An episode of “Changing the Conversation” podcast
Kristin Dempsey and host Ali Hall discuss harm reduction strategies in a Motivational Interviewing context.
February 26, 2024
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Ali Hall, Host (00:05): Hello, and welcome to Changing the Conversation. I’m your host today, Ali Hall, joining you from San Francisco, California. Our topic is motivational interviewing and harm reduction. My guest today is Kristin Dempsey calling in today also from San Francisco, California. She’s a practicing licensed marriage and family therapist and licensed clinical counselor. She also provides consultation for clinicians in dialectical behavior therapy, trauma-informed care, and all kinds of other things, including motivational interviewing. Kristin is core faculty at the Wright Institute’s Counseling Psychology Program in Berkeley, California, and is lecturing faculty at San Francisco State University. Hi, Kristin, and welcome.
Kristin Dempsey, Guest (00:54): Hi, Ali. Thank you so much for having me back. I always enjoy being here.
Ali (00:57): Great to have. You have just published a book, and I love it, called The Harm Reduction Workbook for Addiction. What is this?
Kristin (01:09): Yeah, thanks, Ali. Well, it’s a workbook as it states in the title, and it’s a book that allows a reader to explore their own relationship with substances or behavior that maybe they’re challenged with, say something like gambling or shopping. And it allows people to go through from the beginning of exploring and being curious with themselves about the relationship to the behavior using the spirit and skills of motivational interviewing.
(01:39): So someone starts out just having a certain sense of what is going on for them, how do they feel about it, and then as they can move through the book, they can get to the end or maybe they actually take a step to change their behavior or maybe not, maybe they’re just continuing to explore that relationship, but it’s a place to get started.
Ali (02:01): Well, that’s fantastic, Kristin. And one of the things I found unique about the workbook is it uses the skills of MI as self-help that in this, the reader explores their own skills about journaling, self-reflection rather than having a conversation with a practitioner who is using MI skills. What is it that makes it different, this workbook experience as you’ve written it?
Kristin (02:26): Well, that’s true. That is really quite different. And how MI typically is used is us as trained practitioners will be the facilitators, will be the guides of a process that allows people to explore, potentially come up with their own change talk, and then we, of course, facilitate and help shape the change talk, which may or may not get to a place of planning around change. Here, the book is kind of the practitioner in a way, or really at least that guiding role is given to the text as opposed to any individual. So as someone’s going through, each chapter is meant to build on the chapter before.
(03:08): However, someone could always start just somewhere in the middle of the book and just start to learn something that might interest them. So for instance, in the beginning, I might just be exploring or thinking about some aspect of, “What is my concern? Do I have a concern?” And maybe I do that or maybe I just hop over to look at something around self-compassion because I have interest in self-compassion or maybe I’m interested in concepts around affirmation because that sounds like an interesting piece. So the reader has a lot of control in their exploration, which is unique and is definitely a different application of motivational interviewing.
Ali (03:49): So it’s not just guided by what the practitioner thinks is most helpful or the starting place. Really, the reader can pick and choose anywhere they want to start is perfect, so there’s that autonomy support piece of it. It also sounds super convenient for someone who would like to take a look at stuff, maybe think about stuff, maybe not, maybe doesn’t have access to a provider or may feel some shame or stigma about seeking professional support or maybe hasn’t had good experience with professional support if they’ve felt pushed around and told what to do in previous interactions. It sounds really ideal in a lot of ways.
Kristin (04:29): Yeah, thanks for that, Ali. I did actually think of a number of those issues when I put together the book and actually so did our editor. And I think at some point when I was writing it, maybe at a number of points when I was writing it, I would actually imagine possibly someone in a bookstore just wondering, looking at the shelves as people often do, looking at self-help. And maybe there is this place of, “I wonder. This is something I’m thinking about.” And it does allow for this quite accessible, very private, very individualized experience. Someone can just go and open and start to be curious. And I do think that the access, the great way to explore some of these issues is really shifted a great deal when it can be like this process. And we know there’s a lot of good that comes from journaling, especially journaling and recovery. So, yes, I think all of those pieces are really important in terms of access.
Ali (05:30): And what I’m hearing too, I think, in the field there’s really this distinction in harm reduction. There’s harm reduction, but also capital H, capital R harm reduction. For you, what’s the difference here and what aspect does this book address?
Kristin (05:49): Well, I think we have the small H, small R, which is just harm reduction as a practice, and it’s a practice of how we approach behavior and how we approach really wellness in creating some aspect of ongoing recovery for individuals. That’s not about this expectation of an outcome. And I think especially when we come to substance use and other potentially, quote-unquote, compulsive behaviors, there’s been a sense, historically, that abstinence, complete stoppage of all behavior is the only way that someone can truly recover. Harm reduction has as a tenet, that we have all kinds of behaviors that make up our world and we have potential consequences from them and that whether we like situations or not, that we have options to be able to reduce harm and increase wellness. And there’s all kinds of different ways of doing that. So it’s not anyone’s particular path.
(06:54): So there’s a lot of freedom and places to get started and that so many things beyond completely quitting can be considered harm reduction. Whereas Harm Reduction with a capital H, capital R is really more of a social justice movement. I’m using a definition from the National Harm Reduction Coalition, which really talks about the movement as being built on a belief in and respect for the rights of people who use drugs. So this movement is about helping people who use drugs be part of leadership and help support communities in reducing the negative consequences associated with drug use. So that’s the difference between harm reduction with a capital H, capital R, and the small H, small R.
Ali (07:38): That’s really helpful, Kristin. Thank you. And it really sounds like there are a lot of right ways to do things. The aim or the ultimate goal of the person really is front and center along a continuum and anywhere the person wants to be and aims to be is really accepted and welcomed. I also am thinking a little bit about M, maybe if we were sitting down and talking with someone, we might have a menu of options of topics we could support a person as they’re thinking about. So under the harm reduction umbrella, what might be some things or some interventions that folks can try out in the book?
Kristin (08:21): Certainly, under the harm reduction umbrella, there’s a number of things that people can do, and probably the most, maybe obvious ones or things that people think about, would include things like cutting back on a particular substance or behavior and just checking it out. And I call it sampling or experimenting, just seeing what it’s like. If I cut back for a couple of days, then maybe I can come back and check and see what was that like? Maybe there’s also an aspect of completely trying abstinence for a time being. It could be for a very short period of time, it could be for longer than that. But again, this umbrella does include abstinence as well as potentially cutting back. I think a lot of times when we think of harm reduction and abstinence, we think of them as dualities, as harm reduction or abstinence. But actually, abstinence, like stopping a behavior, is underneath the harm reduction umbrella.
(09:24): It might be obtaining more information about someone’s substance use just to learn more and to become more informed about what some options are. It might be experimenting and going to different meetings just to see what the community support is like out there. It might be finding and experimenting in other, say, pleasurable activities or other things that might help provide a certain amount of coping or support that maybe, at least partially, was managed by the substance. So there are a lot of different types of things, really, it’s an infinite number of things that can fall under the harm reduction umbrella. And these are just a few.
Ali (10:10): Thanks for that. So it sounds like moving away from something, moving to less of something, moving to more of something else, moving towards something, all of these sound like really wonderful options. I know in the world of MI, providing choice and supporting autonomy, all of that and many other things are utterly trauma-informed and highly prized in our world. But I’m just curious, where does the trauma-informed piece come into this book and when we talk with folks about harm reduction or they do these self-reflection activities, how does this meet this trauma-informed aim that we always have for ourselves?
Kristin (10:56): Well, one thing about harm reduction in general that tends to be trauma-informed is that it provides choice. So choice and autonomy are really central tenets of trauma-informed care and of harm reduction. So one of the things we know about trauma is that typically, we’ve been traumatized. If we’ve experienced something that has been experienced as traumatizing for us, we lost our sense of control, we lost our autonomy, typically, when we’re experiencing that trauma. So to be able to come to a behavioral choice and have it be our choice and to have support in that to support our autonomy is inherently empowering for an individual.
(11:41): Also, there’s, I think, important pieces too around a certain sense of safety. So when we are making any choice that’s our own choice, we’re doing that in such a way that we have control over it. And when we’ve been traumatized, experience of trauma is one of losing control and losing ability to essentially take care of ourselves. So in a harm reduction way, if I am able to be informed, make choices, feel like I have control over what it is I’m doing and how I do it, that’s essentially an important component of the trauma-informed and harm reduction approach.
Ali (12:22): It really sounds powerful for supporting not only autonomy but a sense of personal agency. I think it’s really tempting, especially when everyone around a person is pressuring them to stop doing something or cut down on something that it feels like holding onto that behavior is a way of asserting agency and autonomy. And even if we have some of our own ideas and our own concerns about, “Well, it’s like I’m holding a hot coal in my hands, and I know it probably would be good for me to let that go in some ways or at least reduce the time that I’m holding it, but because others are pushing me, I feel backed into that corner of holding onto something.” And I am guessing that this way of self-reflecting to expand the sense of choice and control and real personal agency then allows folks to make a series of decisions to explore and to experiment in a climate of acceptance and self-acceptance that they may not have readily in their world.
Kristin (13:32): Yeah. Thanks for that, Ali. And you’re making me think of something that is really important, and that is, how does someone develop any behavior to begin with, whether it’s a substance use issue or some other behavior that may eventually become problematic? Typically, we don’t do these things because we want to start having problems with them somewhere down the line. Typically, they serve a purpose and there’s a function that using a substance has or another type of behavior has for us. And if I’ve been traumatized, if I’ve had adverse experiences early in life or even later on, substances can actually be helpful, at least in some ways, sometimes for a very long time. And there might be a place where they’re not so helpful anymore, or the consequence of use isn’t so helpful anymore. And yet when someone comes and tells us that we have to do something, again, takes away our agency.
(14:31): And it’s something that I’ve had an amount of attachment to because maybe it has been helpful for me. There’s almost like a double whammy there of, “I don’t know if I want to just automatically give it up and I don’t know if I want to have you tell me what to do or if I want to give up control to you.” It’s really easy to see how, potentially, that kind of dynamic can be really activated. And again, the importance of, I think really trusting people. I think we talk about trust in trauma-informed care a lot. And I think this book in harm reduction itself, it trusts the person who’s using, it trust the client or patient or whatever name we want to give someone, the person who has the concern, it trusts them to be able to start to explore and find their own best options.
Ali (15:22): Yeah, sure. So substances can help me skillfully meet different values that are important to me, but really, the space and safety to try on different ideas, to find other skillful ways to develop, to meet either that same need or value or other needs that I may have set aside during that time. It sounds like a really valuable exploration. And I note just a wee little bit about research indicating that creating some sort of recovery narrative for ourselves, if we’re thinking about it that way, we’re really writing a new story.
(15:57): So creating a recovery narrative and providing opportunities to self-reflect can aid our own engagement in and fuel our own motivations that we already have inside for recovery efforts, whatever we decide those are going to be. Well, full disclosure, I’ve had a chance to review the book. I know you have many guided exercises that use the spirit and skills of MI that help with these kinds of self-reflections and new story-building, really, creating a new narrative. What are a couple of examples? It may not be fair for me to ask you this. What are a couple of examples of some of your favorite activities in the book?
Kristin (16:42): I have a lot. I was actually just looking at the book before we got started and the book’s just out. It’s brand new, but my book–true to me and who I am–is already fully covered in coffee. So there we go. You can tell it’s already being put to my good use. And a couple of things that I love, and anytime I go out and I explore this book with folks, one of my favorite things to do, I love doing the double-sided reflections, which we know motivational interviewing is a way of helping people explore a bit about the status quo and possibilities for change. And I have folks in this book to spend some time doing their own double-sided reflections. Like on the one hand, “This is what my substance use has provided for me.” And on the other, “This is where I’m challenged.”
(17:31): And it’s just so important to allow people the place and space to have both the good things and the not-so-good things potentially exist together instead of being cut off and you can only look at one at a time just to have that psychic experience of being able to be whole and to look entirely at the challenges as well as the promises. So I have that exercise that I really enjoy that leads to other types of exploration as well. And then another one I like is I like to have people look at places where they’ve maybe had, I don’t like to use the term fail, but I reframe the thing as fails, FAIL, as First Attempt In Learning.
(18:15): So this idea to have folks go through and look at places maybe where they’ve been challenged, maybe they had a recurrence of a substance use or other things where they maybe didn’t have the best outcomes for themselves in their own opinion, and have them reframe it instead of as a failure or a place where I’ve been stuck or a place where I’ve missed the mark to instead look at, “This is a place where I learned and this is what I learned.” And this whole idea of being able to look at everything as a learning opportunity, I just think is so freeing and it provides so much positivity and potential for growth. I really want to help folks approach this from a very strong growth perspective. And those are a couple of my favorite exercises.
Ali (19:03): Yeah, I love those. Those are key, this idea, the double-sided reflection almost as a dialectic of embracing two or more things actually are true in any moment and what might be another way. And we get that by embracing the paradox and transcending it. I also love this reframing really shining a new spotlight on something for us and looking at mining for the gold and the good and experiences, that’s how we learn and that’s how we grow. Well, this is amazing work, Kristin, and thank you for all that you do. And thank you for joining us today.
Kristin (19:39): Thank you, Ali. I’ve really appreciated this conversation. It’s always so much fun talking with you, but also I just love the way you help me explore some of the work I’ve done and allow me to share it with the community. Really appreciate the opportunity. Thank you so much.
Ali (19:52): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (19:58): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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