Substance Use Management: A Harm Reduction-Principled Approach
SUM replaces the indoctrination of the disease model of addiction ideology so common in the treatment system today with an ideology of actual improvement and a process of respectful and collaborative engagement.
Four steps to guide the counselor in the practice of SUM are described below:
Process: Step One -- Overcoming Fifty Years of Expectations
Making a transition to SUM's multi-goal approach requires a good degree of re- framing of what it means to give or receive help for drug problems. It is so entrenched in popular belief that abstinence is the only successful outcome of the drug help system that "cleaning/drying/sobering up" are part and parcel of any common understanding of treatment.
In reality, people could benefit from the treatment system by simply moderating their drug use or otherwise relieving drug related problems. These non-abstinent alternatives are real outcomes today, even though they are not assisted directly and, at some level, the individual's continuing use is judged a failure by the program.
Unfortunately, the treatment system, as it exists today, is generally not satisfied with the common outcome of moderation and improvement. In the last week, three people have come to me who have had their lives improved dramatically by methadone treatment but who are being threatened with expulsion from the program for having illicit drugs in their urine.
It is as if we are saying, "Significant improvement is not enough, you must be perfect in your abstaining or we will deprive you of the medication which has greatly improved your life".
This punitive approach is commonplace within the drug help system.
As well, there is a general lack of support of drug treatment in that it is inadequately funded and seldom available even for those it appeals to.
In total, SUM offers a deliberate process of interaction for use with the diverse options mentioned above.
SUM practice would require up-front explanations of clients regarding the goals of SUM (any positive change as a person defines it for herself) and giving a clear understanding that ongoing drug use may or may not be a part of a successful treatment outcome.
SUM cannot be practiced without the counselor sincerely having and explaining this perspective to those he works with.
Process: Step Two -- Creating an Environment for Free Choice
Continuing the buffet table metaphor, Step Two would involve the counselor giving the person seeking help a clean plate and silverware, introducing her to each dish if not familiar with it, and allowing her to select dishes and portion sizes.
Assisting someone to make these choices freely without guiding her to the dish (approach/method/goal) you or your agency most prefer requires great skill and respect for the person. Limiting any 'help' in this step to explaining all options with equal balance and having the readiness to support the client's choice(s) as they freely make them is critical.
As well, accepting the client's level of intensity and prioritizations they give each choice is a critical aspect to SUM. Such client directed selections are essential steps to initiating SUM's work.
The more options available and the more the person believes it is she who directs treatment's work through her free choices the more efficient and successful treatment will be. Too much time and energy is lost today in dancing with a person seeking help to orient them towards abstinence when this is not their true inclinations.
Such coercion's and deceptions build poor relationships and SUM practitioners avoid them.
Process: Step Three -- Working in the Right Direction
By working entirely with the choices of the person you are helping you are saying two things loud and clear that are critical to SUM's practice:
1) The person is not only in charge but self-responsible; and 2) The counselor accepts and respects this fact at all times.
I have found such an approach releases the counselor of undue responsibility for the person they are assisting and thus allows a healthier, more realistic relationship. Many counselors will rejoice in the release of this burden associated with forcing a goal of abstinence-only.
Others may struggle to accept this as truly 'caring' and 'helpful'. Clearly, today's counselor will be challenged to clarify her own desires from those of the people she is helping and to deal with the emotional turmoil that can arise from accepting and respecting the inclinations of someone not only seeking help but also who is 'sick'.
In SUM, no one is 'too sick' to make their own decisions regarding their drug use no matter the shame or devastation in their lives. SUM accepts the reality that people will always make their own decisions regarding their drug use.
Openly addressing the issues involved in this choice allows a person to make a better decision for themselves.
The work of SUM consists of engaging people in activities in four areas:
1) Knowledge - impacted by providing information in various forms (e.g. learning the metabolic effects of intoxication/detoxification, understanding aspects of various forms of drug ingestion);
2) Attitudes/values/beliefs/morals/faith/emotions - engaged through focused discussion and clarification (e.g. clarifying what a person truly considers beneficial and detrimental about their drug use);
3) Skills - impacted by practice of new behaviors (e.g. watching and then demonstrating how to tie a tourniquet so it can be released after getting a hit thus preventing overdose and infections).
4) Environment - working to change the forces in one's surroundings through various means (e.g. attending Narcotics Anonymous meetings for a person looking to become abstinent or creating an organization of committed drug users to advocate for greater social justice).
Process: Step Four -- Evaluating Impact and Reconsidering Directions
By offering respect and working with your client's direction and intensity you are laying the ground work for an honest evaluation of progress -- beyond shame and fear of condemnation. The clarity that comes from acceptance and respect of an individual works its miracles here.
Unburdened by punitive measures and failure to achieve program given goals, people can be more honest in evaluating the effectiveness of what they have chosen to work on.
Such examinations should be a regular part of SUM in order to reassess any and all aspects of the chosen SUM plan. What some consider a overly permissive system in SUM is purposefully so due to the benefits from such an approach in the evaluation phase.
By laying a bridge of connection through respect and collaboration the person seeking help will very likely have developed an alliance with the counselor and be likely to use this relationship to re-examine their actual experiences and plan other directions for their next effort at improvement.
The cycle of the four process steps described here are critical to SUM's practice but should only used as a guide. It would be contrary to SUM's respect and collaboration to force someone to proceed through an orderly series of steps when they would rather dance to a different tune. The general steps of offering many options, assisting free choice, and evaluating impact may work best as a fluid process.
Some argue that the disease process of addiction prevents SUM from being an effective approach. Ultimately, if the person the counselor is assisting is experiencing the disease of addiction in its classic sense (and it is clear some do fit it very well) she will get to the point where she recognizes abstinence as the only option that will work for her.
While this recognition may take a little longer than if abstinence is required from the outset as the only option, this approach will have not severed the connection with treatment. Ultimately, SUM processes will have engaged an individual and can more solidly move in any direction her experience dictates.
The leading processes are respect and collaboration instead of the dogma, alienation and shame currently utilized today.
Redefining Denial and Enabling
Often used as tools of control and coercion, 'denial' and 'enabling' have served to keep counselors from venturing too far away from the status quo of abstinence- only. SUM addresses these issues with the light of respect and collaboration so as to see these processes for what they truly are -- both potentially helpful and potentially hurtful.
Denial -- ignoring clear consequences of one's actions -- is often a term of manipulation in the current treatment system.
It usually means the person seeking help has a different view from the counselor.
In SUM, denial is irrelevant because you are practicing a client-centered respectful process which has regular evaluations of effectiveness in terms the person has defined for herself -- the coercion and condemnation are absent from the relationship and often there is no more 'denial'.
While discomfort at realizing and accepting elements of one's behavior and its consequences is commonplace, SUM assumes there is good reason for it - probably in a protective sense -- and that ignoring real cause and effect will not be needed as much in a relationship of true respect and collaboration.
In fact, I believe such support is the worst enemy of thinking that is out of touch with reality.
According to Webster, enabling simply means "provision of the means or opportunity for doing". Clearly, whether enabling is constructive or destructive depends upon what is enabled.
Traditionally, talking with significant others of problematic drug users about enabling often helps them recognize their own role in the user's drug consumption and how to 'get tough' in helping the drug user to get better.
While self-examinations are never out of place for anyone and much can be gained from such insights to relieve drug problems, enabling must not be used to generate punishment and condemnation for lack of abstinence. Such tag-team oppression towards a person with drug problems increases her risk of harm. Still, lines sometimes need to be drawn in relations with another person.
SUM re-frames enabling as both helpful and hurtful according to both its impact and the values of the person acting it out.
SUM suggests that there are two kinds of enabling -- one hurtful and one helpful -- and the trick is in elucidating their difference. Each person can only determine for herself which variety of enabling she is practicing with the following guides:
If the enabler's action in question is not consistent with her own values, and also directly causes harm to the other person, then this action is harmfully enabling.
If the enabler's action in question is consistent with her own values, and does not directly cause harm to the other person, then this action is not harmfully enabling.
Thus, reflexive determinations of treatment-undermining enabling are impossible without self-reflection by the person or perpetrator, as you will. Thus, in SUM, significant others of the person seeking help are assisted to clarify for themselves their role and direction in relieving drug problems just as the person seeking help is.
For example, giving money to a drug user, if consistent with the giver's wishes, is clearly not directly harmful to the drug using person. What they do with the money after receiving it may be harmful but this is beyond the control or the giver. Accepting only responsibility that is within your control is critical to SUM as well as good health in general.
Building an Institution Based on Any Positive Change
The overview above, in mostly broad strokes, calls for changes in our practice of offering help for relief of drug-related harms. I contend that SUM must be respectful and collaborative in its role in changing the current system.
Only by being attractive, inspirational and beneficial will the treatment system be improved by any new perspective.
Transition from the current system will be both revolutionary and subtle. My belief in the transformational ability of SUM is based on my recognition that humans will migrate to places of peace, respect and self-determination if given the chance.
An additional consideration in providing any service is its funding. In this regard, SUM offers a major advantage over an abstinence-only focus. The process of SUM described above is very cost efficient, wasting little time or energies on activities which have little chance of being accepted. Similarly, one should be able to demonstrate concrete financial benefits brought about by the SUM approach to relieving drug harms.
For instance, safer injection as a person's selected treatment can be taught and practiced effectively in a relatively short time.
The payoff from these, sometimes small changes, in technique can mean the difference between acquiring HIV or Hepatitis or not. To an insurance company this means saving hundreds of thousands of dollars yet these potential improvements are often ignored by the treatment system today. SUM may indeed be more attractive to funders.
12 Step groups, for those wanting what the group offers, are models of beneficial environmental entities to the practice of SUM - cheap, widely and freely available, somewhat self-defined, respectful, focused principled versus prescriptive. SUM would support Self Help Groups of all kinds as options on their broad tables of choices for improvement.
Increasing diversity of requirements for membership and attraction to such programs will be a critical aspect of the success of SUM as a constructive movement. Forcing self-help on someone is not only contrary to SUM's principles but also destructive.
SUM may not only guide the improvement of the drug problem help system but assist in the recovery of lost humanity and dignity of associated institutions. As SUM helps the treatment system leave behind the oppressive role it has played for the criminal justice system and other institutions, it offers hope for development of a more autonomous institution and one based on expertise and impact.
Denning 2000. Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. New York: The Guilford Press.
Institute of Medicine 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: US Government Printing Office.
Kishline 1994. Moderate Drinking: The New Option for Problem Drinkers. Tucson: See Sharp Press.
Marlatt 1998. Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. New York: The Guilford Press.
Hester, RK and Miller, WR 1995. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd Edition, , Boston: Allyn and Bacon.
Weil 1972. The Natural Mind. Boston, MA: Houghton Mifflin Company.
Vaillant 1995. The Natural History of Alcoholism: Revisited. Cambridge, MA: Harvard Press.
Zinberg, 1990. Drug, Set and Setting. New Haven: Yale University Press.
Source: Substance Use Management: A Harm Reduction-Principled Approach to Assisting the Relief of Drug-Related Problems [PDF]
Chicago Recovery Alliance