Integrative Harm Reduction Psychotherapy Shifts Paradigm of Recovery

For clinicians working with patients who are struggling with substance use disorder (SUD), integrative harm reduction psychotherapy can help foster engagement and strengthen a therapeutic alliance en route to recovery, Andrew Tatarsky, PhD, told attendees at the East Coast Symposium on Addictive Disorders earlier this month.

Shortly after the Symposium, Dr Tatarsky, founder and director of the Tatarsky Institute in New York, spoke with Addiction Professional about the principles of harm reduction, what sets integrative harm reduction psychotherapy apart from other harm reduction-based approaches, and best practices for helping patients to establish meaningful and attainable goals in recovery.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: At the East Coast Symposium, you discussed 4 principles of harm reduction. What are those principles and how do they define the harm reduction framework?

Andrew Tatarsky: There's actually a fifth idea that I think is a good starting place, which is the idea of compassionate pragmatism—that we're all driven by compassion to reduce suffering and improve the quality of life of the people that we're trying to be helpful to, but that we need to take a pragmatic attitude toward evaluating what we're doing continuously in terms of what's working and what's not.

Harm reduction is not a kind of ideological approach; it's really rooted in pragmatism. We need to be continually evaluating our policies and practices in terms of how well they're working. If we look at the scope of the addiction problem and problematic substance use and how few people are being treated in this country effectively by traditional addiction treatment, those data really suggest that we need to question what we've been doing and open up to something new.

Harm reduction is really about trying to do what works with a given population or even with a given individual. We need to be open to constantly questioning, challenging, and being willing to change and adapt, our practices. But having said that, I think, for me, the major core principle shift is away from abstinence-only assumptions—that abstinence is the only acceptable goal and the only measure of success. Rather than requiring abstinence, a harm reduction approach says, “Let's embrace any positive change, and not impose our assumptions and our values on the people that we're trying to be helpful to. Let’s begin with what they identify as a step in the right direction.”

The second principle enables us to truly start where people are and focus on what they need, what they want, and what they're motivated to begin working on. Starting where people are means that we acknowledge that each person is an individual, and we need to tailor what we are offering people.

The third major principle shift is in embracing gradual, incremental change in a positive direction. In a way, abstinence we might think of as a quantum change, which might be the ultimate goal, but it’s starting where people are and then supporting people in moving in a positive direction, however they define that. For many people, just simply showing up is a major positive step toward being willing to invite the practitioner into what they're struggling with. Then we can begin to goal set in as small or as large steps as people are ready, willing, and able to embrace.

Finally, another fundamental shift is toward embracing a kind of collaborative stance with patients that we want to support people in getting in the driver's seat of their process of change and then working to empower them in a collaborative way. Pat Denning, who was one of the other major contributors to harm reduction psychotherapy, said that we could think of ourselves with our clients as therapeutic teams so that we're really working together to support them in their process of positive change rather than the traditional, top-down, authoritarian prescriptive approach, which is basically disempowering. This collaborative stance really aims to empower and support people on their own terms.

AP: A term you have used specifically is “integrative harm reduction psychotherapy.” Can you just clarify what that terminology means?

AT: We’re in the midst of a major paradigm shift in how we understand problematic substance use or what we call addiction. An older disease model suggests that addiction is primarily a biological process. … There's a much more complex way of understanding addiction as being a reflection of an interaction of biology, meaning, and psychology. Often trauma is a part of that, as well as one's social circumstances. So, when we think of it in this way, we need to have a treatment approach that is potentially able to address all of those complex factors. That suggests to me why we need to have an integrative approach.

We need part of the treatment approach to focus on clarifying the personal, relational, and social meanings that substances come to play in people's lives, and why people turn to substances in response to suffering as a way of coping, surviving, and caring for themselves. We need to focus on clarifying that complex meaning. The things that we turn to that actually help us feel better over time can become deeply ingrained habits or what we call ‘overlearned habits’ that become encoded in neural networks. We also need to have focus in therapy on assessing problematic behavior and helping people goal set in a in a very specific way. This suggests that we need a cognitive behavioral kind of strategic approach.

Moreover, mindfulness or cultivating a capacity to be aware of and tolerate distress in the moment, supports both of these focuses on clarifying meaning and in assessing and changing problematic behavior. All of that then takes place within that harm reduction frame that I just described.

Now, what distinguishes this from other harm reduction approaches? I think that most people know about harm reduction in terms of its public health applications. That's really how harm reduction has proliferated helping people stay alive and healthy, with strategies like using clean syringes, having access to Narcan to reverse overdose. Condom use or even seat belt use are forms of harm reduction. Harm reduction psychotherapy takes these principles and applies them to a behavior change process as opposed to helping people stay alive, which is actually the foundation of anything else that we might do with folks.

AP: Do you have any recommendations for engaging with active substance users, getting them to buy into this harm reduction philosophy, and helping them to establish meaningful and attainable goals in recovery?

AT: Firstly, the overwhelming majority of people who struggle with substances, at least at the point that they become concerned about their substance use, are not ready to commit to abstinence. So, I think that traditional abstinence-based treatment has been a kind of a mismatch. Certainly, there is a percentage of folks who are interested and committed to working toward abstinence, but at the beginning of a positive change process, I would say that most people are not, and so the power and the beauty of a harm reduction approach is that simply inviting people who are actively using substances and struggling with substances into a treatment process on their own terms without requiring abstinence opens the door to this tremendous group of people who have been denied care. The therapeutic engagement strategies have to do with that inviting patients to engage at whatever level at which they are ready to begin their positive change process, and then meeting them with empathy and curiosity, and reflecting back that empathy in a way that sends the message to folks that we're really accepting them on their own terms. That frame best supports a therapeutic alliance, and that therapeutic alliance is really the foundation for everything else that we might do to support people.

There are a lot of other elements. The relationship that builds around that alliance in itself can be profoundly healing because many people who struggle with substances have had very negative experiences with treatment, with police, with families who have been counseled to kick them out because of their use. That has contributed to a lot of the shame, guilt, and despair that people that struggle with substances feel. Shifting to this harm reduction frame that says, “We are going to invite you into care with curiosity, respect, empathy, and a kind of collaborative stance” can send a message that you matter, you count, there are people in the world that are willing to accept you on your own terms. That can create a space for people to feel like they can then begin to inquire into all the complex reasons that they are using substance and the function those substances play in their lives. That opens up a conversation about alternative ways of caring for oneself that may be less risky and more in line with their values and so on.

Reference

Tatarsky A. A new “addiction” paradigm: From disease to meaningful dilemma, from abstinence-only to integrative harm reduction psychotherapy (IHRP). Presented at East Coast Symposium on Addictive Disorders. November 3-5, 2023; Ponte Vedra, Florida.