WHERE HARM MINIMISATION BECOMES HARMFUL

Three harmful factors have arisen out of harm minimisation:
collusion; the castration of therapist; and the disparagement of
abstinence-based programs.

Harm minimisation has definite advantages: it is an effective
mechanism for reducing the spread of blood borne diseases; if people
can return to moderate drinking there is a greatly increased
possibility of treatment compliance; crime is reduced when clients are
on methadone; there are obvious benefits in creating an environment
that facilitates honest communication between clients and staff, and
there are benefits for all concerned if a lapse can be prevented from
deteriorating into a relapse. Abstinence is difficult to achieve and
if harm can be reduced by lowering the goal posts, then well and good.

For all the advantages of harm minimisation however, there is a
question of collusion that needs to be addressed.

If a person's behaviour harms another person, then they cannot claim a
right to continue to behave in the manner that inflicts that
suffering. With addiction, there is usually a direct link between drug
use and harm caused to relatives, friends, children, victims of crime
and society in general. The majority of clients discontinue such
harmful behaviour when they are not using drugs. If a person can
reliably predict that they will harm people if they choose to drink or
use drugs, then they have lost the right to use drugs.

In abstinence based approaches, the question of collusion does not
arise. If a client uses drugs and thereby places herself or himself at
risk of becoming a perpetrator again, treatment is stopped for a
limited period, clearly indicating that this behaviour is not
supported. The line is clear for staff and it is clear for clients.
Clients know the treatment contract and know the result of a breach of
the contract. Value judgements do not need to be made, discriminating
one client from another in terms of the consequence of a lapse.

No such line exists in the harm minimisation approach. When does a
lapse become a relapse? In supporting the client after a lapse, at
what point is the therapist supporting the behaviour? Does the
therapist resort to value judgements with regard to a point where they
terminate treatment? For example, a therapist judges a client to have
lapsed, but not relapsed. In therapy the client mentions resorting
back to old drinking patterns of behaviour which involved bashing his
partner. Does the therapist continue to help the client to learn not
to behave in this way, even though the drinking is continuing as is
the violence? Is the therapist actually facilitating the violence?

Once we have knowledge of a behaviour that is harming someone else,
especially children, we are bound to make it very clear that we do not
support that behaviour. In other bebaviours that involve harm to other
people, such as domestic violence or child sexual assault, when we
work with perpetrators, we have no qualms about making it clear that
the abusive behaviour will not be tolerated. However, one may
understand the psychological conflict of the client, boundaries need
to be set so that the therapist is very clear that they are not in any
way colluding with the client in harming someone else.

As a therapist working in the addiction field, it is a legitimate
intervention to tell clients when their behaviour is not acceptable.
Especially in the field of addiction, setting boundaries is a
compassionate intervention. Frequently clients who have become
addicted are emotionally and physically way out of safe boundaries.
Helping these clients become safe includes clear, non-discriminatory
and non-judgemental boundaries. A consequence of harm minimisation is
the erosion of boundaries and a confusion with regard to when it is
legitimate to set limits. The current state of the drug and alcohol
field includes: pressure to retain clients in methadone; pressure to
retain clients in therapy; we give clients needles and syringes; we
make it OK for clients to tell us about their illegitimate drug use;
we normalise relapse by talking about addiction as a relapsing
condition (diabetics often break their diet, but it would be rather
odd to call diabetes a relapsing condition!); and we publish articles
in government funded magazines about "how to beat the piss police" and
we advertise the latest steroids. In this state of play, one is left
wondering about the meaning of therapy.

Therapy involves a client asking for help. Something is not working
and they want help to fix it. Following an assessment of the problem
the therapist gives the client an explanation of what he or she is
able to offer. The client accepts or rejects the offer. If the
client accepts the offer and then finds she or he does not like the
process, he or she has the right to discontinue treatment. While the
therapist will probably have room to move and can negotiate to a
certain extent, he/she must not compromise their professional
judgement for other motives such as retaining the client in treatment
or, even more corrupt, trying to avoid the client's displeasure. The
therapist needs to be accountable in that the therapy is based on best
practice, a sound philosophy, clear parameters and adequate outcome
measures. The therapy cannot be accountable if the process is not
defined.

In the old days, if a client relapsed, we had a lovely out, we would
say that they weren't ready to change. This absolved us of any
responsibility. I'm not sure that harm minimisation is not another way
that we avoid responsibility. If we give no direction, allow clients
to determine their goals and see our roles as merely providers of
either drugs or skills, we cannot be held accountable for the people
who do not succeed.

One may argue that, in terms of statistics, numbers that do succeed in
harm minimisation ventures are as good as if not greater than those in
abstinence based programs. This is a very dubious argument.
Quantification of qualitative outcomes is always suspect. Does one
client in a methadone program for a year really equal one client
abstinent for a year?

We would be very foolish to think that we have the answers to the
treatment of addiction. Relapse prevention does not produce
staggering results, controlled drinking works for only a very few and
methadone is no panacea.

Drug addicts are people who have become trapped in a conflict of
wanting to use drugs very, very badly. The desire to use drugs
competes with even their most powerful instincts. They readily place
their own lives at risk. The most likely cause of this situation is
that drug addicts have a biologically determined increase in the
reinforcing properties of their drug of choice and/or a decrease in
the aversive properties of said drug. The rest of us do not have this
conflict. We do not have to make a choice between drugs and life
because drugs do not have such powerfully reinforcing properties for
us.

There are two ways of helping people deal with this problem. The
first is a sufficient supply of drugs such that there is a
significantly reduced need to compromise values. At this stage, this
is only possible for narcotic addictions. Methadone clearly reduces
crime rates, the spread of blood home diseases and affords clients
dignity. On the other hand, it also renders clients with a reduced
drive and substantially decreased quality of life.

The other way of helping people deal with addiction is via abstinence.
The experience of hundreds of thousands of people who have been
addicted to drugs is that if they abstain from the drug of addiction,
the obsession to use the drug lifts and they can get on with their
lives.

While abstinence is effective in removing the obsession to use drugs,
it is a very difficult goal to achieve because it involves the person
giving up the thing that they most like doing. Relapse is therefore
predictable. However, for those people who do achieve abstinence, and
for those people's children and families, the attainment of this goal
gives them far, far more than any drug based program. Once the person
has attained sustainable abstinence, they effectively do not have a
drug problem. They may have a problem related to the prospect of
relapsing but essentially the drug problem is over.

It is time to recognise that abstinence based programs are a
legitimate option. It is also time to have a much closer look at the
harm that is being caused by harm minimisation.

Checked-by: Patrick Henry