harm reduction approach with a traditional abstinence-only program. In that study, Tsemberis et al. (2004) randomly assigned 225 clients with dual disorders to receive housing contingent on treatment and sobriety (control) or to receive immediate housing without treatment prerequisites with comprehensive services (experimental). They found that the experimental group had increased retention rates, enhanced housing stability, and a higher sense of perceived choice, while not experiencing any increases in psychiatric symptoms or substance use (Tsemberis et al., 2004; Tsemberis et al., 2003). Therefore, preliminary research does suggest that harm reduction combined with integrated treatment, motivational interventions, and stage-wise approaches can lead to treatment retention and stable housing without exacerbation of symptoms associated with either mental health or substance use disorders. However, research in this area has just begun and more empirical studies are needed that measure the long-term outcomes of programs that utilize harm reduction approaches with dually diagnosed clients. In particular, there is a lack of studies that examine whether residents in these programs actually reduce their use or eventually achieve sobriety. Studies that measure long-term outcomes associated with reduction of other risky behaviors, hospitalization rates, criminal activity, and
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unemployment are also necessary. To date, the key questions as to whether harm reduction leads to better long-term outcomes in these areas with this population remain largely unanswered.
HARM REDUCTION AND STAFF ACCEPTANCE Incorporating a harm reduction approach into social service programs requires practitioners who can effectively engage clients, tolerate risky behaviors, and possess the flexibility and willingness to accept reduction of harmful behaviors related to drug use as a legitimate and appropriate outcome. Many practitioners may resist the harm reduction approach on philosophical and ethical grounds because they fear that not taking an abstinence-only approach is irresponsible or encourages drug-using behaviors by “sending the wrong message” to clients (Brocato & Wagner, 2003). Given the long history of abstinence-only models of substance use that view addiction as a disease and abstinence as the only relevant outcome, implementing a harm reduction philosophy runs the risk of polarizing staff with clients caught in the middle (Zweben, 2000). Currently more research is needed that sufficiently explores the issues that surround the implementation of the harm reduction approach in programs serving dually diagnosed clients. Ackerson and Karoll (2005) recently evaluated two assertive community treatment teams using a harm reduction approach with dually diagnosed clients and found that team leaders encountered resistance to the harm reduction approach from practitioners within the team and from practitioners in other agencies and systems the team dealt with due to the philosophical differences between harm reduction and traditional treatment. They recommended that administrators engage in staff education and outreach to address these implementation issues. In addition, in a small qualitative study, Koutroulis (2000) discussed the difficulty workers had in integrating the notion of abstinence and harm reduction. She highlighted the tension workers experienced in regard to their perceptions that working to reduce substance use was legitimate from a public health standpoint, but not legitimate in a political context. The idea that abstinence was a legitimate goal of harm reduction was difficult for workers to resolve given the predominant notion that the two concepts are separate from each other. In another study, Ogborne and Birchmore-Timney (1998) surveyed workers in a number of different service areas and found that respondents
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to a mailed survey varied in their level of support for harm reduction approaches. Most respondents supported needle exchange programs and a majority supported developing non-abstinence-oriented short-term goals with clients, whereas there was much less support for methadone maintenance programs and prescribing heroin to addicts. Multivariate analysis also revealed that support for harm reduction was contingent on acceptance of pharmacological and cognitive-behavioral interventions and working in an outpatient treatment service. Acceptance of the disease model of addiction was negatively correlated with acceptance of the harm reduction model. In addition, because harm reduction encompasses a broad range of approaches, many workers accept some forms of harm reduction while resisting others. The U.S. public policy of the “war on drugs” and moral views of drug use combined with clinical workers’ legitimate concerns regarding the ethicality of accepting substance using behaviors that certainly have negative health, family, and legal consequences for their clients also contribute to this ambiguity. Clearly, given the controversies that surround harm reduction, programs implementing this approach may encounter barriers from staff and outside agencies (Ackerson & Karoll, 2005). To address the gap in the literature in this area, we explored perceptions of the harm reduction approach with 37 community mental health workers using semistructured focus groups and written questionnaires. This evaluation occurred just prior to the start of a new housing program incorporating the harm reduction approach with people who have a long history of psychiatric and substance use disorders and homelessness. Participants were employed at Places for People, Inc., a nonprofit community mental health agency located in St. Louis, Missouri, that has provided supportive and rehabilitation services for people diagnosed with severe psychiatric disorders since 1972. The agency currently provides community support and psychosocial rehabilitation services to approximately 300 clients via six community support teams. In 2004, Places for People, Inc., implemented a new housing program called CJ’s Place, which exclusively serves people with histories of psychiatric illness, substance use disorders, and homelessness. This program was specifically developed to serve individuals who have trouble maintaining housing due to their psychiatric and substance use disorders, and consists of a newly built secure apartment building with 18 efficiency apartments. The building has a locked front entrance and cameras for security purposes, and employs a 24-hr desk clerk at the front door
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whose job is to monitor visitors and to provide security, support, and friendly visiting when needed. The program uses a harm reduction approach in that it does not require residents to achieve and maintain abstinence from alcohol and other drugs to continue to receive services and remain in the housing program. Residents may consume alcohol in their apartment units, but may not consume or possess alcohol in the building’s common spaces or congregating areas. Possession and use of illegal substances on the premises is strictly forbidden. Residents of CJ’s Place continue to receive time-unlimited comprehensive community support services from one of the six community support teams that provide all Places for People clients with services. These teams are comprised of between five and seven mental health professionals that include masters and baccalaureate-level social workers, psychologists, and counselors. Each team provides Places for People clients with comprehensive services in the areas of housing, employment, benefits, mental health and substance use treatment, skills training, social support, and crisis services. Residents can stay in the program on a time-unlimited basis as long as they abide by program rules, which include not using or possessing illegal substances on the premises, not engaging in illegal or disruptive alcoholor drug-related behaviors, respecting the physical and property rights of others, and refraining from other disturbing behaviors. While in the program, residents have access to, and are encouraged to participate in, integrated treatment programs that use a motivational, stage-wise treatment approach (Miller and Rollnick, 2002; Prochaska et al., 1992). Using a harm reduction approach, residents are educated and encouraged to engage in harm-reducing behaviors such as reduced use, substitution of less harmful substances, safer sex practices, and healthier lifestyle choices in a safe and nurturing environment. Abstinence, although not a requirement to stay in the program, is viewed as an endpoint of a broader continuum of legitimate outcomes. Consequently, residents admitted into the program must have at least some desire to change their substance use behavior. Clinical staff members are trained to engage with clients on a deep and authentic level and to help clients move toward abstinence at their own pace. It is also accepted within the agency that the harm reduction approach does not work for all clients and that CJ’s Place may be inappropriate for clients who require a more structured, abstinence-based approach. In these cases, staff and clients are encouraged to pursue options that best suit the clients’ needs. Indeed, although most clients
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have done well at CJ’s Place during its first year, some have moved out due to an inability to negotiate the flexible rules of the residents in regard to alcohol and drug use. To prepare for this program, clinical staff, supervisors, and administrators at Places for People, Inc. attended several intensive in-service workshops and training programs conducted by an outside harm reduction training institute in the year leading up to the start of CJ’s Place. Staff also received intensive training from outside consultants in integrated treatment, motivational interviewing, and stagewise treatment techniques and principles. The acceptance and understanding of the harm reduction approach varied among staff. Therefore, the purpose of this evaluation was to identify the attitudes and perceptions staff had of the harm reduction approach just prior to the start of CJ’s Place to facilitate its effective implementation. The results of this evaluation could be useful to program administrators by highlighting the concerns and perceptions social service practitioners may have regarding the harm reduction approach. Program administrators could then use this information to formulate innovations in the areas of staff training and education regarding the harm reduction approach. The information gained from this study might also be used to inform the mental health literature on how best to incorporate the harm reduction approach in mental health and other social services programs and settings.
METHODS This mixed-method study used survey and focus group methods with 37 staff members of Places for People who were working on six clinical teams. This study was granted approval by the institutional review boards of Places for People, Inc., and the university with which the authors are affiliated. Administrators of Places for People, Inc., approved the inclusion of identifying information regarding the agency in this article. Results questionnaires and focus groups were deidentified and shared with the participants of this study. Researchers worked with the executive and associate director of the program and the leaders of each individual team to recruit participants for this study. All clinical members of each team were eligible for participation. At the time of the study, there were 38 eligible participants. Team leaders encouraged members of each team to participate in the study. One
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person was not able to participate in the study due to scheduling conflicts. Participants were assured that their responses were confidential and the executive and clinical directors of the agency were not present in any of the focus groups. To lessen impact on staff time and schedules and increase participation, it was decided to use focus groups with each team during normal team meeting hours instead of individual interviews. For the same reasons, questionnaires were completed by participants immediately prior to each focus group.
Questionnaire The principal investigator, in consultation with Places for People administrators, developed the questionnaire used in this evaluation. Survey items dealt with perceptions and attitudes toward the harm reduction approach. The questionnaire consisted of 34 statements with corresponding responses. Participants were asked to rate their level of agreement with each statement by choosing one of five responses: strongly agree, agree, unsure, isagree, and strongly disagree. Questionnaires were analyzed using descriptive statistical methods.
Focus Groups We collected data regarding staff perceptions and attitudes toward the harm reduction approach via one-time focus groups. Participants consisted of the same 37 clinical staff that completed the questionnaires. One focus group was conducted with each of the six clinical teams. Each audiotaped focus group lasted between 1.5 and 2 hr. We analyzed participant responses in each focus group for themes regarding perceptions and attitudes about the harm reduction approach. Commonalities in participant responses were identified and explored using an inductive, content analysis approach (Krueger & Casey, 2000; Miles & Huberman, 1994). We developed codes for participant responses, which we then collapsed into broader categories and subcategories using a constant-comparative method across all focus groups (Miles & Huberman, 1994). We categorized responses into two broad categories, positive and negative aspects of the harm reduction approach, with subcategories linked to each. We then shared these results with participants during a meeting at the agency to give participants an opportunity to clarify, dispute, or add to the results of the focus groups. There were no disagreements or additions voiced during this meeting.
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RESULTS Participant Characteristics Eighty-four percent of the 37 practitioners who participated in this study were women, 89% were White, and the remaining 11% were African American. Concerning education, 51% reported receiving master’s degrees, with others having bachelor’s or associate degrees. One person had not attended college. In terms of longevity at the agency, 41% of participants reported being at the agency more than 7 years, 19% between 4 and 6 years, and 4% between 1 and 3 years.
Questionnaires The majority of participants held positive views about the efficacy and appropriateness of the harm reduction approach and embraced many harm reduction principles. However, there were some individuals who were skeptical of harm reduction and a few who were largely opposed to the approach. In addition, several participants indicated that they required more training in harm reduction and were unsure of how harm reduction is applied in practice. Results from questionnaires were categorized into three separate sections. The first section reports participant responses to questions about their attitudes toward harm reduction in general. The second section reports participants’ attitudes regarding abstinence and substance abuse treatment, and the final third section discusses responses to questions that dealt with participants’ perceptions about training issues in harm reduction.
Attitudes Toward Harm Reduction As Table 1 indicates, when asked whether they agreed or disagreed with the statement “The harm reduction approach is an effective form of treatment,” 81% of participants agreed (35% strongly), and 19% reported they were unsure. Furthermore, 92% of participants agreed (43% strongly) with the statement “People diagnosed with psychiatric disabilities and addictions can benefit from the harm reduction approach,” and 84% agreed (43% strongly) that the harm reduction approach is a useful and valid form of treatment. In addition, 70% disagreed (27% strongly) with the statement, “The harm reduction approach is dangerous,” although 27% said they were unsure. Similarly, 81% of participants
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TABLE 1. Participants’ General Attitudes Toward Harm Reduction Item
Harm reduction is not an effective approach for substance abuse. The harm reduction approach is dangerous. The harm reduction approach is an effective form of treatment. Harm reduction strategies encourage drug and alcohol use. People diagnosed with psychiatric disabilities and addictions can benefit from the harm reduction approach. People diagnosed with serious psychiatric disabilities and addictions can benefit from harm reduction approach. I believe that housing services should NOT be contingent upon abstinence. The HR approach is effective in retaining individuals in treatment. The harm reduction approach is a valid and useful treatment modality. The HR approach doesn’t make people accountable for their behavior. The harm reduction approach supports drug use. I believe housing services such as CJ’s Place should be reserved for those willing to achieve/maintain abstinence.
Strongly agree
Agree
Unsure
Disagree
Strongly disagree
0.0%
0.0%
10.8%
51.4%
37.8%
0.0%
2.7%
27.0%
43.2%
27.0%
35.1%
45.9%
18.9%
0.0%
0.0%
0.0%
8.1%
10.8%
64.9%
16.2%
43.2%
48.6%
8.1%
0.0%
0.0%
48.6%
48.6%
2.7%
0.0%
0.0%
48.6%
40.5%
8.1%
2.7%
0.0%
40.5%
29.7%
24.3%
2.7%
2.7%
43.2%
40.5%
13.5%
0.0%
0.0%
0.0%
13.5%
8.1%
54.1%
21.6%
0.0%
10.8%
2.7%
56.8%
27.0%
0.0%
5.4%
5.4%
48.6%
40.5%
disagreed (16% strongly) that harm reduction encourages substance use, 11% were unsure, and 8% agreed with this statement.
Attitudes Toward Abstinence in Substance Abuse Treatment Results showed that participants were in support of the general principles of harm reduction. The vast majority of participants (84%) agreed
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that “a legitimate goal of treatment is to help people reduce their substance use to a level that allows them to function effectively in society.” Similarly, 90% disagreed that complete abstinence is the only goal of substance abuse treatment. Furthermore, 76% disagreed that recovery from substance abuse was defined by achieving complete abstinence, and 73% also disagreed that abstinence was a reasonable and achievable goal for all clients (see Table 2). A very high percentage of respondents, 95%, disagreed with the statement, “Acceptance of substance use has no place in treatment.” Finally, 92% disagreed with the statement, “You can’t help someone recover by tolerating drug use in any way,” and 92% agreed that “relapse is a natural part of the recovery process.” Overall, these data indicate that the vast majority of staff were generally accepting of treatment outcomes other than abstinence, although a small minority were clearly either ambivalent about or unaccepting of treatment outcomes other than abstinence. TABLE 2. Participants’ Attitudes Toward Abstinence in Substance Use Treatment Item
Complete abstinence is the only goal of treatment for alcohol and substance abuse. Abstinence is a reasonable and achievable goal for all people. Acceptance of substance use has no place in treatment. You cannot help a person with addictions if you tolerate the use of substances. Recovery from substance abuse means complete abstinence from drugs and alcohol. You can’t help someone recover by tolerating drug use in any way. Relapse is a natural phase of the treatment process. A legitimate goal of treatment is to help people reduce their substance use to a level that allows them to function effectively in society.
Strongly agree
Agree
Unsure
Disagree
Strongly disagree
0.0%
5.4%
8.1%
49.5%
40.5%
5.4%
10.8%
10.8%
54.1%
18.9%
0.0%
2.7%
0.0%
67.6%
27.0%
0.0%
2.7%
2.7%
56.8%
35.1%
0.0%
13.5%
8.1%
54.1%
21.6%
0.0%
2.7%
5.4%
48.6%
43.2%
62.2%
29.7%
5.4%
2.7%
0.0%
32.4%
51.4%
8.1%
2.7%
2.7%
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Attitudes Toward Level of Training in Harm Reduction Approaches Participants were less clear about whether they were adequately trained and understood the harm reduction approach (see Table 3). Less than half (46%) agreed that they were adequately trained, 30% indicated they were unsure whether they were adequately trained in harm reduction, and 22% did not feel they were adequately trained. Similarly, whereas 46% agreed that they fully understood the harm reduction approach, 32% were unsure, and 19% disagreed with the statement. Finally, 76% of participants agreed with the statement that they needed more training in the harm reduction approach.
Focus Groups: Positive Aspects of the Harm Reduction Approach Focus group participants expressed positive thoughts about and acceptance of the harm reduction approach. The following presents the two most often discussed aspects about the harm reduction approach that participants found to be positive. All of the following quotations are from anonymous research participants.
Relationship-Oriented Participants indicated that the most positive aspect about the harm reduction approach was that it places primary importance on engagement and developing positive, accepting, and tolerant relationships, as illustrated in the following quote: TABLE 3. Participants’ Attitudes Regarding Their Level of Training in Harm Reduction Approaches Item
I feel that I am adequately trained in the harm reduction approach. I feel that I fully understand the harm reduction approach. I need more training in the harm reduction approach. I have serious concerns about the level of training I have received to work effectively with this population.
Strongly agree
Agree
Unsure
Disagree
Strongly disagree
8.1%
37.8%
29.7%
13.5%
8.1%
13.5%
32.4%
32.4%
13.5%
5.4%
24.3%
51.4%
16.2%
8.1%
0.0%
5.4%
18.9%
10.8%
54.1%
10.8%
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Harm reduction is all about the relationship you are able to form with the client. It allows for a relationship to form with the person. . . . It gives people room to grow. Participants stated that the harm reduction approach helped them to better engage clients because substance use and relapse were not viewed as failures or weaknesses, but as a natural and expected part of the treatment process. Similarly, participants indicated that the tolerance and acceptance necessitated by the harm reduction approach enhanced the quality and strength of their relationships with clients. For example, one participant stated: [It] helps build relationships between clients and staff. . . . Everything that gets done happens because of the relationship with the client and it can take years to build trust. . . . Harm reduction coincides and compliments that process and helps build relationships because it doesn’t build on shame and guilt. In addition, accepting relapse as a part of the overall process of recovery, rather than viewing it as a failure, was seen as helping to strengthen relationships with clients over the long term, and serving as a foundation for future success, as illustrated in the following two quotes: [Harm reduction] works because some of our clients have had the longest and most supportive relationships they have ever had, and because we said we are here for you [the client] and we’re not going anywhere. They eventually have been able to use that relationship to become sober. Relationship building over time can help people build a foundation so that if they do slip, they don’t slip all the way back down. Gradually, harm reduction helps stay with the person through the hope and belief that next time maybe they can make it, and not have to go all the way down if they have a relapse.
Nonjudgmental and Empowerment-Focused Participants indicated that the harm reduction approach enhanced their ability to accept their clients and endorsed client-directed decision making. The harm reduction approach allowed providers to position abstinence
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along a broader continuum of viable outcomes and thus expanded what they perceived as acceptable goals. This allowed for more flexibility and enabled providers to take a more nonjudgmental stance toward clients’ alcohol and other drug-using behaviors: [A] person decides where they want to go and develops a relationship with the worker. . . . [A] goal is change, and the client makes the decisions and works with the worker. . . . [Harm reduction] accepts the client where they are at and respects their choices. . . . Participants often complained that the abstinence-only approach to treatment placed them in a paternalistic role in regard to clients’ drugusing behavior and resulted in them overlooking positive gains made by clients. This often led clients to hide their drug use from providers to avoid feeling shame or guilt. The harm reduction approach, on the other hand, allowed providers to be more accepting of their clients, which often led to more open and honest relationships, as illustrated in the following quote: [Harm reduction] makes people feel safe to discuss their use without having to worry about being punished or made to feel guilty and they are able to now talk through it and move to the next stage of recovery. Participants indicated that the harm reduction approach focuses on developing recovery goals with clients and then providing clients with the support they need to move forward at their own pace while maintaining their dignity. Participants reported that abstinence-only approaches often reinforced a sense of worthlessness already existing in clients, whereas the acceptance and respect reflected through the harm reduction approach helped clients move forward with their recovery goals and enhanced their quality of life. Drugs sometimes are used to mask the shame and pain inside. . . . [The] abstinence model adds to that sense of failure and shame. Our relationship is such that we can form a relationship and communicate to clients we care and that they are worth it and can get rid of shame and form an idea that they deserve a better quality of life and that they are not this screwed up.
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Focus Groups: Negative Aspects of the Harm Reduction Approach Several participants expressed concern over some aspects of harm reduction they believed were troublesome or could lead to negative outcomes. We summarized these concerns into the two content areas, which are presented in order of frequency and importance.
Lack of Natural Consequences—Enabling The most common critique of the harm reduction approach was its perceived propensity to enable clients to continue using drugs by shielding them from the natural consequences of their behaviors as illustrated by the following quotes: Will this just allow people to use more safely with no progress, expectations or consequences? What are the consequences associated with using? It is hard to understand the limits of the model. [Harm reduction] doesn’t teach natural consequences for clients. . . . [It] shelters them. . . . What does that do to clients’ mentality? Participants critiqued the approach’s tolerance for the use of alcohol and drugs as removing incentives for sobriety. Tolerating substance use was seen as sending the wrong message to clients and sheltering them from the consequences of that behavior. These consequences could range from legal sanctions and punishments to loss of housing or service benefits. Many participants feared that clients enrolled in the CJ’s Place program would lose their motivation to change because the consequence of losing their housing was removed if they used drugs. Maybe it’s time clients spent time in a shelter because they have exhausted their resources. . . . Harm reduction teaches them the wrong lesson. . . . Maybe they should hit bottom to learn and feel the consequences. . . . Harm reduction shelters them from that. . . . You shouldn’t reward bad behavior. Other participants supported harm reduction, but stated that a misunderstanding of the approach contributed to overprotection by not holding clients ultimately responsible for their behaviors and to a commitment to change, as evidenced in the following quote:
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If not done well, the expectations of the client for themselves and the expectation of the worker drops. . . . Enabling can happen and the client doesn’t grow. . . . You have to continue to set goals. . . . Abstinence is not a requirement but it is a goal to move toward. Participants also stated that the harm reduction approach often conflicted with the way they had been trained: [It is a] difficult model to implement because you feel like you are enabling because of the way that we are traditionally trained. Feels strange because it feels like you are tolerating drug use and sometimes encouraging it.
Ambiguity of Approach Several participants noted that the harm reduction approach lacked concrete methods of implementation and were frustrated at its ambiguity regarding long-term outcomes. As indicated in the following quote, participants were concerned that the approach endorsed the idea that abstinence was not a realistic possibility for some clients and that a reduction in use was all that could be hoped for in the long term: What is the mission of harm reduction? Education? Acceptance? What? . . . If I can’t accept the model, how can I implement it? . . . It’s a change in the way one thinks. . . . Harm reduction has good points, but there are ethical problems. . . . Why do we have to accept that they are always going to use? Why that for them? We wouldn’t with our brothers or sisters. There seems to be an incongruence about the philosophy of the harm reduction model. . . . Is the goal to stop drug use or to only keep safe from the harm but accept that they will always use? Participants voiced the need for more training in the harm reduction approach, as they were unsure about implementing it in actual practice. Participants were clearly concerned that the approach lowered expectations for some clients and voiced confusion about the ultimate goal of the approach: So the definition is acceptance, safety and slowly getting them off drugs. You want to see some sort of change in the person. . . . I don’t
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want it to just be they went from a dime bag to nickel bag. . . . [We] need training about what is harm reduction. How will we use it? What is the goal and mission? Other participants who endorsed harm reduction voiced frustration because they felt that other practitioners at the agency held misperceptions about the approach and viewed it as permissive and enabling: It’s not switching from crack to pot. Other staff [are] missing the point that the goal is to get off of drugs, but the road to get there is different. [They are] misunderstanding that harm reduction is enabling. [It’s] not enabling. . . . [It’s] just a different way to get off of drugs that focuses on safety. It was evident from participant responses in both the questionnaires and the focus groups that the harm reduction approach was not consistent with the philosophies and backgrounds of all practitioners in the agency. Whereas some found that the approach enhanced their practice, other practitioners experienced a difficult time reconciling its philosophical tenets with their own training, background, and practice philosophies. Still others expressed frustration over what some perceived to be the approach’s lack of clarity, resulting in the conclusion by some that resources must be invested in proper training and supervision to implement the approach effectively at the agency.
DISCUSSION The mental health practitioners who participated in this study revealed a complex array of competing and contradictory attitudes about the harm reduction approach. Although many of the practitioners in the study revealed positive attitudes toward harm reduction, many others held reservations about the benefits of harm reduction and some voiced opposition to using the approach. These findings hold important systemic and programmatic implications for administrators and supervisors of community mental health and social service programs considering harm reduction. Practitioners in favor of the approach found that it helped them engage clients more effectively and build stronger, more trusting, and longer lasting relationships. Practitioners said that the flexible and accepting nature of the approach facilitated more honest and open communication with
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clients that ultimately strengthened the worker–client relationship. Similar findings were discovered when the harm reduction approach was first developed in the Netherlands (Inciardi & Harrison, 2000; Riley & O’Hare, 2000). In the Netherlands, practitioners used the harm reduction approach in their “street work” to engage drug users who were not ready to begin intensive drug treatment and as a result were better able to engage clients who might otherwise have never had access to treatment (Marlatt, 1998). Client engagement itself has also been identified as a key aspect of recovery from psychiatric disabilities (Linhorst, 2006; Mancini, Hardiman, & Lawson, 2005; Rapp, 1998) and is a vital component of the integrated treatment model of treating people with dual diagnoses (Drake et al., 2004). The possibility that harm reduction fosters stronger therapeutic relationships is significant given the difficulty in engaging dually diagnosed clients and retaining them in treatment as described earlier. The utilization of this approach is compatible with integrated treatment for dual disorders. For instance, integrated treatment utilizes the overall view that recovery from psychiatric disabilities and substance use disorders is a complex process that requires global and comprehensive lifestyle changes (Brunette et al., 2001; Carey, 1996; Drake, 1996; Minkoff, 1996). Residential treatment programs that use an integrated treatment approach for clients with dual diagnoses have been shown to be most effective when intensive and long term (Brunette et al., 2001). Therefore, the harm reduction approach may assist practitioners in helping retain clients in integrated treatment programs longer via stronger relationships and as a result help them move toward more advanced stages of sobriety. More research is indicated that examines the role of harm reduction in the formation of stronger relationships and how this mechanism can lead to more positive outcomes for dually diagnosed clients in residential treatment programs. In addition, working with clients with dual disorders is a challenging area of practice. Practitioners in this study voiced frustration that traditional, abstinence-based practice models hindered their ability to form positive relationships with clients because it fostered a sense of shame and guilt in clients who were unable to achieve and maintain complete sobriety. The ability of practitioners to foster stronger, more productive, and ultimately more satisfying professional relationships with their clients may have positive implications in regard to reducing staff frustration and burnout (Brotheridge & Grandey, 2002). More research examining whether harm reduction can lead to more positive emotional outcomes for
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practitioners could provide vital information to program administrators who may be struggling with staff morale and turnover issues. Practitioners were not in agreement about the appropriateness of the harm reduction approach. Some participants believed that the harm reduction approach enabled their clients to use drugs by not holding them to the expectation of complete abstinence and that tolerating any drug use was in effect a de facto endorsement of drug abusing behavior. A number of participants struggled with the idea that their clients would no longer feel the need to stop using drugs or work toward sobriety because the negative consequence of using drugs was removed. In addition, some participants struggled with the idea of accepting substance use behaviors, because these behaviors were, in and of themselves, harmful. Using substances undoubtedly can lead to harmful consequences such as overdose, victimization, incarceration, symptom exacerbation, and family disruption. Participants clearly struggled with the ethics of being accepting of behavior that could lead to such harm. Indeed, academic and nonacademic training programs may not be adequately preparing practitioners to process these types of ethical issues. These contradictions can also be traced to the intense ambiguity that some participants identified as problematic of the harm reduction approach. Whereas some participants were clearly in favor of the approach and had no reservations about its efficacy and utility, others struggled with the idea of being tolerant of substance use because they were trained in the traditional treatment approach that viewed abstinence from alcohol and drugs as the only legitimate outcome.
Limitations This study had several limitations. First of all, this study evaluated only 37 staff members at a single agency. This descriptive case study is used solely as a way to highlight relevant implementation and future research areas and results should not be generalized to any broader population or other agencies. Second, the use of focus groups may have limited the responses of participants due to a lack of confidentiality and privacy inherent in focus group research. Individual interviews may have resulted in participants being more forthcoming in their responses. Third, due to the lack of appropriate measures, the authors developed the questionnaire for this study. As a result, reliability and validity information for this questionnaire could not be established, severely limiting the confidence in the accuracy of results. Finally, because the questionnaires were
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completed by the participants immediately prior to the focus groups, the possibility of reactivity could not be ruled out.
Implications The ambiguities and contradictions voiced by participants in this study have important implications for social service administrators considering the harm reduction approach. One implication is that it is probably beneficial to engage program staff in an ongoing and open dialogue to assess staff understanding and acceptance of a harm reduction perspective. Administrators should initially hold a series of intensive workshops for all agency staff in harm reduction philosophy and practice. Training can be provided either by outside sources or via well-trained administrators and supervisors within the agency. In-service training in harm reduction techniques should be implemented at regular intervals, and opportunities should be made available for staff to attend harm reduction workshops and conferences outside of the agency. In addition to open discussions and regular training, ongoing and wellinformed clinical supervision is important for effective implementation. Agency administrators and supervisors should be well trained in the harm reduction approach and be able to mentor staff on how to apply the approach in practice. Finally, agencies using a harm reduction perspective should conduct ongoing evaluations of staff competency and acceptance of the approach, ideally by utilizing outside evaluators. These evaluations can be used not only to determine how well staff members are implementing the harm reduction approach, but also to identify and reduce staff polarization regarding the approach through open dialogue and discussion.
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RECEIVED: 11/29/05 REVISED: 08/24/06 ACCEPTED: 11/13/06
