In this piece I am going to first define abstinence, harm reduction, heroin and HIV. Then i’m going to compare and contrast the abstinence model versus the harm reduction model in relation to a person who uses heroin and has also HIV under the counselling context.

 The term 12 step applies to a number of self-help groups which have grown from the original alcoholics anonymous movement. 12-step groups are fellowships of men and women who meet regularly to support each other in their efforts to achieve and maintain abstinence. Groups are run by the members themselves who are not professional counsellors. They have a spiritual foundation are not affiliated with any organised religion.  (McMurran, 1994)

For the purposes of this essay groups like NA(Narcotics Anonymous) would represent  a traditional abstinence group and the Minnesota Model would represent a counselling approach in relation to addiction counselling.

 The idea of harm reduction first emerged explicitly in Dutch drug policy during the 1970s and 1980s from concern about the social integration of people who use drugs into society  with a goal of maximizing the contact that problematic drug users have with social, treatment, health, and other community services. (Lowinson, Ruiz, Millman, & Langrod, 2005)
From 1981, absolute abstinence was abandoned as the primary goal of all drug-misuse treatment efforts in Amsterdam. (DCU, 2004)

It was the realization that people who use drugs shared needles that spread the human immunodeficiency virus (HIV) that soon made harm reduction official drug policy. Public health officials in the United Kingdom expressed it well: “HIV is a greater threat to public and individual health than drug misuse” (Grund JP, London) and later the same idea became policy in Australia, Canada, Switzerland, and many other countries (Lowinson, Ruiz, Millman, & Langrod, 2005).

In Ireland in 1990 methadone maintenance became a policy. The likes of the Coolmine therapeutic community and Trinity Court use a combination of harm reduction practices and counselling services to achieve their goals.

The main harm reduction interventions used in Ireland are information and education associated with drug use, health care in relation to infectious diseases associated with drug misuse, needle and paraphernalia exchange programs and drug substitution treatment, mainly with a methadone maintenance programme.

From a counselling perspective we might name motivational interviewing at a key therapy for use with this model.

 Human immunodeficiency virus (HIV) is a lentivirus that can lead to acquired immunodeficiency syndrome (AIDS), a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections. (Wikipedia, HIV, 2009)

Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. The four major routes of transmission are unprotected sexual intercourse, contaminated needles, breast milk, and transmission from an infected mother to her baby at birth. Screening of blood products for HIV has largely eliminated transmission through blood transfusions or infected blood products in Ireland and the developed world.

Diacetylmorphine (INN), also known as diamorphine (BAN) and heroin, is a semi-synthetic opioid drug synthesized from morphine, a derivative of the opium poppy. It is the 3,6-diacetyl ester of morphine (hence diacetylmorphine). The white crystalline form is commonly the hydrochloride salt diacetylmorphine hydrochloride, however heroin freebase may also appear as a white powder. (Wikipedia, 2009)

Often it is known as smack, gear, H, Skag or Junk. Street heroin is usually a brown/white powder, smells acidic and is usually mixed with other substances. It is either smoked - "chasing the dragon", snorted or dissolved in water and injected under the skin or into the vein. Heroin produces little effect if taken by mouth. Injecting creates a more powerful high. As we can see from the diagram below heroin as a street drug is the most dangerous in terms of dependence & physical harm.

 Both the abstinence model and the harm reduction model have similar goals. The goal in this case is to create a better quality of life for the person receiving the service. Typically when a drug user comes for help they are assigned a key worker who goes through the process of assessment, develops a care plan, and then introduces the drug user to the various services that their particular philosophy of treatment prescribes to.

The primary goal of a counselling approach such as the Minnesota Model is a  lifetime abstinence from alcohol and other mood-altering chemicals and improved quality of life. This goal is achieved by applying the principles of the 12-step philosophy, which include frequent meetings with other recovering people and changes in daily behaviours. The ultimate goal is personality change or change in basic thinking, feeling, and acting in the world. Within the model, this change is referred to as a spiritual experience.

If we compare the abstinence approach to caring for an individual who uses heroin and has HIV we would find that they would be encouraged to stop using heroin completely and to abstain from sex.

While with the harm reduction programme the individual may be taught how to use heroin more safely i.e. clean needles and spoons and other paraphernalia or to substitute methadone for heroin and to practice safer sex.

Abstinence does not work for everybody and often the spiritual aspect of the 12-step movement of faith in a higher power is off putting for some people.

Motivational interviewing techniques go hand in hand with the harm reduction model as one of the key factors with motivational interviewing is dealing with ambivalence, the ambivalent desire to carry out one action while pulled by the desire to carry out an opposing action. In this case the desire to continue on using heroin with HIV versus other options that the individual identifies themselves. This might be reducing the amount of heroin used or to go on to a methadone maintenance programme to stabilise their health and to help the anti-viral drugs prescribed work better.  One of my own clients would say in one sentence how she had lost so many friends to Heroin overdoses but still felt that one last ‘Q’ wasn’t going to kill any one, which illustrates this ambivalence well.

1.       Express empathy which guides the therapists to share with clients their understanding of the clients' perspective. “ when I asked you why you like to take heroin and you told me about your abuse I understand that taking the heroin can give you temporary relief from the feelings of shame and guilt that you expressed to me ”

2.       Develop discrepancy, this guides therapists to help clients appreciate the value of change by exploring the discrepancy between how clients want their lives to be vs. how they currently are (or between their deeply-held values and their day-to-day behaviour). From a counselling perspective this really means that we would encourage the client to consider the benefits continuing taking heroin with HIV and the benefits of seeking alternatives to this and perhaps the consequences and impact on the health of the individual if they continue on with their lifestyle of heroin use while infected with HIV. “ so on one hand you enjoy the benefits of heroin and how it makes you feel but on the other hand you tell me you want to extend your life as long as you can ”

3.       Roll with resistance, this helps the therapist to accept client reluctance to change as natural rather than pathological. We might expect that the heroin user who has been diagnosed with HIV will be scared and reluctant to look at alternatives. It would be important that the individual feels ready for a change in their behaviour. It is imperative to avoid the confrontational-denial trap at this point.

4.       Support self-efficacy, guides therapists to explicitly embrace client autonomy (even when clients choose to not change) and help clients move toward change successfully and with confidence. If the client decided they should find out about safer sex we might use a scale to rate how important it is for them to practice safer sex. “ so Mary you've said on a scale of 1 to 10 of having safer sex that you consider you are at eight so why eight rather than seven ?”

5.       Avoid argumentation (and direct confrontation). Arguments create resistance. For instance using the safer sex piece it would be important not to drive home their responsibility to the community to practice safe sex and tell them that would be irresponsible not to as this may drive them away from treatment if it brought shame and guilt feelings for them.

The main goals of motivational interviewing are to establish rapport, elicit change talk, and establish commitment language from the client. (Miller & Rollnick, 2002)

Motivational interviewing is a way of being with a client, not just a set of techniques for doing counselling. Motivational interviewing builds on Carl Rogers'  humanistic theories about people's capabilities for exercising free choice and changing through a process of self-actualization. 

The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership. Your role in motivational interviewing is directive, with a goal of eliciting self-motivational statements and behavioural change from the client in addition to creating client discrepancy to enhance motivation for positive change (Miller and Rollnick, 2002).

The idea behind the SCM is that behaviour change does not happen in one step. Rather, people tend to progress through different stages on their way to successful change. Also, each of us progresses through the stages at our own rate.

So expecting behaviour change by simply telling someone, for example, who is still in the "pre-contemplation" stage that he or she must go to a certain number of NA meetings in a certain time period is rather naive and counterproductive because they are not ready to change. This will serve to create resistance, and we've learnt that we have to roll with the resistance!

Each person must decide for himself or herself when a stage is completed and when it is time to move on to the next stage. Moreover, this decision must come from the client (an internal locus of control) as stable, long term change cannot be externally imposed.  Prochaska and DiClemente 1980.

In my opinion I feel that while abstinence is a worthy goal it is often unworkable. If large numbers of people who are also intravenous drug users become infected with HIV the wider community/society is placed at risk. HIV passes from drug users to their sexual partners especially if they IDU’s also work in the sex industry. HIV-Positive women can transmit the virus to their children. We could consider the harm minimisation model as the public health model as preventing HIV infection has become a priority over abstinence in modern Irish society.

From a counselling perspective I believe that the motivational interviewing approach is more empowering for the client. I think it is important to look at the wider context of why people use drugs. Taking away a coping mechanism from a drug user may do more harm than good unless the core issues that led to drug use are dealt with in the first place. I have found with the addicts I have worked with that overwhelm in their lives or histories of abuse or low self-esteem are the reasons that have led to drug use. I feel it is only when these issues are dealt with that true change will occur.

DCU. (2004). A Review of Harm Reduction Approaches in Ireland and Evidence from the International Literature. Dublin: NACD.

Grund JP, S. L. (London). AIDS and drug misuse, part I: report of the Advisory Council on the Misuse of Drugs. 1988: Her Majesty's Stationery Office.

Lowinson, J. H., Ruiz, P., Millman, R. B., & Langrod, J. G. (2005). Substance Abuse, 4th Edition. Lippincott Williams & Wilkins.

McMurran, M. (1994). The psychology of addiction. Taylor and Francis.

Miller & Rollnick. (2002). Motivational Interviewing: Preparing People to Change. Guilford Press.

Wikipedia. (2009). Heroin. Retrieved from Wikipedia: http://en.wikipedia.org/wiki/Heroin

Wikipedia. (2009). HIV. Retrieved from Wikipedia: http://en.wikipedia.org/wiki/HIV