The Benefits of Harm Reduction in Adolescents

Substance use and abuse remains one of the major public health problems amongst American youth. A report from the Substance Abuse and Mental Health Services Administration (SAMHSA; 2013c) estimated that on a daily basis more than 881,000 teens smoke cigarettes, over 600,000 smoke marijuana, and more than 400,000 drink alcohol. The number of teens dying from drug use and overdoses now exceeds the number of deaths from motor vehicle accidents in the US.

According to the Center for Behavioral Health Statistics and Quality (CBHSQ; SAMHSA, 2013a), in 2011 there were about 280,000 drug related emergency department (ED) visits by adolescents between the ages of twelve and seventeen, of which 181,005 involved the use of illicit drugs and alcohol, or intentional use or abuse of pharmaceutical and over-the-counter drugs. Additional estimates included sixty-three ED visits for drug-related suicide attempts among adolescents.

Based on these alarming statistics, the question becomes this: Is the inflexible adherence to the idea of total abstinence worth harm or death? Many professionals working in the addiction field insist on total abstinence while ignoring the harm associated with such a demand, especially in regard to the adolescent population. Most treatment programs have a high threshold such as attending Twelve Step meetings daily and/or all negative narcotic screens—unwilling adolescents are routinely discharged from treatment as noncompliant due to failure to comply with such demands. It does not take long for adolescents to figure out how to get out of treatment programs by simply giving a positive drug screen and being dismissed. 

Due to the number of adolescents being dismissed and denied substance abuse services because they did not subscribe to the practice of abstinence and were considered noncompliant, I started a program myself. Once admitted into the program, adolescents were shocked to learn that I was not cutting them loose, dismissing them or denying them services if their drug screens came back positive or they did not attend Twelve Step meetings. In fact, they got to see me even longer as they spent more time in the program, and they had the opportunity to gain insight of how substance use and abuse negatively impacted their lives.

Adolescents do not show up for treatment because they want to stop using. They present as a result of coercion by the legal system, their schools or their families. When we as professionals realize that we are working with a population that sees no reason to stop their use of substances, the least we can do is try and reduce the harm associated with their use. This becomes even more difficult when the substance is marijuana, especially since it is legalized in several states.

In my experience, abstinence only limits who can be helped and how, while harm reduction lets go of the presumption that abstinence is the required goal and opens the door to the possibility of engaging adolescents. Substance users are engaged where they are, not where providers think they should be.

To be involved in a total abstinence program, individuals have to buy into being labeled an “addict” or “alcoholic,” and this raises major concerns for adolescents. Some social scientists and helping professionals have deemed negative labeling as unhealthy and stigmatizing (Fisher, 2010). 

Lewis, Dana, and Blevins (2010) noted that the term “abstinence” has several meanings in the context of substance abuse prevention and treatment. Abstinence primarily refers to a general prohibition against the use of any psychoactive substances by any individual. The authors indicated that the most widely used and oldest perspective of prevention and treatment is focused on maintaining or achieving abstinence. Currently however, more emphasis is being placed on harm reduction. 

Harmful behavior happens; it always has and it always will. Rather than labeling the person who engages in such behaviors as good or bad, harm reduction asks the following question: To what extent are the consequences of this individual’s behavior harmful or helpful to the individual and to others who may be affected? Drug use is rarely independent of other high-risk behaviors such as unsafe sex and driving under the influence.

From a harm reduction perspective, a strong emphasis is placed on personal choice and responsibility. It does not condone underage drinking or consumption to the point of intoxication, however, it does ask the question, “If this happens, what can be done to reduce harmful consequences?” The aim then focuses on harm reduction and to find methods that work for adolescents and not on blaming them for failure to change. Harm reduction recognizes abstinence as an ideal outcome, but accepts alternatives that reduce harm. Harm reduction is client-centered and is not an anti-abstinence paradigm for responding to substance use disorders (SUDs) and addictive behaviors.

A key feature of harm reduction is pragmatism. The harm reduction approach accepts that for some, use of mind-altering substances is inevitable and that some level of drug of use is a normal activity (Pates & Riley, 2012). For drug users, their decision to use is accepted as fact, as their choice—no moralistic judgment is made to either to condemn or support the use of drugs regardless of the level or mode of use. The dignity and the rights of the drug users are respected. The extent of their drug use is of secondary importance to the harm resulting from the use.

Harm reduction can be viewed as both a goal and a strategy. What we have learned from applying motivational interviewing (MI) and motivational enhancement therapy (MET) approaches (SAMHSA, 2013b), is that the way in which information is presented can affect how it is received. MI is a psychotherapeutic approach which is ideally suited to be implemented within a harm reduction context. It is based on the belief that people can get better even while using drugs and that not all drug use is drug abuse. MI focuses on building a relationship that fosters understanding and helps resolve ambivalence. 

Principles of Harm Reduction (Collins et al., 2012):

1. High-risk behaviors are a social construction
2. High-risk behaviors are here to stay
3. High-risk behaviors may be both adaptive and maladaptive 
4. Harm reduction does not seek to pathologize high-risk behavior
5. Harm and harm reduction exists on a spectrum (there is a difference between the use of illicit substances and the use of the same substances while driving a car)
6. Individual behavior is embedded in the larger social context
7. Harm reduction is fundamentally pragmatic, not theory-driven
8. Harm reduction is an ethical practice

Early in the history of substance abuse treatment professionals believed that intervention could not work until individuals reached their personal bottom and found the motivation to change. We should not wait and watch people harm themselves or others until they hit their bottom. Our young people are dying. Purchase (1996) noted that “We all set our own rate of change; we change at the pace that is possible for each one of us.”

A harm reduction approach is congruent with what we know about adolescent development and decision making. Adolescence is a time of experimentation and risk-taking. Adolescents also tend to reject authority in their decision making and engage in behaviors that potentially have negative outcomes. Schwebel (2004, p. 33–40) has developed a developmentally appropriate therapeutic approach, referred to as “the seven challenges,” for working with young people and their age-specific concerns:

1. Talking honestly about themselves and about alcohol and other drugs
2. Looking at what they like about alcohol and other drugs and why they are using them
3. Looking at the impact of drugs and alcohol on their lives
4. Looking at their responsibility and the responsibility of others for their problems
5. Thinking about where they are headed, where they want to go, and what they want to accomplish
6. Making thoughtful decisions about their lives and their use of alcohol and other drugs
7. Following through on those decisions

Harm reduction methods have been used and validated in England, Canada, the Netherlands, and the United States (Collins et al., 2012). The use of harm reduction is not an endorsement for alcohol and other substance abuse, but a methodology that helps people better manage reckless physical and social behaviors that potentially endanger themselves and others.

What type of treatment works? Therapists need only offer three critical conditions to prepare the way for change: accurate empathy, nonpossessive warmth, and genuineness. In contrast to the traditional models, the principle of harm reduction is that drug problems are the result of serious life problems as well as a source of serious problems. Drug use can be motivated by behavioral, sociocultural, and biological factors that need to be understood in formulating effective treatment. People use substances because they work, at least initially, in addressing some psychologically, socially or biologically based needs.

For treatment to have a chance at being successful it must begin with an effort to discover the reasons that have made the substance so compelling in spite of adverse consequences. When treating adolescents with substance use disorders, therapists should go beyond the effects that the drug produces and try to understand how adolescents deal with drugs, what led them to use drugs, and what role drugs have in their lives. Adolescents’ chosen goals are more powerful motivators than goals set by the therapist or required by others. 

It is important to take into account adolescents’ perceptions. Rather than looking for examples of self-worth in everyday life, look to create an opportunity for those feelings using their perceptions. It is also important is to take into account their reaction to the authority figures. The opportunities afforded by MI enhance self-esteem and increase belief in people’s ability to have some control in their lives, therefore circumventing hostility towards authority figures. 

Apply motivation at all levels. In young people there is often little evidence of dependence on a substance. Change the focus to the behavior and focus on motivation to change the behavior in such areas as interpersonal relations. It is also important to keep the therapeutic sessions brief.

Rogers defined empathy as “the therapist’s sensitive ability and willingness to understand clients, thoughts, feelings, and struggles from their point of view” (1951, p. 98). According to Norcross (2010), empathy involves entering the private, perceptual world of others and, in therapeutic contexts, involves communicating that understanding back to clients in a manner that can be received and appreciated. Both are of critical nature in working with adolescents towards change.

The primary goal for early sessions is to engage adolescents while providing an atmosphere that is considered empathic and nonjudgmental. This goes a long way in the therapeutic process, including alliance and outcomes. The term “therapeutic relationship” refers to the professional interaction between clients and counselors, whereas the term “therapeutic alliance” refers to the quality and strength of that relationship (Hoervath & Bedi, 2002). It is important to stop and evaluate how we define terms because often we apply different meanings to the same word. 

When setting goals with adolescents, remember that the goals need to be theirs and not ours. Keep the goals to weekly at the beginning. Here’s an example of some goals:

• The changes I want to make are . . .
• The most important reasons why I want to make these changes are . . .
• The steps I plan to take in changing are . . .
• The ways other people can help are . . .
• I will know if my plan is working if . . .
• Some things that could interfere with my plan are . . .

Setting goals fosters a sense of direction; they help adolescents feel more hopeful. Goals serve as a therapeutic anchor and prevent adolescents and therapists from drifting. They also reinforce collaboration and help to evaluate progress and outcome. It is also important to identify these goals clearly, because we might enter into the room with well-meaning intentions and forget the danger associated with adolescents not sharing the same goal or treatment outcome. Get the goals committed to writing; verbal goals are no different than a new year’s resolution, and how many of us keep those? 

People are more likely to change if they have autonomy in the decision-making process for reasons they have determined and endorsed. Some questions that I ask are: 

• What would you like to see different about your current situation? 
• What will happen if you don’t change? 
• If you to decide to change, what would you have to do to make this happen? 

These interventions are consistent with solution-focused approaches that also work well with adult populations (Corey, 2013).

When adolescents are asked what they would like to change, the most common response is often “I want to get out of this program.” Use this. For example, I will add this to their goals and will explain to them how to achieve this goal. It might not be the number one goal I was looking for when I asked the question, but it is a goal and the process of engaging the young person has begun, as well as the formation of a therapeutic alliance. Even a court-mandated youth has made a choice to attend—the alternatives might hold all negative consequences such as going to jail or expulsion from school, but a choice has been made nonetheless. Young people are often more persuaded by what they hear themselves say than by what other people tell them. Sometimes you need to repeat what they have said.

When I started the adolescent program, one of my goals was that every high school student would graduate without having lost a friend to alcohol and drug use/abuse or suicide. After twenty years, this is still a work in progress. I want to believe that if I can keep them alive until they are twenty-five, many of them will mature out of this behavior. However, in the meantime, the substance abuse group continues to be a success based on the foundational principles. The group meets twice weekly for ninety minutes. Narcotic screens are given weekly, using positive-negative and quantitative (THC) results. We do not require Twelve Step attendance, but if adolescents or their parents would like them to attend we provide information and meeting locations.

Over 90 percent of the adolescents attending our group are court ordered treatment, therefore engaging them in the group process becomes priority. The longer they are in the program and I can keep them engaged, the better the chances of helping them and getting them invested in their long-term success. When court ordered, the teen must have negative narcotic screens to successfully complete the program. They will suspend their use during participation in group and comply with the rules of the program.

In group we evaluate risk-taking behaviors on all levels, including the need for substances. I discuss my belief that young people are not addicted to a particular drug, they are addicted to intoxication. They agree with this statement, but often cannot explain why this is the case aside from they are bored with life, it eases their stress, and it is an effective coping mechanism based on their worldview.

When measuring success beyond the group, the percentage of total abstinence is roughly 10 percent, while there is a big decrease in substance use in moderation. To me, the more important statistic is the 30 to 40 percent of group members who have reduced their use and in so doing have reduced the harm associated with substance abuse. 

I have found that the harm reduction philosophy is very difficult for counselors in recovery to buy into. I have been told by counselors that I work with who are in recovery that the program can trigger relapse for them and is not fair. They subscribe to the notion that if they have to be abstinent, then why not everyone who has a substance abuse problem? Some of this thinking is due to them looking at adolescents as little adults, which they are not, and at all substance use as abuse.

Nothing is more rewarding than when adolescents who were in the program at age fifteen return at age twenty-one to let us know how much we did for them and tell us about their successful life after treatment. This is harm reduction at its best.

Collins, S. E., Clifasefi, S. L., Dana, E. A., Andrasik, M. P., Stahl, N., Kirouac, M., . . . Malone, D. K. (2012). Where harm reduction meets housing first: Exploring alcohol’s role in a project-based housing first setting. International Journal on Drug Policy, 23(2), 111–9. 

Corey, G. (2013). Theory and practice of counseling and psychotherapy (9th ed.). Belmont, CA: Brooks/Cole Cengage Learning.

Fisher, M. S. (2010). Different ways to treat addiction. Roanoke Times. Retrieved from http://www.roanoke.com/webmin/opinion/different-ways-to-treat-addiction/article_5b3c9b8f-f860-5b39-801a-6d9a8cfd1a71.html

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 37–69).  New York, NY: Oxford University Press.

Lewis, J. A., Dana, R. Q., & Blevins, G. B. (2010). Substance abuse counseling (4th ed.). Belmont, CA: Brooks/Cole Cengage Learning. 

Norcross, J. C. (2010). Evidence-based therapy relationships. Retrieved from http://www.nrepp.samhsa.gov/pdfs/norcross_evidence-based_therapy_relationships.pdf

Pates, R. & Riley, D. (2012). Harm reduction in substance use and high-risk behavior: Internal policy and practice. Hoboken, NJ: Wiley-Blackwell.

Purchase, G. (1996). Anarchism and ecology. Montreal: Black Rose Books.

Rogers, C. R. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.

Schwebel, R. (2004). The seven challenges manual. Retrieved from www.sevenchallenges.com/App_System/Lib/Documents/7C_Manual.pdf 

Substance Abuse and Mental Health Services Administration (SAMHSA). (2013a). Drug abuse warning network, 2011: National estimates of drug-related emergency department visits. Retrieved from http://www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (2013b). Enhancing motivation for change in substance abuse treatment: Treatment improvement protocol series 35. Retrieved from https://store.samhsa.gov/shin/content/SMA13-4212/SMA13-4212.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (2013c). The CBHSQ report: A day in the life of American adolescents: Substance use facts update. Retrieved from http://archive.samhsa.gov/data/2k13/CBHSQ128/sr128-typical-day-adolescents-2013.pdf