First published on thefix.com By Jeannie Little LCSW and Patt Denning PhD 11/19/15
Determining what is best for the individual: structure, containment, direction, and freedom of choice.
One of the most critical aspects of harm reduction is the notion that people should be empowered to choose their own path to recovery. In HR treatment, a client’s relationship with substances is explored and, hopefully, understood, potentially leading to reduced harm or a reduction or cessation of use. This is in contrast to non-HR approaches, where abstinence from substances is more likely to be imposed on the client through the control and authority of the treatment provider. Here, in the first of the two articles that will conclude the “Harm Reduction Umbrella” series, two clinicians who have been of primary importance in the history and development of the harm reduction model of addiction theory and treatment, Jeannie Little and Patt Denning, describe their thought process around assessment and treatment planning. As will be seen, in contrast to certain aspects of the widely-used ASAM criteria for treatment planning, they argue that the clients’ motivation for change should be the cornerstone of decision-making.
In a previous piece a critical question about assessment and treatment planning was put forth:
“The important question is not whether a person is or is not powerless or whether she should or should not be abstinent from one or all of her drugs. The answers to these questions change over time. The crucial question is the extent to which a person needs containment, structure, and direction, versus their need to explore their relationship with substances free of outside influence. In other words, at times people (and that includes all of us!) need someone to tell them what to do, at other times they need to be with someone who has the capacity for infinite flexibility.”
In this article, we will discuss how we understand structure, containment, and direction and the ways that we go about determining the right level of each for each person.
When we refer to “structure” in substance use treatment, often what we mean is putting someone in a restrictive environment that will eliminate risk, regulate behavior and prevent any contact with psychoactive substances. We also assume that such programs will be directive. That is, they will tell their participants what to do and how to do it in order to attain abstinence and maintain “recovery,” often thought of as synonymous.
But the true definition of structure is much simpler. Structure refers to organization or order that is coherent (i.e., it is clear, understandable, orderly, and consistent) and stable (i.e., it is predictable, stays relatively the same over time with changes occurring in a gradual rather than disruptive manner). No program or organization lacks structure, including harm reduction, the most flexible of all programs. Where they differ is in the level of restrictiveness and directiveness. To what extent do they exert control over one’s activities? Do they restrict contact with the “outside world” and activities within the program? Or are people free to come and go as they please? To what extent do they tell participants what to do? Do they prescribe the goals and direct the methods to achieve those goals? Or do they support the client’s choices (short of harm to self and others) and methods? To what extent do they impose punitive sanctions for failure to “comply” with program rules and expectations? Do they punish, humiliate, or dismiss? Or do they applaud the strength displayed by someone who resists?
This term can be used to describe a variety of concepts in a variety of environments. Containment within a restrictive environment imposes external controls to restrict freedom, activity, and contact with both people and drugs. Physically containing environments fall on a continuum from most restrictive (locked facilities like prisons and psychiatric facilities) to least restrictive (mutual aid groups or harm reduction therapy). More than 50% of people in substance use treatment are there involuntarily under the mandate of the criminal justice system. Still, more are there as a result of a family intervention. Whether mandated by the legal system or by family, coercion is often the mechanism that gets an individual into a restrictive treatment environment.
Containment can also extend beyond the confines of a treatment program; monitoring is another mechanism of containment. Urinalysis, breathalyzers, ignition-locking devices, and ankle-monitoring bracelets which are alcohol sensitive are all used to enforce compliance with abstinence requirements.
Containment also refers to emotional containment. Winnicott’s concept of the “holding environment” refers to an emotional environment that provides care, nourishment, and understanding and that gives a person the feeling that she is secure. Emotion regulation, which is supported in part by a secure base, is the ability to experience a full range of feelings in response to people or events, to tolerate emotional arousal, to react both spontaneously and with restraint, and to recover one’s equilibrium after emotionally wrenching experiences. Khantzian theorized that poor affect tolerance is one of the core deficits that leads some people to self-medicate with substances. Though physical containment can assist with emotion regulation by controlling the amount and type of environmental stimulation, it is really a psychological process that involves the ability to evaluate and understand what is happening, to self-soothe, to focus one’s attention, and to act with consideration to both internal and external factors.
Here we refer to the extent to which a program or therapist prescribes outcomes and/or dictates both outcomes and the methods to achieve them. The vast majority of programs (rehabs, outpatient treatment, and self-help groups) prescribe a lifetime of abstinence from psychoactive drugs. Most also prescribe a lifetime of membership in a 12-step group, a sponsor, and stepwork. Standard treatment tends to direct activities within programs, with the same groups and activities required for all participants, including timelines or stages that people move through based on behavior and program adherence. Often this direction comes with exhortations that failure to follow “the program” will lead to “jails, institutions and death.”
The Continuum of Options
The most restrictive programs—prisons, jails, therapeutic communities, other residential rehabs, and inpatient detoxes—offer, or impose, depending on your perspective, constant monitoring of activities and behaviors. Not only are they restrictive, but these programs tend to be highly directive. Less restrictive, but still typically directive are partial hospital programs, sober living houses and outpatient programs. They might also, to varying degrees, use monitoring devices, thus extending their reach beyond the physical bounds of the program. If participation is coerced, then the whole process is involuntary.
Self-help groups, more properly called mutual aid, fall on their own continuum of containment and direction. While not physically restrictive, attendance is sometimes mandated. Reporting (e.g., the show of hands for people who are “newcomers” at 12-step meetings or sharing the number of drinks and drinking days one has had in the last week at Moderation Management meetings) is an accountability device that, if internalized and remembered while away from the group, provides a sense that the group is always present. This can be experienced by prospective members as helpful and emotionally containing or as intrusive and oppressive.
In 12-step groups, goals and methods are clearly prescribed. Both Moderation Management and SMART Recovery (Self-Management and Recovery Training) have a clear direction or prescribed goal—moderation of alcohol use or abstinence, respectively, but the structure of meetings is not directive. They function as facilitated discussions where people can explore their relationship with substances, evaluate their individual risk situations and, to some extent, set their own goals. The HAMS (Harm Reduction, Abstinence, and Moderation Support) network is harm reduction’s mutual support group for alcohol. Rather than prescribe a particular goal, it encourages people to choose safety, moderation or abstinence, and to define moderate drinking for themselves.
Harm reduction programs fall on the least restrictive and directive end of the continuum, with participants choosing not only their goals but also the pace and the intensity of participation or treatment. We refer to this as “dosing”—just as people dose themselves with drugs as they wish or see fit, they also dose themselves with treatment, coming and going as they need or want with no penalty. Harm reduction is multidirectional—safety, moderation, abstinence, and/or attending to issues other than substance use are all worthy directions for change. It is client-directed and empowering. Because a core value of harm reduction is self-determination, we see our role as facilitators rather than directors of a person’s change process. We make recommendations only after considering the strength of the therapeutic alliance and only after being invited by the client.
Advantages and Disadvantages of Containment and Direction
Physical restriction and direction can be desirable for people who desperately want to break habits or for people who need medical intervention and monitoring. It is also appealing to families who just want their loved one’s behavior to stop, to bring order to chaos. Lack of containment and direction can risk harm for people who are impulsive and whose substance use is potentially dangerous to self or others. In any of these circumstances, some restrictive environments are helpful and, at times, necessary. Just as a child who is about to run out in the street needs to be picked up and put indoors, adults sometimes need to be gotten out of harm’s way. And, for people who can retain the image of the breathalyzer, the urine sample bottle, or the ankle bracelet, these “Big Brother” devices can be effective deterrents of unwanted behavior.
On the other hand, being restricted can retraumatize people whose lives have been arbitrarily controlled by others; who have been abused as children or as adults; who have been institutionalized; who have been terrorized in their families, neighborhoods, or countries; or who have been locked up in jails and prisons. Since most people who persistently misuse substances have trauma in their histories, anyone might have sensitivities that would render restrictive programs more harmful than helpful.
All programs should offer emotional containment, but many use interventions that are emotionally dysregulating. Confrontation, the almost exclusive use of groups in most treatment, the steps that require one to conduct a “searching and fearless moral inventory,” and the assignment to write one’s autobiography can arouse fear, anger, and traumatic memories, in turn triggering the very behaviors that one is trying to help! The challenge is to provide sufficient structure to enable the change process without overwhelming the individual or arousing resistance and rebellion.
How We Decide
The ASAM (American Society of Addiction Medicine) treatment criteria recommend that placement be determined based on severity across six dimensions. In general, the higher the acuity of substance use, the more critical the medical or psychiatric complications, and the weaker the recovery environment, the higher the intensity of treatment recommended. An important dimension is readiness to change, which recognizes that, despite high acuity, if people are not ready to change, high intensity placements might be wasted. This modifies placement considerations, but only in the absence of moderate to higher severity in the other dimensions. In other words, when assessment indicates moderate to severe and co-occurring complications, higher intensity treatment is recommended regardless of a person’s motivation to change.
We disagree. Motivation should always be the primary consideration, except in cases when safety concerns require immediate intervention. Since adults are not children (though they might be either metaphorically or literally running out into the street), it is important to take a more nuanced approach in order to build a therapeutic relationship that can influence positive change. In early harm reduction groups in the 1990s, we learned quickly that people vote with their feet. In those early groups, members often said, “People know what they need and when they need it. We trust that they are taking care of themselves in the way that they need to today.” They were telling us that respect for their autonomy was key to their cooperative and enthusiastic engagement. We use this language explicitly with our clients, and they appreciate it.
Although radically client-centered and directed, harm reduction therapists do make recommendations for more restrictive treatment environments, including abstinence-based rehab. We also use targeted directiveness. We might recommend abstinence from certain drugs or from all drugs for a certain period of time. In fact, when practicing Substance Use Management (SUM), a specific practice that is part of the harm reduction continuum, the therapist routinely gives instructions regarding how to count, measure, control, and otherwise change a client’s drug or alcohol use. These instructions are based on the client’s unique psychology, biology, and level of self-awareness; the drug’s pharmacology; and therapist’s experience. And there are no negative consequences imposed by the therapist for failure to follow the instructions, rather we examine the reasons the client has not used them.
The question is not just “What is needed?” It is also “What will be helpful and not harmful?” We make determinations or recommendations based on the need for immediate safety and on other considerations discussed in the second part of this article. The first question we ask is who decides and the next question is how we decide.
In the next week’s article, we review several cases of people whose complexity demands client-specific and flexible treatment recommendations.
Jeannie Little, LCSW, CGP and Patt Denning, PhD, are the co-founders of the Harm Reduction Therapy Center in San Francisco. Both are primary developers of Harm Reduction treatments for alcohol and other drug problems. Their work at the Center has had an enormous impact on the understanding and optimal treatment of substance use disorders. They are the co-authors of Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol and the Second Edition of Dr. Denning’s groundbreaking Practicing Harm Reduction Psychotherapy. An updated and revised edition of Over the Influence is due out in Fall of 2016.
This article was originally published on thefix.com.