Harm Reduction

Organizational Considerations

Background Thinking

Organizations need to incorporate a deeper understanding of what is helpful and provide skills for their staff to provide the best help.

It can be helpful to view HR as counter-cultural meaning that the changes needed to be made are as difficult for staff as they are for clients

What Do Effective Helpers Need to Know?Helpful Assumptions/Principles

– Behavior Change is Difficult – Change need not be rushed– Clients want change – but not necessarily

the change you want to see– The relationship is the most important

piece – as long as there is a relationship, there is a chance for change

Why is behavior change difficult? The behavior meets some kind of need The behavior may have been adaptive

at one point and now it’s not, but the groove is worn

The cycle of guilt and shame A big change is overwhelming Co-occurring disorders complicate

change

What works

Addressing basic needs – “Begin where client is”

Relationship building Remembering who the “expert” on the

problem is and, whose problem it is Developing an “anything goes” attitude

toward the client Exploring options rather than prescribing Motivational Interviewing skills are key

Motivational Interviewing

MI helps clients regardless of readiness to change

MI can be seamlessly integrated into other interventions

MI works in all types of areas – anywhere a client might be “stuck”

Read all about it: http://www.motivationalinterview.org/clinical/whatismi.html

Harm Reduction – How does it fit? An HR approach is a paradigm shift

away from a strict adherence or abstinence model

It changes treatment planning so that it begins with what is most practical and possible for the client to achieve

It incorporates a broader view of the client’s problem and menu of solutions

Myths and Misconceptions

Harm reduction is the same as “enabling.”

Condones substance abuse or makes light of critical treatment requirements

Is antithetical to an adherence based approach

Advantages to Harm Reduction

Keeps the provider/client relationship alive Pragmatic – if adherence isn’t realistic,

something else is You can feel good about smaller successes Eliminates the tension that exists between

providers and the “non-compliant” client Liberates the provider from responsibility for

the outcome Focuses on the process, not the outcome

(“What else can we try?”)

Challenges to Implementation

Focuses on the process, not the outcome (“Are we there yet?”)

Requires being able to hold conflicting ideas and thoughts at the same time

Not everyone “gets it” (especially clients) Not achieving abstinence/adherence frustrates

providers (and clients) It makes some people feel like they are doing the

wrong thing Staff are not empowered to “fire” clients they are

frustrated with

Harm Reduction Philosophy? What’s that? Guiding principles for providers that focuses

on the relationship, not the outcome Recognizes that behavior change is difficult

and may not change according to plan Changes how the issue of “responsibility” is

factored into the treatment equation Ideal if philosophy is agency-wide and

adoption is facilitated from the top – down.

Incorporating Harm Reduction Organizationally

Full administrative buy-in Solid harm reduction philosophy Solid supervisory structure Start talking about HR in the interview Ongoing staff development Integrated disciplinary action policy

Full Administrative Buy-In

If you have the support of the agency’s top brass, implementation of an agency-wide HR approach is much easier.

If you don’t have administrative support, model, model, model

Solid Harm Reduction Philosophy Have a document to which your staff

can refer Use participatory management

strategies to get it adopted

Solid Supervisory Structure

Ideally, all clinicians should meet with an experienced supervisor regularly

Keep an eye on supervisor to staff ratios

Case conferences facilitated by experienced supervisors

Form clinical supervision groups

Start talking about HR during interviews Ask clinical candidates to read HR

philosophy and ask a question about integrating those principles in their practice

Look not for knowledge about HR, but openness and tolerance in answers

Ongoing Staff Development

Offer in-services to clinical staff Facilitate reading groups of HR

materials Be creative and plan for ongoing needs.

Changing a culture is never a one-shot deal

Integrated Disciplinary Action Process Keeping “anything goes” in balance to

ensure staff safety and maintain a sense of staff empowerment

Provide leadership that balances where staff members are in relationship to where clients are. Work toward the goal of using “bad behavior” clinically instead of reacting by punishing it.

Being Mindful…

All clinicians take a harm reduction approach at least some of the time. The trick is to hone one’s skills in order to operate from this philosophical place more often and on-purpose

Be gentle with yourself and your colleagues. This approach requires a lot of the provider. If you are feeling stressed, you need more support

Contact Information

Jan Caughlan, LCSW-C

Director of Mental Health and Social Work

Health Care for the Homeless

111 Park Ave.

Baltimore, MD 21201

443-703-1207

jcaughlan@hchmd.org