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This allows the client to place their level of behavior on the continuum and assess the levels of risk associated with their behaviors. The continuum also allows the client to assess the ways in which their behaviors over time, by examining the ways in which their behaviors are now different to past behaviors. This may allow clients to recognize that they have already made some progress toward less harmful behaviors, or may allow them to identify specific events which led to developing more risky behaviors. The harm reduction model allows the client to assess their current situation and plan the actions which they wish to take to change their future behaviors.
Applications of the model
The harm reduction model has been applied predominantly to drug misuse issues, however it is also appropriate to apply the model for a wide range of social and health behavior changes. The model has been successfully used in many areas including weight loss, tobacco addiction and alcohol addiction. From the principals it is possible to develop appropriate, situation-specific continua for almost any client who wishes to change behavior and decrease potential harms.
Harm reduction has been found to be an effective tool in the treatment of alcohol addiction, due to the accessibility of the model. The model has been successfully used due to the methods by which it addresses problems related to alcohol abuse without requiring complete abstinence from an individual. Many of those who have failed on traditional abstinence programs such as those promoted by Alcoholics Anonymous have made some progress using harm reduction techniques. The techniques have been successful as they set a series of stepping stones which have been decided by the client themselves. This may lead to full abstinence at some future time, although that decision is left to the individual themselves and not imposed upon them (Witkiewitz and Marlatt, 2006).
Strengths and limitations
The main strength of the harm reduction model is in the way which the model can be applied in a non-discriminatory way to any area of the population. The underlying principles are based upon approaching the client in a nonjudgmental way, which should remove many of the prejudices which may be associated with other models. For example some of the groups who are most at risk of harm from substance abuse are those of ethnic minorities and low socio-economic status.
There main limitation to the model is that in order for the nonjudgmental principles of the approach to be achieved it is necessary for health professionals to remove any personal stigma or prejudice. There is no room in the harm reduction model for the personal opinions of the health care or social care professional to allow their personal feelings to become involved in the decisions made regarding treatment. This may be difficult for some professionals, particularly those who have worked for many years in an environment which has promoted other models. For example nurses who have worked in an environment in which they have been encouraged to urge patients to quit smoking may struggle to adapt to a framework in which it is not acceptable to enforce abstinence.
Harm reduction model and substance abuse
Harm reduction theories were first applied to substance abuse in the 1920s when a group of English doctors concluded that it may be necessary occasionally to maintain a person on drugs in order to help them lead a more productive life (Riley, 1998). The province of British Colombia in Canada became the first North American jurisdiction to adopt methadone maintenance as a form of harm reduction, with much of North America following in the 1960s (Griffin, 1998). When HIV infection became a serious threat for injecting drug users, harm reduction strategies became more comprehensive and more holistically based.
Harm reduction is quickly taking hold as an alternative to the moral model (exemplified by the ongoing "war on drugs") and the medical model (addiction defined as disease). These two models have long dominated U.S. drug policy and addiction treatment philosophy. Harm reduction is seen by advocates to be a middle path between the two polarized opposites of the medical and moral models. It promises to provide practical and humane assistance to drug users, their families and communities. Active drug users have provided much of the impetus for the development of harm reduction including their advocacy in the Netherlands 'needle exchange' programs which are designed to reduce the risk of HIV infection among drug users who would otherwise share potentially infected syringes. Critics of harm reduction reject it as being overly permissive in its rejection of strict 'zero-tolerance' policies and its promotion of alternatives to abstinence. Some have labeled it a 'front' for drug legalization (Marlatt, 1998: 2-3).
Basic principles of harm reduction in substance abuse
There are five basic principles which have been identified for harm reduction. It offers a practical alternative to the other models available which focuses on the consequences of harmful behaviors rather than the moral implications. Secondly, harm reduction accepts alternatives to complete abstinence such as needle exchange programs and methadone maintenance. Thirdly, harm reduction is based on consumer input and demand rather than a 'top-down' model, which makes drug users more receptive to the model. Harm reduction also supports low threshold access to treatment and a user-friendly approach. This reduces barriers to treatment and widens access. Lastly, harm reduction is based on compassionate pragmatism rather than on moral idealism (Marlatt, 1999). One of the major differences between harm reduction and other approaches toward substance abusers is that through the harm reduction model they are accepted as individuals who are capable of rational, informed choices. The harm reduction theory accepts that drug users will choose to reduce harm to both themselves and to society when given the knowledge and the opportunity to do so (Des Jarlais et al., 1993). The model does not attempt to either condone nor condemn drug use, but does respect it as a choice (Hilton et al., 2001).
Major guidelines and tools for assessment
The model of harm reduction fits with the Transtheoretical Model of Change, which has been proposed as model which reflects behavioral change in an individual. According to this model, the first stage in change is the precontemplative stage. At this stage, harm reduction strategies should provide a comprehensive assessment of behaviors in a nonjudgmental and supportive atmosphere. This is the stage at which the professional should begin to build a relationship of mutual trust and respect with the client to ensure that they remain approachable to the subject of change despite not having reached the decision to change at this stage. Assessment of the client's behaviors should be used at this stage to point out problems, raise doubts about behaviors and discuss positive aspects of change.
The second stage of change in the transtheoretical model is the contemplative stage, at which the client intends to change their behavior within the next six months. It is at this stage that the continuum of behaviors should be introduced to identify with the client their current risk of harm. This stage provides an opportunity to discuss the concept of a spectrum of options for change, allowing the client to make decisions about which areas of the continuum they feel capable of achieving under their current personal circumstances. At this point it is important that there is an emphasis on the client's rights to change their mind. There should be a thorough analysis of the risks and rewards of the current behaviors, and information should be provided to aid the client in achieving their goals.
The next stage in the transtheoretical model is the preparation stage, in which the client is seriously planning change in the next month. The most important factor of harm reduction at this stage is education and skills training specific to the behaviors that the client has identified as acceptable.
The fourth stage of the transtheoretical model is the action stage, during which the changes are implemented. Harm reduction plays an important role at this stage in supporting the change efforts and assisting the client with self-evaluation of the changes and progress which is being made towards the chosen goals. At this stage it may be necessary to alter the goals and strategies at the client's indication.
The penultimate stage of change is the maintenance stage, where the changed behavior has continued for at least six months. Harm reduction strategies continue to play an important role in supporting the changes which have occurred. As the client reaches goals and behaviors change, there should be a reintroduction of the continuum for the client to decide whether they wish to revise the plan and make further changes.
The final stage of the transtheoretical model is relapse, in which the client returns to their previous behaviors. This stage is not met by all, only those in which the process has broken down at some stage resulting in return to harmful behaviors. At this stage harm reduction has an important role in supporting…[continue]
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