Having read the reviews on Tatarsky’s Harm Reduction Psychotherapy, I was drawn to Denning’s book because it looked more like a “how to” text than a collection of case studies. This proved to be right, and the book is a good reference for those who need more of a “cookbook” approach. Denning’s approach, even when writing, is “clientcentered”. This book shows therapists how to empower their clients by validating their drug use as adaptive behavior, and using this knowledge as a basis for treatment.
Patt Denning is a successful harm reduction therapist who has been working in the field of mental health and substance abuse for 25 years. She is the Director of Clinical Services and Training at the Harm Reduction Therapy Center in San Francisco, California. She views addiction as a biopsychosocial phenomena, and her book attempts to explain addiction from this perspective. The book includes case studies illustrating the topic of each chapter, covering the principles of harm reduction, assessment and treatment design, and multidiagnosis patients. Also included are extensive appendices and a report on two of her consultation projects.
Her first chapter on harm reduction touches on the politics of drug laws, suggesting that the harsh penalties for drugs are politically or racially motivated. Denning advises clinicians to sort through their own beliefs regarding getting high to avoid a “countertransferential mire of reflected negative judgements and basic misunderstandings of our patients.” This book also debunks many of the myths surrounding illicit drugs. She notes that the vast majority of drug users are actively working (71%) — most of them full time. This data can help clinicians understand that drug use does not necessarily mean a person cannot be a productive member of society. Denning also cites data showing that even with addictive drugs (heroin and cocaine), less than one-fourth of users become dependent. Another little-known fact is that the highest use of most drugs occurs early in life, with spontaneous remission the rule rather than the exception (tobacco excluded).
Denning defines success as “any movement in the direction of positive change, any reduction in drugrelated harm.” She gives examples of how a rigid adherence to success defined as abstinence only caused more harm to her patients than the drugs they were using. Focusing instead on harm reduction, she explains, allows clinicians to treat addicts as people with problems, not problem people. The adaptive model, which includes harm reduction, is contrasted to the “disease” model of addiction. The disease model views the individual as engaging in mechanically-determined behavior, whereas the adaptive model stresses the purposeful nature of the activity. In the adaptive model, drug or alcohol abuse is seen as an adaptive search for compensatory mechanisms. These mechanisms are reinforcers allowing a measure of normal functioning.
One of the key concepts of harm reduction is viewing addiction on a circular continuum of use, rather than a linear progression. Points on this continuum include experimentation, social/ recreational use, habituation, abuse, dependence (abuse + compulsion + relapse potential), physiological dependence and persistent addiction.
Illicit drug use doesn’t always lead to abuse. The focus of this treatment modality is on the harm done and on the needs of the user, rather than on the drug itself; people can make changes while still using. There is an important distinction made in this text between use and abuse. It is reported that many clinicians feel that the illegality of a particular drug alone makes it abuse. Denning offers an example of a recovering alcoholic who smokes marijuana and thus is considered “abusing,” whereas another recovering alcoholic using nicotine or caffeine is okay.
The third chapter explains how assessment is a form of treatment, in that gathering information is a necessary component to developing a therapeutic relationship. More specifically, motivational interviewing (listing costs and benefits) is a tool to enhance a client’s motivation to change and is a way for clinicians to educate themselves about the clients. It is a technique more about collaboration than coercion. Denning also cautions clinicians to refrain from compiling a detailed drug history in the first few sessions as it diverts attention from the complex psychosocial aspects of drug use.
She describes a multidisciplinary approach to assessment, which includes the following elements:
- client’s stage of change (i.e. precontem- plation, contemplation, preparation, action, maintenance (with possible relapses) and termination
- decisional balance (understanding benefits & consequences of drug use)
- types of drugs used
- level of abuse or dependence
- prescribed medication
- past treatment history (useful in planning for next phase of treatment matching)
- support system (does the client have a support system that can be utilized in time of distress?)
- self-efficacy (essential in the ability to make a change)
- psychiatric diagnosis (and how substance use affects symptoms)
- client’s stated goals (“what would you like to change?”) that derive from unique deci- sional balance worksheet
- developmental grid (outline of key events and personality traits that will guide treatment)
Harm reduction psychotherapy emphasizes the importance of a therapeutic relationship, which creates an environment fostering change. Denning suggests helping this person realize the complex positive and negative reasons for drug use by modeling curiosity and resisting premature conclusions.
When clinicians set goals, they should also be on a continuum, ranging from cutting back to abstinence. The goals should be “observable behavioral changes that are achievable within the context of the client’s life.” The therapist’s goals should be compatible with the client’s stated goals. Denning provides a thorough treatment design and emphasizes that it is not from the “all or none” school of treatment. Instead she cites “warm turkey” alternatives to abstinence, such as tapering, trial moderation, and sobriety sampling, which could include “drug-free days.” She recommends providing an atmosphere in which the patient feels understood rather than judged, and in which the treatment’s goal is to develop a needs hierarchy based on the client’s perceptions and resources. The goals should be a combination of short and long-term goals, a more realistic approach.
In discussing treatment design, she explores the complexities inherent in drug abuse. For instance, she touches on the possibility that a client’s relationship with a drug might be a substitute for intimate relationships. Indeed, most therapists offer themselves as a substitute attachment, but unlike the drug of choice are not always readily available nor are their efforts as successful.
This is a much-needed book that respects the client for his or her uniqueness and autonomy. Her philosophy is reflected in her acknowledgement of client influence: “I owe whatever wisdom I now possess to the patients who taught me that they do indeed know what they want and will allow me to help if I do not stand in their way.” Well said – and a good read.