Please read the attached chapter
1. Can you identify a particular life event, perhaps an outcome of a series of detrimental behaviors, that ignited within you a desire for change?
2. If you were to inventory habits that you have wanted to change for a considerable amount of time, how successful do you believe you would be without making incremental change?
3. Were there any times during the session that you might have felt discouraged by Sally’s ambivalence? Would you have handled the session differently?
4. Person-centered, humanistic psychotherapy techniques were used as part of Harm Reduction psychotherapy during Sally’s sessions. Whatother forms of therapy that you might choose to integrate with Harm Reduction psychotherapy? Please explain why.
Knight-Wheeler_R3_13_000-000_06-24-20 Page 241 21/07/20 11:49 AM 13 Harm Reduction Psychotherapy: A Client With a Substance Use Disorder Michelle Knapp and Adam Kozikowski ■ PERSONAL EXPERIENCE WITH HARM REDUCTION PSYCHOTHERAPY Problematic substance use and its sequelae of interpersonal and social problems are common among individuals seeking psychotherapy. In 2017, the National Survey on Drug Use and Health found that more than 8.5 million adults have both a substance use disorder (SUD) and other psychiatric disorder, and trends show that SUDs are not decreasing (Lipari & Van Horn, 2017; Substance Abuse and Mental Health Services Administration, 2018). SUDs can cause significant psychological and physiological tur- moil for those affected. Unfortunately, few people receive adequate treatment for these disorders. Some reasons may be related to the stigma of substance use, limited special- ized treatment facilities, and lack of providers who are comfortable or knowledgeable in the long-term management of SUDs—conditions that are unlikely to change anytime in the near future. Historically, substance use treatment has focused on an “abstinence-only” model of care. This all-or-nothing approach to treatment places emphasis on the SUD and the cli- ent’s “choice” to avoid change. Though abstinence may be one goal of treatment, focus- ing on this alone may predispose clients to failure. Clients often experience shame or defeat in relapse and are reluctant to face providers and continue with treatment. Harm Reduction psychotherapy is a more contemporary and successful approach to helping clients in their treatment of substance use (Marlatt, 1998). As the authors of this chapter, we have over four decades of combined years of expe- rience working with clients having substance use issues. Initially, we worked as psychi- atric nurses on substance use detoxification units and short-term rehabilitation units of general hospitals. The majority of our experience at that time involved working with practitioners who subscribed to the abstinence-only model of treatment. Nevertheless, we rarely found the expectation of abstinence helpful for our clients. In consequent review of the literature, we were astonished by the poor outcomes of the abstinence- only model of care. As a result, we began to seriously question and ultimately rethink the abstinence-only approach. Knight-Wheeler_R3_13_000-000_06-24-20 Page 242 21/07/20 11:49 AM 242 ■ CASE STUDY APPROACH TO PSYCHOTHERAPY FOR ADVANCED PRACTICE PSYCHIATRIC NURSES In general, we have always found our clients with substance use issues to be a diverse group of stimulating, captivating clients who are flexible and open to participating in psychotherapy. Nonetheless, with the abstinence-only model, the philosophy prevails that clients cannot benefit from psychotherapy while they are using substances. Hence, the belief that when clients articulate their psychological issues while still using sub- stances, they are designated as being in denial; therefore, the fundamental notion is their substance use must be addressed prior to embarking on any psychological work. In those early days, early on when we worked with the “abstinence-only” model, it was our role to encourage clients to accept abstinence as the goal of treatment and to discourage them from working on their other psychological issues until the substance use was addressed. Our exposure to the Harm Reduction model of treatment occurred when we began working as psychiatric nurses at Roosevelt Hospital’s Addiction Institute in New York City with some of the world’s foremost thinkers in substance use treatment. In this set- ting, we developed an in-depth understanding of Harm Reduction philosophy as well as the techniques of Harm Reduction psychotherapy and the benefits it could provide clients suffering from SUDs. We also received high-level supervision from physicians certified in addiction psychiatry. While working at Roosevelt Hospital’s Addiction Institute, we began graduate school at New York University (NYU) to become psychiatric nurse practitioners. At NYU, we received in-depth training in Carl Rogers' Person-Centered Therapy approach as well as William Miller and Stephen Rollnick’s Motivational Interviewing (MI) approach. Both approaches are incorporated into Harm Reduction psychotherapy. After becoming psy- chiatric nurse practitioners, we received further training in Harm Reduction psycho- therapy as well as different therapeutic modalities including Gestalt therapy, Cognitive Behavioral therapy, and Somatic therapies. We incorporate aspects of these approaches into our Harm Reduction psychotherapy as well. As psychiatric nurse practitioners, we have worked at a number of inpatient and outpatient facilities over the past decade. We have developed specialties with a variety of populations having SUDs including the forensic population and the LGBTQ popula- tion. Within these populations, we have been able to treat clients with acute and chronic SUDs across many cultural and socioeconomic backgrounds. Dr. Michelle Knapp also currently works in a specialized opioid agonist therapy setting providing Harm Reduction psychotherapy and medication-assisted treatments to pregnant women who use substances. In addition to our extensive clinical experience, we have taught gradu- ate level courses in SUDs and behavioral addictions and have conducted numerous workshops on Harm Reduction psychotherapy at major universities, psychotherapy training institutes, and at national and regional conferences. Dr. Michelle Knapp is also the director of the Substance Use Sequence at NYU, which awards students a certificate in SUDs after completing three courses and an internship with clients having SUDs. The courses teach students how to treat SUDs and related addictions from a Harm Reduction philosophy and provides them training in both MI and Harm Reduction psy- chotherapy. Adam Kozikowski currently works as an adjunct faculty at NYU where he teaches brain stimulation approaches for clients with SUDs as well as individual, group, couples, and family psychotherapy supervision. In addition, he teaches at the Center for Gestalt Psychotherapy and Training. ■ FOUNDERS AND LEADERS OF HARM REDUCTION PSYCHOTHERAPY There are three important researchers and clinicians who are considered to be important in the development of Harm Reduction psychotherapy. They are Elvin Morton Jellinek, Edward John Khantzian, and Gordon Alan Marlatt. 13. HARM REDUCTION PSYCHOTHERAPY: A CLIENT WITH A SUBSTANCE USE DISORDER ■ 243 Knight-Wheeler_R3_13_000-000_06-24-20 Page 243 21/07/20 11:49 AM The “abstinence-only” model of treatment for clients with SUDs assumes that change cannot be achieved in any area of life until the client stops using substances. There is an assumption made that the substance user is in denial about the “real” problem. This model is grounded in the belief that addiction is a moral disease. In 1960, E. Morton Jellinek, a physiologist, alcoholism researcher, and founder of the Yale Center of Alcohol Studies, challenged this idea in his breakthrough book, The Disease Concept of Alcoholism. He proposed that individuals labeled as alcoholics should be treated as physiologically sick people and that alcoholism is a disease with pathophysiological origins. Jellinek coined the expression “the disease model of alcoholism” and significantly altered the belief that addiction is a moral disease to the belief that alcoholism is a medi- cal disease (Jellinek, 1960). In 1985, Edward John Khantzian, a psychiatrist, psychoanalyst, and professor of psychiatry at Harvard University, published his landmark article, “The Self-Medication Hypothesis of Addictive Disorders,” where he further challenged the “abstinence-only” model of substance use. Khantzian originated the self-medication hypothesis of sub- stance use, identifying substances as external modifiers of emotions. Thus, individuals who use substances are not moral failures, but are attempting to self-medicate and thus ameliorate unbearable states of distress rooted in psychological suffering, rather than for pleasure seeking or self-destruction. He believed that it was unreasonable to expect individuals to forfeit what may be the only thing helping them cope (Khantzian, 1985). Khantzian is considered a pioneer in substance use studies and treatment. In his latest book, Treating Addiction: Beyond the Pain, he describes individual and group treatments for clients with substance use issues as well as accessible resources for mental health professionals working with this population (Khantzian, 2018). Alan Marlatt (1941–2011), a clinical psychologist, is often identified as the seminal founder of the Harm Reduction psychotherapy approach. For 30 years he directed the University of Washington in Seattle’s Addictive Behaviors Research Center with the philos- ophy of compassionate pragmatism rather than moralistic idealism (Snyder, 2011). At the Center, he pioneered research in the Harm Reduction psychotherapy approach for treating substance use and addictive behaviors as well as understanding and preventing relapse. Marlatt acknowledged that the only way to therapeutically engage a client using substances was to encourage some degree of personal control. This was a paradigm shift—a view that respected clients’ capacity for unlimited change. His methodical research connected the physiological and psychological aspects of addiction. Marlatt rejected the assumption that change was all-or-nothing and theorized that there exists a complex relationship between the mind and body that requires helping clients who are “intrinsically unique” find their own “intrinsically unique” starting points. For example, if a client wanted to drink only three beers per day instead of quitting altogether, he would work with that goal. While abstinence is likely the best possible outcome for clients with a history of heavy and prob- lematic substance use, he saw a person-centered approach as key to addiction treatment. Marlatt is considered to be a maverick in the field of substance use treatment—a man who went against the zeitgeist of his time as the philosophy of Harm Reduction had not yet been recognized as a viable option for substance use problems. His classic book, Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors, was published in 1998, and is the first major Harm Reduction book. In this book, rather than insisting on abstinence as a prerequisite to continued treatment, he describes the principles of Harm Reduction and the strategies to minimize self-destructive consequences of sub- stance use and other addictive behaviors. The book discusses meeting substance users “where they’re at” and includes community-based services that empower clients to set and meet their own treatment goals. It gives examples of Harm Reduction strategies such as needle exchange programs, alternative alcohol interventions, and AIDS preven- tion campaigns. An understanding into the often contentious philosophical and policy- related debates surrounding harm reduction are also addressed in his book. Knight-Wheeler_R3_13_000-000_06-24-20 Page 244 21/07/20 11:49 AM 244 ■ CASE STUDY APPROACH TO PSYCHOTHERAPY FOR ADVANCED PRACTICE PSYCHIATRIC NURSES ■ PHILOSOPHY AND KEY CONCEPTS OF HARM REDUCTION PSYCHOTHERAPY Harm Reduction as a philosophy is viewed as a social justice and human rights approach to risky behavior as opposed to a moralistic and criminalizing one. The central tenet is the recognition that many individuals engage in behaviors that carry risk; it seeks to alle- viate the potential harm associated with risky behaviors rather than attempting to pro- hibit them. It supports the view that individuals should not be denied treatment merely because they take risks. The Harm Reduction philosophy encompasses a range