Developing the Reflective
Practitioner:
Supervision in Harm Reduction Programs
A Training for Housing Works 10.29.07
57 Willoughby Street, Brooklyn
Prepared and Delivered by Richard
Elovich, MPH www.richardelovich.com
Training Contents:
• Introduction (slides 2-5)
• The team and group dynamics (slide 6-29)
• Supervision, program philosophy, review of harm reduction,
concepts and skills, trainings into practice (30-71)
• A supervisory framework for staff-client interactions (72-81)
• Supervision as developing reflective practice (82-90)
• Monitoring and evaluation (91-104)
• Cites and resource material for this training (105-6)
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Ground Rules
• Elicit the reasons for having ground rules
from participants.
– Why might it be important for us to have ground
rules?
• Elicit from group members their ideas about
ground rules
– Let’s try to make a list of “ground rules” for the
group that will help each of you individually to get
the most out of our time together.
Training Contract
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Stay focused today. Be on task.
Listening is a key to this training. Reflective
listening. Listening to directions so they don’t
have to be repeated and so you get the task or
exercise right.
Listen to new ideas. Listen to what’s coming up
inside you in relation to what’s being presented.
Try to put your thoughts and feelings into words
instead of “shutting down.”
Acknowledge and respect differences. You can
“agree to disagree” on a contentious point and
move on.
Participate in role plays. Go (forward) and grow.
Everyone has permission to pass. Offer feedback
constructively not personally. Try to receive
feedback as a gift.
•
Learning environment. Try to be okay
with taking some learning risks. Stretch
past your edge of what you know and
what you are comfortable with.
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Confidentiality. Hold the container. Don’t be
leaky.
Turn off phones and beepers.
No cross talk. Allow one person to speak at a
time. Equal time over time.
Start and end on time, including breaks. Be
alert to tendency to fudge this.
Use “I” statements.
Can everybody agree? Is there anything you
absolutely cannot live with?
Now we are off.
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LEARNING PROCESS:
KNOWLEDGE
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Acquisition of content
Retention (store in memory)
Application (retrieve and use)
Proficiency (integrate and synthesize)
What do you see?
Working
together as
a group:
(1) What
makes an
effective
group?
(2)
Accountability:
what does it
mean?
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GROUPS
• Before we pursue groups as tool. We need to
think about what they are.
• We are social animals. We live and die in
groups. We get our sense of ourselves
socially. Most of what we do is social.
WHAT IS A GROUP?
1. List everything you do in a typical day from
the moment you wake up in the morning up
to the moment you fall asleep.
2. Delete from your list all the activities you
perform with groups of people and see what
is left.
3. Let’s discuss.
WHAT IS A GROUP?
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Commuters (regular hour)?
Motorists (regular hour)?
Pedestrians on the street (regular hour)?
Employees in a department of a hospital or
social service setting?
• Sidewalk book venders and place holders?
• Neighbors during blizzard?
WHERE DID YOU FIND
GROUPS?
• Work environment
• Family and kinship
• Civic associations (church, PTA, Senegalese
Association)
• Informal friendship clusters
• Street demonstration
• Student organizing
WHAT GROUPS MEAN TO
PARTICIPANTS
• Someone learns he does not have a disease
and this means he loses group affiliation
• Doctor on television show ER cannot perform
surgery any longer and loses his “master”
identity.
• Someone attempting to stop drinking as to
confront consequences of separating from
peer group
QUESTIONS YOU RAISED
• How do people use groups?
• What happens to a group when someone is
absent? How does group experience absence
of one, two, three members?
What Makes a Group Effective?
• Goals
• Structured
Relationships
• Interdependence
• Mutual Influence
• Interpersonal
interaction
• Motivation
Goals
• Groups exist for a reason. People join groups
in order to achieve goals they are unable to
achieve by themselves. A group may be
defined as a number of individuals who join
together to achieve a goal. It is questionable
whether a group could exist unless there was
a mutual goal that its members were trying to
achieve.
Interdependence.
• A group may be defined as a collection of
individuals who are interdependent in some
way. According to this definition, the
individuals are not a group unless an event
that affects one of them affects them all.
Conceiving of a group as a dynamic whole in
the sense that an event or action that affects
one member is likely to affect all.
• You are a member of a team where each
individual has a specific role and specific
responsibilities
• Who are you accountable to?
Interpersonal Interaction.
• A group may be defined as a number of
individuals who are interacting with one
another. According to this definition, a group
does not exist unless interaction occurs. It is
this interaction process that distinguishes the
group from an aggregate.
Structured Relationships.
• A group may be defined as a collection of individuals whose
interactions are structured by a set of roles and norms.
According to this definition, the individuals are not a group
unless their interactions are so structured. A socialpsychological group is an organized system of two ore more
individuals who are interrelated so that the system performs
some function, has a standard set of role relationships among
its members, and has a set of norms that regulate the
function of the group and each of its members.
Mutual Influence.
• A group may be defined as a collection of individuals who
influence each other. Individuals are not a group unless they
are affecting and being affected by each other; therefore, the
primary defining characteristic of a group is interpersonal
influence. A group is two or more persons who are
interacting with one another in such a manner that each
person influences and is influenced by each other person.
Motivation.
• A group may be defined as a collection of individuals who are
trying to satisfy some personal need through their joint
association. According to this definition, the individuals are
not a group unless they are motivated by some personal
reason to be part of a group. Individuals belong to the group
in order to obtain rewards or to satisfy personal needs. It is
questionable that a group could exist unless its members’
needs are satisfied by their membership.
GROUP DYNAMICS
• Emphasis on process of group rather than group as an object.
Thinking thorough this a bit will help us use groups not just
rotely as received tools but as creative health practitioners
who work with group process.
• What a group needs to be.
 Roles, expectations, norms, and procedures within group
process.
 Understanding the development and life of a group process.
CREATING PRODUCTIVE GROUPS
A pseudogroup
•
A traditional work group
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An effective group
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A high-performance group
Group Dynamics
• Robert Bales (1965) three themes:
dependence on the leader; pairing among
members for emotional support; fight-flight
reactions to a threat to the group.
• Shultz (1958) three issues: affection; inclusion;
and control.
• Tuckman (1965) five stages: forming;
storming; norming; performing; and
adjourning.
• Forming: uncertainty in which members try
to determine their place in the group and the
procedures and rules of the group.
• Storming: conflicts begin to arise as
members resist the influence of the group
and rebel against accomplishing the task.
Members often confront their various
differences and conflict management is the
focus of the group.
• Norming: group establishes some consensus
regarding a role structure and a set of group
norms for appropriate behavior. Cohesion and
commitment increase.
• Performing: group members become
proficient in working together to achieve the
group’s goals and become more flexible in
developing its patterns of working together.
• Adjourning: the group disbands.
Stages to Group Development*
1.
2.
3.
4.
5.
Defining and Structuring Procedures
Conforming to Procedures and Getting Acquainted
Recognizing Mutuality and Building Trust
Rebelling and Differentiating
Committing and taking ownership of the goals, procedures,
and other members
6. Functioning maturely and productively
7. Terminating
* Johnson and Johnson
What is supervision?
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Supervision
• Managing the program
• Monitoring the effectiveness of the individual
worker, the team, the service delivery, and the
effectiveness of standards, codes of ethics and
conduct
• Developing reflective practice in harm reduction
oriented service programs
• Assisting individual workers and the team to apply
and adapt concepts, approaches, and skills from a
training to their practice
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ARE CONCEPTS AND SKILLS IN
TRAININGS APPLIED AND
INTEGRATED INTO THE WORK
PEOPLE DO?
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• On a Scale of 1 to 10
1 = not evident in the work…
10 = very evident in the work
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Harm Reduction
Stages of Change
Motivational Interviewing
A Strengths Based Approach
• How is each reflected in the work?
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Why articulate program philosophy
Assumptions about drug users
Harm reduction among drug users
Intravention and intervention
Implications of harm reduction in all domains
PROGRAM PHILOSOPHY
Program Philosophy
• An evidence based program philosophy that:
examines and clarifies underlying
assumptions—about drug use, about the
people who use drugs, about opioid
dependence and people who are opioid
dependent,
• Examines and clarifies the principles, goals,
processes, technologies and acceptable
outcomes of harm reduction.
Why have a Program Philosophy
• The program philosophy should be consistently
reflected in program policies and practices.
• In order to be evaluated, a program’s specific policies
and procedures—like any health or medical program—
need to be logically consistent with its overall
philosophy.
• Moreover, programs need to inform and, if needed,
clarify philosophy, policies, and procedures to each and
every member of the service delivery team and to
clients/patients, their relatives, as well as members of
the local community.
Exercise
• In smaller groups, divide a flip chart sheet into three
components of harm reduction program philosophy:
• examine and clarify underlying assumptions—about
drug use, about the people who use drugs, about
patterns of opioid dependence and people who are
opioid dependent
• Identify and discuss the principles, goals, processes,
technologies, and outcomes of harm reduction.
• How should the program philosophy be consistently
reflected in program policies and practices.
Each group presents:
Putting Harm Reduction
Trainings Into Action
Understanding the Harm Reduction
Model to apply it consistently in service
delivery to injection drug users
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Managing a Harm Reduction Oriented
Service Program
– Management of Staff
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Team Meetings
Supervision
Clear Policies and Procedures
The Learning Environment
Reducing Burn-out
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Where should we focus?
• Each supervisor presents a thumbnail sketch
of a client. Getting to the bottom line?
• Why now?
• What are themes that emerge?
• Selecting a case to examine that helps identify
a problem or problem solving, engages the
group in thinking about practice, and is an
opportunity to learn together
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Trainings
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Harm Reduction
Stages of Change
Motivational Interviewing
A Strengths Based Approach
Reflective Practice
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Two Salient Features of Harm
Reduction
1. the harm reduction model is clearly predicated upon
the recognition that some “behavioral outcomes”
have greater situational importance than others.
Specifically, the harm reduction model prioritizes the
prevention of HIV transmission.
2. As a strategy by which to achieve reduction in the
transmission of HIV, harm reduction is based on the
recognition that particularly behavioral goals must be
tailored to the specific needs and real-life capacities
of the individuals to whom they are directed.
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• Research consistently shows that (1)
attunement to drug user readiness, interest,
or capacity to change, i.e., attunement to
individual drug users expectations of his
encounter with help(ers), and (2) the quality
of the helping relationship (respect, credibility,
trust, rapport) are directly associated with
positive results.
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Facets of Harm Reduction
• Acknowledges real and tragic harms
associated with licit and illicit drug use.
• Seeks to have greatest impact on reducing
drug related problems by engaging people
wherever they are on spectrum of drug
use.
• Involve drug users in setting realistic
incremental goals for change.
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Facets of Harm Reduction II
• Provides risk reduction options rather than
seeking to impose uniform label or
outcome for all participants.
• Uses low threshold easy-to-access and
flexible services to encourage engagement
by the most reticent or chaotic.
• Fits the service model to the population,
rather than population to the service
model.
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Facets of Harm Reduction III
• Integrates harm reduction into other
health & human services or into natural
settings of target population.
• Rather than the demand for abstinence as
the only acceptable goal, uses a hierarchy
of goals, with the immediate focus on
addressing the most pressing and practical
needs.
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Facets of Harm Reduction IV
• The harm reduction models serves a service delivery
principle in which the task is that of providing risk
reduction education and the tools that will enable an
individual to make the most health-promoting choices
possible in a given set of circumstances and situations.
• As such, it contrasts rather sharply with approaches to
service delivery that are predicated upon “cure” versus
“failure to cure” or upon idioms of failure, blame, and
deviance.
• It also contrasts with “incentive” strategies for
behavioral change that rely on the mediums of
coercion, penalty, and criminalization.
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Facets of Harm Reduction V
• The harm reduction model contrasts with many of the
more “mainstream” or “established” behavior change
models whose behavioral goals are derived from outside
the particular social and economic conditions and context
in which drug users live.
• Establishing an effective relationship with an DU can be
more important than telling the individual that he should
not use drugs or he should get into treatment.
• The health and well-being of the individual DU and the
direct response to the needs that he or she presents and
defines as primary, are first-order goals of service delivery,
not an abstract set of agency standards and procedures
that have been “cut and pasted” across all interactions.
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Facets of Harm Reduction VI
• In attempting to develop services for DUs, it is critical
that we remember to fit the service model to the drug
user, rather than the drug user to the service model.
• The harm reduction model reminds us that we cannot
offer constructive assistance until we know that person
to whom we are reaching out, not as an
epidemiological category or as a marginalized or
stigmatized sub-population or class of people, and that
we cannot know that person until we are prepared to
we are prepared to listen and provide them with the
opportunity to be heard.
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“Cure” versus “Failure to Cure”
• Many service delivery systems focused on abstinence from drugs as the
only healthy and safe choice, an initiative that has proven to be largely a
failure among injection opiate users.
• The clear message was that drug use was wrong and that use endangered
access to services.
• Implicitly, emphasis on an abstinence model, communicated to drug users
who failed to measure up to this standard that they were in some way
wrong, deficient, and perhaps unworthy of services or the community.
Along with the criminalization of drug possession and the stigmatization of
heroin and opiate dependence, this has led many drug users to either stay
away, alienated, or to misrepresent their drug use, thus negating any
possibility of therapeutic discussion, including a critical opportunity for
HIV intervention.
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• Many service delivery systems focused on abstinence from drugs as the
only healthy and safe choice, an initiative that has proven to be largely a
failure among injection opiate users.
• The clear message was that drug use was wrong and that use endangered
access to services.
• Implicitly, emphasis on an abstinence model, communicated to drug users
who failed to measure up to this standard that they were in some way
wrong, deficient, and perhaps unworthy of services or the community.
Along with the criminalization of drug possession and the stigmatization of
heroin and opiate dependence, this has led many drug users to either stay
away, alienated, or to misrepresent their drug use, thus negating any
possibility of therapeutic discussion, including a critical opportunity for
HIV intervention.
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The Fallacy of “Anchoring”
• The provider makes an assumption based on available
data and throws an anchor down. We may act from
biases or feelings or what others expect from us.
• Everything gets built up from the anchor.
• Despite challenging data, i.e. low numbers of IDUs
engaged in needle exchange, the provider is reluctant
to pull up anchor and look for alternative area to look.
• You lose your wallet on a dark street but you only look
for it under the street lights. Grounded ethnoepidemiology looks outside the convenience biases of
the street lights. Coupled with good outreach, this is a
good beginning for program improvements.
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Putting Harm Reduction
Trainings Into Action
Understanding the Harm Reduction
Model to apply it consistently in service
delivery to injection drug users
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A Strengths Based Approach
•
First, to establish a helping or therapeutic alliance, the counselor needs to develop
what is sometimes called “accurate empathy,” which means, putting his or her
own opinions or judgments aside in order to accept the person as he is (rather
than who the counselor thinks he should be), so that the individual doesn’t have
to justify or defend himself.
– Accurate empathy on the part of the counselor means being genuinely interested in
understanding the individual’s perspective on his experiences or allowing him to describe the
situation as he sees it.
– This is distinct from the medical practice of labeling or diagnosing a person and his behavior.
•
•
Secondly, to help someone change, the counselor must have hope for this
particular person, no matter how hopeless he seems or feels about himself. The
counselor must see within the person possibilities, resiliencies, and capacities for
change and even transformation.
Thirdly, research on optimal treatment outcomes demonstrates that in addition to
establishing respect and trust, the counselor needs to be attuned to the
individual’s stage of readiness for change. Change can be incremental, and clients
are viewed as amenable to change when abstinence is not the only option.
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Establishing the “Quozon”
•
First, to establish a helping or therapeutic alliance, the counselor needs to develop
what is sometimes called “accurate empathy,” which means, putting his or her
own opinions or judgments aside in order to accept the person as he is (rather
than who the counselor thinks he should be), so that the individual doesn’t have
to justify or defend himself.
– Accurate empathy on the part of the counselor means being genuinely interested in
understanding the individual’s perspective on his experiences or allowing him to describe the
situation as he sees it.
– This is distinct from the medical practice of labeling or diagnosing a person and his behavior.
•
•
Secondly, to help someone change, the counselor must have hope for this
particular person, no matter how hopeless he seems or feels about himself. The
counselor must see within the person possibilities, resiliencies, and capacities for
change and even transformation.
Thirdly, research on optimal treatment outcomes demonstrates that in addition to
establishing respect and trust, the counselor needs to be attuned to the
individual’s stage of readiness for change. Change can be incremental, and clients
are viewed as amenable to change when abstinence is not the only option.
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Fundamental Tools for all members of
the team: Creating the “Quozon”
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•
•
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•
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Accurate empathy
Open-ended questions
Reflective listening
Eliciting ambivalence
Exploring ambivalence
Motivational Interviewing
Accurate Empathy
• The principle of empathy is acceptance.
• Through respectful reflective listening the counselor
seeks to understand the client’s perspective without
judging, criticizing or blaming.
• Acceptance is not the same thing as approval or
agreement.
• Ironically, this kind of acceptance of people as they are
seems to free them to change, whereas insistent nonacceptance tends to immobilize the change process.
The person focuses on defending, arguing, winning the
argument or the counselor’s acceptance, rather than
self- reflection and self-assessment.
Accurate Empathy cont
• Express empathy, which helps create the safe
and non-judgmental setting for the
participant, regardless of the setting
• Skillful reflective listening is a fundamental
tool of motivational interviewing
• Ambivalence is accepted as a normal part of
human experience and change, rather than a
pathology or sign of incapability or
defensiveness or resistance.
Figure I Источник: Прохаска, Норкросс, ДиКлименте (1994)
Прекращение
Поддержание
Действие
Подготовка
Созерцание
Присозерцание
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Common ways to raise the issue of
safer behaviour include:
• situational cues: if the user has an abscess, complains
of sickness, says they have recently been to hospital or
had hepatitis, or a recent HIV test, these are all good
points at which to start talking about less risky
injection
• incorporate a HIV prevention message in a broader
conversation focusing on IDUs’ health in general or the
social, health and other problems of IDUs
• an occasional chat like `How are you', `How are things
going', might be enough to get a conversation started
in which health will be one subject
A framework is like a floor plan, a
blueprint, or way of looking at something
• Let’s look at the staff-client interaction framed
by three Habermasian concepts:
communicative action and strategic action;
system and lifeworld; and macro and micro
interactional(Habermas, 1984).
• Habermas’s concepts rooted in the early critical theory of the
Frankfurt School have been utilized in medical sociology to
retheorize and illuminate doctor-patient relations in terms of
doctor-patient communication and interactions in ways that
integrate micro-macro perspectives (Scambler, 2001;
Scambler G., 2001; Waitzkin, 1989, 2001).
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The Professional – Client
Interaction
Crudely rendered, the tension
between communicative action and
strategic action for Habermas is
between a transaction whose
outcomes are achieved jointly and one
appearing to be mutually structured
but whose results in fact organized
toward a particular end.
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Communicative Action
Communicative action refers to
interaction mediated through talk and
oriented to ‘consensual coordination
of individually planned patterns of
action. Instances of communicative
action express claims that are subject
to critical evaluation. Speakers can
‘rationally motivate’ hearers to accept
their contributions because they can
assume the ‘warranty’ for providing
good reasons that would stand up to
hearers’ challenges of claims, i.e., that
the communication is true or not true,
appropriate or inappropriate,
justifiable or unjustifiable, sincere or
not sincere.
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Strategic Action
Strategic action on the other hand
occurs when one party aims through
speech to produce an effect on others.
He instrumentalizes speech for
purposes that are contingently related
to what is said. Strategic action is
oriented to achievement of an object
rather than to understanding. In one
form, open strategic action, the
clinician/speaker openly pursues an
aim of influencing the hearer. Here,
there is an associated claim to power,
as in asymmetrical relations with a
subordinate.
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The tension between the
two
Communicative action is one where
one interlocutor (the patient)
communicates with another (the
doctor) in such a way that
identification and assessment of a
problem is achieved jointly, and action
(treatment) emerges from the
encounter.
In “strategic” communication, by
contrast—the kind we have seen to be
most common in the funded service
setting--the exchange is organized
toward a particular desired end. While
the doctor may engage the patient in
conversation, he has objectives in the
encounter that exist prior to and with
little consideration of what the patient
says and he hears.
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The System and the
Lifeworld
For Habermas, this tension between
strategic action and communicative
action exists within a system which is
also divided—between the system of
power relations and that of the
lifeworld—the circumstances and sets
of relations and resources in which a
person experiences the macro
structures.
When a person enters a hospital he
becomes a patient, is to a lesser or
greater extent isolated from the
lifeworld, and for the period he is
there is subject to objectives and
procedures of the system of
knowledge and expertise that is
independent of him.
If, by contrast, a patient is treated on
an outpatient basis, he remains
embedded in a different set of
relations that also determine his
ability and interest to engage.
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The System and the
Lifeworld (con’t)
Ideally, for Habermas , the life world
and communicative action are in
harmony, reflecting a social world
within which individuals interact with
others to decide and organize their
affairs in the private sphere of their
families or households or in the wider
public sphere. By contrast, strategic
communication sits more comfortably
in the sphere of the system, comprised
of the economy and state, each
operating with their own apparatus,
financial gain and power. When
economy and the state intrude in
inappropriate and unaccountable ways
into the lifeworld they can be said to
‘colonize’ it.
In just this fashion the ‘voice of
medicine’ has partially colonized the
‘voice of the lifeworld’ in hospital
doctor-patient encounters and
relations.
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The System and the
Lifeworld (con’t)
How do we connect this framework
with a better understanding of harm
reduction?
How does this help us think about and
identify tensions that may exist
between agency imperatives and the
culture in service delivery (the system)
and the communicative action and
lifeworld pattern expected in harm
reduction approaches.
What does this have to do with
reflective practice?
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Maslow’s Hierarchy of Needs
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Reflective Practice
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Monitoring and Evaluation
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ASTOR MODEL FOR PROGRAM
MONITORING
• The purpose of organizing program
description according to ASTOR Model
(Sigma Research, UK) is for clarity and
coherence, connecting programmatic aims
with settings, target populations,
objectives and activities, and resources.
Aims can be measured for impact.
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Aims of ASTORS
• Aims are (1) identified and therefore
pragmatically anchored in preliminary needs
assessment and ongoing assessment in action
of gaps, unmet needs, or specific areas in need
of change; (2) exist in logical relation to setting,
target groups, objectives and activities and
resource allocation. Objectives can be
monitored and the aim or impact can be
assessed or measured.
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Setting of ASTOR
• Setting (context): Where does intervention
occur? How do people come into contact
with it?(Derived, again, from needs
assessment.)
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Target of ASTOR
• Target group: Among whom is the
proposed change intended to occur?
What is the profile of the population we are
targeting? Is the epidemiological category
or population we use meaningful “on the
ground” to the people we are targeting for
an intervention?
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Objectives of ASTOR
• Objectives and methods: What does the
intervention consist of? Monitorable
activities in program to achieve aim.
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Resources of ASTOR
• Resources: Human and financial costs.
How much time will it take?
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NEEDS ASSESSMENT
• Needs assessment allows us to draw evidence together
to determine what variables affect the dependent
variable. If we know the variables that affect the
incidence of injecting drug use we can construct a
more detailed and operational layer of aims. From the
map of variables, we start turning the variables into
aims. For example, if not having information about the
association of injection drug use to exposure to HIV
has an impact on the numbers of young people starting
to inject heroin, then we will construct a specific aim to
increase awareness.
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• Mapping out the aims, based on needs assessment, and then
situating them within a larger social picture, allows us to
build up a complex picture of what effects drug demand in
a specific population. Programs start with the best aims
they can come up with based on the evidence available.
Aims describe the situation we are working towards; or,
stated differently, need is an absence of an aim being met.
As health professionals, we determine the ideal situation we
think a population should be in and then map how far away
from that situation the population is. It is the practitioner’s
job to move the population closer to the aims we have for
them.
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Monitoring con’t
• Consistent use of unique identifier systems
across all program encounters and activities
can produce data for a report on service
utilization
• Qualitative interviews can add insight and
deeper understanding of utilization patterns.
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Criteria for an Evaluation I.
• An evaluation cannot be undertaken without
first determining through monitoring reports
that:
• (1) there is a logical connection between the aim and the
objectives of the activity;
• (2) members of the target population are being reached in the
settings in which the provider agreed upon and in sufficient
numbers and with sufficient regularity;
• (3) proposed activities are taking place in the manner that
was proposed;
• (4) resources were available to support these activities.
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Client Driven Evaluation II.
• Clients in a focus group identify domains that
are of concern to them, e.g., health, housing,
social relationships, nutrition, drug use, legal
status, etc.
• Within each domain, clients’ brainstorm and
identify first individually and then as a group:
worst outcome, best outcomes, and
incremental outcomes.
• How would they know?
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Client Driven Evaluation III.
• Clients discuss and try to arrive at a group
consensus of findings.
• This identical process is repeated in 1-2 other
focus groups.
• Findings are refined and tested out in 2-3
other groups.
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Client Driven Evaluation IV.
• This can then be constructed as both a
quantitative and qualitative evaluation that is
consistent with harm reduction and peerdriven.
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Sources for this Training and
Resource Material I.
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Burrows, D. (1999). How to Start and Manage a Needle
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Sources for this Training and
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Marlatt, G. (1985). Relapse Prevention: General
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