When “Just Say No” is Not Enough: Teaching Harm Reduction

by Cayce Watson, MSSW, LAPSW

     Harm reduction is a strengths-based and client-centered helping strategy that is utilized in both prevention and practice models (Bigler, 2005). Although its roots are embedded in addictions treatment and public health, the principles of harm reduction can be readily observed in a variety of social work settings. Social work practitioners currently employ this perspective in the fields of social policy, domestic violence, community outreach, HIV education, and binge drinking prevention campaigns (Van Wormer & Davis, 2013).  Harm reduction can be applied across levels of practice and reveals the significance of both case and cause advocacy in social work.

     Social work education is designed to prepare eclectic practitioners and critical thinkers who utilize social work ethical principles to guide professional practice (CSWE, 2008 EPAS). Teaching harm reduction in the classroom often challenges social work students in evaluating their personal beliefs about clients, who have been dubbed "difficult" by the system of care. It also provides an opportunity for utilizing professional values to guide practice, redefines successful outcomes for clients, and explores the prevailing social and political stigma of vulnerable populations. Many students and practitioners feel this service option can blur the lines between granting approval for unhealthy behaviors and the prevention of further harm.

     The first step of teaching harm reduction is clarifying what it is not. It is not giving clients carte blanche to slip further into addiction and despair. It is working with clients by supporting autonomy, increasing options, and reducing risks.

     Traditionally, this perspective is defined as a series of practices geared toward ameliorating the social, legal, and medical consequences associated with high-risk addiction.  Practical examples include reducing infectious disease transmission, providing education on safer sex practices, preventing drug-related risks and overdose, offering agonist treatment for opiate users, and supporting rapid HIV testing (Van Wormer & Davis, 2013). Davis (2013) provides a broader definition and affirms, “Harm Reduction is a helping strategy that suggests the most pragmatic way to engage people in positive change is to focus on making risky behaviors less risky, without necessarily insisting that the behavior be changed” (pg. 1).

     The National Association of Social Workers also supports this approach.  In Social Work Speaks (as cited in A Social Work Perspective on Drug Policy Reform, 2013), harm reduction is listed among relevant treatment options that should be considered in addressing alcohol, tobacco, and other drug problems. Additionally, the 2013 NASW Standards for Social Work Practice with Clients with Substance Use Disorders maintains, “The harm reduction approach is consistent with the social work value of self-determination and ‘meeting the client where the client is’” (p. 7-8).

     Using harm reduction to explore social work’s professional value base provides students with a conceptual framework for values clarification and ambiguity recognition and tolerance in practice. Additionally, several parallels exist between social work practice and harm reduction, including championing social justice, supporting self-determination, and seeking strengths-based options amid adversity. Emphasizing collaboration with clients’ treatment goals, empowering at-risk individuals to be their own change agents, and viewing clients as the experts are essential to both. The value of dignity and worth is also paramount when working with vulnerable clients who have been socially and politically stigmatized. Often, social issues such as poverty, oppression, gender-based discrimination, racism, and availability of community resources can increase one’s risk for harm, as well as one’s ability to handle issues related to that harm (Harm Reduction Coalition, 2014).

     Bigler (2005) states:  Personhood stands above moral judgments regarding risky or socially negative behaviors. The worker keeps her/his own values in perspective and seeks humane solutions to difficult and perhaps even personally challenging problems. A person is not left to suffer simply because the experience, the disease, or the harm is a natural consequence of her/his own behavioral choices. (p. 76)

     Furthermore, shifting students’ focus to strengths by exploring clients’ interpersonal, social, and environmental possibilities also emphasizes dignity and worth and enables the subsequent empowerment of clients (Saleebey, 2000). A strengths-based focus includes defining success in the client’s own terms. A client who attempts to stop smoking and is able to reduce the number of cigarettes she smokes from 15 to 7, respectively, is successful. The ultimate goal may be to abstain from cigarettes entirely, but small steps warrant praise and recognition and can become the building blocks for sustainable change. Abstaining from the behavior becomes an option that the client pursues when ready. Choice and acknowledging readiness for change promote self-efficacy.  This can be applied to many behaviors clients hope to address. 

     While harm reduction and social work have much in common, this perspective is rarely included in courses outside addictions-related electives. A great deal can be learned by incorporating this content into both micro and macro level social work courses. Students can explore values clarification and ethical decision-making, the social and political barriers to effective social policy and prevention, and a deeper understanding of vulnerable populations. Student learning can be reinforced through experiential exercises designed to identify and process potential value conflicts and foster empathy. Some exercises that have worked in my courses include: simulating client grief and loss associated with behaviors related to addiction or other issues; brainstorming stereotypes and the shame and stigma associated with such labeling; and exploring connections between situations, feelings, and behaviors that often contribute to substance use and negative coping behaviors.

     Additional resources on Harm Reduction can be found at:

References

Bigler, M. (2005).  Harm Reduction as a Practice and Prevention Model for Social Work. Journal of Baccalaureate Social Work, 10 (2), 70-86.

Council on Social Work Education. (2008). Education Policy and Accreditation Standards. [PDF Document].  Retrieved from http://www.cswe.org/Accreditation/2008EPASDescription.aspx

Davis, D. (2013). Addictions and Substance Use, Health Care and Illness Harm Reduction. Encyclopedia of Social Work.  Retrieved from http://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-171?rskey=AjuaYA&result=1&q=harm%20reduction

Harm Reduction Coalition. (2014). Principles of Harm Reduction. http://harmreduction.org/about-us/principles-of-harm-reduction/

National Association of Social Workers. (2013). NASW Standards for Social Work Practice with Clients with Substance Use Disorders. [PDF Document]. Retrieved from http://www.socialworkers.org/practice/standards/naswatodstatndards.pdf

National Association of Social Workers. (2013). A Social Work Perspective on Drug Policy Reform Public Health Approach. [PDF Document]. Retrieved from http://www.naswdc.org/advocacy/DrugReformWP.pdf

Saleebey, D. (2000). Power in The People: Strengths and Hope. Advances in Social Work, 1 (2), 127-136.

Van Wormer, K., & Davis, D. R. (2013). Addiction Treatment: A strengths perspective. Thomson/Brooks/Cole.

Cayce Watson, MSSW, LAPSW, is a Licensed Advanced Practice Social Worker ​and has worked in the field of addiction as a social work practitioner and a research coordinator. ​Currently, she serves as an​ Assistant Professor and Field Coordinator in the Social Work Department at Lipscomb University in Nashville, Tennessee.