Harm Reduction

1. Harm Reduction Organizational Considerations

2. Background Thinking • Organizations need to incorporate a deeper understanding of what is helpful and provide skills for their staff to provide the best help. • It can be helpful to view HR as counter-cultural meaning that the changes needed to be made are as difficult for staff as they are for clients

3. What Do Effective Helpers Need to Know?Helpful Assumptions/Principles • Behavior Change is Difficult • Change need not be rushed • Clients want change – but not necessarily the change you want to see • The relationship is the most important piece – as long as there is a relationship, there is a chance for change

4. Why is behavior change difficult? • The behavior meets some kind of need • The behavior may have been adaptive at one point and now it’s not, but the groove is worn • The cycle of guilt and shame • A big change is overwhelming • Co-occurring disorders complicate change

5. What works • Addressing basic needs – “Begin where client is” • Relationship building • Remembering who the “expert” on the problem is and, whose problem it is • Developing an “anything goes” attitude toward the client • Exploring options rather than prescribing • Motivational Interviewing skills are key

6. Motivational Interviewing • MI helps clients regardless of readiness to change • MI can be seamlessly integrated into other interventions • MI works in all types of areas – anywhere a client might be “stuck” • Read all about it: http://www.motivationalinterview.org/clinical/whatismi.html

7. Harm Reduction – How does it fit? • An HR approach is a paradigm shift away from a strict adherence or abstinence model • It changes treatment planning so that it begins with what is most practical and possible for the client to achieve • It incorporates a broader view of the client’s problem and menu of solutions

8. Myths and Misconceptions • Harm reduction is the same as “enabling.” • Condones substance abuse or makes light of critical treatment requirements • Is antithetical to an adherence based approach

9. Advantages to Harm Reduction • Keeps the provider/client relationship alive • Pragmatic – if adherence isn’t realistic, something else is • You can feel good about smaller successes • Eliminates the tension that exists between providers and the “non-compliant” client • Liberates the provider from responsibility for the outcome • Focuses on the process, not the outcome (“What else can we try?”)

10. Challenges to Implementation • Focuses on the process, not the outcome (“Are we there yet?”) • Requires being able to hold conflicting ideas and thoughts at the same time • Not everyone “gets it” (especially clients) • Not achieving abstinence/adherence frustrates providers (and clients) • It makes some people feel like they are doing the wrong thing • Staff are not empowered to “fire” clients they are frustrated with

11. Harm Reduction Philosophy? What’s that? • Guiding principles for providers that focuses on the relationship, not the outcome • Recognizes that behavior change is difficult and may not change according to plan • Changes how the issue of “responsibility” is factored into the treatment equation • Ideal if philosophy is agency-wide and adoption is facilitated from the top – down.

12. Incorporating Harm Reduction Organizationally • Full administrative buy-in • Solid harm reduction philosophy • Solid supervisory structure • Start talking about HR in the interview • Ongoing staff development • Integrated disciplinary action policy

13. Full Administrative Buy-In • If you have the support of the agency’s top brass, implementation of an agency-wide HR approach is much easier. • If you don’t have administrative support, model, model, model

14. Solid Harm Reduction Philosophy • Have a document to which your staff can refer • Use participatory management strategies to get it adopted

15. Solid Supervisory Structure • Ideally, all clinicians should meet with an experienced supervisor regularly • Keep an eye on supervisor to staff ratios • Case conferences facilitated by experienced supervisors • Form clinical supervision groups

16. Start talking about HR during interviews • Ask clinical candidates to read HR philosophy and ask a question about integrating those principles in their practice • Look not for knowledge about HR, but openness and tolerance in answers

17. Ongoing Staff Development • Offer in-services to clinical staff • Facilitate reading groups of HR materials • Be creative and plan for ongoing needs. Changing a culture is never a one-shot deal

18. Integrated Disciplinary Action Process • Keeping “anything goes” in balance to ensure staff safety and maintain a sense of staff empowerment • Provide leadership that balances where staff members are in relationship to where clients are. Work toward the goal of using “bad behavior” clinically instead of reacting by punishing it.

19. Being Mindful… • All clinicians take a harm reduction approach at least some of the time. The trick is to hone one’s skills in order to operate from this philosophical place more often and on-purpose • Be gentle with yourself and your colleagues. This approach requires a lot of the provider. If you are feeling stressed, you need more support

20. Contact Information • Jan Caughlan, LCSW-C Director of Mental Health and Social Work Health Care for the Homeless 111 Park Ave. Baltimore, MD 21201 443-703-1207 jcaughlan@hchmd.org