Harm Reduction: A Model For Social Work Practice With Adolescents

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 reduction approach seeks to meet clients where they are, establish rapport and help them modify or give up their risk-taking behavior. This article presents 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 Northern Iowa, Cedar Falls, Iowa 50614 (E-mail: [email protected]). 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 clientsintomethadone maintenance and needle exchange programs; giving women returning to their battering husbands a safety plan for self protection; and an after-school program to help gays and lesbians “talk through” problems of internalized homophobia that might otherwise seek self-destructive 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 online 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. Exceptions are Abbott (2000) and van Wormer and Davis (2002). Abbott provides 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 reduction 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: Implications for Social Work Education”by McNeece (2003). I believe, indirectly, the empirical research in the federally funded Project Match (1997) which confirmed the effectiveness of a variety of treatment approaches 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 consensus 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 thepre20 THE SOCIAL POLICY JOURNAL Page 3 vention of alcohol, tobacco, and other drug problems and harm reduction strategies aimed at persons affected by such problems. In this article 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 areas of social work for which the harm reduction model has special relevance. Emphasis will be on adolescent risk taking in the areas of sexuality 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 opposes 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 criminalization 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 generated 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 Baltimore and Seattle have moved in the direction of such progressive policies. Because harm reduction measures are diversified and highly pragmatic (as opposed to moralistic), scientific research plays a key role in convincing legislators and other policymakers to sponsor the establishment 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 government’s reluctance to publicly endorse non-abstinence based programs for youth, there is much grant money available for experimental

treatments, as, for example, the Cannabis Youth Treatment Series described at the National Clearinghouse for Alcohol and Drug Information and unveiled by the Substance Abuse Mental Health Services Administration (SAMSHA, 2000). This series compared traditional with alternative approaches, including motivational therapy, in which clients, 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 reduction, note that in the research literature today, the measure of treatment success relevant to substance misuse is a reduction in use and in harmful consequences;the traditional measure was always complete abstinence 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 strengthsbased approaches to help people help themselves by moving steadily in the direction of reduction of high-risk practices. As practice, harm reduction entails removing barriers such as lack of childcare or bureaucratic constraints that impede people from getting treatment. Typical advice given to clients is of the order of, “Don’t drink on an empty stomach,”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 “antisocial”and“borderline”in mental health,“criminal personality”in criminal justice, and“alcoholic/addict”in substance abuse treatment is avoided; clients provide the definition of the situation as they see it. The traditional message imparted to kids, such as in educational programs, is the total and immediate abstinence from all dangerous, risk-taking activities such as no sex before marriage and don’t drink until you’re 21. Peterson, Dimeff, Topert, Stern, and Gorman(1998) warn against the“boomerang” 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 different 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 tolerance in the schools–such practices commonly supported by the American 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 experience, in the foundation laid down by the colony of religious zealots in Massachusetts Bay. The essence of this foundation was the holy experiment known to the world as Puritanism. In his classic, Wayward Puritans: 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 baffling. 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 destiny. Sooner or later persons would give evidence of the category to which they belonged. Those who had reason to fear the worst would inevitably 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 society 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.Theuniqueness of this history is important because many of the differences between Old and New World attitudesconcerning drug use and work ethic have their origins in these humble beginnings. Sexual prudery and enforced 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 separation. 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–provides mandatory alcohol and drug treatment and a continuum of community services to ensure compliance with its two-year program. Education, 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). Addiction 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 between 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-taking behavior of youth. Drinking, drug experimentation, sexual expression–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 sexuality. She advocated teaching young people in school sex education classes about the risks of unprotected sex and giving them ways to reduce these risks. A public uproar ensued, and Elder’s remarks ultimatelyresultedinher dismissal(Petersonetal.,1998). Official government 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 abstinence as an important option, but also provides information to reduce the risk of AIDS, venereal disease, and unplanned pregnancy. In Amsterdam 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 environment and to keep an eye on children in need of help. The situation regarding 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 community 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 increase the risks for harmful experimentation. Prevention of early childhood abuse and trauma is key to prevention of the development of the kind of substance misuse that relates to affect-use of chemicals to counteract 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 welfare 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 coordination of efforts across national and local bodies; these bodies include education, 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 reduction gets the seal of approval. The aim of all these efforts is to help children get through adolescence relatively unscathed, and to prevent experimentation with substances, the use of which carries the potential for personal destructiveness down the road. Many of the developmental changes that are necessary prerequisites for becoming healthy adults unfortunately increase an adolescent’s risk of smoking, drinking heavily, or using drugs (Botvin and Botvin, 1997). Primary prevention efforts can be divided into seven general strategies: • Child protection aimed at the cycle of violence and substance misuse; • School-based prevention programs directed toward social influences prompting youths to smoke; • Information dissemination approaches focusing on immediate consequences of smoking (bad breath, breathing problems); • School programs based on dialoguing with youth to answer questions 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, tobacco, 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 socialworkers 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 youngsters not to drink until they reach 21, then suddenly to become responsible drinkers is unrealistic (Boroson, 1993). Information based on ideology 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, growing rates of HIV infection, and risk of lethal overdose among teens, and especially marginalized teens, harm reduction holds the maximum potential 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 excitement who are striving to be “cool.” These youth are most likely to be responsive 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 another 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 impact. 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 emotionally 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 treatment 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 combination with other approaches emerged as having the most effective impact on substance use behavior. These approaches, as Botvin and Botvin indicate, 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 empirical research with first-year college students in helping them moderate their drinking through brief motivational counseling sessions, reported 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 reportedly 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 motivated to make a health-seeking choice. The focus thus becomes the client’s motivation. Motivational interviewing (MI) is a non-confrontational 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 Rollnick (1991), MI, in its basic formulation and precepts, closely parallels the strengths perspective of social work practice (van Wormer and Davis, 2003). The strengths approach, as Saleebey (2002) suggests, is “a versatile practice approach, relying heavily on ingenuity and creativity, the courage 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 important 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 relationship between therapist and client. In working with youth, this relationship 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 principle 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 assesses the level of the client’s motivation for change and, instead of engaging in a tug of war with the client, “rolls with resistance.” MI techniques 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 reduction meets the youth where the youthis and is disarmingly nonthreatening. 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 ambivalence is expected and, in fact, deemed healthy. Central to the whole framework is the belief that clients are amenable to change. This optimism closely parallels Saleebey’s notions of “promise and possibility” (2002, p. 15). MI therapists draw on the stages of change model, originally formulated 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 following 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 sometime 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 appropriate for social work because it is compatible with the mission and concepts 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 motivational 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 direction 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 between 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-orleave-it” manner. Typical questions are, “What do you get out of drinking?” “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 enhancement. 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 needle exchange programs, are controversial and under funded. Programs for teens such as DanceSafe, which tests Ecstasy pills for toxic substances for youths attending raves to ensure their safety before youths consume them, are privately funded and operated by volunteers. Recently passed legislation, however, threatens persons helping in any capacity at raves with arrest. In Canada, Youthlink Inner City serves the hard-to-reach and alienated 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, describes 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 decision-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 empiricallybased 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 policies 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 broadened 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 firsthand of harm reduction in their coursework in addictions at the University 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 prevention and treatment before the problems have grown severe. One program in Iowa that has been well received is the Strengthening Families Program. This program, when introduced in Iowa, has significantly delayed 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 persist 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 issues 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, programscanbeimplementedincollaborationwithteachers 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 individualized 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 centeredness, 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 families, especially African American and Latino families, who lose their loved ones to the criminal justice system; and to society through providing 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 counseling intervention would be geared toward community prevention work and early treatment of drug users to monitor their use and life style. Because the “abstinence-only” model emphasizes treatment after the drug dependent person has “hit his or her bottom,” an opportunity to introduce 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 significant number of people out there. I’m thinking especially of adolescents 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, tobacco, 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 reduction: 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 historical 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 center 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 behaviors (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 education. 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 edition (pp. 20-27). Washington, DC: NASW Press. National Institute on Alcohol Abuse and Alcoholism (2003, April). Underage drinking: 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: Authorities abandon faith in prohibition and enhance “harm reduction.” Newsweek, 20. Prochaska, J. and DiClemente, C. (1992). In search of how people change: Applications 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. Alcohol 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 enhancement 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 Strategy: 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), 3548. 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/