Global Developments in Harm Reduction Therapy and Substance Use Treatment

Last November 2016, NoBox’s founder and director, Ma. Inez Feria, participated in the 11th National Harm Reduction Conference, held in San Diego, California. She spoke on the panel on Global Developments in Harm Reduction Therapy/Substance Use Treatment. Below is the transcript of her speech.


Like many, I grew up being told to stay away from drugs, and to stay away from people involved with drugs. 

So when a family member became involved with drugs, we didn’t know what to do. We knew there was such thing as rehab, so we called “rehab,”and back then, treatment was treatment. No one talked about being abstinence-based or anything, it was just treatment. It was just this thing. And you send them to rehab because that’s what people do. It was expected to be like a carwash: go through the program, become clean, and everything was going to be okay.

Through that program, I got to know people who were involved with drugs, and realized that they are people, really nice people. But what transpired during the treatment process just did not jive with what I learned in psychology about human behavior, about the principles of learning. It ignored basic respect for the people there going through the program. 

So I started asking questions, because I wanted to understand. The counselors did not like that. They said I was intellectualizing, because we were in denial. 

So I searched on my own for information. At that time, internet was new in the Philippines and I was online practically 24/7. There was such wealth of information, and I found things there that were consistent with what I understood about human behavior, and good clinical practice, and respect. And it was strange, because there actually was a name for it: Harm Reduction.

So I pursued this. I had the chance to be here in the US and that’s when I met Dr. Andrew Tatarsky, Dr. Fred Rotgers, even Patt Denning and Jeannie Little. I was just this person, going around, connecting with whom I could, trying to get more information to learn more. Everybody was very kind and generous in sharing their insights and everything. It was a continuous -- and continuing -- learning process.

So when I went back to the Philippines, I began my work in the field by running a residential center embracing harm reduction. This was kind of radical in a way. 

Typically, parents and siblings bring family members into rehabs, asking how long the program would take. We’d say, we haven’t gotten to know your son yet, so we wouldn’t know what he needs.

They’d ask if we had a “team.” And here in the Philippines, that means what they’re really asking is, do you have a team of big burly people in a van who can forcibly pick up our family member and bring them to your rehab? And we said no, that’s not our style.

These were strange concepts to them, so it was also a process of educating families, to help them understand, to strategize on how to speak with their family member. 

There was one family who thought their son wouldn’t agree to the center, but their son chose to stay with us. People who joined us in our residential center walked in, and most of them stayed. Things like that were happening. 

When clients who had already left the center found themselves using again, they actually called us and asked if they could come back. Asking to come back was definitely unheard of, because the usual narrative is people trying to avoid and escape from rehabs!

And we knew that if they were using shabu -- methamphetamine hydrochloride -- they had most likely hadn’t slept for several days. They most likely hadn’t eaten. So we made sure when they got there, they would have good, warm food to eat. We told them, you can  go ahead and rest, and we can talk when you’re ready to talk.

Because harm reduction means understanding people’s needs and where they’re coming from.

The other thing is that parents and family members would ask us to do drug tests, and we would ask: Why? And they’d say, because we have to know if they used or not. To which we’d say, it’s a waste of money! Because we know they’re going to tell us anyway. If you create that kind of environment and you have that kind of relationship, they are going to tell you anyway. And it now becomes a process we can work through and learn from; it becomes a real learning opportunity.

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There are also cases where someone would come on outpatient basis, and family members would say, “oh, he’ll never come back.” But they did. And stuck to it. Because it was something that was agreed on, and they decided what they could commit to. So they actually came. So it is possible. 

But it hasn’t always been that easy.  I’ve been screamed at and threatened by parents and family members because they didn’t agree with how we did things. Like the one time we believed one of our clients was ready and could leave the center and the family didn’t want that. They wanted him to stay, and had the resources to pay for his stay. But we stood our ground. 

And while we stood our ground, that also made me realize that just having a center and just providing services were not going to be enough. If society continued to stigmatize and discriminate against people using, or who had been using, it railroads whatever gains had been achieved during treatment. 

And that’s why NoBox, this organization, was born. Apart from providing direct services, NoBox is also an advocacy organization because we need to address the socio-cultural, eco-political environment in which use and treatment exist.

NoBox has embraced harm reduction as a philosophy, a way of life, a way of approaching different situations. And this includes embracing harm reduction in pushing for harm reduction at the institutional and policy levels. We follow the same guidelines for advocacy as with integrated harm reduction therapy -- building alliances; not attacking people who may have different views, and instead figuring out where they might be coming from; and exploring areas of commonalities and figuring out what is doable, knowing that change is a process and will not happen overnight. 

So we are doing this work now, by: 

Continuing our practice. We still provide services for people who need help for use-related concerns by offering harm reduction counseling, creating a safe space in our office for people to come in even it means just getting honest information, and giving people a place to hang around in for a while and speak with someone if they wish.

Expanding our services to include community-based harm reduction treatment and developing community-specific responses using a harm reduction framework. 

And ironically, this expansion of our work was brought about by the challenges of our government currently engaging in an intense War on Drugs. Since July 1, just about four months ago [at the time of this speech in November], almost 5,000 people have already been killed and almost 800,000 people have been forced to surrender, to waive their rights, and are awaiting some kind of “treatment.”  Local government units we call Barangays suddenly have an influx of people with no services or programs to provide. 

So that’s where we come in.

But we cannot just provide services alone, as I had mentioned. We have to educate and engage the general public to help them understand what this “harm reduction” is. Because the mentality there is still drugs are bad, you get rid of drugs, and you take care of people using drugs. 
Hosting engagement activities and crafting a communications strategy - we create our own venues for conversations that offer a narrative away from the binary discussion of drugs as simply good versus bad. We especially target what we call ODPBs -- outside the drug policy bubble -- because we don’t want to just be preaching to the choir. 

We need to share that harm reduction is based on science wrapped in kindness, and we need the public to understand this to accept it. 

We take every opportunity and accept practically every invitation to dialogues, and to engage and speak on harm reduction therapy. This has actually increased in the past months of the War On Drugs, because drugs suddenly became foremost in people’s minds. People are asking questions and many have realized they don’t really understand this whole drugs issue and are now really seeking out alternatives to all the killings and human rights violations that have been going on.

So now our work also involves engaging with policymakers and key influencers towards embracing harm reduction, and we are working towards reforms, for the decriminalization of drug use. It will be challenging, but we are starting the work.  And also to reform the current treatment system by institutionalizing harm reduction principles in all drug-related policies, particularly in treatment and education. 

All these have required us to examine our communications strategy. So, again, it is never to attack, but only present what is, and what can be. 

To share a quick story, just before I came here, I had the opportunity to speak at a mental health convention organized by our  Department of Health. I spoke about the beauty and amazing things that harm reduction has brought about, but wasn’t sure how the response was going to be. 

But when I got home after, I received a message that made me want to cry -- 

“The insights you shared really made me rethink the way we treated our residents. Sometimes we can be very "controlling" in trying to help them without realizing that the decision to change is exclusively theirs. Will definitely share with my team the "AHA" learnings. It is really time for us to "reflect" professionals we have been used to always be directive. We want our clients to obey without questioning..we expect them to be in the "Action" stage and we easily get frustrated if they cycle back to previous stage..but your talk yesterday has opened my mind ..and heart... not to stop trusting….  To be honest, I was quite "closed" then with what I heard you were advocating. But hearing you talk…  really touched not only my mind but heart as well. We need to focus on the goal: RECOVERY of our clients. Whatever it takes!”

The person who send this message is the chief of a government-run rehab, which is very abstinence-based, so this is very significant in our continuing efforts to mainstream Integrative Harm Reduction Therapy, together with Dr. Tatarsky, our drug policy agency, and also with our other allies.

It is so important that we always make that human connection in anything we do, and this had been forgotten when it comes to people involved with drugs. This is what Harm Reduction reminds us of. 

People have told us, repeatedly, that we were being too nice, even naive, that we don’t have time to be kind. But it’s not that. It’s just basic human decency, and, best of all, it works. When people feel they are being treated and seen as people again, then amazing things begin to happen. 

Thank you.