← Compassion in a T-Shirt
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- [00:01]
A
Hi, I'm Dr. Stan Steindl and welcome to Compassion in a T shirt. My guest today is Didi Stout, counsellor, educator, trainer, and longtime advocate for harm reduction. She's the author of Coming to Harm Reduction, Kicking and Screaming now in its second edition, which brings together powerful stories of radically loving people who use drugs and the families who support them. Didi has worked for decades at the intersection of compassion, addiction and social justice. And I'm thrilled to explore her journey and her vision for the future of harm reduction. And so I bring you Didi Stout. Dee Dee Stout, welcome to Compassion in a T shirt.
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B
Thank you, Stan.
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A
Lovely to have you here. Yes, great. I've got your actual. Brilliant. Oh my gosh, yes, another big one. I got it on, on Kindle.
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B
Yeah, thank you.
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A
So it's a, it's a wonderful read, actually. I wondered if you could just give us a little sense of the kind of structure or the idea of the book, first of all, just to sort of. Yeah. Explain the concept there because it really involves a number of interviews of people from different, you know, kind of perspectives on harm reduction.
- [01:23]
B
Yeah, it sure did. And it was not the book I had set out to write, I'll put it that way. And I realized about halfway through the process that this had taken on a life of its own. And I was fine with that. I mean, I'm grateful that sometimes I'm also what we consider here, autistic, what would be called, you know, Asperger and I, I get a little bit pigeonholed, you know, and we need to hold on to things. And it was like, no, this needs to go where it needs to go. And the next thing I Knew, I had 40 odd interviews and thought, oh my God, that is twice as many as I had in the first book. What am I going to do? But they were so great. And I realized that so many of these voices had never been really heard. You know, they'd get occasion here or there, they'd be well known in their area like their state or their city or something like that. But there wasn't any way that everyone had kind of gotten together and been put into a book and said, here are the voices of people that are behind harm reduction. Here is what they actually do and who they actually were work with and how they do that. And so that was really my impetus. Yeah, but not.
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A
Yeah, it's a, it's a bunch of inspiring stories. I mean, and from all the different perspectives from, from, you know, kind of lived experience through to policy, through to treatment approaches and you, you have it all separated in those different parts. And, and, but, but what about you? How did you come to, to harm reduction?
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B
Kicking and screaming?
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A
Yeah.
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B
I know. I had. I guess we'd have to go back to my introduction to motivational interviewing, which will be great here because obviously you're part of that as well, and I'm part of Mint. And I wound up finding out about what's now called the Emmy study. And that was the first one that Bill Terry and Carolina Yane, who are all at the University of New Mexico, did to study how to teach motivational interviewing. They knew that it was helpful, but they didn't know how to teach other people yet. And so they put out a call through nida, through our National Institute of Drug Abuse, and looked for clinicians who were willing to come to University of New Mexico and do this training and then be followed for a year. And then, of course, they had three different ways. So, you know, one group didn't get followed. I think they got a follow up at the end of the year. Another one got all the materials and the videos and everything. And another one, it was something else, and I can't remember anymore. And I had sent in a tape. You had to send in a cassette tape back in those days. And the young man, who was someone that I knew from other circles, he was a client and had been for a long time, and it was a former heroin user. He had come into my office and he had first called me and said, deedee, I don't think you want me to come in. I used today and he hadn't used in a long time. I was like, oh, man, you. And I had told him about this recording and he'd agreed to it. And I said, you know, I'm doing this recording and I have to mail the tape tomorrow. I can't, I can't find anybody else. You gotta come in, buddy. And he was like, okay, come in. So he proceeds to come in. He eats the entire bowl that I had a jelly beans in front of him, passes out for part of the time on the couch, right? Kind of wake him up and get him back. And I send him the tape and think to myself, oh, my God, this is awful. This is just miserable. And like, finally get notified that I've been accepted. Now, two things from that. One was my joke was to Bill, when I asked him this one time, Bill Miller, so did you think that you heard something in what I did that was reasonable and you could build on, or was it, oh, my God, get this woman in here before she hurts anybody else.
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A
Right.
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B
It's awful. And, you know, Bill, obviously, he laughed and he said, no, no, no. It was the first one. Yeah, I'm not sure that's true, but I'll take it. But the other thing that happened, two weeks later, he called me and, you know, thanked me for seeing him, and he said, would you drive me to treatment? And I said, what? And he, you know, he was married, and I thought, why aren't you asking your wife? And he said, you are the only person and definitely the only professional who has ever seen me when I was loaded and didn't shame me. And that meant so much to me that you would see me. And then I drove him home, too, because I couldn't let him drive his car when I knew he was under the influence. That brought tears to my eyes and still does. And that is the kind of radical love that I came to know was Harm reduction was saying, you know, I got rid of the part in my office policy that said, if you're under the influence, don't come in. I don't want to see you. Yeah. It said, no, if you're under the influence and you want to see me, you betcha. Come in. I can't imagine that scenario. But if you're willing to do it. Why would I not be willing to see you? That's a gift. You are really letting me see you in this environment that you're living in, in this unhealthy relationship that you've got to. Something that at some point meant everything to you and was really helpful, and now it's not, you know, what a loss that is, the grief that must go along with that. So, yeah, so it was motivational interviewing and a bit of selfishness.
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A
How interesting. Oh, yes, okay, I see what you mean. But, yeah, but it's. It's a very moving, poignant point that he was making, wasn't it? Which is that his experience of treatment providers or that sort of area of the world had actually for him been a shaming experience. And that, you know, that it sort of makes you stop and think, really, doesn't it, that, you know, when. When. Because really, shame is the last thing we want. It's in. In something like that, you know, shame causes people to hide away or to, you know, sort of not want to sort of come forward. But for him to have you accept him in that way, you know, the radically. The radical love that you were able to show by just having him there and not rejecting, not shaming and so on, was Became the beginning of something, I guess, for him.
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B
Yeah.
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A
And harm reduction is just a de. Shaming process. It really is, in a way.
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B
You know, at its core, I think it does it both ways. It also. It d. Shamed clients, but it also depowers me, you know, and by that I mean it also takes the responsibility of the client off me for the first 12 years. And I was trained in a hospital based rehab, in fact, the one that I went through back in 1988, and, you know, thought that was the best thing in the world. They handed me the keys to the hospital. Wow. You know, how much better does that get, right? And I was good at my job. The last thing that a patient ever gave me, and it's sitting up here, but you can't see it was a writing crop, a leather writing crop. You know, the thing that you jockeys use to.
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A
Oh, yes, yeah, right, right. Symbolic.
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B
Yes. And he said, this is my experience of you as my primary therapist. Okay. Now it gets better, Stan. Because he meant that as a compliment.
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A
Compliment. Okay.
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B
That to me is the scary thing. And I have kept that through all of my moves. That was 1990 somewhere in there, so 35 years at least, to remind me of who I can go back to being very easily if I don't stay on top of this. Because I live in a culture that believes that that is the way to get people to make change, Especially if they're substance users of any kind. They don't even have to have a disorder. You just. Drugs are bad. Unless, of course, I'm using them and then it's not a drug. All right. Something else.
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A
There's a sort of a humility then to it in the. In the harm reduction kind of therapist is sort of not being seduced by that feeling of power, you know, the whip, you know, sort of.
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B
That's exactly right.
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A
And instead being kind of humble about it and also, you know, respecting the person enough to give them the power and responsibility, I guess, but. But at the same time, still welcoming them in. You know, there's no. There's no negative consequences imposed if someone, you know, kind of slips here or there or whatever it might be on. On. On what is.
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B
That's right.
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A
A sort of a. Often a varied journey towards recovery.
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B
Absolutely. You know, now Prochaska and D. Clementi use at Norcross. Sorry, John. You know, they use the spiral. Right. Instead of the wheel, which I love. And even had a client that I worked with, a methamphetamine user many years ago who is probably one of the Most intelligent people I've ever known. And just incredibly bright young man, frighteningly bright, and would ask me in session, what am I doing all the time? And sometimes I'd have to say, could we do this piece? And then I'll explain why. And he'd go, okay. So I brought it in one day and said, so when they had just made the change and said, so here are the two kind of stages of change. And we'd had that conversation about stages of change. And I said, which one do you like better? You know, what do you think? And he said, oh, I like the spiral better. And really, tell me why. He said, because even when I'm on the backside, I'm still on the road. That's it. That's exactly right. And with a wheel, either you're on the wheel or you're off the wheel.
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A
Yes.
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B
Right. So he saw that as very. Also indicative of his experience of drug use. There were some positives and there were some not so positives, and it kind of went back and forth in this spiral and twist in his life.
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A
Yeah. Again, such an important example of the frame that we might take and. And the way that I. I don't know whether this is true for that person, but it's almost. It feels a little bit like there's a. It's sort of d. Shaming there as well, because we can still feel like we're on the road, even if we're sort of on the back end or how you put it. And that's.
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B
Right.
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A
As opposed to on or off the wheel or.
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B
Or Right.
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A
Sort of good or bad or using. Yes. Yes.
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B
And that's how we think of drug use. And certainly in this country, you know, you're either. And in. Recovery is really just code for abstinence. You know, we're. Some of us are really working to change that, but that's essentially what it means. And you are either using a substance or you're not using a substance. And of course, that doesn't work either. You know, I mean, I have other. I had my coffee this morning. I don't know about you, but I really like to have my one cup of espresso in the morning. It's about the only thing I get to have anymore, you know, so. And that's a drug.
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A
Yeah.
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B
I may like the taste, but I'm also drinking it because I'd like that little boost in the morning. I'm not a morning person. Never have been. So that's helpful. Well, that's a drug. It's changing how I feel, physiologically. But boy, you better not talk about that as a drug. No. Or Starbucks would become a drug dealer.
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A
Yes. Yes. There's a section in your book somewhere, I think, or it might have been in a blog on your website. But just that idea of how not all drugs are seen as equal in a way, I think that's sort of the point you're making, that caffeine is a drug or alcohol or whatever, and some get to be legal or something.
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B
Yes.
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A
And then certain morality gets then attached to that somehow, and then all of a sudden, all of a sudden those ones are kind of fine and other ones aren't fine. Even though alcohol, for example, causes so much suffering in a way, you know.
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B
Yeah.
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A
And there's a. There's an imbalance there.
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B
Well, and in fact, alcohol, at least here, I don't know the stats for other countries, but for our country, alcohol causes about 150,000 deaths annually. Well, that's more than even at the height of the opiate crisis, I'm going to call it, because it wasn't an epidemic. That is far and beyond anything. Heroin, generally speaking, used to be in the 15, 20,000 deaths. So you look at that and go, wait a minute, how did heroin become this, you know, more evil than Baltimore kind of drug? And here's alcohol that's celebrated, that is looked at as, oh, this is fun and gay and. And I'm not against alcohol at all, but how did this happen? And you know, the person in your neck of the woods sort of is Julian Buchanan, who has been just brilliant at creating means that show this. Now, he was one of the first ones I saw that did a meme with a bar with somebody sitting with, you know, a pint of beer or whatever it was in front of them saying, you know, oh, I'm never going to go for those overdose consumption sites. That's ridiculous. And going, right, what. What do you think you're sitting in right now? Yeah.
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A
Yeah. Yes. It's interesting. I mean, in amongst all of that, in amongst the, The. The sort of. The. The shaming and really the d. Shaming, and amongst the. The recognition around power and humility and, and in amongst this kind of. Kind of, yes, the, the legality, but the morality kind of, you know, that, that people put onto things like where. Where does compassion come in, do you think? Like, if you. As you look back on all of that, what. What role did. Com would compassion play? Do you have thoughts there?
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B
I do. You know, I think first of all, it was beginning to understand the difference between empathy and compassion. You know that I like to say to my students that empathy is a feeling, and it's important. You can't have compassion without empathy, but you can have empathy without compassion, because compassion also includes that action. Yeah. I not only care about what you're going through and feel that on a deep level, I want to do something about it with you. Not for you, necessarily, but with you. And I'm willing to experience that feeling, whatever you're going through, that tribulation, that challenge with you as a partner. And I think that is exactly what motivational interviewing has taught me as well. At its core, it's about that kind of partnership. That's why I say that when clients come in under the influence, it is such a gift. And, you know, I'm really humbled by that, that somebody would show me that side of themselves. You know, it shows a great deal of. Of trust in me. You know that. And it used to be the therapists would say, well, you can't work with someone under the influence. And. And I'll even admit maybe it won't be the best session. I don't know. But they're there. And it was Steve Rollnick ages ago that taught me, you know, somebody is in your office, they're motivated for something. So start there, get out of your head, whatever you think or whatever the stakeholder said you should be looking at, and just say, they're in my office. Okay. What is it that you're motivated to talk about or to do or what do we need to examine right now?
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A
Yes, because compassion isn't any one particular thing. And in that instance. Yes, the compassion is about creating that safeness for the person to show up and be present and to kind of have that trust in the therapist to not then reject or shame or get them in trouble somehow, but rather.
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B
That's right.
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A
Even just.
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B
That's another piece of it. Right? Yes.
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A
Yeah. Because just sort of sitting with a person can be a powerful act of compassion in that sense, I suppose. And there was another little anecdote there where someone was inviting the person to the group meeting and just saying, look, if you turn up and you just sleep in the chair, you just sleep in the chair. That's okay. Sort of a thing. And you know that there's a very.
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B
It's.
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A
Yes. The sort of the heartfelt desire to try to do something to alleviate.
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B
That's right.
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A
The suffering. But not necessarily do we get to do what we might like, want to do in the therapy sense, but we do something to alleviate Suffering and actually.
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B
I think that can be a real positive too. Huh. Maybe it's time I don't do what I think we need to do. Yeah, maybe it's time for me to kind of turn that over to you, my client, and you tell me what you think we need to do. You know, what do you need in this moment? One of the things that I talk a lot about with students or the graduate students that I sometimes get to teach and say there's, we need to talk about this countertransference, this anxiety that you have, and rightly so. I talked about it with a group yesterday and around your clients, risky behaviors. You know, you got into this work because. And we call it the helping professions. You want to help someone. However. And we had just seen Bill's little clip on the fi. The writing reflex. I was doing a training in mi. I said, so you know, the irony of this. And he speaks to that is this is exactly what we got into the field to do to try and help people not step into that pit over here or not go down that road, because we know what's going to happen. Well, one, you don't really know what's going to happen. You can take a reasonable guess, sure, but you don't have a crystal ball. So what if you just ask the person, would it be okay if I shared with you my concern? You know, isn't that more respectful? And you still get to probably say what it is that I've never had anyone say no to me. Doesn't mean they're going to listen. But I've done my part and I've shared what I think that I need to say as a professional, and it's out there and they can make a decision what they want to do. But, you know, again, it's that respectfulness as you're talking about, and I think that's what harm reduction is to me in its bottom line. It's respectful and it is in some ways sadly radical. You know, I wish it wasn't so radical.
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A
Yes. Yeah. Well, that, that's, that's actually. I guess. Yeah. My next question, I mean, what, what, what really is your definition of harm reduction? I suppose.
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B
Let's see, what did I write down here? You know, harm reduction technically is anything that reduces risk, any behavior. Right. So we think about. We know there are a lot of car accidents, auto accidents, in all different worlds. And, you know, in our various countries. Do we outlaw cars? No, we try to make cars safer. We instigate. You know, I was a kid when they had seat belts put in. And I remember when shoulder straps came in and what a big brouhaha that was. And in the 70s, when Nixon decided he was going to lower the speed limit to 55, oh, my God, you would have thought we were going to say, you know, I don't know, you know, you can't have your beer anymore. Right. It was just an outrage. And we did that not even for safety, but because that was during the oil embargo. And so the cost here of gas just went up astronomically. In fact, you couldn't go to the gas station anytime you wanted. There was sort of a lottery that allowed you to go to the gas station. So, you know, there's a lot of reasons. I'm also getting to why we might reduce the risk, Right? So we do this all the time with all sorts of things. Condoms are the biggest one that we can think of having gone through. And I got into the field around the HIV and AIDS crisis during that time, and so that's another one. But you can think of decaf coffee. That's harm reduction. Low fat, whatever, that's harm reduction. I mean, there's so many examples that we walk through life and we're probably doing all day long, but when it comes to substances, suddenly it's like, I.
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A
Don'T know, you should just stop.
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B
Yeah, right, right. Those are just bad. And you should just stop it now. One of the most effective treatments for substance use disorders is something called contingency management, right? Sort of a reward system. Researchers do this a lot, right? They'll ask people to come in to do research and say, we'll give you five bucks if you come in, or 50 bucks, or, you know, whatever it is, Amazon gift cards. And so people do. That's how you get them into the study to start with, when you use it with substance users and say, I'll give you whatever it is. Amazon gift card, if you come in and give us a negative urinalysis, let's say, for whatever your drug is, and then we're going to give you the gift card and they do it. Dr. Carl Price, if you know of him, Columbia chair, first black person to hold a chair at Columbia University. His last book was called Drug Use for Grown Ups. And he admitted to being a heroin user, an IV heroin user, recreationally. Still married, still has his kids, still still has his job. I don't think he's going to get any more NIDA grant money. But it's. But, you know, he was. He wanted to kind of pull the layers back but he did this study with crack cocaine users, and he was convinced that people would not stop using crack for five bucks. They did? Yeah, he said it. He was just blown away by this. I said, oh, my God, who would have thought? Because we've all, in this country, again, been indoctrinated to believe drug users. In my first book, I use an expression that came out of 12 step that says, how do you know an addict is lying? And the answer to that is their lips are moving. Well, when you start looking at people in that way, human beings in that way, that is not compassion.
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A
That's shaming again, isn't it?
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B
Exactly. Exactly. And that's how I was trained. Don't trust. Don't believe anything they tell you. Don't, you know, don't give them an inch. Don't let them. Oh, those are splitting behaviors. You know, they're just trying to split you here. You know, everybody was splitting in those days, or they were a sociopath, if you were a man. You know, I mean, I like to think of it as my granddaughter, who's three and a half, has told some fibs already. Well, she's just trying to get her needs met, whatever that need is. We don't call her manipulative and a liar and say, okay, we're not going to ever believe her again. We just go, okay, she's three and a half. It's the same process, if you will. If I can't. If I can't make this environment safe enough for you to tell me the truth, that's on me. And I've had that experience with a client. It took her a year and a half to tell me the truth on something. I was so grateful when she did and came forward with that and shocked that she did, but I always believed her anyway. I believe what? Because whatever she was telling me in that moment was all she could tell me. She had had so much trauma in her life, and she just couldn't trust. And I thought, well, of course you can't. Why should you? Just because I have some letters past my name, you're supposed to trust me? That's insane. Yeah.
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A
Yeah. There's actually. If somebody is lying to us, the first thing we should think about is what might it be about me or our relationship that motivates the person to feel that they have to lie? It might just be that we just need to create more safeness in the relationship. Or it might be that they're doing it because they know if they tell the truth on this matter, that they'll only be judged and disapproved of and so on. I mean, that's right. It feels like harm reduction is actually a very kind of creative process in a way. It's about thinking laterally a bit or, you know, kind of coming up with ways that for this person might achieve that aim, which is to reduce the risks around things. And it's sort of. You mentioned some policy examples where maybe, you know, the legislation is kind of helped to reduce risk, but this is kind of like a. A conversation where the person themselves is coming up with. With ideas about what might it be that will just.
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B
That's right.
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A
Reduce risk.
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B
That's right. And as Scott Miller would say, who I studied with quite often, he would say it has to be in a way that makes sense to them and in a way that's doable for them. Right. So there has to be this partnership again, you know, that's going to get the outcome that they want, you know, so again, we need to let go of our outcomes, and that can be tricky. And I also appreciate that we have stakeholders that it may be your supervisor, it might be your college professor, it might be the insurance company, it might be the probation department. There could be. It could be the parents. Right. I mean, there's lots of different people in there who want certain things. And when it comes to drug use, what they typically want is for it to stop. And I get it. That's their anxiety. Oh, if it just stops, then that'll solve everything. Which of course is not true ever. But that's the myth that we have around this. So if people just stop, then we can get back to our life is essentially what that is. But we can't force people to do that, you know, I mean, Bill Miller studies have shown that over the last 40 years, you know, trying to convince people to, you know, cajole them, to nag them, to threaten them, whatever it is, just doesn't work. Yeah. Does it work? Sometimes, sure. Anything can. Does it work? Most of the time? Not even close.
- [30:43]
A
People are much more likely to follow through with something they've chosen themselves to do, I suppose. And so it's a. Harm reduction, too, is a. An evocative process, trying to sort of see can we be creative in our conversation, but perhaps the person can have a think about, you know, what makes sense to them and something that they feel they can actually achieve. The first edition of your book was about 15 years ago, I think, and this is now the. The second edition, although you mentioned before we started recording that it's Kind of like volume two, really, in a way. But yeah, over that time, I mean, has the notion of harm reduction or the definition of it or the practice of it, I suppose, changed? Really?
- [31:29]
B
It has. I mean, there's some interesting things about that. And thanks for that question because I have kind of a new direction in my life that I'm trying to take with all this. I think the definition has pretty much stayed the same. One of the biggest changes in the Biden administration was we could now say the words harm reduction in a grant application, which prior to that, you could not use those. That term. You could call it risk reduction. You could call it. There was a bunch of euphemisms. I think people had kind of crib notes when they were writing grants. Okay, we can say these phrases instead of. But he took it off and said, okay, you can say harm reduction. And it was amazing. Well, I think we got a little complacent, frankly, because obviously that's not happening now in, in the second Trump administration. That is completely off the table. In fact, in his. One of his latest executive orders, he put in quotes, literally, so called harm reduction. We are not funding so called harm reduction. And I thought, wow, talk about a shift. So now we're saying the words, but not in a good way at all. So harm reduction, to me, and I think where I'm kind of leading to is we've done a really good job in this country of talking about what we sometimes label Narcan and needles. You know, so Narcan is the. Naloxone is the generic. Narcan is the brand name of the opiate overdose reversal medication. Used to be IM intermuscular. Now it's in a spray and it works very effective. You know that it almost instantly throws somebody into withdrawal. Not good for them in the sense of they're not going to be happy about it or comfortable, but they will be alive. That is the good news. And handing out needles. So syringe exchange, now what we used to call needle exchange programs here, neps, but now our syringe. Syringe service providers is the new phrase SSPs. Got to keep up. And I'm delighted with that because that has helped people to stay alive. It has reduced hepatitis B and hepatitis C and HIV and, you know, other bloodborne diseases. And it's fabulous. However, I think we've done such a good job that that's all people see in kind of the public. Oh, you people never talk about treatment. You know, people never talk about change. And I got to thinking about that As I was writing this second book and thought, they're right, we have not done a good job of talking about treatment. Well, what do I do? I'm trained in harm reduction psychotherapy. That's treatment. Therapy is treatment. That's what I've been doing for 25 years. What do you mean there's no treatment? And actually, Alan wrote about it. And Alan Marlette, forgive me, in his book called Harm Reduction, there's a chapter on harm reduction psychotherapy. That was 1998, you know, here we are, 20, 25, and I even heard a PhD student who calls themselves a harm reductionist say, there's no treatment for harm reduction. It was just a gasp that, oh, my God, we've. We've really done something wrong. Now, Pat Denning and Jeanne Little, who wrote the first book called Practicing Harm Reduction Psychotherapy, the first edition was 2000. Second one, I think, was in 06. And they're mentors of mine, along with Alan and a buddy of mine, Andy Tursky, Dr. Andrew Tursky out of New York, wrote the next book called Harm Reduction Psychotherapy, very close title. And that, I think, was in 03. You know, so again, early kind of 2000s, these books are coming out or in that area. Well, those have been out for a while. That's like 20 years, folks. And that's treatment. It's not traditional treatment. It's not. You're coming in here. We don't have any residential places, unfortunately. So people aren't coming in and saying, I'm going to quit drinking, let's say. And so I'm coming into this place that might be appropriate, even if they want to quit. Because abstinence is a part of harm reduction, Right? For some people like me, that's the ultimate harm reduction. But it's not right for everyone, nor is it necessary. You know, Bill Miller has shown this in his studies, as did Alan and others in this country with their moderation experiments and the books that they've written on that. And instead, you know, all we've done is sort of say it's either treatment as abstinence over here, and then it's harm reduction here. Like, no, there's this huge bridge between it called harm reduction psychotherapy. Now, what I tell people is that what I do is I help you to examine your relationship to a substance or whatever the behavior is, and invariably the client will say, relationship. I don't have a relationship with it. Actually, you do. That's the point. You know, I mean, you. We have relationships with all sorts of things in our lives. Right. That's not a bad thing. And if we can examine it in a non judgmental place where I can just hold this space for you and you can talk about it, you can figure out what you want to do. As Bill Miller might say, we can help somebody talk themselves out of whatever it is they're doing and find their own internal reasons for making a change which may or may not be abstinence.
- [37:52]
A
It's almost like people have confused the sort of, the treatment outcome with the idea of what is treatment or something.
- [38:02]
B
I think that's fair and that's a good way to explain it.
- [38:04]
A
Yeah, yeah, that, that, that we've gotten kind of caught in. Not caught, but sort of focused maybe on the idea that abstinence is, is the treatment outcome or, and you know, kind of, but slash treatment and, and it's, it's almost a public relations kind of a thing, you know, like helping people to, to sort of, you know, communicating this notion of harm reduction that, that actually encompasses abstinence as a, as a treatment goal. You know, that if that, that may, that may be the person's goal too is, is abstinence or, or periods of abstinence or you know, kind of other forms of change. You know, there's, there's lots of possible helpful outcomes there and, and, and, and certainly harm reduction psychotherapy is a, a treatment approach and then the outcome is really about harm reduction and the changes could be sort of many and varied. Yeah, it's interesting to think how to get the word out there about.
- [39:08]
B
I think in some ways maybe we need better pr.
- [39:12]
A
Maybe it's this thing about some of the myths though, because there are some kind of myths and misunderstandings about harm reduction. I mean, so called harm reduction in the recent executive order just speaks to that, you know, that there's this sort of, this complete sometimes just misunderstanding of what we're even talking about here. Like what are some of the common myths that really relate to that?
- [39:42]
B
Yeah, great question. And I talk about it in the first book even more. I think I did bring it up in the second book. I think I reworked some of those.
- [39:51]
A
You did.
- [39:52]
B
And again, I'll bring up Julian Buchanan's name because I think he has a paper that has 65 different. I was like, Julian, jeez, that's too many for me in the book. But I was impressed. But the first one is that idea that we don't believe in abstinence. And I remember believing that. I remember sitting in my drug and alcohol classes when I was Taking them, not teaching them. And we learned two things about harm reduction, actually, three. So the first one was that harm reduction is enabling drug addicts to keep using. And the second one is it's methadone. And the third is, we don't like either of those. Those are not options. Not in this country, by God. You know, that sort of way of looking at it. And I remember kind of pulling those apart and realizing, you know, I was an illicit drug user for 20 years. And I thought back on my times and thought, you know, okay, let me think about a time that I asked for permission. This idea of giving people permission to use that I'm enabling the ability. I couldn't think of one. I've never asked for permission. Would it be okay if I fill in the blank? Who does that? Can I have a beer tonight? Is that really what. You know, maybe. Honey, can you watch the kid while I have a beer tonight? You know, I could see something like that. But are you actually asking for permission to do something like that? That doesn't make sense to me that an adult in particular is going to do that. And this idea about methadone. Well, methadone is one of the best treatments for heroin or other opiate problems. If you do develop this unhealthy relationship to an opiate, it's fantastic. And it's old. We know it. It was developed in the 60s, know, Nyswander and Dole were the two chemists that. That invented it. So we know all this literature about it. It's amazing. Anyway, it's full of all this judgment. Here we go with that morality again. Well, you're just trading one drug for another. Well, that's what insulin does. My pancreas can't make insulin, so I need to take it. So what does that mean? Or, you know, and I like to say, when it comes to treatment. So this is another sort of one of the myths that there's no that idea of there not being any treatment for it and that we shouldn't be treating people who are not willing to give up their drug. My dad had triple bypass surgery, decade or something ago, and I was in Chicago, where he lives, and was going over to the hospital. And I'm thinking in my head because I've always got the stuff, you know, we're thinking about, right? And no one said to him, jim, you need to really pull back on the beef and on the cheese and on the butter. He grew up on a farm originally. You know, I mean, this is what the Midwest is. Cows, corn, butter, cheese, Right. And I said, nobody said that to him. Nobody said, when you get serious about your diet, then we'll talk about having surgery. In the meantime, you're going to have to suffer. That doctor would have been taken out, possibly in handcuffs, but certainly the board that he certified by would have said that is completely unethical, but you can't do that. And yet we do that to people who have these unhealthy relationships or these complicated relationships to substances all the time. Now, Pat Denning said it best in her. I think it was in the first edition of her book and said, why is it that with substances we ask people to not have the symptoms of their condition before we'll treat them? Do we tell people with depression, you can't be depressed or I'm gonna. I won't treat you. That's insane. But we do. With substances.
- [44:22]
A
Yes. It's all sort of upside down in some ways, isn't it, with, with, you know, like there's so many comparison areas where it, where one way makes complete sense, but then for whatever reason, when it comes to substances, it many, many people see it the opposite way. And when you, when you look at that, you just sort of shake your head and it doesn't compute really. You know, these myths.
- [44:45]
B
That's right.
- [44:47]
A
As. As prominent as they seem to be, sometimes the myths, you just don't. Don't make sense really, you know, to say that.
- [44:55]
B
I think that's perfect, Stan. You know, and so back to Scott Miller for a second. So when I trained with him, and I did my training with him, same time that I did my mi. Training and I went back and studied with Scott, I think, three times. And every time I would say to him, you make my head hurt because he was blasting through these ideas, these concepts that we had that are embedded in this culture around any kind of behavior, but substance use in particular, that are just wrong, that don't make any logical sense when you stand back and get some perspective on it. But we'd have to get some perspective.
- [45:44]
A
Yes. Harm reduction is giving permission people permission to use and. Yeah, and, but, but who. Whoever asks for permission and, and that's right. You know, who, when told they're not allowed to do it, then actually follows that.
- [45:57]
B
Right.
- [45:58]
A
As well.
- [45:59]
B
Okay, no problem. Shoo. Thanks for telling me that.
- [46:02]
A
Yes, yes, it's.
- [46:04]
B
That was a close one.
- [46:07]
A
The thing that's so good about the book is that it does really bring personal stories in from different perspectives and so on. But is there a particular story in amongst all of that? I Mean, well, there's just so many. And I know there's. I know I'm sure you don't have any favorites. All are equal.
- [46:25]
B
You can ask me the favorite of my kids. Right?
- [46:28]
A
Exactly, exactly. But is there something there that captures, I guess, the, the heart of, of harm reduction and, and what you would want people to see more clearly in terms of, you know, debunking maybe even some of those myths?
- [46:42]
B
Well, I think one of the ones that to me is the most powerful is coming from Chris style. And I get to use his name and I get to, you know, breach his confidentiality because he did in his story. So. Yes, and I saw him recently. We went out for a walk. I've known Chris since the early 90s. He was my client at a residential treatment facility at one time and then came into my private practice in the 90s and was with me for many years. And now we get to just be friends and connect on kind of that level. And when I asked him if he'd be interested in letting me use his story for this, you know, and sharing it with folks, he was. First of all, he said he was honored that I would think of that. He is still very much a 12 step attending person. He was a heroin, an IV heroin user for many years. He has had continuous abstinence for decades now. So there's that piece he's abstinent. And he said to me recently what he learned about harm reduction was really how I worked with him and that was letting him be himself in the room and being okay with that, that whoever he was, whatever he was feeling or thinking in that moment was okay and that he took that approach and is using it with the people that he sponsors in saying, you know, if you, when they would come and say, oh my gosh, I don't know if I should be using Suboxone. So now in 12 step, you know, in some areas there's concern about using the opiate agonist antagonist for helping people to, to move away from illicit opiates is essentially the purpose of them. And they're very effective. They are the gold standard. And he would say, yeah, you know, if, if that's what you want to do, if you think that's going to be helpful to you and keep you away from fentanyl or whatever it is, sure, I, I'll work with you. You know, it became a non issue and I had really intended to do that. You know, that was not how it started, but it became that. And he realized that people who have their own preconceived notions, often based on their own recovery experiences. You know, I did it this way, so by God, you should do it this way, too. That wasn't very effective, and in fact, it often harmed people. You know, and he said, thank you for giving me that gift. And I said, you know, hey, I'm just channeling the. The folks before me. I mean, thank you. And, you know, this comes on, I'm standing on those shoulders.
- [49:54]
A
Yes.
- [49:55]
B
And I appreciate that. But I think that's the point. And I love the stories because to me, that's how you change culture. It's not from people telling you what to do. It's not even laws are helpful. Don't get me wrong, I'd love to change some of the policies and laws. Absolutely. It gets a frame, but it still doesn't change behavior. When we change behavior is often when we hear about someone else who's going through it, or when we have that chat late at night with a girlfriend or a boyfriend, you know, who's helping us through it, or our partner that says, hey, have you thought of it this way? You know, could we talk about it in this frame? Maybe. Or I went through something similar. Maybe my sharing this would be helpful to you. Which, ironically, is going right back to the origins of 12 step. That's all it was supposed to be. Yeah. Yeah. I had this problem. This is what I did. Don't know if it'll be helpful or not. Happy to share it.
- [51:00]
A
I wonder whether some of the. The myths around harm reduction come from a kind of a tribal sort of competitive thing between approaches or something that. That. Because I definitely noticed in your work that you're much more keen to bring approaches together. Really. And. And you notice that.
- [51:20]
B
Thank you.
- [51:21]
A
Yeah. To find the common ground, to see where it. Where they can complement each other. And Chris's story, really. Yeah. Kind of exemplifies that as well. There's a. There's a really interesting sentence here where he says, you know, in my AA meetings, I found that some people accepted abuse as a rite of passage. They were saying things to newcomers like, you have to take the cotton out of your ears and put it in your mouth, or maybe you're not done using drugs yet, and so on. And this.
- [51:50]
B
He.
- [51:51]
A
He was able to kind of find the sweet spot, really, between an abstinence approach, which he's obviously very committed to, and then also bringing in that harm reduction idea as well. And by doing that, really stepping away from. Again, the shaming piece.
- [52:09]
B
Yeah, Yeah. I think that's the Greatest thing. And he was a young man at the time, we were both younger then, who was really full of a lot of shame, you know, But I've never known a drug user, not of what we might call a problematic or chaotic drug user who wasn't full of shame. That's the irony of all this. Nobody had to shame me for my drug use. I already felt horrible, I felt morally bankrupt, I felt stupid, I, I felt, you know, less than human. I seriously didn't believe. I, I deserve to breathe the same airspace as other humans. And I still feel like that from time to time. It doesn't just go away, it does reduce in my experience. But you know, it's part of the reason oftentimes we get involved with substances is because it makes us feel better. Yeah. And there's something inherently, I think this is the other thing about that's kind of a myth about harm reduction, that it has to be one thing or the other. Either drugs are bad or they're fabulous. And it's like, well, why can't they be all the above? Right? Depending on your intention, depending on your experience, on what you're using, how much you're using, what's in it these days, that's a big thing. What your expectations are of it. You know, the whole drug set setting sort of theory. And that's one of the pins in our tent of harm reduction psychotherapy. There are five theories that we're based in and that's one big one is understanding more about the drugs you're using or about the people that you're working with, helping them. So a lot of times when I'm working with folks, it's around helping them to learn to set intentions. And maybe the intention is I want to get snot flying drunk and just be stupid. Okay, then go do that. But do it intentionally and have a good time. Don't do it accidentally and then be beat yourself up the next day because you did it. Like, can we get rid of that part? Because that doesn't help anything. In fact, it keeps you more stuck in that cycle. So now you're going to have to use again because you feel awful and you know, here we go and here we go. So yeah, yeah.
- [54:54]
A
It's the important importance of intention and kind of self compassionate intention in a way is what we're. Did you say snot flying drunk? Is that, was that the phrase? That's brilliant.
- [55:07]
B
Yeah, that's an old midwestern phrase in Chicago. It's crazier than batshit. Okay, that's another One.
- [55:14]
A
Okay, well, you've done some, some obviously wonderful work for a long time in this area. And to have the, the second edition and so on out now is, Is very exciting. What do you imagine is the future for harm reduction or harm reduction psychotherapy? I mean, what, what do you anticipate? But what would you like to see as well, in terms of where it's all heading?
- [55:41]
B
That's such a great question. And of course, that's the fourth question that I asked every one of the contributors.
- [55:46]
A
Yes, you saw that I was using your framework.
- [55:51]
B
You know, and I think right now, because of where we're at, literally in this administration and, you know, we're stuck where we are for a while, it's going to be, how do we keep the momentum? How do we kind of push that aside and say, you know, it is what it is. One of the things I love about harm reduction, excuse me, is that it's pragmatic. It's, this is what it is, so let's get over ourselves. And this is what it is. So what can we do to go forward now? And I think that's where we're at and where we're going to have to be for the next few years. And for a lot of folks, it's also going to be going kind of back underground for a lot of the services that they provide. Now, I don't have to do that because of the work that I do, but things like needle exchange, syringe services, Narcan might even have to go underground in some places. Testing strips. That's another thing that's here in California we're quite protected because we're quite liberal in that kind of thinking, at least, and understand that test strips actually help people to make intentional decisions of what they're using. But in some states, it's against the law. You know, we just had a doctor that was arrested, a doctor that was arrested for testing a drug. So that's going to be the tricky part. But this is where harm reduction has lived forever. You know, the history of harm reduction comes out of queer and people of color who have been having to take care of each other in their own communities forever because nobody else was doing it. So if we look at it that way, I think it can be really powerful and say, yeah, we can do this. We're just going to have to stop the infighting. Let's just not listen to that exterior noise, refocus and let's do this.
- [58:10]
A
Yes. I love the subtitle, of course, of your book, which, which is Stories of radically loving people who use drugs. And I guess that's, that's what you're saying there. It's, it's, it's always been radical action and radical advocacy, and that's a part of harm reduction and, and no doubt always, always will be. Sometimes policies and legislations and so on are a little bit more on your side or aligned, and sometimes they veer away. But that's, that's the radical aspect of it, I guess that's right. And, well, I, I, you know, let.
- [58:50]
B
Me just add, if I could stand that right now. We have been told by some leaders the compassion is weakness, and of course, we don't want that in this country. So compassion is now radical. And I'm okay with that. I'm perfectly okay with that. Yeah, yeah.
- [59:13]
A
Yes. No, I, I, I, I, I should look into that and what, what comments have been made and, and because, of course. Yes, that's, yeah, that's my whole sort of mission too.
- [59:24]
B
I know.
- [59:25]
A
It's kind of what made me think of it, getting the word out there that, you know, like, we can be sensitive to suffering and do things to try to help alleviate it. You know, that's what it's all about, really, isn't it?
- [59:37]
B
Yeah. And that's powerful. That isn't weakness, you know, that is true strength.
- [59:45]
A
Agreed. Well, DD Stout, thank you for the book. It's, I, it's currently on, on Kindle in Australia for $11 and something. So it's, it's, it's a, yeah, it's a really good deal at the moment. And, and I guess in America, yeah, for, in US Dollars, it's probably more affordable again, but it was really great to dive into it and hear all those stories and, and to, to learn from you as well today. So thank you very much for speaking on compassion in a T shirt.
- [60:18]
B
Yeah, thanks so much, Stan. I really appreciate it.