Harm Reduction in Practice
Harm Reduction is working toward Any Positive Change. But what does that look like in your practice? Don't you have to tackle drug use before anything else? What if they keep identifying the wrong goals? If the treatment fails, shouldn't I stop working with them?
The flowchart below will give you a starting place to conceptualize reducing harms as directed by the client. Perfection is not the goal. Remember, better is better!
Check out the case studies below for ideas about how to support Any Positive Change for your clients.
Ilona is a 36yo married mother of a 3-year-old. She has a history of alcohol dependence in her early 20s. She came into your family practice for an upper respiratory infection. She confided to you during routine health screening that last weekend while her husband was away and her son was at his father’s, she was feeling low and drank a couple bottles of wine alone at home.
Now she is feeling guilty and afraid that she will fall back into old habits. She says, “Please don’t take my son away. This isn’t his fault and he shouldn’t be punished for my failure. I know if I can get myself together, I can still be a good mom.”
You continue the process of SBIRT (Screening, Brief Intervention, Referral to Treatment) by thanking her for telling you and assuring her that as long as her son is safe, you have no intention of reporting her to CPS.
Then you discuss her current goals, and how she was able to change her drinking for the better in the past. She says she wants to stop drinking alone, and that 2 bottles of wine didn’t feel good the next day.
In the past, she found help at her temple and through prayer. You encourage her to seek counseling with an Imam, recommend a Moderation Management group for women, and the two of you work out a safety plan for her son in case she finds herself drinking too much again. You thank her again for telling you and let her know that you will give her a call next week to see how she is doing.
Sara is a pregnant 19-year-old woman who lives in a car with her boyfriend and uses heroin and methamphetamine. You have been providing Subutex and counseling for her for about 3 months, and she is now 28 weeks along. You are frustrated because she frequently misses appointments and has been unable to consistently provide negative urine samples.
Every time you see her, she says she wants to quit, but nothing is changing. You have told her that she will be reported to the police and child protection services if she doesn’t straighten up, but nothing you say seems to sink in. You are thinking of dropping her as a client and you discuss her case with your supervisor, who suggests trying a Harm Reduction approach.
Next time she comes in, she is over 2 hours late and has bruises all down her arms. You start by thanking her for coming in, then tell her that you want to try a new approach in this session. Instead of starting right away on her drug use, you ask her what her most important need is today, right now. She and her boyfriend have been fighting because he says she is “poisoning my child”. She says, “I’m afraid he will hit me and hurt the baby. I can’t do anything for myself or my baby until I have somewhere safe to stay.” You arrange a place for her at a women’s shelter and start the paperwork for placement in more permanent housing. You thank her again for coming in and give her the number for a 24-hour crisis line to call if she needs anything before your next session.
Next week, she doesn’t show up again, so you call the shelter. You arrange with staff to reschedule her for tomorrow and hope for the best. The next day, her urine comes back positive and she looks defeated. She says, “I’m sorry, I’m just a fuck up. I can’t do anything right. You should just give up on me. I don’t deserve to be a mother.” You acknowledge that things are hard right now, but you believe that she can change for the better. The rest of the session, she mostly just cries and berates herself while you listen and offer encouragement.
Next week, she comes in looking happy, provides a negative urine, and tells you she got a part time job! You congratulate her and spend the session making plans for the future and the baby, who she plans to name Elise.
The following week, she is late again, and her urine is positive for heroin. She says, “Nothing I do matters, I’ll always just be a stupid junkie.” You invite her to look at the progress she has made as proof that she can change for the better and spend the session encouraging her and reminding her that messing up is a normal part of the recovery process.
Next week, and the 6 weeks after that, she provides negative urine and maintains a positive attitude. Once the baby is born, she moves into transitional housing with on-site counseling, and you don’t see her again.
Two years later, she comes into the clinic with Elise and tells you she is going back to school for her GED and working part time. It wasn’t always smooth, but she is doing a little better each day, and she thanks you for believing in her when nobody else did, not even herself.
Marco is a 28-year old married transman with a 2-week-old baby. He came into your lactation clinic with his husband Rohan for follow up on his low milk supply related to history of breast surgery. His supply is increasing, and he only needs to use formula for 2 feedings each day.
He is having trouble with gender dysphoria related to chest feeding and pumping and is anxious about having to do it in public soon. He thought that if he could just make it through the pregnancy, the dysphoria would fade, but now, he is focusing on his chest so much that it is worse than ever.
After gentle prodding from Rohan, they tell you that Marco’s distress was so bad yesterday that he had a panic attack and drank 5 or 6 whiskey sodas and smoked half a pack of cigarettes to calm down. They pumped and discarded Marco’s milk all night, because the inpatient IBCLC had told them that alcohol passes into human milk.
First, you thank them for asking for help, then you ask if Marco would like to speak to his OB/GYN about a prescription for anti-anxiety medication to help with the dysphoria. Marco says, “We tried that during the pregnancy, but the medication made me feel worse than before, and besides, it’s not safe for lactating, and providing milk for Sofia is so important to us.”
You then ask if there was anything that had worked in the past that might work again. Rohan says, “Well, you won’t like this, but years ago, we both quit drinking and cigarettes by using cannabis…” Marco cuts in, “I know it’s not recommended, but at this point, I’m willing to try anything. I can’t give up on chestfeeding and I feel like if I don’t get some relief, I’m going to either drink myself to death or just straight up kill myself.”
You say, “I know that providing milk for Sofia is important to you, but I also want you to know that prioritizing your health does not make you bad parents. Any amount of human milk is a gift, and having a mentally healthy parent is also a gift.” You provide them with some handouts on cannabis and breastfeeding, let them know that while the data is not conclusive, it is very likely to be safer than alcohol or tobacco, and give them the number of a 24-hour crisis line in case Marco has another panic attack.
Marco says, “Thank you. I’ve been thinking about this all night and beating myself up for not being perfect. I guess parenting is sometimes about choosing the least worst option. I’m not sure what I’m going to do, but at least now I feel like I have choices.”