Sie sind auf Seite 1von 14

Harm Reduction:

A Model for Social Work Practice with Adolescents


Katherine van Wormer
THE SOCIAL POLICY JOURNAL 3 (2), 2004, 19-37.

ABSTRACT. A practical antidote to the war on drugs, the harm reduc-


tion approach seeks to meet clients where they are, establish rapport and
help them modify or give up their risk-taking behavior. This article pre-
sents the case for harm reduction techniques for work with youth whose
risk-taking behavior is problematic. Emphasis is on drinking, drug use,
and high-risk sexual activity.

KEYWORDS. Harm reduction approach, client-centered approach,


strengths perspective, adolescents, high-risk adolescent behavior
INTRODUCTION
“Meet the client where the client is,” the popular slogan of social
work practice, sums up harm reduction philosophy in a nutshell. From
its origins as a way of addressing the negative consequences of drug
use, the harm reduction concept has grown considerably in recent years
(Hill, 1998). An international public health movement, harm reduction
joins client and therapist in the realistic pursuit of reducing the harm in
Katherine van Wormer, MSSW,PhD, Professorof SocialWork, Universityof North-
ern Iowa, Cedar Falls, Iowa 50614 (E-mail: vanwormer@uni.edu).
The Social Policy Journal, Vol. 3(2) 2004
http://www.haworthpress.com/web/SPJ
 2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J185v03n02_03
19
Page 2
one’s life. Typical strategies include: helping clients substitute a less
harmfuldrug for alifethreateningdrug;recruitmentof clientsintometha-
done maintenance and needle exchange programs; giving women re-
turning to their battering husbands a safety plan for self protection; and
an after-school program to help gays and lesbians “talk through” prob-
lems of internalized homophobia that might otherwise seek self-de-
structive channels of expression.
Although social work and the harm reduction approach are a natural
fit and widely integrated in Europe (see van Wormer, 1999), the U.S.
social work literature is remiss in terms of describing the utilization of
this practice/policy perspective. A search of Social Work Abstracts on-
line as of August, 2003 reveals ten listings for harm reduction, only four
of which are in American social work journals–from Health and Social
Work are articles by Brocato and Wagner, (2003); Reid (2002); and
MacMaster, Vail, and Neff (2002); and from Social Work Research an
article by Burke and Clapp, (1999). (Actually, this is a big improvement
over one year earlier when only one article from a U.S. journal of social
work was listed.) For point of comparison, PsycInfo lists 388 at the time
of this writing. In substance abuse texts written by American social
workers, as well, the harm reduction model is relatively absent. Excep-
tions are Abbott (2000) and van Wormer and Davis (2002). Abbott pro-
vides a two page description of the model and includes a chapter by
Dunn (2000) that utilizes the stages of change model consistent with
harm reduction and strengths-based principles. The van Wormer and
Davis volume, similarly, is strengths-based and utilizes a harm reduc-
tion conceptualization throughout. One can expect to hear much more
about harm reduction and its practice counterpart, motivational inter-
viewing, in the future, however. The prestigious Journal of Social Work
Education recently published “After the War on Drugs Is Over: Impli-
cations for Social Work Education”by McNeece (2003). I believe, indi-
rectly, the empirical research in the federally funded Project Match
(1997) which confirmed the effectiveness of a variety of treatment ap-
proaches but which showed that motivational strategies worked well
and especially well with angry clients, has brought a belated effect to
bear on treatment offerings. At the same time, there is a general consen-
sus that prevention is preferable to treatment and that harm reduction
strategies, like the public health model, are geared toward preventing
the development of addictions problems in the first place.
A further promising development is the endorsement by the National
Association of Social Workers (NASW) (2003) in their handbook of
policystatementsof acomprehensivepublichealthapproachfor thepre-
20
THE SOCIAL POLICY JOURNAL
Page 3
vention of alcohol, tobacco, and other drug problems and harm reduc-
tion strategies aimed at persons affected by such problems. In this arti-
cle we will examine the principles of a harm reduction or public health
framework, relate these precepts to the strengths perspective of social
work practice, and explore work with adolescents as just one of the ar-
eas of social work for which the harm reduction model has special rele-
vance. Emphasis will be on adolescent risk taking in the areas of sex-
uality and substance abuse.
HARM REDUCTION Versus TRADITIONAL APPROACHES
What is the harm reduction approach? To define this term, we need to
take into account the two aspects of harm reduction that are often poorly
differentiated in the literature–these are the policy and practice aspects.
As policy, harmreductionis anoutgrowthof theinternationalpublichealth
movement. Its most familiar representation is as a philosophy that op-
poses the criminalization of drug use and views substance misuse as a
public health rather than criminal justice concern. The goal of the harm
reduction movement is to reduce the harm to high risk takers and to the
communitiesinwhichtheylive,includingtheharmcausedby criminal-
ization of the substances (Jensen and Gerber, 1998). Proponents of this
model generally oppose laws against drinking by young adults under
age twenty-oneand harsh punishmentsfor drug use and possession. The
war on drugs, from this viewpoint, exacts a deadly toll. This toll is gen-
erated in terms of: use of contaminated, unregulated chemicals; the
spread of hepatitis, tuberculosis, and AIDS through the sharing of dirty
needles; the social breakdown in America’s inner cities; and political
corruption elsewhere (van Wormer and Davis, 2002). In Europe, in fact,
it was the AIDS epidemic of the 1980s which catapultedharm reduction
policies into prominencein several countries, including Britain (Abbott,
2000). Drug use was medicalized, and the behavior of drug use closely
monitored at methadone and other clinics where a safe drug supply was
provided under medical supervision. SeveralU.S. cities including Balti-
more and Seattle have moved in the direction of such progressive poli-
cies.
Because harm reduction measures are diversified and highly prag-
matic (as opposed to moralistic), scientific research plays a key role in
convincing legislators and other policymakers to sponsor the establish-
ment of such strategies. Proof is essential, moreover, to establish which
programs are truly harm reducing, as Canadian public health specialist,
Eric Single(2000), reminds us. Fortunately, despite the U.S. federal gov-
ernment’s reluctance to publicly endorse non-abstinence based pro-
grams for youth, there is much grant money available for experimental
treatments, as, for example, the Cannabis Youth Treatment Series de-
scribed at the National Clearinghouse for Alcohol and Drug Informa-
tion and unveiled by the Substance Abuse Mental Health Services Ad-
ministration (SAMSHA, 2000). This series compared traditional with
alternative approaches, including motivational therapy, in which cli-
ents, in individual sessions, are given the message that the decision to
stop smoking marijuanais up to them.Results with a large sample showed
that there was substantial reduction in marijuana use with the various
methods that were applied. Consistent with the principles of harm re-
duction, note that in the research literature today, the measure of treat-
ment success relevant to substance misuse is a reduction in use and in
harmful consequences;the traditional measure was always complete ab-
stinence from the drug (van Wormer and Davis, 2003).
At the practice level, harm reduction is an umbrella term for a set of
practical strategies based on motivational interviewing and other strengths-
based approaches to help people help themselves by moving steadily in
the direction of reduction of high-risk practices. As practice, harm re-
duction entails removing barriers such as lack of childcare or bureau-
cratic constraints that impede people from getting treatment. Typical
advice given to clients is of the order of, “Don’t drink on an empty stom-
ach,”or “Don’t drink and drive.”Duncan, Nicholson, Clifford, Hawkins,
and Petosa (1994) describe how they confronted an epidemic of paint
and solvent “huffing” after two boys died from inhaling paint fumes in
plastic bags. Educational presentations to youth groups emphasized the
dangers of huffing and warned them if they did do it,to at least use paper
bags instead of plastic bags which could be lethal.
In this client-centered approach, use of negative labels such as “anti-
social”and“borderline”in mental health,“criminal personality”in crim-
inal justice, and“alcoholic/addict”in substance abuse treatment is avoid-
ed; clients provide the definition of the situation as they see it. The tradi-
tional message imparted to kids, such as in educational programs, is the
total and immediate abstinence from all dangerous, risk-taking activi-
ties such as no sex before marriage and don’t drink until you’re 21. Pe-
terson, Dimeff, Topert, Stern, and Gorman(1998) warn against the“boom-
erang” effect of these absolutist approaches as alienating of youths and
lessening adult’s credibility. An approach stressing choice in decision
making, in contrast, empowers youth to make practical decisions about
their own lives. Given the obvious reluctance of drug users to volunteer
for treatment under the old, police-dominated system, new and very dif-
ferent forms of intervention must be developed (McNeece, 2003).
PUNITIVE TRADITIONS ON THE AMERICAN CONTINENT
Forcing young unwed mothers to carry their babies to term; returning
parolees who have relapses to prison; mandatory sentencing; zero toler-
ance in the schools–such practices commonly supported by the Ameri-
can public and policy makers reflect a punitive ethos that has its roots in
Colonial times.
Like the very language that shapes our every thought and deed, the
present day American value system is rooted in the New England expe-
rience, in the foundation laid down by the colony of religious zealots in
Massachusetts Bay. The essence of this foundation was the holy experi-
ment known to the world as Puritanism. In his classic, Wayward Puri-
tans: A Studyin theSociologyofDeviance, Kai Erikson (1966) provided
a colorful portrait of this society and of the dissenters among them.
Theirs was a society run by the clergy whose role it was to interpret the
scriptures for guidance in all matters of living. Indeed, back in England,
the English had found their narrow liberalism and lack of humor baf-
fling. To Puritans who reached Massachusetts, the truth was perfectly
clear: God had chosen an elite few to represent Him on earth. It was
their responsibility to control the destinies of others.
Influenced by the doctrines of predestination, the Puritans believed
that people were either to be saved or condemned–this was their des-
tiny. Sooner or later persons would give evidence of the category to
which they belonged. Those who had reason to fear the worst would in-
evitably sink to the lowest echelons of society. In accordance with the
will of God, punishment for offenders was harsh.
We find the peculiar ethos of Puritanism in evidence in American so-
ciety today. Despite the modern secularism, the Puritan ethic manifests
itself in the severity of punishment, the moralism pertaining to “welfare
cheats,”commoncriminals,andusers of illegalsubstances.Theunique-
ness of this history is important because many of the differences be-
tween Old and New World attitudesconcerning drug use and work ethic
have their origins in these humble beginnings. Sexual prudery and en-
forced abstinence from drink, however, were not a part of the Puritan
scene. The Puritans regarded drinking intoxicants as conducive to good
health. The restrictions against consumption of alcohol were added later
after the impact of hard liquor had become a cause for concern (Bryson,
Katherine van Wormer
23
Page 6
1994). The spirit of Puritanism–the rigidity and punitiveness, however,
survived in these later developments, and are evidenced in many of the
policies of today.
The War on Drugs is taking a double toll on children, first in taking
their parents away and subjecting them to the tragedy of premature sep-
aration. The stigma of having one or both parents incarcerated weighs
heavily upon a growing child. The second toll on children occurs when
their own reactive, acting-out behavior brings harsh consequences. Half
of the 1.5 million kids with a parent in jail or prison, in fact, will commit
a crime before they turn 18 (Drummond, 2000).
Youths who get into trouble with drugs and who are sent to juvenile
facilities have high rates of recidivism (Noble and Reed, 2000). Yet
more and more youths are being dealt with harshly in juvenile court for
minor crimes and tried as adults for major crimes. An innovative and
carefully orchestrated development–the Drug Courts movement–pro-
vides mandatory alcohol and drug treatment and a continuum of com-
munity services to ensure compliance with its two-year program. Edu-
cation, vocational experiences, and life skills training are provided.
Results from the over 300 programs nationwide indicate that Drug
Courts have been highly effective in saving taxpayers money (“Study
Shows Drug Courts Reduce Substance Abuse, Crimes,” 1998). Addic-
tion treatment costs between $2,000 to $3,000 per person. Compare that
to the $25,000 or so required to incarcerate someone. Today, there are
treatment strategies, moreover, that are specifically geared to a person’s
maturity level or, in other words, to his or her readiness to address the
substance use issues.
Harm reduction philosophy is built on pragmatism and compromise.
It operates on the beliefthatbetween moderateuse (as of a drug) and life
threatening behavior, moderation is better. It does not always gel well
with American moralism, therefore. As Marlatt (1998) explains:
Consistent with a policy of total abstinence, the principle of zero
tolerance establishes an absolute dichotomy between no (zero) use
and any use whatsoever. This all-or-none dichotomy labels all
drug use as equally criminal (or sick), and fails to distinguish be-
tween lighter and heavier drug use or degrees of harmful use.
(p. 51)
Philosophically, harm reduction has its roots in European pragma-
tism; the focus is on maintaining good health rather than punishing bad
behavior. From this perspective, allpotentiallyrisk-taking behavior such
24
THE SOCIAL POLICY JOURNAL
Page 7
as sexuality is viewed along a continuum ranging from no involvement
or abstinence at one end to extremely harmful activities at the end, with
casual practices in the middle.
HARM REDUCTION AND ADOLESCENT RISK TAKING
Society’s moralism is especially pronounced with regard to risk-tak-
ing behavior of youth. Drinking, drug experimentation, sexual expres-
sion–all are behaviors, the consequences of which are feared and even
resented when engaged in by youth. In the 1990s, in fact, U.S. Surgeon
General Joycelyn Elders took a realistic stance toward adolescent sexu-
ality. She advocated teaching young people in school sex education
classes about the risks of unprotected sex and giving them ways to re-
duce these risks. A public uproar ensued, and Elder’s remarks ulti-
matelyresultedinher dismissal(Petersonetal.,1998). Official govern-
ment policy has largely supported abstinence-only sex education. Yet,
as Peterson et al. indicate, scientifically controlled studies show that
discussion of safe sex practices with youth does not lead them to initiate
sexual activity earlier than they would have otherwise.
Harm reduction, the preferred European approach, emphasizes absti-
nence as an important option, but also provides information to reduce
the risk of AIDS, venereal disease, and unplanned pregnancy. In Am-
sterdam on weekends, peer counselors seek out rave dancers, provide
them with glow-in-the-dark pamphlet racks and cushions, and inform
them about uppers and downers and keeping safe. “Just Say Know” as
opposed to “Just Say No” is the group’s motto (Power, Johnson, and
Theil, 1999). “Knowledge is power” as the saying goes. It, knowledge,
is also empowering.
PREVENTION AS HARM REDUCTION
Harm reduction strategies with youth apply at various levels ranging
from community-based educational programs to individual guidance.
Some methods of reducing harm are indirect–for example, reducing the
size of schools and classes to create a more personal learning environ-
ment and to keep an eye on children in need of help. The situation re-
garding drinking and drug use parallels the high-risk sex situations.
Often, inevitably, intoxication and unhealthysexual behaviorgo together.
Unlike law enforcement strategies which focus on reducing the supply
Katherine van Wormer
25
Page 8
side of drugs, harm reductionis geared to reducingthe demand for drugs.
This form of prevention is sometimes termed primary prevention and
includes early childhood education, treatment programs and commu-
nity interventions to reduce indirect risk factors such as parental alcohol
abuse and child mistreatment.
The public health approach to preventing harm is multidimensional
and ideally operates across systems. Knowledge of the developmental
progression of substance use is important for the focus and timing of
preventive interventions (Botvin and Botvin, 1997). Knowledge of the
typical pathways that lead into reckless behavior is also instrumental in
alleviating or treating underlying psychological problems that can in-
crease the risks for harmful experimentation. Prevention of early child-
hood abuse and trauma is key to prevention of the development of the
kind of substance misuse that relates to affect-use of chemicals to coun-
teract low feelings resulting from early childhood trauma. Social policy
initiatives must include a coordination of services to protect children
from the earliest age onward. Parenting courses, periodic public health
nurse visits to all homes where there are babies,a well-funded child wel-
fare system to ensure the safety of children are the first priority–these
are among the initiatives that are sorely needed. In the U.K., the Labour
government has introduced new strategies that are based on a coordina-
tion of efforts across national and local bodies; these bodies include ed-
ucation, health, and prevention services to reduce the demand for drugs
(Howard, 1998). The message to the British “drug tsar,”according to this
report, is that treatment is a cornerstone to reducing demand; harm re-
duction gets the seal of approval.
The aim of all these efforts is to help children get through adoles-
cence relatively unscathed, and to prevent experimentation with sub-
stances, the use of which carries the potential for personal destructive-
ness down the road. Many of the developmental changes that are
necessary prerequisites for becoming healthy adults unfortunately in-
crease an adolescent’s risk of smoking, drinking heavily, or using drugs
(Botvin and Botvin, 1997).
Primary prevention efforts can be divided into seven general strate-
gies:
• Child protection aimed at the cycle of violence and substance mis-
use;
• School-based prevention programs directed toward social influ-
ences prompting youths to smoke;
• Information dissemination approaches focusing on immediate con-
sequences of smoking (bad breath, breathing problems);
• School programs based on dialoguing with youth to answer ques-
tions honestly and provide information about which drugs are the
most dangerous and to promote moderate drinking over bingeing;
• Mass media campaigns showing the negative side of alcohol, to-
bacco, and other drug misuse;
• Social resistance and personal competence skills approaches (e.g.,
anxiety management skills, assertiveness training);
• Campaigns to reduce or eliminate TV beer ads, student newspaper
local bar and national beer ads;
• Advocacy for the hiring of more school counselors and socialwork-
ers to work with high-risk students (bullies, victims, children who
suffer from mental disorders, children of alcoholic/addicts).
Because of the extremely addictive properties of nicotine, an all-out
effort should be made to keep youths from ever starting to smoke; this
effort should be bolstered by community and media support. A clever
strategy to get youths to quit smoking is to involve them in strenuous
exercise programs. According to an article in the Washington Post health
section (Krucoff, 1999), a study of male runners showed that 70 percent
of those who smoked subsequently quit. Almost half of the women in an
exercise group quit smoking as well.
Alcohol, in contrast with tobacco, has positive, health-benefiting
properties. Many families enjoy moderate drinking while condemning
intoxication; cultural traditions come into play here. Moderate drinking
and abstinence should therefore be presented in health education classes
as equally acceptable choices. Since practically all youths will at least
sample alcohol, a focus on safe and unsafe practices associated with its
use would seem to be the only practical course to take.Expecting young-
sters not to drink until they reach 21, then suddenly to become responsi-
ble drinkers is unrealistic (Boroson, 1993). Information based on ideol-
ogy rather than fact, furthermore, will be given little credibility by teens.
The whole strategy of demonizing alcohol for youth and reserving its
pleasures for adults over a certain age merely increases itsattractiveness.
Given the high ratesof pregnancy, sexually transmitted diseases, grow-
ing rates of HIV infection, and risk of lethal overdose among teens, and
especially marginalized teens, harm reduction holds the maximum po-
tential for protection (de Miranda, 1999). Leshner (1999) describes two
paths to drug use; these pathways have significance for treatment. The
first path involves the group of kids who are seeking novelty or excite-
ment who are striving to be “cool.” These youth are most likely to be re-
sponsive to prevention education about the harmful effects of drugs on
their bodies, for example, the side effects of steroids on the testicles and
complexion. The second path to substance use involves dynamics of an-
other sort. Using drugs to escape emotional pain, youths in this category
are bent on self-medication. Their problem is getting through the day;
messages about long-term damage are apt, therefore, to have little im-
pact. Teen-age girls tend to fall in this category, drinking heavily to
ward off depression and relieve stress while boys tend to do it for thrills
or heightened social standing in the group (Alex, 2003, October 24).
Girls thus require gender-specific educational efforts. Fear arousing
messages beamed at adolescents, paradoxically, are irrelevant to emo-
tionally troubled youth and apt to attract rather than deter the risk takers
among them. Leshner recommends professional help for youth with
problems. Sadly, only one in five of every adolescents in need of treat-
ment services actually receives such treatment (U.S. Department of
Health and Human Services, 2001).
In a survey of research effectiveness studies, Botvin and Botvin
(1997) found that social life skills training either alone or in combina-
tion with other approaches emerged as having the most effective impact
on substance use behavior. These approaches, as Botvin and Botvin in-
dicate, utilize well-tested behavioral intervention techniques; they also
help prepare adolescents to deal with strong feelings without resorting
to use of alcoholand other drugs. The coping mechanisms acquired here
should be invaluable in later life as well. Marlatt (undated), a professor
of psychology at the University of Washington who is noted for his em-
pirical research with first-year college students in helping them moder-
ate their drinking through brief motivational counseling sessions, re-
ported excellent results in small group work with high school seniors as
well. The goal was to move students from where they were into taking
small, manageable steps toward healthy living. School officials report-
edly were pleased with the results and requested that more workshops
be offered.
MOTIVATIONAL INTERVIEWING
As a practice technique, harm reduction strives to get the client moti-
vated to make a health-seeking choice. The focus thus becomes the cli-
ent’s motivation. Motivational interviewing (MI) is a non-confronta-
tional model basedon the fundamental truth from social psychology that
decisions to move toward change are more powerful if they come from
within. Derived from the teachings of psychologists Miller and Roll-
nick (1991), MI, in its basic formulation and precepts, closely parallels
the strengths perspective of social work practice (van Wormer and Da-
vis, 2003).
The strengths approach, as Saleebey (2002) suggests, is “a versatile
practice approach, relying heavily on ingenuity and creativity, the cour-
age and common sense of both clients and their social workers. It is a
collaborative process” (p. 1). Traditionally,work in the substance abuse
field has focused on breaking client resistance and denial (Rapp, 1998).
According to this more positive framework which builds on client’s
strengths and resources, however, client resistance and denial are often
viewed as healthy, intelligent responses to a situation that might involve
unwelcome court mandates and other intrusive practices.
As in the strengths formulation, the focus of MI is on collaboration of
counselor and client as well as on personal choice (see Saleebey, 2002).
When the focus on the professional relationshipi s on promoting healthy
lifestyles and on reducing the problems that the client defines as impor-
tant rather than on the substance use per se, many clients can be reached
who would otherwise stay away (Denning, 2000; and Graham, Brett,
and Baron, 1994). Central to this approach is the building of a relation-
ship between therapist and client. In working with youth, this relation-
ship is crucial in terms of promoting self-esteem and the confidence to
try on new roles. In the MI orientation, the strategy is to help develop
and support the client’s belief that he or she can change; this is the prin-
ciple of self-efficacy (SAMHSA, 2000).
The motivational, like the strengths approach, meets the client where
he or she is at that point in time. The harm reduction practitioner as-
sesses the level of the client’s motivation for change and, instead of en-
gaging in a tug of war with the client, “rolls with resistance.” MI tech-
niques are geared to help people find their own path to change. The
therapist provides feedback through additive paraphrasing, a technique
that involves selectively reflecting back to the client what he or she
seems to be saying about the need to reduce or eliminate self-destructive
behaviors (van Wormer and Davis, 2003).
Ideally suited for work with troubled and rebellious teens, harm re-
duction meets the youth where the youthis and is disarmingly nonthreat-
ening. There is no moralizing tone here, no forcing teens to sit in a circle
and label themselves as alcoholics or addicts. A certain amount of am-
bivalence is expected and, in fact, deemed healthy. Central to the whole
framework is the belief that clients are amenable to change. This opti-
mism closely parallels Saleebey’s notions of “promise and possibility”
(2002, p. 15).
MI therapists draw on the stages of change model, originally formu-
lated by Prochaska and DiClemente (1992). This model is built on the
assumption that treatment interventions can be matched to the client’s
readiness to change. Taking an adolescent who is ambivalent about drug
taking, we can conceive of him or her as progressing through the fol-
lowing stages of change:
• Precontemplation: (for example, “My parents can’t tell me what to
do; so what if I get high now and then?”)
• Contemplation: (“When I’m high, I’m high but being down is a
drag.”)
• Preparation: (“I know the things I’m doing will have to stop some-
time in the future.”)
• Action: (“The date I’ve set is my birthday; I’m going with a friend
to one of those groups, just to try it out.”)
• Maintenance: (“It’s been a few months, a few dull months. But my
mind seems much clearer. I’ve made some new friends.”)
Patricia Dunn (2000) finds that the stages of change model is appro-
priate for social work because it is compatible with the mission and con-
cepts of the profession, is an integrative (transtheoretical) model, and is
grounded in empirical research. Through building a close therapeutic
relationship, the counselor can help the client develop a commitment to
change. The way motivational theory goes as this: if the therapist can
get the client to do something, anything, to get better, this client will
have a chance at success. This is a basic principle of social psychology.
Examples of tasks that William Miller (1998) pinpoints as predictors of
recovery are: going to AA meetings, coming to sessions, completing
homework assignments and taking medication (even if a placebo pill).
The question, according to Miller, then becomes, “How can I help my
clients do something to take action on their own behalf?” A related prin-
ciple of social psychology is that in defending a position aloud, as in a
debate, we become committed to it. One would predict, from motiva-
tional enhancement perspective, that if the therapist elicits defensive
statements in the client, the client will become more committed to the
status quo and less willing to change. For this reason, explains Miller,
confrontational approaches have a poor track record. Research has
shown that people are more likely to grow and change in a positive di-
rection on their own than if they get caught up in a battle of wills.
The starting point for the therapist is to determine where the client is,
at what level of change. As Boyle (2000) indicates, it is not unusual for
involuntary clients to enter treatment at the precontemplative stage. At
this preliminary stage, the goals for the therapist are to establish rapport,
to ask rather than to tell, and to build trust. Eliciting the young person’s
definition of the situation, the counselor can reinforce discrepancies be-
tween the client’s and other’s perceptions of the problem. During the
contemplation stage, while helping to tip the decision toward reduced
drug/alcohol use, the counselor emphasizes the client’s freedom of
choice. “No one can make this decision for you” is a typical way to
phrase this sentiment.Information is presented in a neutral, “take-it-or-
leave-it” manner. Typical questions are, “What do you get out of drink-
ing?” “What is the down side?” And to elicit strengths, “What makes
your sister believe in your ability to do this?” At the preparation for
change and action stages questions like, “What do you think will work
for you?” help guide the youth forward without pushing him or her too
far too fast.
(For more on motivational enhancement strategies for social workers
see Dunn (2000) and van Wormer and Davis (2003). The seven-part
professional training videotape series presented by Miller and Rollnick
(1998) provides guidance in both the art and science of motivational en-
hancement. The role plays provide a highly useful didactic technique.)
INNOVATIVE PROGRAMMING
The difficulty in offering true harm reduction programs for teens in
the United States relates to the potential conflict between agency policy
and political legislation. Harm reduction policies for adults such as nee-
dle exchange programs, are controversial and under funded. Programs
for teens such as DanceSafe, which tests Ecstasy pills for toxic sub-
stances for youths attending raves to ensure their safety before youths
consume them, are privately funded and operated by volunteers. Re-
cently passed legislation, however, threatens persons helping in any ca-
pacity at raves with arrest.
In Canada, Youthlink Inner City serves the hard-to-reach and alien-
ated youth who frequent downtown Toronto. Since the harm reduction
model is widely accepted in Canada, this agency appears to be widely
respected despite a shortage of funds (Youthlink, 1999). Alan Simpson,
BSW, (June 12, 2002), in private correspondence with the author, de-
scribes this progressive program:
Youth link Inner City runs a drop-in centerfor street-involved youth
aged 16-24 and utilizes a harm reduction approach with all aspects
of youth. This ranges from a needle exchange program, access to
health care, providing food for many youth who haven’t eaten in
severaldays andmainlyacceptingtheyouthwhere theyareatnow.
This process can be very hard to imagine, let alone put into
practice. Many agencies use an abstinence-based objective and the
only success is that which can be measured on a scale. The use of
harm reduction, especially with this population, is empowering
and gives a voice to those who have been marginalized in so many
ways. In our eyes and opinion, youth who have started to become
aware of what is affecting them and have started to make changes
that improve their decisions and lives are a success to us. Once you
give a person the information and the ability to utilize the deci-
sion-making process for his or her gain, improvements will be
made. InnerCity works extremely well in helping youth make this
transition.
InnerCity is committed to the reduction of the transmission of HIV.
A needle exchange program and free condoms are provided in the hope
of curbing the spread of this disease, according to the web site. Some of
the other services available at this drop-in center range from medical
care, welfare and housing services, legal advice by volunteer lawyers,
recreational activities, and job referrals
IMPLEMENTATION
OF HARM REDUCTION STRATEGIES FOR TEENS
We have talked about what social workers can do as practitioners,
drawing on their best listening skills and using motivational strategies
to engage youth to choose a sober lifestyle. Schools of social work
should require coursework related to substance use, teach empirically-
based interventions, and encourage field placements in substance abuse
treatment programs that use motivational and other harm reduction
strategies (Brocato and Wagner, 2003). Policy courses, as Brocato and
Wagner further suggest, should include drug policy with the other poli-
cies covered.
In Iowa, we have had an interesting experience due to our exchange
with the University of Hull, England. Each summer several visiting
British students do their field practicum at substance abuse treatment
centers to learn about 12-Step approaches. In so doing, they have broad-
ened the horizons of counselors and medical staff with whom they have
worked. This is one way of introducing new ways of doing things,
through the introduction of international perspectives–same problem,
different solutions. American students, meanwhile, have learned first-
hand of harm reduction in their coursework in addictions at the Univer-
sity of Hull.
Once social workers have grasped the essentials of harm reduction,
and more specifically, of motivational techniques, and are equipped
with research on treatmenteffectiveness, theycan shape policiesthrough
their influence in the course of school social work or substance abuse
counseling. They can speak to parent’s groups and conduct workshops
for teachersandcounselors.Insurancecompaniestodayareamenableto
motivational strategies, probably because of their cost-saving qualities
and this has opened the door in many states to a stronger focus on pre-
vention and treatment before the problems have grown severe. One pro-
gram in Iowa that has been well received is the Strengthening Families
Program. This program, when introduced in Iowa, has significantly de-
layed initiation of alcohol use by improving parenting skills and family
bonding (National Institute on Alcohol Abuse and Alcoholism, 2003).
Making oneself known to legislators, progressive and otherwise, is a
crucial first step in influencing state policy. While punitive policies per-
sist at the federal level, social workers can take advantage of devolution
(or the turning over of responsibility for social welfare functions to the
states) to work through state representatives. This can be done through
informative Fact-Sheets (sent by email or personally delivered) at the
time a relevant bill is introduced in Congress and legislators are anxious
to learn of cost-benefits ratios and of treatment effectiveness research
findings. Social workers can advocate by attending county-level public
forums with their legislators to produce their evidence and keep the is-
sues of concern alive. Letters to the editor in the local newspapers can
argue that funding (especially from gambling and tobacco settlements)
be targeted to anti-smoking initiatives and other media prevention cam-
paigns. From a harm-reduction perspective, social workers should lobby
legislators to advocate for neighborhood drop-in centers where teens
can drop in or their parents can bring them for immediate and informal
counseling sessions.
In summary, programscanbeimplementedincollaborationwithteach-
ers in the schools and substance abuse counselors, who are colleagues
working within the system, for strategies to help our youth reduce the
harm to themselves. Another option is working at the broader policy
level for the funding that is needed for public health policies aimed at
the prevention of risk-taking behavior.
CONCLUSION
A common misconception of harm reduction is to see its ultimate
goals as incompatible with the 12-Step approach. Sustaining a healthy
lifestyle is probably the goal of all treatment models. Harm reduction
can be distinguished from traditional approaches in that it is individual-
ized and low key. Through showing a great deal of patience while the
young person gropes for his or her way to sobriety and safe living, the
harm reduction practitioner helps the client move from high levels of
risk-taking toward progressivelysafer behaviors. Harm reduction seeks,
above all else, to save lives. Clients, accordingly, are reinforced in
whatever moves toward sobriety, abstinence, and safe sex practices they
are able and willing to make.
The harm reduction framework differs from that of many traditional
counselors of the 12-Step school, in short, in its flexibility, client cen-
teredness, strengths perspective, and orientation toward public health.
This approach is especially relevant to acting-out youth, youth who
above all, need someone to talk to, someone older and wiser who will
listen. Society’s proclaimed zero-tolerance approach, all the metaphors
of war used in connection with the war on drugs, the one-size-fits-all
treatment schemes–these off-putting policies are harm-inducing rather
than harm reducing. They cause harm to the young who tune out the
message that drug use and unsafe sex can have consequences; to fami-
lies, especially African American and Latino families, who lose their
loved ones to the criminal justice system; and to society through provid-
ing punishment rather than care. Money invested in the drug war could
be far better spent on prevention and the demand side of drugs.
Under an expanded harm reduction model, social work and counsel-
ing intervention would be geared toward community prevention work
and early treatment of drug users to monitor their use and life style. Be-
cause the “abstinence-only” model emphasizes treatment after the drug
dependent person has “hit his or her bottom,” an opportunity to intro-
duce life-saving measures at early stages of drug use and/or problem
drinking is lost. Forcing young people to attach a label to themselves is
inconsistentwith social work’s value of self-determination. In the words
of a visiting British addictions worker who was speaking before an
Iowa student audience, “You are failing to meet the needs of a very sig-
nificant number of people out there. I’m thinking especially of adoles-
cents who do not identify with a label such as alcoholic or addict but
who could benefit from help on their own terms” (Hobby, 1996).
REFERENCES
Abbott, A. (2000). Values, ethics and ethical dilemmas in ATOD practice. In A.
Abbott
(Ed.), Alcohol, tobacco, and other drugs: Challenging myths, assessing theories,
individualizing interventions. (pp. 44-73). Washington, DC: NASW Press.
Alex, T. (2003, October24). Shouldreformbe genderspecific? Des MoinesRegister, B1.
Boroson, W. (1993, August 8). Drinking age: Abstinence vs. moderation. The Record,
17-20.
Botvin, G. and Botvin, E. (1997). School-based programs. In J.H. Lowinson, P.
Ruiz,
R. Mulliman, and J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook
(pp. 764-775). Baltimore: Williams and Wilkins.
Boyle, C. (2000). Engagement: An ongoing process. In A. Abbott (Ed.), Alcohol, to-
bacco, and other drugs. (pp. 144-158). Washington, DC: NASW Press.
Brocato, J. and Wagner, E. F. (2003). Harm reduction: A social work practice model
and social justice agenda. Health & Social Work, 28 (2), 117-125.
Bryson, B. (1994). Made in America. London: Minerva.
Burke, A.C. and Clapp, J.D. (1999). Ideology and social work practice in substance
abuse settings. Social Work, 42 (6), 552-562.
de Miranda, J. (1999, June 7). Harm reduction holds potential to reach
marginalized
youth. Alcoholism & Drug Abuse Weekly 11 (23), 5.
Denning, P. (2000). Practicing harm reduction psychotherapy. New York: Guilford
Press.
Drummond, T. (2000, November 6). Mothers in prison. Time, 105-107.
Duncan, D.F., Nicholson,T., Clifford,P., Hawkins,W. and Petosa, R. (1994). Harm
re-
duction: An emerging new paradigm. Journal of Drug Education, 24 (4), 281-290.
Dunn, P. (2000). The stages and processes of change model: Implications for social
work ATOD practice. In A. Abbott (Ed.), Alcohol, tobacco, and other drugs.
(pp. 111-143). Washington, DC: NASW Press.
Erikson, K. (1966). Wayward Puritans: A study in the sociology of deviance. New
York: Wiley and Sons.
Graham, K., Brett, P.J., and Baron, J. (1994). A harm reduction approach to
treating
older adults. The clients speak. Paper presented at the 5th International
Conference
on the Reduction of Drug Related Harm. Toronto, Ontario, March 7-10.
Hill, A. (1998, Spring). Applying harm reduction to services for substance using
women in violent relationships. Harm Reduction Coalition, 7.
Hobby, J. (October 22, 1996). The harm reduction model. Talk presented at Covenant
Medical Center, Waterloo, Iowa.
Howard, R. (1998, October 8-14). Labour in power. Community Care, 17-29.
Jensen, E.L. & Gerber, J. (1998). The social construction of drug problems: An
histori-
cal overview. In E.L. Jensen & Gerber, (Ed.). The new war on drugs: Symbolic and
criminal justice policy. (pp. 1-23). Cincinnati, Ohio: Anderson.
Katherine van Wormer
35
Page 18
Krucoff, C. (1999, March 23). Smoke and mirrors. Washington Post, 20.
Leshner, A.I. (1999). Science-based views of drug addiction and its treatment.
Journal
of the American Medical Association 282 (14), 1314-1316.
MacMaster,S.A.,Vail, K.A.,and Neff, J.A.(2002). The Xchange point: A drop-in cen-
ter for African American active injection drug users. Health and Social Work, 27
(3), 227-229.
Marlatt, G.A. (1998). Basic principles and strategies of harm reduction. In G.A.
Marlatt (Ed.), Harm reduction: Pragmatic strategies for managing high-risk be-
haviors (pp. 49-66). New York: Guilford.
Marlatt, G.A. (undated). Expert opinion: Harm reduction works. Alcohol
information.
Retrieved on 8/13/2003. Online at: www2.potsdam.edu/alcohol-info/
McNeece, C.A. (2003). After the war on drugs is over: Implications for social work
ed-
ucation. Journal of Social Work Education, 39 (2), 193-212.
Miller, W. (1998). Enhancing motivation for change. In W. Miller and N. Heather
(Ed.), Treating addictive behaviors, 2nd Edition (pp.121-132). New York: Plenum
Press.
Miller, W.R. and Rollnick, S. (1991). Motivational interviewing: Preparing people
to
change addictive behavior. New York: Guilford.
Miller, W.R. and Rollnick, S. (1998). Motivational interviewing: Professional
training
videotape series.
National Association of Social Workers (NASW) (2003). Alcohol, tobacco, and other
substance abuse. In NASW, Social work speaks: NASW policy statements, 6th edi-
tion (pp. 20-27). Washington, DC: NASW Press.
National Institute on Alcohol Abuse and Alcoholism (2003, April). Underage drink-
ing: A major public health challenge. Alcohol Alert, no. 59. Rockville,MD: U.S.
Department of Health and Human Services.
Noble, M.C. and Reed, C. (2000, January). Kentucky drug courts. Bench & Bar 64
(1),
6-10.
Peterson, P., Dimeff, L., Tapert, S., Stern, M., and Gorman, M. (1998). Harm
reduction
and HIV/AIDS prevention. In G.A. Marlatt (Ed.), Harm reduction: Pragmatic
strategies for managing high-risk behaviors. (pp. 218-297). New York: Guilford.
Power, C., Johnson, S., and Theil, S. (1999, November 1). Europe just says maybe:
Au-
thorities abandon faith in prohibition and enhance “harm reduction.” Newsweek, 20.
Prochaska, J. and DiClemente, C. (1992). In search of how people change: Applica-
tions to addictive behaviors. America Psychologist 47, 1102-1114.
Project MATCH Research Group (1997, January). Matching alcoholism treatment to
client heterogeneity: Project MATCH post treatment outcomes. Journal of Studies
on Alcohol 58, 7-28.
Rapp, C.A. (1998). The strengths model: Case management with people suffering from
severe and persistent mental illness. New York: Oxford University Press.
Reid, R.J. (2002). Harm reduction and injection drug use: Pragmatic lessons from a
public health model. Health and Social Work, 27 (3), 223-226.
Saleebey, D. (2002). Introduction: Power to the People. In Saleebey (Ed.). The
strengths perspective in social work practice, 3rd edition. (pp.1-22). Boston:
Allyn
& Bacon.
Single, E. (2000). The effectiveness of harm reduction and its role in a new
framework
for drug policy in British Columbia. Presented to the National Federal/
Provincial/
Territorial Meeting on Injection Drug use. Vancouver, January 31.
36
THE SOCIAL POLICY JOURNAL
Page 19
Spear, L. (2000). Modeling adolescent development and alcohol use in animals.
Alco-
hol Research & Health, 24 (2),115-123.
Study Shows Drug Courts Reduce Substance Abuse, Crime (1998, November 11).
Available online at www.jointogether.org.
Substance Abuse and Mental Health Services (SAMHSA) (2000). Motivational en-
hancement therapy and cognitive behavioral therapy for adolescent cannabis users:
5 sessions.CannabisYouth Treatment Series. Online at: www.health.org/govpubs/
Teenager’s Brains not Fully Developed. (2000, September 25). Waterloo-Cedar Falls
Courier, A8.
Tsui, M. (2000). The harm reduction approach revisited: An international
perspective.
International Social Work 43 (2), 243-251.
U.S. Department of Health and Human Services (2001). National Drug Control Strat-
egy: 2001 Annual Report. Washington, DC: Office of the National Drug Control
Policy.
van Wormer, K. (2002). Harm induction vs. harm reduction: Comparing American and
British approaches to drug use.Journal of Offender Rehabilitation, 29 (1/2), 35-
48.
van Wormer, K. and Davis, D. (2003). Addiction treatment: A strengths perspective.
Belmont, CA: Wadsworth.
Youthlink (1999). What is youthlink-Innercity? Online at: www.youthlink.ca/inner
city/