Harm Reduction

Harm Reduction
Discuss the viability of harm reduction as a treatment approach from an evidence-based perspective.
MOTIVATIONAL INTERVIEWING
It would be extremely satisfying if we could simply tell our clients that one key thing that would make them see why they should stop unhealthy behaviors… and then have the clients actually do whatever it is we’re suggesting.
People often respond poorly to being told what to do, though. Even if they don’t actively tune out, most people are unlikely to change behaviors just because someone points out the reasons to stop doing unhealthy things or start doing healthy things.
People who need to make lifestyle changes will be at different levels of readiness. A person’s ability to enact change will depend on what stage of change the person is in, the amount of ambivalence the person feels toward changing, and the motivation a person has for changing.
Motivational Interviewing is a client centered approach that takes a non-judgmental, non-confrontational and non-adversarial approach to help a person explore change. Building on the stages of change, Motivational Interviewing helps a person see the gap between their current behavior and their identified goals. MI does not necessarily take a person through each stage. In fact, you can undo the work you and your client have done if, for example, you push the client toward planning a change strategy too soon.
Precontemplation: Raise doubt, increase the client’s perception of risks and problems with current behaviors
Contemplation: Tip the decisional balance, evoke reasons for change, risks of not changing; Strengthen client’s self-efficacy for change of current behavior
Preparation: Help the client to determine the best course of action to take in seeking change. Develop a plan.
Action: Help the client implement the plan, use skills, problem solve, and support self-efficacy.
Maintenance: Help the client identify and use strategies to prevent relapse, resolve associated problems.
Relapse: Help the client recycle through the stages of contemplation, preparation, and action, without becoming stuck or demoralizing because of relapse.
There are four elements of Motivational Interviewing that differentiate it from other counseling approaches. These are:
the need to express empathy with the client,
the need to highlight the dissonance between the client’s stated values or desires and the behavior in question,
the ability to roll with resistance and allow the client to work through ambivalence,
the need to promote the client’s ability to enact change if she or he wants to.
Let’s see how what it might look like to apply motivational interviewing to a specific issue. Bear in mind, an actual interview would have much, much more dialogue than the points that we’ll be making in this presentation. Ted is meeting with a substance abuse and addiction counselor. He has been referred to counseling because he came up positive for marijuana in a random drug test conducted at his place of employment.
Erik says, “Before we start, I want to explain that what we say here doesn’t go back to your employer. But, I’ve been asked to talk with you and see if I can be helpful to you.”
As you can see, Erik tries to establish a respectful and trustworthy environment.
Notice how Erik demonstrates empathy with Ted. He is not claiming to agree with Ted’s position, but he hears it non-judgmentally and can show Ted that he’s been heard.
Ted: “It really ticks me off that my company is getting involved with my private life. This is something I do in my own time. It doesn’t affect … I mean, I don’t smoke at work. Ever. Or come to work stoned. I’d never do that.”
Erik: “So, as far as you’re concerned, this is something apart from your work performance. It’s something you do on your own time and the company has no reason to be concerned.”
Here Erik tries to amplify the disconnect between Ted’s drug use and his feelings that it is under control and not something that bothers him. Erik is also “rolling” with Ted’s resistance by reflecting the disconnect back to Ted in a question. Erik allows Ted to be an expert on his feelings and values and in doing so, allows Ted to explore the juncture between goals and action.
Ted: “Well, every once in a while … well, one of my friends from high school started doing cocaine and even though that wasn’t something I’d ever really thought about doing, I thought I’d try it. But it’s not something I consider myself doing routinely.”
Erik: “Yeah. What’s your own reflection on that? In high school, you said you weren’t into cocaine; marijuana was there, that’s kind of continued, and now you find yourself using cocaine and speed, and some other things. As you step back and look at yourself here and you’re saying where am I going in my life? What have you thought about that?”
Erik reinforces Ted’s sense of self-efficacy. As you can see, Ted is moving away from resistance talk toward change talk.
Erik: “I hear confidence in the way you say that if you were to decide that you need to make a change…if you were having a baby, for example, that you could make that change. You feel pretty confident that you’ve got that ability within you and its more that you haven’t seen the need in doing that yet.”
Ted: “Right.”
Erik: “And in some ways, you don’t want to see that this is the time, because you’d be letting go of something you think makes you who you are.”
Ted: “That’s really it, because one fear I have is about that is that everybody wants to tell me that I’ve got to completely radically change my whole life, and that if I even look at a beer, I’m just a big druggie drunk. So, in a sense, I’m kind of afraid of what changes I’m going to need to make but still stay who I am.”
Bill Miller, one of the developers of Motivational Interviewing, tells us that if the therapist makes the argument for change, it is natural to argue against it and become entrenched in maintaining the original behavior. However, when we make our own argument for change, hear our own voice, we talk ourselves into what we need to do. Here, Erik is helping Ted take that step.
Erik: “It sounds, though, like you are considering making some changes. On a scale of 1 to 10, now important do you think it is for you to stop using pot and other drugs?”
Ted: “That’s a tough question. I guess I’d have to say that it’s about a seven.
Erik: “That’s a lot. How come it isn’t around a two or a three?”
CONCLUSION
Change is a dynamic process and it is important when using motivational interviewing not to be prescriptive, but instead to help elicit behavior change by helping clients to explore and resolve ambivalence.
CREDITS
Subject Matter Expert:
Lynn K. Jones
Interactive Design:
Christina DiMeo, Patrick Lapinski
Instructional Design:
Felicity Pearson
Project Management:
Julie Greunke
Talent:
Jason Herder, Pat Lapinski, Brent Berheim
Licensed under a Creative Commons Attribution 3.0 License.
Evidence-Based Interventions
Readings
Use the Internet to complete the following:
Read “Evidence-Based Approaches to Drug Addiction Treatment” in the National Institute on Drug Abuse’s 2012 guide Principles of Drug Addiction Treatment.
Use the Capella library to complete the following:
Read Rowan et al.’s 2013 article, “What Is Valued in Gay and Lesbian Specific Alcohol and Other Drug Treatment?,” from Journal of Gay & Lesbian Social Services, volume 25, issue 1, pages 56–76.
Read Lushin and Anastas’s 2011 article, “Harm Reduction in Substance Abuse Treatment: Pragmatism as an Epistemology for Social Work Practice,” from Journal of Social Work Practice in the Addictions, volume 11, issue 1, pages 96–100.
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