Harm Reduction in Alcohol Health with Expert Dr. Andrew Tatarsky
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MIke Hardenbrook:you could benefit from drinking a bit less, head on over to sunnyside.co to get a free 15 day trial. I'm your host, Mike Hardenbrook, published author, neuroscience enthusiast, and habit change expert. In this episode, I sit down and discuss the concept of hard reduction with doctor Andrew Tatarski,
Mike Hardenbrook:a renowned expert whose innovative approach is reshaping addiction treatment. With decades of experience in a passionate advocate for change, doctor Totarski challenges traditional abstinence models. Instead, advocating for personalized compassionate care. So don't miss out on this discussion with one of the fields most influential voices. I have Andrew Tatarski here with me on Journey to the Sunnyside.
Mike Hardenbrook:Andrew, thank you for coming on today.
Andrew Tatarsky:I'm very excited to be with you, Mike.
Mike Hardenbrook:Well, Andrew, you are a pioneer when it comes to harm reduction and, more specifically, harm reduction psychotherapy, a term that you actually coined, I believe. But can you give us a little bit of a history lesson around what harm reduction is, what your work in harm reduction,
Andrew Tatarsky:boy. That's a lot of history to, you, collapse with some cliff notes. No. Harm reduction as a philosophy and primarily as a public health strategy was born in the eighties, in the mid and late eighties, in the midst of the HIV AIDS crisis, you know, and in Europe. And then it was kind of brought to the United States by a bunch of activists and, public health people.
Andrew Tatarsky:And it really, focuses on addressing or reducing the harms associated with risky behavior and at that time, primarily, IV drug use, you know, to help people stay alive and safe. And, unfortunately, it took an epidemic, you know, the HIV AIDS crisis, to force the society and and the globe really to shift away from what had been and still is to a great extent a prevailing kind of abstinence only ethos about drugs and alcohol. That is if you're in trouble, you know, the only reasonable or acceptable goal is that you gotta stop. And, you know, people were dying all over the planet, And so that forced the shift away from this kind of requirement or commitment to getting people to stop using, to helping people who are using and not ready to stop to use more safely. And so that's really the the primary shift.
Andrew Tatarsky:Now, in the, I guess, the, early nineties, myself and a small number of psychotherapists, mental health professionals, actually were introduced to arm the harm reduction philosophy and really saw it not just as applying to public health, and many other life saving kinds of activities, but we saw it as a framework that could support setting up helping relationships. Really, this is how I've come to think of it. You know, applying it to psychotherapy, to counseling, and even more, recently, you know, to the full range of helping relationships, including, you know, peer support and support of significant others. So, and I'm gonna try to make this real quick so we can unpack a lot of this in our discussion, but Sure. I had gotten into the addictions field, right out of graduate school, in the early eighties, because I had seen a bunch of people that were struggling with substances in my training.
Andrew Tatarsky:And I just thought this was an incredibly wonderful, diverse, group of people who were suffering and really wanted and needed support to make positive change in their lives. And that was such a positive set of experiences I chose to specialize in the addictions field. When I came into the field, I was taught that, you know, everything I learned in graduate school, we had to throw out because when you're talking about addicts and alcoholics, I put that in quotes because I really question those concepts. All bets are off. And I learned this disease model abstinence based approach to treatment or abstinence only approach.
Andrew Tatarsky:I worked in that, in that field, in that way for the first, I guess, about 8 years of my career. And while I think we helped a bunch of people, what I began to see in our programs, and then as I looked around at the fields at large, that we were not helping the overwhelming majority of people that were coming to our programs. The majority were not completing. The majority were not stopping, and, actually, the people that were coming to addiction treatment were a tiny fraction of the people that were struggling. That those data, are more true today than ever before.
Andrew Tatarsky:And so that you know, when I would say failure to treat the overwhelming majority of people that are struggling kind of forced me to kind of question the basic assumptions, the basic narratives of addiction as disease and abstinence only as a framework for setting up treatment. In the late eighties, early nineties, I began a small private practice, and I began getting referrals from people that were actively struggling but were not interested in stopping. They seemed to be good candidates. They wanted therapy. They wanted help, so I figured the traditional approach is not helping the majority of folks.
Andrew Tatarsky:I'm just gonna break the rules and experiment. Many of those people did incredibly well. They cut back. They stopped in some cases. They worked on other life issues.
Andrew Tatarsky:Now I'm in this kind of theoretical philosophical crisis. You know, the dominant approach isn't helping most folks. Breaking the rules is what's going on. So I had the good fortune of having a relationship with a man named Alan Marlatt, who was really a giant in the addictive behaviors field, one of the people that introduced mindfulness into the addictive behaviors field. I called Alan up in 1994, and I said, what's going on, Alan?
Andrew Tatarsky:And he said, you're doing harm reduction. That phone call, which I remember, you know, clear as day, I was sitting out in my little patio on the phone, you know, completely transformed my life and my career as I really learned about harm reduction, as I said before, as a set of principles that I think of as, offering of a whole different way that we can frame helping relationships that basically opens the door to the tremendous majority of people that we have not been effectively able to help. So that simple shift from abstinence only, essentially, to any positive change, you know, meeting people where ever they're ready to begin their positive change journeys around what's important to them. So it kind of clips the traditional approach on its head. Instead of saying, we know what your problem is.
Andrew Tatarsky:We know what you will have to do, and if you don't do it our way, you can't come into treatment. We say, well, actually, we just met you. We don't know. You're a unique human, struggling with your own unique version of a substance use issue. Let's really start where you are, create a safe space to support you in discovering what's true for you about your problematic relationship to substances or other risky behavior, and what goals and approach to change best suit you.
Andrew Tatarsky:So I think that that, set of principles, basic harm reduction principles, really lends itself to engagement, creating safety, creating alliance, empowering people, you know, working collaboratively to support them in their discovery and on their journey as they define it. And all of those elements are really highly evidence supported, as improving, you know, our effectiveness at helping. And and by the way, it opens the door to diversity. Right? So diversity of goals, safer use, reduced use, moderation, including abstinence.
Andrew Tatarsky:And I think that's a major misunderstanding about harm reduction that it's like harm reduction or abstinence. This is an umbrella concept that enables us to meet people across the full diversity, you know, of positive change goals, of readiness to change, you know, And then, you know, meeting people where they are becomes the point of contact around which we can establish our helping relationships. That's a little
Mike Hardenbrook:bit I love all of this, and you actually beat me a little bit to the punch because I was gonna ask as you were winding down there. You know, do you think that was this something that you felt within you within your practice anecdotally from patient to patient that you felt like some in some way, the current model wasn't serving the vast majority or was failing people that were even open to entering it. Because I do remember, and you can correct me if my stats are wrong, but I think it was something around 10% actually seek treatment that need it and 42% follow through with actually completing that treatment. Is was it the data that was showing you? Was it the was it the interactions?
Mike Hardenbrook:Or was it a combo of both that started this paradigm shift inside of you?
Andrew Tatarsky:Well, I would say that it was the my first, my my experience in helping folks and my experience, you know, looking at the programs that I was working in. And in fact, I had the good fortune to, become the clinical director of a couple of programs, I think, that were premier programs. And we were trying to do state of the art, really cutting edge work, but we were still hamstrung by this abstinence only ethos, really, which I think, you know, was the only way that you could think about working with folks that were addicted, struggling with substances. So I was, you know, looking at our data and and becoming increasingly disturbed and ultimately shocked. And then I began looking around at the data of the field more generally, and that just seemed to confirm it.
Andrew Tatarsky:And and the field essentially was saying, well, you know, I mean, blaming the patient. You know? Well, these are tough patients. You know? They haven't hit a low enough bottom.
Andrew Tatarsky:They, are not ready. They're not sufficiently motivated. So the mismatch between, you know, the failure basically was being blamed on the patient, and I and I began to think there's something wrong with that picture. You know? What are we not doing?
Andrew Tatarsky:What are we doing as a field to contribute to that failure? The data you cite, are mind blowing, and today, they are the same. I didn't have all the data back then, but now federal government does a household survey on drug use and health every year, and they estimate they estimate today that there are roughly 48,000,000 people in the United States that struggle with what we call substance use disorder. That's more severe problematic substance use. They also estimate that there are a 100,000,000 Americans or people living in America that struggle with problematic substance use that doesn't meet substance use criteria, the sort of criteria, 100,000,000.
Andrew Tatarsky:We're talking about a 148,000,000 people living in this country. What percentage of the adult population is that? And only 2,000,000 of that huge number go to specialty addiction treatment. And as you said, SAMHSA tells us that less than half actually complete treatment. We know that many people who complete don't maintain their gains.
Andrew Tatarsky:So what's wrong with this picture? The impetus for harm reduction back in the eighties was HIV AIDS. I think the impetus right now to embrace it, and luckily, finally, there's an increasing embrace of this model across every sector of our country. And it's the overdose, drug poisoning crisis, which is killing over a 100000 people a year, from illicit substances. But we also have roughly that number of people dying from alcohol related causes, every year.
Andrew Tatarsky:So the harm reduction impetus is really we gotta do better. You know? How can we improve our effectiveness in helping? Alan Marlott called that compassionate pragmatism. Compassion is the impulse to reduce suffering or improve help improve the quality of life.
Andrew Tatarsky:The pragmatic part is that we have to be courageous and honest with ourselves as individual practitioners, and I think as a field, as a society, and really look at what's not working and have how can we improve what we're doing to be more helpful to more people? That's really where this comes from. And I think the data is showing that harm reduction public health, harm reduction therapy, harm reduction substance use treatment, all of the elements of it actually work better.
Mike Hardenbrook:I can relate so much because, I guess, I would fall into that category of the 100 +1000000 that you that wouldn't categorize under a substance use disorder, but I had problematic habits around substances that I wanted to change. And I didn't relate or identify with the disease model or the abstinence model where I had to admit it was a disease. I had to give myself a label. I had to say it I was powerless for the rest of my life, and that the only answer was this one method. And so I think you would probably agree whatever works for you is is the right solution.
Mike Hardenbrook:But at the time, when I wanted to make a change, I felt a a little bit of an impasse on where I could go since that was really the only one that was front and center.
Andrew Tatarsky:That's right. That's right. That's the only one that was front and center for, many, many years. And, unfortunately, it is still the case in many places, you know, around the United States, Although it is you know, I I think of this this moment as being in the midst of a paradigm shift. I mean, it's really on the order of a scientific revolution where, the way that we understand the spectrum of problematic substance use is shifting.
Andrew Tatarsky:There's a growing embrace of, an alternative to what you mentioned, that disease model, which I think of as, I mean, just a model. I I I must say, there's a was a philosopher, semanticist named Korzybski who came up with the idea that the map is not the territory. Many people have heard that phrase. You know, our maps, our models are not the thing. You know, there are attempts to make sense of it.
Andrew Tatarsky:So the disease model was an earlier attempt to understand and make sense of this phenomena, which is it's it's real. There's something there that, you know, many, many people experience feeling out of control and feeling desperate, feeling like like they're invested in doing something that, you know, can really threat and harm things that people really care about, including their lives. Yet the disease model, I think, suggests, a reductionist view to biology. And I think, a, the the phenomenon, the experience, the behavior that we're talking about is much more complex, is multiply determined, is basically unique for each person. It's kind of how I think about this new paradigm, this new way of thinking.
Andrew Tatarsky:And it requires a different model, to kind of really understand that complexity. And, b, it hasn't worked very well just like for you. And you said, it it turned you off to treatment. You didn't wanna and you didn't identify with the idea that you were sick, you were diseased, you had a pathological relationship with alcohol. So you it it it decreased your motivation to get help and probably prolong the problem in some sense Yeah.
Andrew Tatarsky:Contributing to that. So what if we come up with a new model that really can be much more individualized, can be curious about the multiple determinants that might be contributing to one's problematic relationship substances that I think include the psyche, the body, relationships, habit, social context, you know, what's happening around us. After all, during the pandemic, you know, lots of people increase their substance use, and many people who were really stable in their recoveries or their positive change, you know, sell back into old habits. And, they didn't all suddenly, you know, get this disease. You know?
Andrew Tatarsky:I mean, there's a I think one of the things I I have come to increasingly embrace is the idea, like, Gabor Mate kind of has shared shared this idea that it's a response to suffering. We turn to something, a substance, another activity when we feel overwhelmed, when we feel bad, when we don't have other skills, other coping strategies, other resources. And then over time, we can that can become the go to. You know, even when some of those sources of suffering begin to change and kinda take on this life of its own. I know, you know, in the work that you've done, that's very consistent with the idea that, of learning, of habit, that that these complex behaviors become deeply ingrained in neural networks such that if we decide, hey.
Andrew Tatarsky:I don't wanna be doing this anymore. It ain't so easy to kind of change these patterns. But shifting from a disease model to, you know, meaning, function, relationships, social context, habit, we can identify those specific variables or vulnerabilities, you know, for each person and help people begin to goal set, around different solutions, different strategies, different ways to care for express, and then we can work on the behavior change front. We have a lot of knowledge, skills about how to help people make those kinds of changes. So, actually, it's more its model is a much more hopeful, model that can lead to very specific steps people can take on their own.
Andrew Tatarsky:And, if they choose to get the professional
Andrew Tatarsky:support with with that.
Mike Hardenbrook:If there's one thing that I know in my research writing and own personal experience is that there's a massive amount of complexities ranging across personalities, use, behaviors, you know, you name it. And so I think a one size fits all is really unrealistic to think that that that has to be the solution. But let's zoom out for 1 minute to, like, a 10,000 foot view. We start we sort of got into what the quote, unquote disease model or abstinence model is in our reduction model. Can you give us, like, just a real quick, you know, overview of what each of those are and maybe some of the the main differentiators that you see, you know, and where it's all going?
Andrew Tatarsky:Well, the disease model, it's like a, it's like a story. Right? An addiction story. In the early days, or back in the middle part of 20th century, Jelinek was one of the major proponents, but it really got out through traditional addiction treatment. And the story is that addiction is a permanent chronic progressive disease only arrested by complete and total abstinence.
Andrew Tatarsky:And that was largely drawn from the big book of AA, which, Jelinek did a study of AA members. Not a very scientific study. He did a survey of self selected AA members and ask them about their views and their experience about addiction. And based on that, AA is a wonderful program for people for whom it works based on the big book, which was written by a bunch of nonprofessionals. It sound, you know, that pathway helpful.
Andrew Tatarsky:But based on that survey, he wrote the disease model of alcoholism, and that book came to characterize the addictions or alcohol and substance use field. Right? So that mock that narrative, that story, only arrested by complete and total abstinence. The corollary one corollary is if you don't accept it, you're in denial. So, you know, you have to accept the disease model, in order to be a good patient or be a good person in recovery.
Andrew Tatarsky:And if helpers don't enforce it, we're enablers. So that kind of has given rise to a field that feels that it's important that we enforce in whatever way we possibly can, you know, cajoling, supporting. I mean, coming from love, I believe most people in this field are in it for love, Shuri, for the money. And yet the model, you know, only leads to that one pathway to change. The acceptance that you're have a disease, you're out of control, you must commit yourself to abstinence, And then there's a sort of a psychoeducational and and some good behavior change strategies involved with this.
Andrew Tatarsky:And usually, traditionally, it means also you have to go to AA as the premier abstinence based self help program. One of the things I'd think the limitations of it is it puts the behavior change process before many, many things that often need to be addressed for people before they're ready to make positive change in their lives. Ambivalence, you know, the role that the substance is playing. It may be actually helping, you know, to manage serious psychic distress. It may be helping people stay alive, you know, self medicating suicidal depression, you know, paralyzing depression or anxiety, trauma, the symptoms of trauma.
Andrew Tatarsky:So to the extent that the substance use is intertwined with these really complex personal issues, and often those get entwined in relational issues and lifestyle, you know, to try to change the behavior before you've, a, understood that connection, b, begun to identify the factors that may be driving it or contributing to it, and then maybe helping people come up with alternative solutions is just a no brain it's a setup for failure, or it it's not intuitive for people. It doesn't make sense. That's not how I experienced my relationship with substances. So what a harm reduction approach does is it says, actually, let's clear away all of those presumptions. Let's let's presume that we all are products of this society.
Andrew Tatarsky:We've internalized all of these narratives consciously and unconsciously. They can block us from actually being able to see and hear that unique person who's sitting in front of us. So the first step is we have to put our assumptions. We have to check ourselves as helpers, you know, because we need to kind of stay on top of and clear away those assumptions, those agendas, our values, our emotional reactions, which may be very real for us, but may be very out of step with that person. Right?
Andrew Tatarsky:Then the harm reduction frame says, you know, we can meet people with any positive change that they're ready to begin working on. What motivates them? What brings them? Then so that's the any positive change idea. So we abandon the abstinence requirement or really any requirement except the person wants to make positive change, then we can truly start where people are as unique individuals.
Andrew Tatarsky:That's sort of the second principle. Right? You know, what brings you? What are your goals? What do you want to work?
Andrew Tatarsky:How can I be helpful to you? So that stance is both gonna, you know, help us identify issues that we can come together in alliance working together as therapeutic team, right, to support that person on their journey rather than imposing ours. And that really lends itself to, you know, a strong collaborative helping relationship. Then we can start goal setting in tiny small incremental steps. Okay.
Andrew Tatarsky:This is where you are. What would be a positive step that you'd like to explore? I mean, maybe what's your ultimate goal? Abstinence, moderation, safer use. But maybe what's the first step in the change process that we can begin to experiment with, either around the substance use or maybe around clarifying the connection to other issues, addressing some other issues, you know.
Andrew Tatarsky:And then we get to to to bring our curiosity, our respect, our compassion, our, collaborative spirit to invite that person to kind of become an empowered participant in the change process. And then we get to kind of work together, you know, to clarify goals, to clarify a positive change process or or strategy or treatment plan. We get to ferret out all of the complex factors that are contributing, that are unique for that person. Pat Denning called that assessment as treatment, where, you know, in our Good Therapeutic Alliance, we can put our heads together and now create a space to begin exploring into this complex relationship to substances. One of the techniques that I love is, and I know you talk about this in your book, urge, stirfu.
Andrew Tatarsky:So, the Alan Marlatt actually gave us this technique. He contributed that. If we can bring mindfulness that is curious, accepting, and kind awareness to what's present in the moment, and in this case, to an urge. And we can bring that mindful awareness to an urge and simply breathe with it, sort of he says it's like the breath is like the surfboard that, you know, surfs over the waves of that urge. We cannot put a little pause around it.
Andrew Tatarsky:Now we can do this work as individuals working on our own change process, or we can teach our clients or patients or loved ones. And it it can be something people can get better at regardless of whether they're ready to begin working on behavior change. It's a it's a skill that can actually help people sit still with the the distress of feeling an urge and not acting on it. And like surfing, if you practice it, get better at it. Yeah.
Andrew Tatarsky:Then that itself can lead to all sorts of other techniques and strategies. I think about that urge as, like, the axis of change.
Mike Hardenbrook:A lot of the people that are listening identify with that in some form or another because they want to change their habits around alcohol, using Sunnyside. You know, in in Sunnyside, as you know, is a platform that really takes that harm, reduction approach in the 5 core principles, which I'd love to hear your take on those, which are rooted in planning, tracking, community, coaching and analytics. So what's the importance of each of these pillars?
Andrew Tatarsky:Well, planning is key. You know, I was gonna say, once we do that microanalysis, we begin to get a sense of what are the aspects of our drinking that we wanna change. That's identifying what's problematic. Right? But then I find it very useful to try to get as clear as possible about your ideal or optimal drinking plan.
Andrew Tatarsky:How do you ideally want alcohol in your life? And, you know, I've spoken to lots and lots of really bright, capable, creative, successful people, you know, successful in many ways, you know, in their lives, who have concerns about their drinking. When I ask them, how do you think about, you know, ideally having drinking in your life? Know what the number one answer is. It'll it'll be like a talk show.
Andrew Tatarsky:What is it? I asked. I don't. Haven't really thought about it. Precisely, how do I want alcohol in my life?
Andrew Tatarsky:You know, that optimal drinking plan, I think, is a framework. It's a great strategy for really beginning to think through in a very specific way. You know, subjectively, I don't I wanna feel in control. I don't wanna feel ashamed. I don't wanna feel stupid.
Andrew Tatarsky:I don't wanna lose my judgment. I don't wanna worry about my health. That's kind of the subjective goals. But then, objectively, what kind of pattern of use would actually help you achieve that in terms of amount, frequency. And so here's where the planning comes in.
Andrew Tatarsky:Amount, frequency, under what circumstances. Right? And this can be a work in progress. So, you know, let's initially come up with a guesstimate about what that's gonna look like. Now we can start evaluating it.
Andrew Tatarsky:Here's where the tracking comes in. You know, tracking, you know, when I begin to implement my plan, how does it work out? You know? If I, you know, drink x number of drinks measured, paced over time, in a certain circumstance, does it actually help me achieve my goal, or do I go overboard? And then I have to kinda go back to the drawing board and tweak the plan.
Andrew Tatarsky:Right? And then we might also add in identifying the times when I go overboard or get into trouble. What are the factors and the circumstances there that may contribute to that? And then we need to kinda goal set and plan around those issues as well. So we're working both on the alcohol front and, you know, the other fact identifying and addressing the other factors.
Andrew Tatarsky:So that's planning and tracking. I think tracking, Whether you track with mindfulness, just kinda go out and observe your urges, observe your behavior, observe observe the connections, sequences between an event, thought, feeling, a drink, urge, thought, the behavior, and then how does it work out? Or tracking with, you know, the Sunnyside app. What this does is it it reinforces mindfulness. So part of what we're supporting people in doing is moving from a mindless tracker, you know, as I said, people who haven't really thought about it, to a very mindful drinker.
An:I mean, that's that's
Andrew Tatarsky:the major bottom line commitment to do I want to become a mindful drinker. And as people become mindful, that itself is associated with positive change in so many ways. Like, I'm noticing that I don't feel good. I'm I'm throwing all these drinks back, but, you know, then I wind up feeling awful. You know, what'll happen if I just slow it down?
Andrew Tatarsky:Drink a little later. Actually, start measuring my drinks and get a shot instead of a martini. Observe the differences. I think of it, and I talk with my clients about doing experiments. No.
Andrew Tatarsky:Play with the change. It's an experiment. You can't fail because it's all about gathering information. Yep. What did you learn from that experiment?
An:So how
Andrew Tatarsky:did it work out? Now what might be the next step for that optimal drinking plan? Now you mentioned 3 other values that I can't recall at the moment.
Mike Hardenbrook:Yeah. So I wanna I wanna make a comment. Whenever I've heard you talk and
MIke Hardenbrook:you say, let's try an
Mike Hardenbrook:experiment, that resonates so much with me as such an easy step because it's such a low commitment, such a low friction ask of somebody. It just says, let's try something together.
Andrew Tatarsky:Yeah.
An:That's cool.
Mike Hardenbrook:Yeah. The other would the other one would be community. Uh-huh.
Andrew Tatarsky:Well, you know, Alcoholics Anonymous has proven to the world that, you know, community helps many, many, many people. Alcoholics Anonymous is a great program for many people, and it's not, it's not a good fit for, I would say, the majority of people that struggle with substances. What what many people don't understand is AA is sort of the only criteria for membership is a desire to stop drinking. So, actually, you don't need to stop drinking to go to AA. And in that sense, it actually is a kind of harm reduction program, but it's about a desire to stop, and there's a pretty strong, community, expectation that, you know, you're working towards stopping.
Andrew Tatarsky:And there's also a very, specific program that you generally need to buy into. And for many people, it's life saving and it really resonates with them. I would say for the majority of problematic drinkers, it doesn't. And so we need lots and lots of other communities, I think.
An:You
Andrew Tatarsky:know, many people have said that one of the major problems in contemporary society is that we've lost a lot of our traditional communities, supportive communities. And I think for some people, going to a bar is like their community. You know? But I think people in isolation feel more scared, more overwhelmed, are more vulnerable to turn to substances and other kinds of problematic behaviors to comfort themselves.
An:Now so, of course,
Andrew Tatarsky:you know, having communities like moderation management or or a variety of different sort of mutual support organizations that can really meet people around a variety of different goals is really important. And the more of these different mutual aid programs we have, the more folks, you know, can find their community. Moderation management is a is a community for people who are interested in pursuing or exploring moderation. I would say the majority of people that are concerned about their drinking are there. I think Sunnyside Oh,
Mike Hardenbrook:and by the way, many people
Andrew Tatarsky:come through moderation management and other non abstinence focused, programs actually choosing abstinence. So, Sunnyside, I think, is another community, in effect, that people can connect with on the app, and be really a part of this very large community of people all over the world that are pursuing the same kinds of goals. And I think I'm also aware that some folks come into, you know, get involved with the app around a moderation goal, and some of them choose to stop drinking. So, this is the beauty of the harm reduction approach. I mean, that this phrase occurred to me one day that we don't need to know the destination to begin the journey.
Andrew Tatarsky:So I think most people start a positive change process with substance use confused, unclear, maybe in crisis, maybe ambivalent about making change. Harm reduction organizations, treatment, apps Say, you don't have to commit to your ultimate goal to get started. Just start planning, tracking, becoming more mindful, thinking about what changes you wanna make. Start, you know, working in a positive direction toward a discovery of what that ultimate ideal healthiest goal for you will be. And any positive change is gonna reduce the harm, increase people's well-being, increase people's hope, self efficacy, you know, the sense that, you know, I can make changes.
Andrew Tatarsky:I'm not powerless. And then we can all kinda walk together toward that ultimate discovery.
Mike Hardenbrook:Yeah. I mean, I think one of the things that you say there is, it's it's a low friction ask. It's a starting point. You know, Let's say we were talking about abstinence. If you're just problematic drinker and then the idea of, is giving it up forever, that's a big life decision you gotta make.
Mike Hardenbrook:It probably not your highest, most clearest point. Whereas you can start taking small steps that maybe reduce your anxiety, maybe reduce your angst, and maybe you can start making decisions long term for yourself when you're in better state of mind. From my perspective, that's one of the most beautiful things I think about what you're doing with harm reduction.
An:Cool.
Andrew Tatarsky:Well, thank you. I mean, I I think harm reduction for me is a beautiful philosophy. It's it's firming. It's respectful. It's empowering.
Andrew Tatarsky:It honors diversity. It's about people working together collaboratively. You know? I mean, actually, I think that it's, a good philosophy that probably has much broader, applicability to human relations in general because it's really about, mutual respect and collaboration and empowerment and, you know, creating a safe space to have difficult conversations about potentially challenging really challenging and difficult issues, which a lot of people around the world are having difficulty doing these days. Yes.
Mike Hardenbrook:You know, I think it is about meeting people with their goals and working together. Do you think, like, Sunnyside provides that environment for an alliance to create a plan together and then follow through and and all the way till you meet that goal?
Andrew Tatarsky:Absolutely. It's very user friendly. It's very respectful. It's very individualized. It it has a lot of things that you know, resources that people can take advantage of, kind of allows people to do it at your own pace.
Andrew Tatarsky:So and and, you know, and it is when you get involved with the app, you join a community. And and they're actually people that can you know, you can connect to for mutual support in a variety of ways. So I think it's a it's a great resource, and, I'm glad to know about it and, you know, to become a part of the Sunnyside community in whatever way that I can.
Mike Hardenbrook:Yeah. We love your value and input and coming to do, you know, a podcast like this. And, you know, we got to meet last week and, you you know, used a valuable resource to be able to offer feedback and, encouragement that, you know, a lot of the things we're doing here, we're on the right track.
Andrew Tatarsky:Yep. Can I, share with, the folks that are listening about the the latest developments in my professional life? And I think, you know, that's gonna be a really interesting way for Sunnyside to partner with a wonderful organization.
An:About
Andrew Tatarsky:3 months ago, I was invited to join, the team at Silver Hill Hospital in Connecticut, which has recently acquired the Freedom Institute, which has been a traditional addiction treat outpatient addiction treatment center in Midtown Manhattan. And they brought me on board in order to work, with the existing team and to grow the team to create, a full continuum of care based on harm reduction treatment principles. So, we're transforming, the outpatient program to keep an abstinence focused, intensive outpatient program, but then extend the program with individually tailored services to really be able to reach, you know, the whole spectrum of people that are struggling with substance use issues. I think that that that model does not exist, in maybe anywhere on the planet except few small programs are experimenting with that. But, plus, we're also retraining the staff on the inpatient mental health substance use hospital, also incorporate a harm reduction treatment philosophy so that we can have this entire continuum of care where we'll be working with people who are pursuing abstinence and people that are pursuing moderation and safer use, right, in the same, organization.
Andrew Tatarsky:And we're gonna be inviting folks to access the Sunnyside app. And, you know, we've brought some researchers on, and we'll be working with the folks at Sunnyside to really be able to, see just how, you know, working with the app can inform, you know, enhance, support, you know, the effectiveness of what we're doing kind of in the treatment side. And, I'm really, really excited about what we're doing. You know, we're this is a large respected organization that has a great reputation and that is committed to creating, you know, excellent hair. My philosophy is, you know, I wanna create a treatment system that I would feel good about sending anybody that I love to.
Andrew Tatarsky:But, you know, also, you know, piloting or seeing how we can make best use of Sunnyside app
An:is also gonna be a very exciting
Andrew Tatarsky:part of our process.
Mike Hardenbrook:I think it's gonna be really exciting, especially, you know, just like you said, you know, you wanna refer things to people that you love to, and just being out there and trying to help people and meet them where they're at. Well, I I actually wanted to have a few more, comments from you, if you don't mind, around moderation and harm reduction. Because while we talked about, you know, how how well it's working in your practice, it still draws a little bit of controversy. So I'd actually like to ask you, why do you think that is?
Andrew Tatarsky:The first thing that comes to mind is ignorance, and I don't mean that in a pejorative sense. I mean, just that, you know, this, Earl, the the addiction as disease narrative that I think has really saturated our society and also globally.
An:You
Andrew Tatarsky:know, makes a kind of a non abstinence based approach scary. I mean, if you really believe that this is a disease that is only arrested by complete and total abstinence, You know? And people believe it, you know, in the core of their being. Right? That, god forbid somebody put a spoonful of wine, you know, in the boulevance, you know, all and, you know, it's gonna trigger that addictive, you know, relapse that will inevitably result in incarceration, insanity, or death.
Andrew Tatarsky:This is a scary, scary, scary narrative, and I think actually that many people who who have gotten sober with that narrative live in fear. It's a fear based, approach to recovery for many people. I think many others can get past that. Right? They see it as a metaphor, you know, disease.
Andrew Tatarsky:Right? So but for many people, it's very scary. So then you have a whole addiction treatment industry that was bifurcated from, mental health care, that was, you know, based on that narrative. So many, many people, in that industry got sober with that narrative, and so they feel very threatened by a non abstinence based approach threatened, you know, personally. I'm seeing that with some of staff, you know, where I work.
Andrew Tatarsky:It it brings up very complicated issues for people. You know, I was taught I could never drink. How is it that we're now considering that maybe this person can learn to drink? That can be really threatening personally on multiple levels. Or, you know, people have lost, you know, loved ones to overdose, to car crashes, to all sorts of substance related tragedies, you know, and so that reinforces, you know, this notion that abstinence is the only way.
Andrew Tatarsky:Then you've got an industry that is based on promoting this narrative.
An:You
Andrew Tatarsky:know, multimillion dollar rehabs. You know? And the business of rehab is a film. I think that's the title that was done that, you know, explored this business, you know, where CEOs, and any of these large rehab companies are making loads and loads of money based on this industry that by and large doesn't work. People go around the rehab merry-go-round, to the tune of 100 of 1,000 of dollars off.
Andrew Tatarsky:Unfortunately, before they get to a harm reduction therapist, We get many of our patients who have been just abysmal treatment failures, you know, until they come to harm reduction therapy. And I think the government has been invested in it, although that's changing. But, you know, the government criminalized drugs after alcohol was, you know, prohibition was ended so that, those government agencies can have a reason for being. And Nixon and his cronies very explicitly declared a war on drugs for political and racist, reasons to have a pretext for going after his enemies. So think about the criminalization, stigma, and problematic substance use, you know, and the disease model as, you know, the most prevalent narratives that, you know, our society has believed in.
Andrew Tatarsky:So the scientific revolution that I was talking about, the paradigm shift in understanding supports a shift in treatment, but now we've gotta change all of these the ways in which these other narratives have been institutionalized throughout society by the criminal justice system that's based on abstinence, treatment programs that are based on abstinence, people's personal recoveries. The good news is, though, that it's changing. New York State's office of addiction services and support in the last several 5 years or so. That's the organization in New York State that licenses addiction treatment throughout the state. They have made a complete shift toward embracing a harm reduction philosophy and asking all of their licensed programs to incorporate it.
Andrew Tatarsky:Most or if not all of the federal agencies that are involved with, regulating or, you know, overseeing issues related to drugs and alcohol in this country have embraced harm reduction, including the White House Office of National Drug Control Policy, is supporting harm reduction. National Institute of Drug Abuse, it's under Nora Volkow, is supporting harm reduction. SAMHSA. I mean, it's so the people that know what they're talking about and know what the research is and know what the needs are are by and large beginning to embrace this approach. And now we need to help get it, you
An:know, get it
Andrew Tatarsky:across the country. It's advocacy, education, podcasts, and webinars, and, you know, like this one. We've had to educate the public that there is this alternative, and when they hear about it, by and large, they want it. But the problem is that most people don't know about it because many of the reasons I was talking about.
Mike Hardenbrook:Yeah. Well and that's why I'm incredibly grateful and thankful that you are doing the work that you do and that you come on podcasts like this, that you write so many different publications, and that you're all actually, you're all over the Internet. If you just do a Google for your name, you can find some great information there. I know I did, and I, really enjoyed the listens. And, the great point to that question, which ended on a high note, is that it's the work that you're doing is being validated in very high and prestigious and visible places.
Andrew Tatarsky:It's been an amazing journey, I must say. An amazing journey. This is 30 years since I was formally introduced to harm reduction, and back then, it was considered a dirty word if people even knew what it was by most mainstream people. Today, it's now a major part of the conversation. People wanna know about it.
Andrew Tatarsky:More and more, treatment programs are inviting me to train them, consult to them, Places like, you know, Silver Hill Hospital Freedom Institute are making a total commitment to it. Very exciting time. And also over the 30 years, I've met the most incredible people that I've learned from, you know, my clients, my colleagues, harm reduction workers, globally. It's it's a global movement. And, really, I think about folks who are courageous and wanna be more helpful to more people are really heart centered.
Andrew Tatarsky:You know, it's a fabulous community yeah. To be a part of. So you talked about community. The harm reduction, you know, moderation, we haven't talked about psychedelics. There's also an overlap, you know, when we think about doing what works, people who are committed to doing what works rather than, you know, what we've been ideologically programmed to believe are, you know, my communities that, you know, I've learned from, get support from.
Andrew Tatarsky:I feel kinship with Juan. And I invite everyone folks to join us. I often tag things that I write with, you know, join the global harm reduction movement, and be part of the solution. Because it's Yeah. Been that for me, on personally and professionally.
Mike Hardenbrook:So good. And and one of the things you said there that's I think apparent to anybody that's, like, listening is that you definitely need this with your heart. You can feel that your heart is leading you with this. And, and for that, I thank you. If anyone listening wants to learn more, read more, maybe even reach out, where can I direct them to go?
Andrew Tatarsky:Yeah. Thank you. I'd love to hear from people. I always like to be in touch with folks. I've got, as you mentioned, a number of papers I've written that I can share with people for free, or they can access.
Andrew Tatarsky:There are really 2 places. 1 is my personal website, which is andrewtotarski.com. And people there's a you know, people can contact me through that. People can stay up on my various activities. And then freedom institute.org is a website where that's kind of my home in Midtown Manhattan on 53rd Street in Madison.
Andrew Tatarsky:And if people and there will be information there on the harm reduction and form treatment that we're developing and offering there. So that might be interesting for folks to see what that looks like. But, also, if people come to my, personal page, under the about tab, there's a bunch of papers of mine that people can just click on and access for free and download. And, of course, we haven't talked about my book, but, people can find my information about my book, harm reduction psychotherapy, a new treatment for drug and alcohol problems, at my website, ambrochotarski.com. And, actually, the I should say that the the book really started in the core of the book is 10 psychotherapy stories.
Andrew Tatarsky:And I collected these stories from different therapists. One of them is my own to really be, really, stories that bring the work to life, harm reduction therapy to life, by bringing the reader into the therapy office and really getting a sense of what goes on between 2 people when they're doing harm reduction therapy. And one of them is trying to be helpful to the other. And then I wrote a whole book around those psychotherapy stories. So they, you know, they I take that the stories really bring the work to life, and you also get to see many people wound up successfully moderating very difficult relationships to substances.
Andrew Tatarsky:Some of them stopped and ultimately chose abstinence. So you really get a sense of that, variety and diversity that we've been talking about. So that might be something else people would be interested in checking out.
Mike Hardenbrook:Oh, yeah. Definitely. And I think story based I mean, that's almost part of the reason I tried to use myself as a guinea pig because, you know, people can can sort of put themselves in somebody else's shoes in that way. And so I think that was genius
An:that you read it that way. You know, there
Andrew Tatarsky:is another part of my story, and I don't know if how much time, you know, there is. I'll tell very, very briefly, but I know in you picked up on this, in some of your comments that you shared, you know, before the podcast. It's my own story about, my own drug treatment trauma that I experienced when I was 15. You asked me at the beginning how I got into this work, and what I told you was the first story that I told myself, which was true. But about 15 years, really, into my journey of drawing out the therapeutic implications of harm reduction, in my own personal therapy, I made a connection back to an experience I had when I was 15 in a nonresidential therapeutic immunity, a drug treatment program.
Andrew Tatarsky:I had completely dissociated, completely lost touch with. And I realized that that experience, which I have come to think of as a drug treatment trauma, had been working in me to unconsciously to bring me into the field, sensitize me to what was wrong with it, and sort of empower me or inspire me to create this compassionate, harm reduction alternative. I mean, just very, very briefly, you know, I was a child of the sixties and part of, you know, being part of that scene was smoking pot or experimenting with psychedelics. And it was a wonderful experience in many ways. I had a lot of fun, and then I had some really, really bad acid trips and, terrifying experiences that led me to agree to go into this drug treatment program, nonresidential, but very intensive therapeutic community, to get away from that.
Andrew Tatarsky:And initially, it seemed like a very loving, and supportive program, and then I broke a rule. I picked a little plant on the side of the road that I thought might be cannabis to try to smoke it, and it was nothing. But I shared that, and then what had been this kind of loving, supportive community turned basically to hell. I became the target, of the most vicious attacks on, you know, humiliation, sitting in the middle of a room, you know, being yelled at, all names. You know, I tried to fight back where it's supposed to kind of express my feelings, and then they upped the ante with more staff to sort of be more vicious in their attacks.
Andrew Tatarsky:Folks may have heard about the philosophy of, you know, break them down so that you can build them up again. Well, that's what I experienced. They were attempting to break me down. And after some period of time, all feeling like this was, you know, an impossible place to be that they were really attempting to destroy me. I sold the way, I split.
Andrew Tatarsky:I was there voluntarily and I was starting a new high school. For the first time, I couldn't concentrate. I became a high school dropout. I was very lucky to find some safe alternative schools to kind of land in. And then I got on with my life, but the consequences of that were, you know, intense anxiety attacks, that I had never had before as a younger person.
Andrew Tatarsky:And I got back on track, but, it was fascinating to me that, that that experience was living within me and inspiring me to kind of do this work Mhmm. Create this alternative. And so I actually began to share it because I think that many, many people have experienced something like that in drug treatment, and many people have experienced much worse than I did. People who were mandated, people couldn't just leave, people there were programs that had more physical kind of abuse. But I think that we need to name drug treatment trauma.
Andrew Tatarsky:Many people have experienced it and need to kind of have a way of beginning to identify, you know, and name their own difficult experiences to begin a healing process. I think also my story is also a story of how we can transform traumatic experiences into kind of positive creative action. So that's another part of my message.
Mike Hardenbrook:Yes. So glad you shared that story. And for what, you know, when we all have our personal experiences and we look back, we realize how how we got here, not realizing it at the time that it was almost a a good thing that happened, you know, even though it didn't feel so good, but it certainly led you to where you are. And I know that, you know, I would've never written my book to try and help other people if I didn't go through some of those difficult times when I did. And so, yeah, the those, personal experiences really run deep and and drive us forward.
Mike Hardenbrook:And I know that there's one other topic that you talked about there that maybe I could twist your arm to come on for another episode that that would be around you back then with your psychedelic, experience, but then also your work now with psychedelics that we could maybe talk about some other time because we both write and have opinions on that.
Andrew Tatarsky:I'd love to do that. I'd love to do that. That's because I actually also believe that harm reduction informed addiction treatment or substance use treatment is the state of the art right now. How we might integrate Ketamine and other psychedelics when they come online into that state of the art treatment is at the cutting edge in the field right now. I think, the research and certainly anecdotal research or anecdotal experience about the value of psychedelics is just, you know, overwhelmingly positive.
Andrew Tatarsky:But what are the best practices for integrating those medicines into addiction and substance use treatment, I think, is still fraught with lots and lots of questions that we need to answer. But so that's a place where I think we both share, a great interest. So I'd love to have Yes. Come back and explore all that with you.
Mike Hardenbrook:Yeah. I'd love that. It's a whole wide open frontier there to discuss. So I know you gotta go, Andrew, and I appreciate your time here sharing this information, sharing your time, and your life's work is just incredible. So thank you again so much.
Andrew Tatarsky:Thank you so much. And I also very much appreciate the work that you're doing and see it as very, very consistent and overlapping with mine. So that's a wonderful thing for us both to discover.
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