The New Way to Help People Change w/ Dr. Andrew Tatarsky, PhD
Welcome to Journey to the Sunny Side, the podcast where we have thoughtful conversations to explore the science of habits, uncover the secrets to mindful living, and of course, your own mindful drinking journey. Welcome back to part two of my conversation with Doctor. Andrew Tatarski. If you missed part one, we unpacked the roots of the abstinence only model and why it often fails to support the majority of people seeking help for substance use. Today, we pick up with Andrew's personal turning point, the moment he began questioning that system from the inside.
Speaker 1:For context, Doctor. Tatarski is a clinical psychologist, author of Harm Reduction Psychotherapy, and a leading voice in the movement to create more compassionate, flexible approaches to recovery. In this episode, we dive into the core philosophy of harm reduction, how it actually works in practice, and why small self directed steps can be more powerful than rigid rules. Let's get into it. Seem to remember from our last conversation, you had a couple things happen to you in your past.
Speaker 1:One, as a youth that that might be related to treatment trauma, but also I'm remembering there was a point in college when you realized that this doesn't make sense to me. Like, can you go back a little bit and talk about because there's there's a path to to exactly where you are and what you've been doing, and I think some of those points in your lifetime really contributed to some of these understandings.
Speaker 2:Well, so there's a professional story, and then there was an earlier personal story that I only really reconnected with, really remembered a number of years into my professional journey. But the professional story is that, you know, when I was graduate student in training, I just happened to have a lot of patients that were referred to me that were struggling with substances. And I had some really, really positive experiences working with this group of people. I thought they were a very diverse, wonderful, you know, motivated, interesting group of people that were really struggling, and they many of them were able to do incredibly well engaging in therapy and so on. And that inspired me to get a job in the addiction treatment field.
Speaker 2:That was my first job out of training. And when I went to that job, I basically was told, you know, you've gotta throw out everything you learned in graduate school because when we're working with, quote, addicts and alcoholics, it's a whole other ballgame. And I was taught this disease model and the abstinence only approach to treatment. I was said told this is the only way that we can work effectively with these folks. So, I actually worked for the first eight years of my career in various treatment programs within that model.
Speaker 2:And I do think that we helped some people, But over the course of those eight years, I began to notice the majority, the overwhelming majority of our patients were not completing. Either they were just disappearing or in in some cases, we were discharging people from treatment for continued drug use. And over that period of time, I began to become increasingly distressed about that and began to think that it was absurd, you know, that the standard that we discharge people from treatment for the continued problem that they're there for treatment to get help with. But that's what happened then, and that's what I was told that I had to do. And that's what still happens in much of much mainstream addiction treatment today.
Speaker 2:And the patient gets blamed. And I was like, that's absurd. And in fact, I think in in some cases, I actually realized I was perpetuating trauma on the patient by discharging them from treatment. You know, I began to become increasingly horrified and I started questioning the basic assumptions of addiction as disease and abstinence only as, you know, a framework for helping. So I had started a small private practice in the late eighties, and I figured that model was not helping the majority of folks.
Speaker 2:And I did research, and I found that it seemed to be like the standard in the field. That, yeah, most people are not ready for treatment or they're not sufficiently motivated. I couldn't accept that. So in my little private practice, I started getting referrals of people that were actively using substances, really struggling, but they were not ready to stop. And just as I had experienced in graduate school, many of them did incredibly well.
Speaker 2:And so now I was in this sort of theoretical, philosophical, ethical quandary. You know, the mainstream approach is not helping the majority of people and breaking all the rules is. You know, how to understand that? So I reached out to Alan Marlatt, who was a giant in the addictive behaviors research field, and I happened to have a personal connection to him. And I shared with him my quandary, and he said, Andrew, you're doing harm reduction.
Speaker 2:That was in 1994. I was standing in the courtyard, this courtyard to my right here, right out my window, and I remember that conversation like, you know, it was yesterday. It was so life changing. And I said, what's harm reduction? And he explained to me the model, and I really saw it as a framework for setting up helping relationships.
Speaker 2:I mean therapeutic relationships, but I've come to think of it more broadly as a frame for helping relationships. And so that really set me on the journey of really drawing out the therapeutic implications of the harm reduction model. And that has evolved into the work that I now call integrative harm reduction psychotherapy. It's been an evolving treatment model based on harm reduction principles that I've written about, and I have developed intensive fifteen hour training that I've now given in 20 countries around the country. And actually, I recently recorded that training for an organization called the Academy of Therapy Wisdom that will now put something together that we can get out, you know, around the world to people who can't kind of actually show up for a training in person.
Speaker 2:So that's a very exciting recent development.
Speaker 1:Yeah. Very excited. I mean, incredible work. And, you know, from what you just said, basically, I mean, you're pioneering your way through some things. There's some thought collective thought also around this.
Speaker 1:And people are saying this old model, there seems to be there's other ways to reach more people. But from, like, a a principle and just foundational standpoint, anybody that isn't fully educated or informed on what harm reduction is and even the steps that you took it a little further. Mhmm. Can you kind of define that?
Speaker 2:Yes. I think most people know harm reduction through its public health applications. So people equate harm reduction with, for example, giving people clean syringes or distributing Narcan, which can reverse opioid overdoses. That's what I think of as public health harm reduction. But more broadly, harm reduction is a set of ideas or philosophy and then a set of strategies based on that philosophy.
Speaker 2:And the essence of that philosophy is that we want to support people in reducing the harms associated with substance use, problematic substance use, and other risky behaviors without requiring that people stop the behavior. And that's sort of the standard really broad definition, accepted definition. I like to add what I think is implied in that, but it's not just about not requiring abstinence, but it's about not not requiring that people conform to our agenda, our values. Because I think that and so that's like, the abstinence expectation is the big barrier. But, you know, I think that a helping professional needs to keep there, our agendas, to the side.
Speaker 2:You know, we want to refer to them, to our training, to our values, to our beliefs. But when we're really trying to listen and understand how we can be helpful to a given individual, we've got to clear that out of the way so that we can really meet them, quote, where they are. That's a catchphrase. But really meet them where they are without our biases and our presumptions in the way. That's a that's a basic harm reduction stance.
Speaker 2:Meeting people where they are as unique people in unique life circumstances with an open mind and open heart with curiosity and compassion and respect and inviting them to share with us what's important to them. And then that becomes the starting point for us to make an offer of something that is relevant, is useful. And then within that, that can really be the cornerstone of a safe, collaborative therapeutic relationship or alliance that then, you know, is the basis for a collaborative process around working with people to support them on their positive change journey. Right? So it's really all about we start where the person is.
Speaker 2:And then so that's the basic, you know, I think, principle. A few others just very quickly. Alan Marlatt, who was the person that introduced me to harm reduction, is one of the mental health professionals that brought this philosophy over from Europe where it was born. He suggested that compassionate pragmatism is the philosophy that is expressed in harm reduction practice. Compassion is about wanting to support people in reducing suffering or improving the quality of their lives.
Speaker 2:The pragmatic part, though, is it's not ideology ideological. It's doing what works. And what works is gonna be highly unique to this person in this moment. Again, we can only do that by starting where the person is. And then we work together as a therapeutic team to figure out what's the nature of the problem?
Speaker 2:What are solutions? What strategies? What skills? What right? Therapeutic techniques.
Speaker 2:You know, what is the focus that people need? But that it all arises out of this safe space that we've created and this kind of collaboration around inquiry, around exploration, around discovery, and then coming up with a positive change plan together.
Speaker 1:I love the supportive approach, especially as a guy that's rebellious that doesn't like to be told what what to do, and I know I'm not alone in that. Part part of
Speaker 2:your knowledge. My hand there too? I
Speaker 1:mean, I don't think anybody really likes to be told what to do. So, and everybody wants to do what they wanna do. And, you know, one thing I, you know, in talking to you and that I that I understand, but maybe not everybody else does, is that it's not saying that you can continue on doing what you're doing. And an abstinence might be the plan for that person who should be there. Right?
Speaker 2:Well, I'm I'm so glad you said that. One of the biggest criticisms or, I think, misunderstandings is that harm reduction is about giving people permission to get high. You know? As if other people need our permission. Right?
Speaker 2:They're getting high or they're using or whatever they're you know? I I think they don't need our permission. Another great harm reduction pioneer, Edith Springer, she once responded to a question like that by saying, you know, you think if if their mothers and, you know, their significant others couldn't get them to stop, do you think I should I would be able to do that? You know, we would be able to do that? So, you know, it's not about giving people permission.
Speaker 2:It's about creating a space to really, for people to share with us what they're wanting or what they're struggling with. Problematic substance use is suffering. If if somebody's using a substance and it's working for them, or if they're driving a car and it's working for them, or they're skiing and it's working for them, You know, these are all potentially lethal activities. We have nothing to talk about. But but once somebody begins to struggle with a substance, now they're suffering and they're likely in conflict.
Speaker 2:They're really it's a pain it's it it becomes an increasingly painful dilemma. People are not now just having fun. I mean so if we can create a space and to really listen to and align with the suffering and speak to that in some meaningful way. The so called unmotivated person who, you know, doesn't want treatment often becomes highly motivated because people want to feel better. People don't want to feel sick and have all of the negative consequences that can come from, you know, problematic substance use.
Speaker 2:Not sure if that answered the question.
Speaker 1:No. It did. It absolutely did. And, you know, one of the one of the ways that I personally relate to the harm reduction model is that by by total accident, I can relate in that when you wanna make a change, first of all, you're gonna be a different person than you are when you start to make changes, but also you can't see yourself making these large changes immediately for most people. Some people have the ability to just drop it and walk away and never look back, but that is, like, such a small percentage of people.
Speaker 1:But for me, like, what seemed a doable thing was thirty days, and I was able to get there. And at thirty days, thirty more days seemed more doable. And I said, I'll do that. And then it's by the time I got to ninety days, I was not the same person to make that I was from the day one. So I was able to make more bold, confident choices, and what I actually wanted had changed over time.
Speaker 1:And I and I feel like when I listen to you, I can see myself in that way, but it's almost like sitting down with somebody with a road map to say, hey. You keep getting lost going the same direction. Like, let's, like, let's give you the first first street to go down before you try and get to the very end.
Speaker 2:Well, I mean K. This is another basic principle of of a harm reduction approach as I understand it, and that is small steps, small incremental positive change. It occurred to me one day, we don't need to know the destination to begin the journey. So if we begin and we support people in beginning with, you know, I'm suffering. I'm not happy with this, what I'm doing.
Speaker 2:Most people aren't even clear at that point why they're suffering or why they're not happy or what what's actually causing or contributing to the suffering. But so if we begin with that and then we begin to support people in clarifying, making connections, getting clearer about, you know, what's causing the suffering. Is it the pattern of use? Is it, you know, the amount? Is it, you know, the pacing?
Speaker 2:Is it, you know, the actual, you know, substance use plan that somebody is, you know, using, working with? Or is it, you know, related to the conditions, the way someone's feeling emotionally and how that mixes with, you know, substances. But so there may be an initial period of really needing to kind of assess, make sense of, you know, begin making connections. And then that can lead to harm reduction goal setting or small steps in a positive direction, which could be from somebody one night of abstinence or, you know, working on cutting back the substance, you know, one ounce a night or, you know, whatever the small step is that somebody or a commitment to 30 of abstinence if that's what somebody's up for. But so I'm always wondering, well, what is the step that you're up for experimenting with to see if it actually helps you feel better, you know, helps reduce the harm?
Speaker 2:And we can then begin goal setting like that in all of the relevant you know, around substance use, but also around all the other relevant issues in someone's life. As we begin to make sense of, you know, how substance problematic substance use fits into, you know, one's emotional life, one's relationships, one's lifestyle, you know, what's happening, you know, in the world around us, you know, and the impact all of this is having on us. So these small steps begin to help us feel a little better, begin to build some confidence and hope, you know, what we call self efficacy. Right? Hey.
Speaker 2:I can do a little something. Let me take another step. And then, you know, we've helped people reverse a negative spiral and begin what I think of as a positive spiral, which, you know, small steps build, you know, toward. And then, you know, so if that leads to abstinence, that may be an endpoint for some people. For others, moderation or safer use may be where they decide to stop.
Speaker 2:But but we don't need to know that at the beginning. And I wanted to make another comment about what you said, that you don't like to be told what to do. I don't like to be told what to do. I didn't like it when my father pushed me around. So or bullied me.
Speaker 2:You know? So Yeah. Certainly not gonna take it from somebody else. But I think that, as you said, most people don't like to be bullied or pushed around or coerced or threatened. And I think that those approaches can actually derail helping relationships, whether it's with a therapist, a counselor, whether it's with your partner, your family.
Speaker 2:What it can set up is what I call a submit rebel bind. You submit to my authority. I'm the expert. I'm your father or whatever, and then everything will be okay. So you submit in order to calm it down, get your family off your back.
Speaker 2:K. I'll go to treatment. I'll stop because I don't wanna lose my wife or my you know? But now you feel angry, infantilized, controlled, dominated, humiliated, you know, and increasingly enraged. And it can kick up the rebellious drinking, you know, the screw you drinking, which can be in private or it can be in public, and maybe you hurt yourself in the bargain, you know, by, you know, blowing things up with a nice big binge.
Speaker 2:But, you know, then the cycle can repeat itself. Then you submit again. I'll be good. I'll be abstinent. So that can actually set up quote relapse.
Speaker 2:And because it also is it hinges on this idea that you need to be controlled. You know? You're too headstrong. You know? You're you're you're you need to, you know, accept your powerlessness.
Speaker 2:Submit. I think a harm reduction approach flips that on its head. It says, no. You've lost your agency. That's partly why you're having trouble with drinking.
Speaker 2:You need we need to support you in regaining your sense of agency, autonomy, personal empowerment, you know, your strengths, your skills, your right to take charge of where you wanna your relationship with drinking to go. And that then clears a space for people to start making better decisions. And then we can support them with skills, with strategies. But but that basic shift in stance is about empowering people, not disempowering them. So I think for most people, it doesn't work.
Speaker 1:I think I think both you and I agree that whatever works for you is is a good solution. But if we zoom out a little bit, looking at the treatment world as a whole, you know, this model, the traditional model has dominated for so long. You know, I don't know if it's about funding, insurance, stigma, maybe a lack of better known alternatives. However, I know that now it's your mission to bring this to the masses because you've seen it for so long working in clinical settings and and probably anecdotally. And how do how do we change that?
Speaker 1:How do we bring this solution to the forefront?
Speaker 2:Well, there's another very important part of it I think that that we should talk about, and that is we're talking about a fundamental paradigm shift in how we understand what we call addiction or problematic substance use. The old paradigm was disease and abstinence only. And that paradigm has been soaked into the fabric of our culture, not just in the profession, but the culture. And it's promoted in almost every single movie, popular movie, TV show, you know, news coverage of issues. They, you know, speak to that model.
Speaker 2:And it's a paradigm that lives in the in the collective unconscious. You know? And it and, you know, it has incredible implications for people that struggle with substances, who think they're doomed, you know, to helpers who think that those people that they wanna help, you know, are doomed. And and it's also a lens which gets in the way of helpers being able to see that person. But just like I think about when I think about paradigm shifting, you know, it really is on the order of a scientific revolution.
Speaker 2:Like, you know, back in the seventeenth century, they used to think that the the Earth was Right? And that the sun revolved around the Earth. And then some really smart people like Galileo started collecting data saying, woah. I think, actually, the earth revolves around the sun. And first, people thought he was crazy.
Speaker 2:The pope imprisoned him, and he died under house arrest. I don't know if people know that because people that challenge a dominant paradigm are very threatening. That's another way to understand why people get very upset. People get anxious. It's like, wait.
Speaker 2:I've been organizing my whole reality and my whole sense of self based on this paradigm, and now you're telling me it's wrong? You know? The first thing you wanna do is you wanna kill the messenger. You know? But over time, you know, as more data you know?
Speaker 2:And so I think we need to supply people with a new model, a new way to connect the dots. And the way that I do is and I think it's it's it's not just me. It's an emerging model, which is problematic substance use is multiply determined. It's a relationship to substances or activities that is multiply meaningful. People it's a meaningful response to suffering.
Speaker 2:That's what it is. Why somebody who is a is a recreational drinker begins to drink three and four and five. You know, what's happening in their life? What got activated in them that they're turning to the substance rather than people in their lives? You know?
Speaker 2:And and then over time, behaviors that work for us become deeply ingrained habits, and they get chained through learning to external triggers and context and time of day, you know, and they become deeply ingrained in neural networks in the brain and relationships which support it. So there's a lot going on, but if we can actually get that new paradigm, that new model, and break it down, there are a lot of places that we can intervene as individuals or with people we're supporting to make change. Understand the meaning and function and come up with new solutions. Develop some skills to kind of develop healthier habits. Right?
Speaker 2:Work on changing your relationships or the things that are happening in your life that you're unhappy about. So to shift to a meaning model, I think, actually gives hope and and points away to lots of things we can do to work toward positive changes with the substance and related issues.
Speaker 1:How can we have these meaningful conversations with some that identify it is part of their identity. It is who they are. It's what they've invested in and everything. It's so I know that you've had to figure out how to have these conversations where you're actually heard. How do you approach that?
Speaker 2:Well, first of all, I I approach as I do with my clients and, you know, my colleagues, friends, with respect, with curiosity. I invite I invite us to have a meeting of the minds. I I mean, I know that everyone the the overwhelming majority of people who are working in this field are doing it for love. They're doing it Mhmm. They've had lived experience.
Speaker 2:They've had their own experience. They've had family and friends have struggled. This is this is a love mission, you know, being in the field. And I love the the workforce out there, the folks that are doing this. It's not the people that are, problem the problem by and large.
Speaker 2:It's those ideas that limit their ability to be effective. But, you know, so I I I ask people, think about, you know, you know, the the life trajectory, the stories that people tell. You always hear stories of early trauma, of big t trauma, of, you know, my parents had substance use issues. My There was a lot of suffering and mental health issues in my life. There was a lot of arguing in the family.
Speaker 2:Know, we went through a period where my, you know, my dad was out of work and we had a hard time paying the bills and you know, you know, and then I found myself turning to this substance, and I found it was really help. I mean, you'll let's hear the stories and then break it down. Like, so or another way to say it is you could call it a disease if you like that term. You know, it's it came into being because it's so people thought it helped with the shame. Like like, you didn't mean to destroy your family and set out, you know, to nearly kill yourself.
Speaker 2:Nobody does that except and there are some people that are truly self destructive. Destructive, but by and large something takes over and it's not your fault. And I think that's maybe the positive thrust of the disease model. But maybe we could say, but can we get inside of it? Can we sort of take that apart?
Speaker 2:You know, what we're calling the disease. Like what's driving it? What's you know, and start to identify that all of those strands of meaning, of function, of, you know, psychology, of the body, of relationships, the the variables that are playing out in that way and make sense of it. And then we can start acting on what we're learning about in new ways. And so I think we need to support people in thinking about it in a bigger way, more expansive way, thinking about their own life experience, that of their clients.
Speaker 2:It's like, you know, somebody once told me, this guy, it's Donnell Stern, who is a constructivist. He says, you know, our models are just human constructions. Whether you wanna call it a disease or habit or whatever, they're just human constructions. But once you have a a new model, you know, you can't unsee it. So if you think about it as disease and that's the only model you have, you know, you're gonna see disease everywhere.
Speaker 2:But if we offer a different model, maybe people can start seeing it in a new way. Like, before somebody named the Big Dipper, the Big Dipper, I think it was just a bunch of stars. But now that you know that it's the Big Dipper, it's been constructed in that way, you can't not see it. I think you look up and you go, there's the big dipper. So maybe it's like the red pill and the blue pill.
Speaker 2:We have to offer people, you know, a new pill to see things in a more expansive way. And then it has all of these positive implications. And and I should just say finally that new model to me is a clinical and theoretical basis for harm reduction therapy or harm reduction helping more generally.
Speaker 1:Yeah. Well, I mean, if anything that you said there is that, oh, we need to have conversations. All solutions can coexist, and everybody comes from 99.999% comes from a place of love, and the end goal is to make people better and feel happier.
Speaker 2:That's you got it. And I think that's a great place to stop. And I've I've really enjoyed this conversation. I hope I hope it's been helpful, useful to folks out there.
Speaker 1:Yeah. I know this this has been I I could talk to you all day, Andrew. Andrew, before we go though, is there any are there any projects that you're working on that you'd love to announce or talk about for a few minutes?
Speaker 2:Well, I've only got a minute because I have a actually, I have a client who's probably waiting for me right now. You know, this I mentioned this four days of recording a fifteen hour training that I've, you know, given over the last twenty years in 20 different countries. It's now going to be available in the fall through the Academy for Therapy Wisdom, and people should be on the lookout for that. They can also go to my website, andrewtatarski.com, and get in touch with me if they would like some of my written a book, and I've written a number of articles that I can make available for free. I'll also be I'm in the I'm in the midst of plan working with several different groups to plan in person three day trainings in the fall and the beginning of next year in New York, in LA, possibly in Vancouver, and possibly up in Quebec.
Speaker 2:Oh, and I'll be in Iceland and Portugal in the fall also. So Amazing. You know, this is an indication of how the scientific revolution is actually rolling, you know, around the planet. And people are increasingly embracing, you know, these ideas and this this approach to supporting people and making chain good change in their lives.
Speaker 1:Yes. Well, know you have to go, Andrew. I just wanna thank you from the bottom of my heart for sharing time and for changing lives, and I look forward to speaking soon.
Speaker 2:Yeah. And I wanna thank you for the same things, Mike, through your books, through your podcast, through your, you know, many good things that you're doing professionally. You really are also bringing some wonderful things into the world. Thank you, Andrew. Okay.
Speaker 2:Bye bye.
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