Book review by A.Tom Horvath, Ph.D.
Although harm reduction is commonly used in other countries, this approach to coping with problematic addictive behavior is unfortunately uncommon in the US. The authors are two US harm reduction leaders. They founded the Center for Harm Reduction Therapy in the San Francisco Bay Area in 2000. This book is intended for persons considering change. The authors have also written a book for professionals, the acclaimed Practicing Harm Reduction Therapy, now in a 2nd edition.
To provide an overview of this impressive work I will extensively quote it. In response to the question “What is Harm Reduction?” they provide the following three paragraphs (p. 197)
“Harm reduction is a way to help people change their substance use without demanding immediate and lifelong abstinence. It uses many creative strategies to keep people alive and safe while they figure out how to develop a healthier relationship with drugs. For some people, that means abstinence; for others that means moderate or safer use.”
“Harm reduction takes a health perspective rather than a moral or legal perspective, on drug use. Drug use is not bad. It is normal human behavior, and most people don’t get into trouble with it. Drug misuse is a habit that has gotten out of hand, or it is a signal of other co-occurring problems.”
“Harm reduction attends to every aspect of health—physical, mental and emotional, social and economic. It is nonjudgmental, compassionate, and pragmatic—it starts where the person is, stays with the person through the entire process of change, and never ever kicks anyone out.”
The sections of this book are:
Preface: How did we get here?
Introduction: Why harm reduction?
1) Welcome to harm reduction
2) Why do people use drugs?
3) When is drug use harmful?
4) Why do some people get into trouble while others don’t?
5) How do I know if I am in trouble?
6) How do people change?
7) You don’t have to quit to change?
8) Substance use management
9) Taking care of yourself while still using
10) How can I tell if harm reduction is working?
11) Finding the right help
12) A letter to family and friends of people who use drugs
What should you know about drugs: A quick reference
For SMART meeting leaders many of the chapters or appendices alone would be sufficient reason to purchase this book. In particular the quick reference to drugs (the 1st appendix) includes a section, for each drug or drug class, on the “beneficial effects.” This section is consistent with how SMART conducts a cost-benefit analysis (CBA), and provides essential information for understanding the user’s motivations.
SMART meeting leaders will find the entire book to contain familiar language and a familiar motivational perspective. Chapter 7 includes specific mention of the Stages of Change (p. 131) and provides an extended presentation that weaves together the underlying concepts of the Change Plan Worksheet and the Cost Benefit Analysis. Chapter 8 includes Triggers (p. 145), as well as classic harm reduction steps to reduce harm while not stopping or reducing use.
Some SMART meeting leaders might view SMART’s abstinence approach as very different than a harm reduction approach. I suggest the alternative perspective that all approaches to problematic addictive behavior involve making changes that are appealing in the long term but not so appealing in the short term. The extent to which each person is willing to honor the long term over the short term varies person to person, and time to time in the same person. Harm reduction provides a unifying framework for helping anyone, at any moment, in their personal change process.
It falls outside of SMART meeting guidelines to discuss classic harm reduction methods (like changing your route of administration). However, we do focus on “stopping,” which is also a unifying framework. Anyone who wants to honor the long term over the short term will need to “stop” something, to some extent, at some point. The harm reduction approach is larger than, and includes, the SMART approach. It would benefit any SMART meeting leader to be familiar with this larger perspective.
In full disclosure, the back cover of this book includes the following quote from me: “A highly informative, practical, passionate and moving guide…The stories on these pages are reminders of the power of the human spirit.” I’m pleased to say that, after reading this book a second time (for this review), this quote seems even more applicable.
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