Using Harm Reduction when
working with SMI Populations
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BY CYNTHIA HOFFMAN, MFT
www.cynthiahoffmanmft.com
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Presenter Biography
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Cynthia Hoffman, MFT is a psychotherapist
in private practice. She also currently
volunteers supervision to interns working in
Community Mental Health settings. She has
worked with severely mentally ill adults who
use substances for over 13 years. She has
worked in both community mental health
settings and in private practice, practicing
Harm Reduction. She is a also a member of the
the Harm Reduction Therapy Centers Board of
Directors. She has been practicing and teaching
Harm Reduction Psychotherapy for over 13
years in both private practice and agency
settings.
www.cynthiahoffmanmft.com
www.cynthiahoffmanmft.com
Workshop Objective
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Objective: To familiarize the attendees with ACT and
similar programs that work with homeless or
previously homeless psychiatrically ill adults who have
co-occurring substance use issues along with cooccurring medical illnesses and to identify the Harm
Reduction techniques used with this population.
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What is Assertive Community
Treatment (ACT)?
• How the program
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works/History
Who ACT serves
Living situations
Working with all providers:
Benefits of ACT
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How Act Works
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 An ACT team is made up of multi-disciplinary staff
that generally includes case managers, nurses,
psychiatrist(s) and mental health clinicians.
 ACT operates from a “whatever it takes” philosophy
and services are provided “in-vivo”. ACT programs
were initially created to be a “hospital without walls”.
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Who ACT serves
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 Typical ACT clients may present with a variety of
diagnoses including (but not limited to):
Schizophrenia, Bipolar Disorder, Personality
Disorders and Substance Abuse Disorders .
 Additionally, they are also likely to have health
conditions, developmental disorders and
environmental stressors.
 Many are homeless or formally homeless.
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Housing
 Clients in an ACT program may live in a
variety of housing situations. Many are
homeless or at least homeless for periods
of time.
 Some live in supervised board & care
homes and some may live independently
in apartments or SRO’s (single room
occupancy hotels).
 These housing situations often present
barriers in treating clients from a harm
reduction approach.
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Other Providers
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An essential component of an ACT program is the
collaboration with other providers to ensure a
strong continuum of care.
 payee services
 conservators
 housing staff
 hospital staff
 adjunct substance abuse services
Helping to educate other providers on the benefits
of a harm reduction approach can present
challenges and is often met with resistance.
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Benefits of ACT
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 Studies show that substance use is
reduced when wraparound case
management along with providing social
skills significantly reduces a clients
substance use, sometimes by 50%
 Socialization, a sense of belonging
 Main focus of ACT is helping clients to
improve their quality of life and develop
meaningful activities
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Typical ACT client
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 Adult 18 – 70 Average age approx 40
 People of color
 Poor
 Former foster children
 Homeless or Minimally Housed
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Why SMI populations drink and use
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 People with mental illness use substances for a
variety of reasons, including the relief of depression,
anxiety, boredom or to relax and socialize
(Addington & Duchak 1997, Fowler et al. 1998),
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Substances used:
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Alcohol
Crack
Speed
Heroin
Marijuana
Prescription Drugs: i.e. Oxycontin, Klonopin
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Interventions
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INTENSIVE CASE
MANAGEMENT
PSYCHIATRIC
INTERVENTIONS
INDIVIDUAL SUPPORTIVE
THERAPY
GROUP THERAPY
TEACHING SELF CARE
INCENTIVES
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Intensive Case Management
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 Both short and long term goal setting (which
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includes goals that add meaningful activities to a
clients life)
Medical appointments
Help with entitlements
Communication with families
Psychiatrist
Case managers rotate 24 hour on call for off hours
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Psychiatric Interventions
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 ACT psychiatrist meets with the client as needed
which could be from weekly to monthly. These
appointments can be in the office, at the clients
home or at a café.
 Collaborates WITH the client in developing an
effective medication regimen, taking into account
the substances a client uses.
 Discusses substance use and its effects when
combined with medications
 May prescribe vitamins and/or behavioral
interventions (CBT, DBT, etc) instead of or in
conjunction with psychiatric meds
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Individual and Group Therapy
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 Individual Therapy is supportive and about teaching
coping skills.
 Group Therapy is mostly
psycho-educational and open-ended
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“I’ve never had
problems with
drugs. I’ve had
problems with the
police.”
Keith Richards
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Motivational Interviewing
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Whole package of Motivational Interviewing is complicated and
there is much to learn. The spirit of MI is what’s essential.
The Spirit of Motivational Interviewing
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Collaboration
Evocation
Autonomy
Perception
Curiosity
Ethics
Treats Resistance as thinking
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Principles of Motivational Interviewing
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 Express Empathy- Be affirming, help clients express
their personal choice
 Develop Discrepancy – Develop the discrepancy between
the clients goals and their current Behavior
 Roll with Resistance – Avoid Arguments – Know that
resistance is a form of thinking about the issue
 Support Self Efficacy
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Individual Therapy
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 Supportive
 Client Centered
 Motivational Interviewing
 Individualized Personal Goals
 Quality of Life Issues
 Individualized Harm Reduction Strategies
 Identifying and helping client work towards
goals that provide meaningful activities
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Motivational Interviewing
Whole package of Motivational Interviewing is complicated
and there is much to learn. The spirit of MI is what’s
essential.
The Spirit of Motivational Interviewing
 Collaboration
 Evocation
 Autonomy
 Perception
 Curiosity
 Ethics
 Treats Resistance as thinking
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Group Therapy
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Groups provided:
 Health Groups: Diabetes/High Blood Pressure
 Women’s/Men’s Groups
 Anger Management
 Socialization Groups – Lunch Group, Weekend
Planning, Holiday Celebrations, Knitting,
Walking, Music Group
 Art Therapy
 Seeking Safety
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Group Therapy (continued)
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
Harm Reduction. Includes topics:
Stages of change
 Personal Goals
 Family influence
 Dealing with Feelings
 Drug education including safer use
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Teaching self care to SMI population
• Physical - wound care, dental, checking BP,
blood sugar, liver panel regularly
• Psycho-education about physical health, psychiatric
illness, substances used
• Prescribing vitamins i.e B6,
• statistics re: smi populations --50 to 80%
• Safe Injection, clean works and pipes, drinking
water
• Diabetes and High Blood Pressure Education
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Incentives
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Incentives are offered for a variety of issues. They can be
used to encourage someone to:
o take a shower
o attend a group
o reduce use or
o go on a substance use holiday
Some examples of incentives used are:
 Food shopping
 Clothes or household items shopping
 Visits to a massage parlor
 Musical instruments
 A meal at a favorite restaurant
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Incentives (cont)
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Some examples of incentives used are:
 Food shopping
 Clothes or household items shopping
 Visits to a massage parlor
 Musical instruments
 A meal at a favorite restaurant
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Sex
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 Severely Mentally Ill and DD clients have sex.
Oftentimes, alot of it.
 Provide Harm reduction education about sexual
practices
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Countertransference
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 Many come to social because of family issues
experienced when growing up. To experiences are
likely to arise when working with clients. These
should be recognized and discussed in individual
supervision with the supervisor taking care not to act
as therapist to the staff member.
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Working with staff, burnout
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 frustration at seeing these adults make bad choices
 Anger at the system
 The ACT Team Model allows for team members to
help each other in a variety
of ways i.e. going on outreach together,
taking over if one person is ‘burnt out’ on a particular
client
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Challenges and Obstacles
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 Funding
 Stress from everyone to keep clients out of the
hospital even though the hospital might be what they
need
 Growing acuity levels in clients while resources
continue to shrink.
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Contact us
cynthiahoffmanmft@yahoo.com
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