Harm Reduction 102 Jenna Tine, LCSW Senior Vice President of Outpatient Services at The Bridge, Inc. Naomi Weinstein, MPH Vice President of Innovations at ICL (a MCTAC/CTAC partner) October 11, 2018 DAVE

Agenda Review of key points from Harm Reduction 101 Building trust Stage-wise approaches MI tools used in harm reduction Q&A DAVE Membership Meetings Focus Questions/Concerns

Key Points – Harm Reduction 101 Harm reduction embraces all possible responses to risk behavior, from total abstinence to safer continued use. When people feel judged, they avoid connecting. By avoiding judgment and focusing on safety, harm reduction approaches allow for alternate outcomes. People know themselves best. A concern for safety underlies all harm reduction efforts. Harm reduction strategies can be used in engagement, assessment, treatment planning and service delivery.

Working from a Harm Reduction Perspective Build a trusting relationship Collaboratively identify the most pressing issues Collaboratively determine goals and realistic objectives Provide services, build skills, and support safety, small incremental change, and the development of self-efficacy Working from a harm reduction perspective is like working in any other model… except…. The goals and basic steps are the same. But how each of these steps is accomplished is slightly different. First – collaboration. Again, acknowledging that the client is the expert in him/herself Second – acknowledging that what you think is the main issue may not be the priority for the person, and the best way to achieve trust, and movement, is to focus on the person’s priorities Third – While we often talk about skill building and incremental change, this approach forces us to truly operationalize this idea

Building Trust: Showing judgment: Asking about/pushing for treatment first Lengthy assessments to understand history of drug use and associated problems Focusing primarily on the downsides of drug use It is essential that we demonstrate – right from the beginning – that our priority is safety and concern for the individual, not morality and good/bad behavior

Building Trust: We Care! Showing judgment: Asking about/pushing for treatment first Lengthy assessments to understand history of drug use and associated problems Focusing primarily on the downsides of drug use Showing we care: Asking about safety strategies Focusing on any risks that might result from drug use and developing strategies Asking about client’s efforts to stay safe Asking about how drug use is a support

Types of Risk Health Family/relationships Legal Economic Housing Spiritual/sense of self NW: what are some questions you could ask a person to elicit their most pressing issues?

Safety Questions Do you use alone or with a buddy? If you use IV drugs, do you rotate your injecting spot/veins? Have you had police problems because of your use? How do you pay for your drugs? (prostitution, going without food/rent…) Are you able to practice safe sex when using? Do you have a plan to follow if in case of emergency? Do you share equipment or only use your own? Where do you get your syringes? Do you use a syringe exchange? Do you test/taste your shot before you do a full one? Give list of resources here – identify Building up credibility – that shows you are non-judgmental, that you understand some of this world, that you can be trusted Another one – do you taste your shot? Do you share your own rig, v. do you share equipment – it helps to be familiar with the lingo.

Self-efficacy… It is difficult to make change if you don’t believe you will be successful. Need to be aware of people’s personal narrative – success or failure? We can’t join them in their failure narratives – we need to try to create an alternate story

Harm reduction is a realistic approach that acknowledges many people are not ready to suddenly eliminate certain behaviors from their lives. Certain behaviors – includes risky behaviors – eg substance use, sex, food, etc. Not framed as “risky” because not all of the behaviors to be eliminated are risky (eg food)

Stages of Change PreContemplation Recurrence Contemplation Maintenance Not yet considering change Task: Raise awareness Recurrence Contemplation Reappearance of symptoms Task: Cope with consequences and choose next steps Ambivalent about change Task: Resolve ambivalence, move towards change Stages of Change Maintenance Determination Working to maintain change Task: Develop skills to maintain change Committed to change, but still making plans Task: Help identify change strategies Brief review Action Beginning to make change, but not yet routine Task: Help make change, and prevent relapse

Stage-Related Assessment Pre-contemplation: On a scale of 1 – 10, how serious is your use? What would a 9 or a 10 look like? What would be warning signs of a real problem? Contemplation How have you been successful in the past? What have you changed in the past that you thought went well? When clients are in pre-contemplation, we are helping them find their “why” When clients are in contemplation, we are helping them figure out “what” they can achieve NW: Provide contrary questions – what happens if you’ve id’d problems, they appear, and person denies it is still an issue! We don’t need special stage related questions for preparation, action, maintenance – that is what we are good at! If someone says I have a gambling problem and I want help, we know what to do. The problem is how to handle someone who is not sure they even want to make a change

Let’s be patient. Change does not come easily to any of us. New years resolution – same one every year – because we relapse When we fail, we lose a little belief in our ability to make change Behavior changes often take multiple tries. And we are surprised that people don’t believe they have the skill/competency to be effective at change. They develop a failure narrative

“Consciousness raising is a process in which the individual needs to increase his or her awareness about the negative consequences, the causes, and the cures of the problem behavior.” - James Prochaska Do we want/need this? I think it is somewhat muddled as a statement, and there is better we can say

The interactional style most effective in harm reduction is Motivational Interviewing

Motivational Interviewing Elicits person’s own internal desire to make changes Builds self-efficacy (affirmations) Avoids getting into battles about change – the pace is set by the staff person Emphasizes a need for change, and a hope that change can occur

Motivational Interviewing Core Principles & Techniques Expressing Empathy Developing Discrepancy Rolling with Resistance Supporting Self-Efficacy Open-ended questions Affirmations Reflections Summarizing statements

Readiness Ruler Don’t have an alternate set of skills to replace the risky behaviors Find too much benefit in the risky behavior Don’t believe will be successful

Affirmations Be specific – vague affirmations are meaningless Recognize that what you think is “easy” may take effort for your client Affirm effort, commitment, beliefs, or skills

Decisional Balance PROS CONS Making a Change Staying As Is

Mandations To treatment Just because a person is mandated to treatment doesn’t mean he is in action phase. Let’s join our clients where they are internally, not where a judge may mandate them.

Questions from Harm Reduction 101 Do you find that harm reduction approaches lead to abstinence? How do I assess for risky behaviors while not addressing use?   How do you practice harm reduction approaches in outpatient mental health settings? How do you respond to a client who justifies their use by stating that you are giving them permission to use?

Other questions? What can you do tomorrow? What can you do on a more continued basis? Please chat with us to share these ideas and engage in a discussion with us.

Some resources Harm Reduction Coalition www.harmreduction.org Here to Help (a project of the British Columbia Partners for Mental Health and Addictions Information) http://www.heretohelp.bc.ca/factsheet/making- healthier-choices-about-substance-use Washington Heights Corner Project www.cornerproject.org

Upcoming CTAC Events Harm Reduction Q & A - November, 2018 Ask the experts your questions about how to implement harm reduction approaches with your clients. No presentation – just personalized answers to tough questions.

Contact Us ctac.info@nyu.edu Please contact us with any questions and/or concerns! ctac.info@nyu.edu DAVE