Coming Together Kicking & Screaming : Harm Reduction+ 12-Step!

1. Coming Together Kicking & Screaming: Harm Reduction+ 12-Step! Dee-Dee Stout,MA, CADC II Member of MINT; Certified Trainer/Associate, ICCE www.youtube.com/watch?v=N8LZGQ4MkvQ

2. Goals: • Where HR came from • History of AA/12-Step • Convergence of HR & 12-Step/AA • Where we might be going & how we might get there

3. Part I: Come As You Are Harm Reduction http://youtu.be/g4yqsYP0yFY

4. Where Have We Been? History of HR Abroad • Amsterdam: mid-1980’s in response to HBV • “Junkie Unions” led to NEP’s (1984) • G. Alan Marlatt, invited to Amsterdam (1) • Book, 1998 • Australia/UK: mid-1980’s in response to HIV • HR services (NEP’s, safe injection, drug substitution, MMT, non-drug interventions) • 1st International HR Conf in Liverpool, 1990 • Medicalized approach (dates f/1920’s) • Merseyside Model (2) Thanks to HRTC for info

5. Where Have We Been?History of HR Abroad • Other HR Confs • Melbourne, Australia, 1992 • 1st in N. America, Toronto,1994

6. Where Have We Been? History of HR in US • 1985, NY State Division of SA Services, met in response to rising HIV/AIDS cases related to IDU’s • Outreach began including education w/IDU’s on bleach and needle exchange • NE began in spite of threats of arrest & loss of professional licensure; publicity led State Health Commissioner to approve NEP experiment • First NEP designed to fail! Shut down within 10 mos. Thanks to HRTC for info

7. Where Have We Been? History of HR - US • Late 1980’s saw many illegal NEP’s • 1992 NY State Dept of Health allowed 5 community groups to operate legal NEP’s • Hawaii began NEP’s in late 1980’s • Early 1990’s, Tacoma & SF added • North American Syringe Exchange Network & others focused on HIV & promotion of European/Australian HR services Thanks to HRTC for info

8. Where Have We Been?History of HR - US • In 1996 article, “Harm Reduction: Come As You Are”, Dr. G. Alan Marlatt announces “harm reduction is coming to the USA” • Seen as a “middle road” option to the moral model (War on Drugs) & disease/medical model • Use reduction & harm reduction balance recommended by public health group to ONDCP in 1995

9. The New Yorker

10. Give me some better examples of Harm Reduction: It’s about much more than drug use…

11. Defining Harm Reduction • Harm Reduction is a set of strategies that encourage drug users & others, & service providers to reduce the harm done by licit and illicit drugs (and behaviors). In supporting [drug users] consumers in gaining access to the tools to improve their health & lifestyles, we recognize their competency to protect & help themselves, their loved ones & their communities. Harm Reduction Coalition; www.harmreduction.org

12. Other Definitions • G. Alan Marlatt: “Pragmatic Strategies for Managing High-Risk Behaviors” (1998) • Pragmatic, non-judgmental, humane • Emphasizes personal responsibility

13. 4 Basic Beliefs Key to Harm Reduction philosophy • A public health alternative to the moral/criminal & disease models of drug use/addiction • Recognizes abstinence as an ideal outcome & accepts alternatives that also reduce harm • Has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “top-down” policy established by addiction professionals • Promotes low threshold access to services as an alternative to traditional high threshold approaches Thanks to Alan Marlatt

14. Other views of Harm Reduction • Compassionate pragmatism v moralistic idealism • A Menu of Options that includes abstinence (Motivational Interviewing, et al) • Integrates: • Appreciation of the meaning of the behavior for each person: context • Understands the chemical action & effects on each person: empathy

15. Other views of Harm Reduction • Success defined as “any positive change” • Obstacles are poverty, mental illness, racism, other trauma leading to: hopelessness, despair, self-destruction, self-defeating behaviors, abuse of others, & more • Connectedness, mindfulness, willingness for inner growth (recovery) are needed to increase motivation for change

16. Research • Most change happens slowly, over time, and has setbacks (lapses); we should expect this & prepare (AVE guilt) • HR strategies (warm turkey) can assist when abstinence (cold turkey) is not working (Kurt Cobain) • Most people opt for abstinence at some point (easier than moderation?) • Most people will never have a problem with any drug use (80-85%)

17. Some Goals of HR • Save lives • Safer drug use • Reduced drug use • Abstinence • Improved emotional state • Improved health & relation w/healthcare system • Better nutrition • More stable income • Better social relationships • Reduction in isolation • Increase support system • Increased normalization • Risk reductions (HCV, HIV) • Better living environment

18. Some Things for Agenciesto Consider • Who sets the goals? • Are consumers’ priorities accepted? • How & is power reasonably balanced? • What menu of options is offered? • Who decides what change is needed? In what timeframe? • Do you actively seek consumer feedback? Is it used? • Who makes the rules? • Who is seen as competent? • Who does the work of the intervention? • How is drug use viewed?

19. Some Things for Agencies to Consider • Who is on the governing board? • Who designed the interventions? • Is the intervention & staff all non-judgmental? • How are complaints addressed? • Who meets with funders? Presents at conferences? • Is the intervention consumer-friendly? • How are consumers treated? • Do consumers participate in evaluations (not just as respondents)? • Who provides services in the agency?

20. As Harm Reductionists, we examine: • How we treat each other • How our agency treats workers • How we treat other agencies • Our spirit of coalition building - or are we using competition, greed, & jealousy? • How we deal with workers who use drugs • How we deal with workers who don’t use drugs • The Tyranny of PC • Our ability to admit mistakes, apologize, & be open to feedback

21. HARM … • Helping • Advocating • Reducing recidivism • Mending wounds

22. …REDUCTION • Reinforcing healthier options • Educating (accurately & w/permission) • Delivering hope • Uncovering challenges • Celebrating choice • Treatment opportunities • Investing your time • Offering support & • Never, ever giving up on a consumer!

23. Part II: Keep Coming Back! Finding Harm Reduction Principles in AA/12-Step

24. HR Principles & AA: • Calls for non-judgmental non-coercive services & resources for drug users. • AA: “The point is, there is no prescribed AA ‘right’ way or ‘wrong’ way. Each of us uses what is best for himself or herself – without closing the door on other kinds of help we may find valuable at another time. And each of us tries to respect others’ rights to do things differently.” (Living Sober) • “We find that no one need have difficulty with the spirituality of the program. Willingness, honesty and open mindedness are the essentials of recovery.” AA, p570 (italics theirs) • “[a principle against information]…and that principle is contempt prior to investigation.” (ibid)

25. HR Principles & AA: • Recognizes how realities of poverty and other social inequalities affect different users differently, including harmful effects. • AA: “We were resolved to admit nobody to AA but that hypothetical class of people we termed ‘pure alcoholics.’ Except for their guzzling, and the unfortunate results thereof, they could have no other complications. So beggars, tramps, asylum inmates, prisoners, queers, plain crackpots, and fallen women were definitely out. Yes, sir, we’d cater only to pure and respectable alcoholics!” (italics theirs) 12x12, p140.

26. HR Principles & AA: • Does not try to minimize or ignore real & tragic harms & dangers of drug use. • AA: Quoting the AMA in Living Sober: “Alcohol, aside from its addictive qualities, also has a psychological effect that modifies thinking and reasoning. One drink can change the thinking of an alcoholic so that he feels he can tolerate another, and then another, and then another…the alcoholic can learn to completely control his disease, but the affliction cannot be cured so that he can return to alcohol without adverse consequences.” (from an official state issued July 31, 1964) (emphasis mine) • Difference between AOD use, misuse, dependence • Perhaps “true” alcohol dependence is genetic and therefore a disease?

27. What does AA state? • AA promises that one will have a “spiritual awakening as the result of these steps.” (italics mine) Twelve Steps & Twelve Traditions, p106 (Step 12) • “We are not cured of alcoholism. What we really have is a daily reprieve contingent on the maintenance of our spiritual condition.” (Alcoholics Anonymous, p85) • “…[the 12th Step*] is really talking about the kind of love that has no price tag on it.” (ibid; emphasis mine) *Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs."

28. Harm Reduction states… • Use of non-medical psychoactive dx is inevitable in open societies and … • this use inevitably will produce harm both to individuals & society • Drug policies need to be pragmatic & based in fact/science • Protecting the health of dx users is important as they are an integral part of society • Multiple interventions are needed to address the various harms of drug use

29. Historical notes re: Alcohol • US has had a historical inability to come to a consensus about the role of alcohol in society today (www.niaaa.nih.gov). • Alcohol misuse tolerated in colonial times as long as it didn’t interfere with a person’s livelihood or religious observance. (ibid) • Temperance, 19th c: Shift from trying to control the individual to the substance. • Temperance advocated “temperate” use of alcohol • Changed around 1850’s to abstinence & against saloons • Spreading the myths (ie, Demon Rum)

30. Myth #1: Harm reduction is the opposite of abstinence • Zero tolerance demands absolute perfection which is humanly impossible • when one fails, no further treatment is offered • Treatment industry states it sees addiction, or chaotic drug use, as part of a continuum from no use (abstinence) or responsible use, to moderate use, to problematic use, and chaotic use or dependence, and back • nothing is prescribed, all options are individualized • 60% of US businesses have zero tolerance policies to drug use • no treatment offered when workers are caught using drugs, including alcohol • cases where a union is involved is sometimes different, based on their ability to negotiate other outcomes

31. Myth#4: Harm reduction means anything goes • Anything goes would be harmful to many so can’t be harm reducing • Andrew Tatarsky’s story • Mixing HR and abstinence happens whether we agree with it or not • More realistic than traditional treatment • In a cocoon, anyone can make a change!

32. The Beginnings of AA in Treatment • 1935, AA officially begins • Growing acceptance of alcohol abuse & alcoholism as a health problem • AA helps to show that alcoholics can recover

33. More on AA and Treatment • Bill Wilson testified at the first hearing of the Special Sub-committee on Alcoholism and Narcotics held in Washington, DC, July 30, 1969. He stated that AA should not be used as treatment model when asked for his opinion.

34. When Treatment entered AA... • AA became the only way to recover • Recovery became possible only with God or a Higher Power • Recovery came to mean that you were working the Steps of AA • Use of medications was forbidden • Science became suspect including therapy

35. Putting the HR back in AA: Coming together kicking & screaming

36. Attracts v promotes Courage Faith Happiness Serenity Service Trust Hope Forgiveness Gratitude Honesty Humility Open-mindedness Responsibility Love Surrender The Real AA… …just like HR

37. The Real AA also… • Suggests the use of professional help • States one may need medication to support recovery (see next slide) • Doesn’t concern itself with controversy or other outside issues (Tradition 10 )

38. AA & Meds • No AA member plays doctor including psychiatrist(from “The AA member-Medications & other Drugs” pamphlet) • Some drugs have legitimate value and are beneficial when administered by …physicians….we are certainly not qualified to recommend any medications. Nor are we qualified to advise anyone not to take a prescribed medication.” Living Sober, p53 • “…some Higher Power must necessarily [restore us to sanity] if we were to survive.” (Twelve Steps & Twelve Traditions, p?) • Couldn't this also mean medication??

39. Lastly, HOW AA works: Honesty Openmindedness & Willingness

40. Part III: Change, the Easy Part Perspectives….

42. Changing Paradigms Moving from Henry Ford to Bill Miller

44. Our job is not to talk [consumers] out of the woods but to help [consumers] talk themselves out of the woods. • Bill Miller, 2007 • Author, Motivational Interviewing

45. What Do we Know about Change? Change is not pretty! Change is usually better in baby steps Change isn’t linear

46. “Angels in America,” Tony Kushner • Harper: “How do people change?” • Mormon Mother: “Well it has something to do with God so it's not very nice. God splits the skin with a jagged thumbnail from throat to belly and then plunges a huge filthy hand in, he grabs hold of your bloody tubes and they slip to evade his grasp but he squeezes hard, he insists, he pulls and pulls till all your innards are yanked out and the pain! We can't even talk about that. And then he stuffs them back, dirty, tangled and torn. It's up to you to do the stitching.” Harper: “And then up you get. And walk around.”Mormon Mother: “Just mangled guts pretending.”Mormon Mother: “That's how people change.”

47. Acting as if…. Where are you on the Road of Change? And what would get you to the next stage?

49. Culture Shock Redux • Culture change is just like personal change • How do we help our culture(s) become more ready, willing, able to come to “compassionate pragmatism” esp with drug policies • How do we engage and motivate? • What SOC are agencies in? Policymakers? • What are we teaching about HR? • Are colleges teaching appropriate HR concepts?

50. So how do we Change & move forward? • Get active • Become a radical listener to the “other side” • Change name? • Advocate policy change in your agency • Remember, HR is pro-change • Talk about personal responsibility • Know 12-Step & its history • Be open to it as option • Promote abstinence equally as non-abstinence