Harm Reduction

Transcript:

Cassie Gillespie (00:03):

Welcome to the field. A podcast of targeted trainings for child welfare professionals. I’m Cassie Gillespie. Join us as we chat with local experts about topics that are pertinent to child welfare in Vermont.

Tabitha Moore (00:15):

So good morning or good afternoon, depending on when you chose to press play. I’m Tabitha Moore and I will be your host for today’s episode on harm reduction. I’m excited to introduce you to today’s guest, Dr. Aaron Steward, Dr. Steward is the Chief of Psychology at the University of Vermont Health Network for the Champlain Valley Physicians Hospital. Welcome Aron.

Dr. Aron Steward (00:35):

Thanks Tabitha.

Tabitha Moore (00:36):

I’m so glad that you’ve joined us today to talk about harm reduction. Thank you for being here. So let’s start off with the basics. What is harm reduction?

Dr. Aron Steward (00:45):

Yeah, so harm reduction is a set of principles and guidelines that we perceive risk or, people that have risk. We perceive them in a different way. A harm reduction model is the way we perceive our cases so that we can reduce risk.

Tabitha Moore (01:06):

Okay. And you mentioned principals, can you go into that a little bit? Tell some of the principals?

Dr. Aron Steward (01:11):

Sure. And the, the other thing that I think is important when you’re starting to learn about harm reduction is that it’s a shift in perspective and mentality. So we have always perceived risk in the psychological field as something we need to act on and harm reduction gives us the tools that we need to help our consumer or our child or our caseload. We give them tools so that they can then empower themselves, to reduce their own risk. So it’s, it’s a perception or a mentality that we approach a case with so that we don’t believe that we have to do to them, that we rather can help them do to themselves what they want to do to make the life that they want to live. So, harm reduction helps us to promote healing and to promote change, but not by forcing somebody to do that rather by asking them to make the choice to do it and then giving them the tools to do it.

Dr. Aron Steward (02:19):

So just contextually, this came about in the substance abuse world in the 1980s, where people started determining that the models that we were using to enact change on someone else wasn’t creating lasting change, and it wasn’t creating change that was feeling comfortable. It was mandated change, which we know too from the literature and the research does not stick something that’s forced and mandated. We know doesn’t help people change their lives for good. It helps people comply. It gets compliance for a short period of time. And so harm reduction came about in the substance abuse literature, because what we were finding is that people weren’t staying in recovery and weren’t staying clean and sober for any length of time, if they were forced to do so. And so the harm reduction model was a public health strategy that was developed initially for adults with substance use.

Dr. Aron Steward (03:26):

And it has grown over time to include risky behavior reduction. We’ve enacted it using operating motor vehicles under the influence reduction, teen pregnancy reduction, drug and alcohol use production, cutting reduction, all of those risky behaviors that were so hard to treat by mandating people to stop. When we apply the harm reduction model, it is a much more lasting and much more comfortable to the people that we’re helping because we empower them to do so. So I’ll just tell you a little bit about the principles. The principles initially in the eighties were that the harm reduction professional accepts that illicit and licit drug use is part of our world. And we attempt to minimize it’s negative impact rather than forcing people into abstinence. So it’s a recognition that drugs exist and that people will use them rather than trying to get to a model where there will be no more drugs because when we perceive drug and alcohol usage in that way, what we do is push it underground, which is what we do to risk behavior.

Dr. Aron Steward (04:39):

When we mandate compliance is we just teach people to get better at secreting their risk rather than reducing their risk. So the first principle of harm reduction is that we agree that the risky behavior exists and that we want to reduce it rather than abstain from it. The second is that we understand that risky behavior and specifically substance use and substance abuse is complicated. It’s a multifaceted behavior that has many, many, many, many components, which add up to risk. It’s not a simple equation whereby I approach somebody who has substance abuse problems, and I tell them to stop and they stop. That’s not how risk works people don’t self-harm because it’s a simple equation. They self-harm because they been living in complicated neglectful and abusive environments with histories of generational, substance abuse and generational mental illness and generational poverty and generational oppression. They cut because of that.

Dr. Aron Steward (05:43):

And so the response can not be simple. It has to be complicated and creative. So that’s the second principle. The third is that it establishes quality of individual and community life of wellbeing, meaning it’s a holistic, approach not a one to one approach or a system on person approach. It’s a holistic approach where we value that people desire humanity and personal value and recognition. And that, that is the approach to healing that people need community, they need connection. They need relationship in order to heal. And that a simple manualized based treatment will never work in a lasting way for recovery and healing. The fourth principle is that it ensures the person that is experiencing risk have a real voice in their healing and recovery. Again, harm reduction is not, I will enact something on you. It is that I will take you as my partner and ask your opinion on how you need to heal.

Dr. Aron Steward (06:53):

And that is the plan that we will build. And as we go through this podcast and discussion, what I hope you will hear over and over is that the first stage in building a harm reduction plan is asking the person who’s engaging in risky behavior. Why and how, and how much and when, and all of those important questions so that they can build their own recovery model. Another principle is that because the person who’s engaging in risk is the major piece of the puzzle we have to center them in their healing, they have to be the center of the harm reduction plan. Harm reduction recognizes as a next principle, that realities of poverty, class racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect people’s vulnerability and encourage them to engage in risk. These societal unfairness’s that we continue to propagate continue to breed risk.

Dr. Aron Steward (08:03):

And so without understanding that, and without that being a principle of harm reduction, we miss the main reasons why oppressed populations and people of minority status and people vulnerability engage in risky behavior. And we just tell them that they should have more willpower and we just try to force them to be safer. And it’s just not an accurate or true story that people with willpower are safer. It’s a true story that people that have been harmed and hurt the most often harm and hurt other people. And we have to understand that the last principle that I think is really, really important is that harm reduction does not attempt to minimize trauma or tragedy in healing and recovery. It centers trauma or tragedy, and oppression when you are building a safety plan with somebody so that they can feel validated and cared for and recognize as the first step in their recovery. Those are the principals to have is that, and they are certainly wordy and complex, and they will require people approaching harm reduction to ponder and get with themselves about how they feel about recovery and how they feel about trauma and oppression.

Tabitha Moore (09:24):

Yeah. I mean, everything you said there was so powerful and it really was a massive shift in the way that people practice whether it’s substance abuse treatment, or we’re talking about child welfare here today. I just want to make sure that I reiterate some of the more powerful points that I just heard you saying. And I heard that harm reduction is a lens. It’s not an intervention, it’s holistic, it’s empathetic client or patient centered. You’re really meeting people where they are and you’re doing it with rather than two or for. And I really appreciate the emphasis on the cultural context and the fact that issues of oppression play into how people end up harming themselves. Because I think it’s really easy for people to forget, especially people who are in majority positions, or maybe don’t struggle with these sorts of things to not understand why folks do these things, or have these sorts of behaviors. And the last piece that you mentioned. And I really hope that you can kind of go into it a bit was, it sounds like it’s really trauma informed. Could you talk a little bit more about the relationship between trauma and harm reduction?

Dr. Aron Steward (10:36):

Sure. when I was a baby psychologist, I would often ask people to teach me tools to do to people because when I was coming through graduate school, the major learning that they were giving me was that I was going to go out and be an expert, and that I was going to go out and have the answers for teaching people, how to live the lives that they want to live. And when I came into the prisons and jails, I learned really, really clearly that there’s no difference between me and somebody who is an inmate. It’s just that they got less lucky in the deck of cards that they got dealt and they got caught. So that was the only difference. There is no difference in humanity or integrity or values in the majority of the population. And so I have worked really, really hard to learn from mentors and experts about how to overlay principles and guidelines rather than to force tools or tricks on people of how to change their lives.

Dr. Aron Steward (11:44):

And so harm reduction and restorative justice, both of those models I originally approached with, what can you give me to do to people? And both of those models have become intertwined in the way that I perceive the world, which is that people have free, will they have the ability to make decisions about how they want to live life and that rather than an expert, I just get the chance and I’m honored to have this, to walk alongside people while they make choices about how they want to live. And I can, I can perceive them in a way that heals them rather than I can treat them in a way that heals them. And so this is a really important paradigm shift that has occurred with harm reduction in the eighties and restorative justice, even more recently in Vermont where we walk alongside folks that have had very, very difficult and challenging and traumatic lives.

Dr. Aron Steward (12:47):

And we treat them in a trauma informed way. And by trauma informed for me, my definition is I assume that everybody that I’m working with has had substantial trauma and I treat them in that manner. And by treat them, I don’t mean I treat them psychologically. I mean, I treat them as a counterpart to their life experience. I am with them as though they’ve had substantial trauma and harm reduction takes into account that the people that are most harmful and most hurtful have been most harmed and most hurt. And that challenges the way we perceive dangerous and violent people, because we’ve been told for a long time that they are dangerous and violent because they so choose to be, or they’ve been taught to be, and they enjoy that behavior or that, that is who people are. And my experience has been that all people can be dangerous and violent if they have to, in order to survive.

Dr. Aron Steward (13:48):

And that those patterns of behavior become risky and dangerous and maladaptive behaviors. So yes, 100% trauma informed in that in order to apply harm reduction, to cases that are risky, we have to believe that they are good on the inside and that they have been hurt and harmed, and we have to undo that hurt and harm. And I have said many, many, many, many times that relationships and people hurt and harm others and that relationships and people are what heal others and harm reduction and restorative justice are those practices and principles that we overlay in order to help people rise up on their own.

Tabitha Moore (14:27):

So what does that mean for folks doing child welfare work? What does, what does harm reduction look like in the field and, and how do people shift to this way of thinking? I mean, I think about the number of child welfare workers who’ve seen parents either relapsing with drug or alcohol addiction or in terms of some of the harmful behaviors that they’re doing to their children. What does it mean for workers?

Dr. Aron Steward (14:51):

Yeah, so the first thing that I think it means is that we have to get ahold of our own feelings and judgment about other people’s life trajectory. So one thing that I’ve said so many times across the state is that opiate relapse from the numbers looks like somewhere between seven and 11 times people relapse trafficking looks like somewhere between 11 and 14 times people go back into the lifestyle. And so if we are harboring a substantial amount of judgment about relapse and not having the perspective that relapse is a part of recovery is the next step in your recovery is to relapse and then regain your sobriety. That is not about how many times you fall down. It’s about how many times you get back up and the way that you get back up and shortening the duration of use. If we don’t have that perspective, we can get to a place where we are burned out and frustrated by relapse and risk.

Dr. Aron Steward (15:53):

And if we don’t handle our own judgment and our own feelings about the fact that it is not an us and them thing, where we are clean and sober, and the people we serve are not, that is not a true story that we tell ourselves. The true story is that right now in our life, maybe we’re not using. And that right now in their life, maybe they are using right now in our life maybe we’re not cutting right now in our life. Maybe they are cutting right now in our life. We’re not domestically violating against other people, but right now in their life, maybe they are, this is a phase thing. This is a trauma thing rather than a, I’m a better human than another person. And so what it means for DCF workers who apply harm reduction is that it means that we have to be doing our own therapy.

Dr. Aron Steward (16:40):

We have to be inserting pleasure and joy into our own lives. We have to be caring for our own mental health and wellness so that we can approach risk as it actually is, which is that it is risk rather than choice. And so if we can do that in our mind, we can switch our mentality, we can switch our perspective, we can switch our humanity and turn it back on so that all of us have need for humanity, integrity and trauma informed care. We can approach these cases in a much more calm, focused, disciplined way rather than an emotional or risk prevention way.

Tabitha Moore (17:25):

So two of the things that I heard very clearly from you one was about self-examination this idea that we need to understand our own values and our, maybe our biases, definitely our biases and how that impacts how we see the people we work with and how much patience that creates or empathy, going back to one of the earlier principles that we have for them. And then the other thing that you mentioned was this concept essentially that behavior is fluid and changeable, and it’s not a matter of static identity. Like I am not a drug abuser, you know, it’s not part of who I am and you are versus this is something that’s happening right now that these things could potentially change. We don’t know what the future holds. And that really sounds like it creates a sense of humility. And dare I say, cultural humility.

Dr. Aron Steward (18:17):

Yeah. So, so I’m really glad you summarized it in that way. The first thing is that the fluidity of behavior, if I did not believe in that, I would not be able to come to work and work with violent and aggressive and persistently and chronically mentally ill folks, because I would not have any hope. I have a substantial amount of hope because I’ve seen people recover from absolute tragedy and absolute atrocity that should have killed them from the amount of pain, the excruciating amount of pain, but with a harm reduction model, where you take it step by step by step and reduce it rather than stop it. Our brains and bodies are built in a way where we can take bite size change in a far more systematic way than we can take a requirement that we must abstain or stop from something. And we all know that we all know that from our own personal lives, the humanity in this is that we all already know this for ourselves, is that when you give somebody a bite size change, they can approach it and address it in a far more calm manner.

Dr. Aron Steward (19:29):

That’s why we break down goals and objectives. So yes, behavior is incredibly fluid and it has to do with the environment that you’re in and how you feel at that moment. The second thing is regarding self-reflection in a harm reduction model. The first step of that self-reflection is to be honest and true to yourself about what you are judgmental and biased about, and to address that and to put accommodation in for yourself and to figure out a supervision and consultation plan where you are not up against something that you are requiring somebody to comply with, because what we know is compliance doesn’t stick. And so we have to deal with ourselves and figure out our own needs and wants. So, for example, before I had children, I often worked with people that had dangerous sexualized behaviors and their target population of interest was children.

Dr. Aron Steward (20:24):

And after having children I am in constant state of self-reflection, both in my own personal therapy, but also as part of my daily practice of mindfulness is how am I doing, what are my tender spots? What am I struggling with? What am I judgmental about? What am I biased about? And I’ve had an increasingly hard time working with people that have sexualized behaviors toward young children. And so part of my harm reduction model that I apply to myself in, on behalf of my clients is it, if I get a case where I’m asked to build a harm reduction plan or a treatment plan for somebody who has dangerous sexualized behaviors towards zero to three year old’s, I asked somebody else to take that case because I am not currently capable of being as nonjudgmental as human, as kind as I want to be and where I need to be for their own healing. And that involves honesty. And it’s a good practice because harm reduction also involves a substantial amount of transparency and honesty for the people that you’re serving. And there are moments in time where we cannot serve everyone and be everything to everyone. And that’s part of the model.

Tabitha Moore (21:40):

I think that’s such a critical and powerful point, and I’m so glad that you’re giving a personal example. I think sometimes we don’t think of ourselves. You know, a lot of folks think that, we don’t think about ourselves in these contexts. And so it’s really nice to have you provide that level of vulnerability for our listeners. My wonder to you is, and I can almost hear folks in the, in the workforce saying this, what about when we can’t transfer cases? What about when we have to, no matter what this is a case we have to deal with. And I know both of us have had situations like this, I’m really excited to hear what you, what you say, what about when you know what your personal values and biases are. And another reason I’m so glad to hear you say it is because a lot of times people have this mentality that it’s about being not biased rather than understanding and working with them. So what do you say to the workforce? So the people who have cases where it is so personally painful or difficult for them, how do they mitigate, or how do they deal with that?

Dr. Aron Steward (22:41):

Yeah, that’s a really great question. And I supervise a lot of people. And so this often comes up and it comes up for me too, because in locked units, I can’t always stop working with people that trigger my tender spots. Sometimes I can, but sometimes I can’t. And it’s important to self-reflect and also know that there will be times where you have to, or I have to work with and build a harm reduction model for someone who even being near them and hearing the traumas that they are putting on. Other people is incredibly triggering and traumatizing. And so how do we care for ourselves when we have to do that? And I would say it’s a concoction of three things. The first two are important with harm reduction, generally speaking, and I’m glad we’re getting to them. Two of the most important tools for doing harm reduction plans well are one how you document and two how you gain supervision and consultation.

Dr. Aron Steward (23:43):

We cannot do harm reduction in systems with policies and procedures up the wazoo, unless we are documenting well and getting supervision and consultation, we will run into a brick wall where somebody says, you can’t build that plan. You can’t be that creative. You can’t give that much leeway toward risk. You’re encouraging risk. People will say that. And the answer to those statements are, if I document well and I get supervision and consultation, then I can build these harm reduction plans, and I can do it in a way where we will reduce risk, not mitigate risk. And so my first answer to your question is when you’re up against the case, or a human, that really hurts you by working with them, that we have to get really good at nonjudgmental documentation. And we have to get really good at reaching out for supervision and consultation.

Dr. Aron Steward (24:37):

And I do both of those when I’m working with people that I feel like are really painful and hurtful to work with. And the third is that I engage in my own personal therapy, and that is formalized therapy. What people think of when they hear the word therapy as weekly talk therapy, but it is also a self-care plan that is therapeutic for me, that I engage in every single week. And that is I listen to the music that makes me feel good. I listened to the podcast that made me feel good. I play with my kids, and that makes me feel good. I get outside. And that makes me feel good. There is a therapy and a therapeutic experience of self care that we have to engage in when we’re dealing with people that have extreme risk. And when you’re dealing with risky people, they’re going to engage in risk.

Dr. Aron Steward (25:27):

That is part of the world that we live in. And it’s part of the, the field that we work in. And so we have to validate that for our brain and bodies, our brain and bodies need to hear us say, this is a risky job. It is risky for my mental health and risky for myself care. And I am going to actively engage in a harm reduction model for myself of therapy and therapeutic experiences, to bring down that level of emotion and level of trauma. And so I am a huge proponent of giving my employees and my supervisees, the opportunity to engage in therapy, whatever that means for them, so that they can deal with their feelings and re-engage in those cases. And to land that just really quickly for you I will use another personal example that I cannot get away from.

Dr. Aron Steward (26:18):

And that is that in my personal life. I experience a lot of familial oppression and racism. And I also work with in the North country in Plattsburgh, a substantial amount of people that are actively and honestly, and poignantly racist. And it is very difficult to get away from it. And it is true in Vermont as well that I intercept a lot of people that are very, very racist, and it happens all the time in my personal life is very painful and tender, and I can’t get away from it nor do I want to. I want to engage in that work. And so in order to do that, I have to self-care in order to take care of myself. So that’s an example of something that I wouldn’t get away from because I don’t want to. And I can’t.

Tabitha Moore (27:08):

That’s great. Thank you, Aron. You started talking about a harm reduction model. Do you want to go into that a little bit more?

Dr. Aron Steward (27:19):

So a harm reduction model is if we use all of those principles that I went through at the very beginning, whereby the person that we’re trying to help is centered in the plan and their own way of living or the desire that they have, or the way they live is centered in the plan that we validate that risk is a part of this world and that risk doesn’t stop. It just decreases. If we sent her all of those principles, then when we build a harm reduction plan, we are looking for a decrease in risky behavior rather than a stop. And so we have to build goals and objectives with the person that makes sense to them, that they’re engaged in that they have their own voice in, and that are simply a D amplification of risk, rather than I’m telling you, you have to stop.

Dr. Aron Steward (28:10):

And so that looks all different in all different cases and in all different risk behaviors, but I’ll give an example. There are many, many times that I’ve worked with an active self-harmer where we’ve built a harm reduction model that they have to cut with clean blades. They can only cut to certain levels of depth, and they can only cut after they tell somebody that they’re going to, and to many of you’s ears, probably that sounds like I’m condoning cutting behavior. It sounds like I’m encouraging cutting behavior, but what I’m doing is I’m putting safety mechanisms around cutting behavior to reduce the risk of disease transmission, of bleeding excessively, of infection, of, of sharing methods of cutting of contagion. I’m trying to reduce all of those really serious risk behaviors that come along with risk. And so that’s an example of a harm reduction application.

Dr. Aron Steward (29:20):

And we are really well versed in knowing how harm reduction helped in teen pregnancy, because we started talking in middle schools about ways to keep yourself safe rather than abstinence and the numbers don’t lie. So when all of those models came out, we saw a drastic reduction teen pregnancies, except in the state, in the States, they were practicing abstinence teaching. And so it is important to know that these models work, but you have to finagle and be outside the box and creative when you’re thinking about what you can do to reduce harm.

Tabitha Moore (30:00):

And it sounds like it starts with what is my perspective on this? What are my beliefs and my values in that example, like about sexual education and people under the age of 18, and then how does that influence the kinds of things I say and do with people? And is that actually useful? Is it actually going to reduce harm or is it going to drive the behavior underground, as you said?

Dr. Aron Steward (30:24):

Yep, that’s correct. And I’ll give you another couple of examples that maybe land for people. So we had a group of folks trafficking perpetrators in Chittenden County that had survivors and victims trained that the only person that could inject them with their opiates was the trafficker. And so we engaged in a harm reduction model of teaching human trafficking survivors, and victims, how to inject their own opiates. And it sounds wild and crazy to somebody who believes in abstinence, but what it did is empowered them to be less controlled by their risk. And one of my favorite harm reduction models has been to advise people that we want to know more when they’re on run, rather than we want them to stop running away. We want you to stop running away. We know they’re going to run the principle of harm reduction is that they are going to run. And so the harm reduction model is that we want them to be in more contact when they’re on run. We want them to check in and the first 24 hours, we want them to tell us where they are. We want them to tell us how they’re taking care of themselves when they’re on run, rather than telling them that they can never run away.

Tabitha Moore (31:47):

Right. Essentially validating the reality of the situation. And essentially what is our relative powerlessness to force them into decision making.

Dr. Aron Steward (31:58):

That’s right. That’s right. And when I take people with me to engage with people that are in crisis newbies rookies that are just learning the language of harm reduction without fail after an intervention, I debrief with them and they always say to me, I could not believe that you gave that person permission to run or cut or use or all of those things. And we always engage in a conversation of, I’m not giving them permission. I just know they’re going to do it. So I’m building credibility with myself, knowing that they are going to engage in those behaviors. And they trust me more for knowing that I understand the pattern of risk and the pattern of relapse.

Tabitha Moore (32:46):

It reminds me of my parents are coming into my head. My dad always used to say to us, if you can’t be good, be careful. And it’s kind of, you know, it’s kind of along those lines. I have respect for that. So I know we’re running out of time, Aron. Just thinking about, how we learn and, I don’t know where people are listening to this. It might be in their car. Maybe their kids are in a screaming in the background. I also know that with learning, we tend to forget most of what we learned, but if there are two or three key concepts or ideas that you want to sear into people’s minds, if they’re going to forget everything else, what are the two or three big concepts in harm reduction that you want our listeners to be inspired by? And just remember, especially those folks who are going to be joining us later. I think we’re in June for our online learning follow up to this. So what are the two or three key concepts that people should keep in mind?

Dr. Aron Steward (33:44):

The first concept that I want people to keep in mind is that harm reduction plans work to reduce risk over time. And the second is that in order to make them work, you have to document and consult very, very well. You have to get those chops going in terms of consultation and, and get your documentation going. And the third is in order to deal with being the person that holds the accountability for a harm reduction plan, you have to take care of yourself. And that involves therapeutic experiences outside of the harm reduction experience. And so those are the things I would want you to know. And there’s a lot of information out there for people that want to know more.

Tabitha Moore (34:28):

And where would they go to get those things?

Dr. Aron Steward (34:31):

Yeah. So if you want to know about the components of harm reduction, I encourage people to learn more about motivational interviewing. And I also encourage people to learn more about the stages of change by Prochaska and DiClemente. So there’s a model about the stages of change and readiness for change. And if you learn that and you learn motivational interviewing, you have a good platform for preparing your body and your brain for building harm reduction models as a first thing. The second is that there’s a lot of groups and coalitions and conferences and empirically validated research articles, mostly on substance abuse on harm reduction that you can dive deeply and nerd out online. If you want to learn more about those things and attend the conferences, SAMHSA, the federal mental health administration has some good research articles on harm reduction as drug and alcohol reduction plans. And there’s some good tobacco articles as well. So if you want to learn more, there’s a lot of stuff online. And maybe you won’t be surprised, but other countries have engaged in some systemic harm reduction models that are really interesting. So on the Scandinavian countries and the European countries, Canada has some, and every country has chosen a different sort of harm reduction tactic for a different risk. So you can research some of those too.

Tabitha Moore (35:59):

That’s great. Thank you so much, Dr. Aron Steward. Thanks for joining us today to talk about harm reduction in the field of child welfare. We appreciate both your expertise and the work that you do every day. This has been an episode of Welcome to the Field with the Vermont Child Welfare Training Partnership. If you found this podcast useful hop on over to our website, Vermont CWTP and check out some of our other podcast topics. Thanks for listening.

Cassie Gillespie (36:22):

If you have any ideas about topics that you want us to cover or episodes that you’re interested in hearing, shoot us a message. You can reach me by email at Cassie.Gillespie@uvm.edu, or you can leave us a comment on the web page where you downloaded this podcast. Welcome to the Field is produced by the Vermont Child Welfare Training Partnership and the State of Vermont and a special thank you to Brickdrop for composing and recording our music. See you next time!