Dr. Andrew Tatarsky, the founder and director of the Center for Optimal Living, has delivered harm reduction psychotherapy trainings across the planet over the last decade, from Lebanon to Poland to Chile to China.
His journeys have enabled him to exchange ideas with a burgeoning international network of progressive clinicians. Yet the full value of these experiences would be lost without a willingness to listen carefully to the perspectives of different cultures—and to confront some unconsciously held American presumptions.
The Optimal Blog sat down with Andrew to ask why a truly international view is vital to his work, how different cultures understand (or oppose) the harm reduction message, and why he learns just as much on his travels as he teaches.
Why is it so important to you to deliver trainings and collaborate with people in Europe and other parts of the world?
I’ve sometimes thought about the parallel of the evolution of American jazz. In the ‘40s and ‘50s, lots of American jazz musicians went over to Europe, to play and to develop, and then came back to the United States as more evolved people.
I’ve also wondered what is it about the US that in some paradoxical way seems to be slower to embrace new ideas. In many cultures overseas—some of which are emerging from terrible conditions, like communism or great poverty—people are interested in change, interested in learning about what’s at the cutting edge. During my first experience in Poland, I was shocked at how open people were.
As an American, as worldly as I like to think I am, I’m continually surprised by how much ignorance and presumption I have about other cultures. The only way to experience that in a powerful way is to be confronted by it when you’re in another culture.
I think that trying to meet people with a rigorous commitment to challenge our own presumptions is an essential part of harm reduction work—to create a space within ourselves to really listen and invite the other to emerge.
What was the very first training you delivered overseas?
It was in 2005, at a conference organized by a non-profit program in Beirut called Skoun. They invited people from all over the world. I presented a piece on harm reduction psychotherapy and did some training with the Skoun clinical staff. It was a remarkable experience, and I’ve just been invited back to Beirut to do a more extensive three-day training this coming October—it’ll be like a 10-year completing of the cycle.
Opportunities to collaborate with my international colleagues seem to develop organically. For example, a French psychiatrist named Alain Morel was in the audience for my presentation at that first conference in Beirut. He told me that my talk was the first time he had ever heard “harm reduction” and “psychotherapy” in the same phrase, and that shifted him. He went back to France and began developing his own thinking about harm reduction psychotherapy. Two years ago he invited me to France to give a talk to the French Fédération Addiction, the professional association for all addiction professionals and organizations in France. We have since begun a collaboration between the Center for Optimal Living and Oppelia, the substance use treatment organization that Alain directs in Paris.
How did things develop after that first visit to Beirut?
After that I received an invitation to Poland. Marek Zygadlo, then-director at Monar, a treatment program in Kraków, had been at a professional meeting with Piotr Jablonski, the director of the National Bureau for Drug Prevention [the Polish “drug czar”].The two of them had a conversation about getting something new into Poland, and Marek said, “I found this interesting book by Andrew Tatarsky.” Piotr said, “I found that book too.” So they agreed to invite me.
That led to three trainings in Kraków, and also some work with Piotr and the head of alcohol services. Back then I’d never done an extensive, three-day training; being invited to Poland forced me to put the time and effort into really thinking it through, and it’s been a continual evolutionary process ever since.
There was also a six-week intensive course on harm reduction at the Jagiellonian University in Kraków, and I taught several sections of that.
Your next stop was Austria. What happened there?
Out of that I was invited to do some training and teaching at a medical seminar in Salzburg. There had been several medical seminars on harm reduction specifically for doctors from the former Soviet Union and Asia, and I gave a series of workshops on two occasions.
I also benefited from the training available there, participating in activities run by an international cast of characters, including [international “methadone guru”] Dr. Bob Newman, whom I’d heard about for years but first met in Salzburg in 2008.
I was also invited to present on harm reduction psychotherapy at the European Association of Addiction Therapy conference in Vienna. Hundreds of people from all over Europe presented there, but I was possibly the only presenter on psychotherapy and maybe even on psychosocial treatment in general; the overwhelming majority of the presentations were about medications. I had thought that there was more interest in psychotherapy around Europe, so that was striking.
Who supported these presentations and trainings?
All that work was funded and supported by the Open Society Foundations’ International Harm Reduction Development Program, which at the time was directed by Kasia Malinowska-Sempruch [now the Director of Open Society Foundation’s International Drug Policy Reform Program].
Kasia supported my first work in Poland and came to participate in that training. She had been, for a number of years, very involved in public health harm reduction, working to spread syringe exchange and other harm reduction modalities around the world. But participating in my three-day training kind of opened her eyes, she said, to the importance of adding a psychotherapeutic component to harm reduction.
Your work has since expanded even further afield. Where else has it taken you?
Next I was invited independently by some people I met at a Harm Reduction Coalition conference to do an intensive training in Kiev, Ukraine. This was for the International HIV/AIDS Alliance of Ukraine. There, I gave a one-day training to the in-house staff in Kiev, and then a two-day training to the staff that were out in the field.
I also did two different trainings over the span of years in Chile, for example, thanks to an organization called Fundación Paréntesis that invited me—their idea is that the the clinical relationship creates a “parenthesis” of healing around the individual, to help them step out of their life conditions and begin a process of healing. They’re working with the most disenfranchised, traumatized people throughout Chile. I delivered two trainings in China, as well, working with methadone providers there.
Have you ever come across hostility to harm reduction overseas?
In Russia, the social and political structure is more vehemently anti-harm reduction than in the US, and has really clamped down and made any discussion of harm reduction, even substitution treatment, dangerous to your career.
I found this out for myself when I was invited to give a training in St. Petersburg by a particular professor and clinical researcher at Pavlov State Medical College. He later got back to me and said, “Oops, we can do it underground or off the radar with our addiction fellows, but we cannot do a public training”—his chairman had put the nix on that. So we had to find another NGO, which we did—an organization called Humanitarian Action—and they organized the training. That was again funded by the IHRD program, now directed by Daniel Wolfe, another strong supporter of integrative harm reduction psychotherapy.
This professor in St. Petersburg told me that he had been interviewed on television not long before. The interviewer asked him about methadone and he simply gave the scientific facts about methadone. Then, he told me, the Russian government’s minister of health called his chairman and said, “If he ever gives that talk again, tell him he’s out of a job.”
They can’t even talk about it. On one level, it’s the same divide between the old-time thinking and a new, progressive model. But each country, each culture has its own complicated dynamics.
What’s the typical content of the trainings you’ve delivered overseas?
The training has been evolving ever since I first rolled it out in 2007. It covers the evidence behind the notion that an integrative harm reduction psychotherapy or substance use treatment is an essential component of effective treatment for the majority of people struggling with problematic substance use. It also covers areas like the challenges of implementation, the limitations of traditional treatment, clinical technique, therapeutic tasks, strategies, case studies and so on. Integrative harm reduction psychotherapy takes the principles of harm reduction as a framework, then integrates theory and technique from various therapeutic orientations—psychoanalysis, cognitive-behavioral, mindfulness, social self-help intervention—and blends them in a way that’s tailored to the unique needs of each individual.
Over the years I’ve given one-, two- or three-day versions of this training in many different places. The core body of knowledge is adapted to different cultural contexts and different clinical populations through the tweaking of topics and information, based on specific needs.
How can you best meet those widely varying needs of the people your international trainings serve?
I always do some research to be prepared with some understanding of the particular client group. But generally—and this is in keeping with the harm reduction spirit—my presumption is that people in their context, in their culture, in their work settings have the expertise and the knowledge that I don’t have.
To kick a training off, I generally conduct what I think of as a needs assessment, where the participants brainstorm about the challenges of their particular clinical population and work settings, as well as the challenges presented by the broader culture of that society and the impacts of these challenges on clinicians.
Patients challenge clinicians with practical, strategic, technical and professional needs and demands. But they also—particularly people that are engaged in very risky, frightening behaviors—challenge clinicians at a feeling level. Understanding, managing and even making use of your own emotional experience in working with very challenging people is a key to working effectively with folks.
So that needs assessment uncovers the context that a particular group is working in, which then informs our work throughout the training. We’re continually looking to relate my model to, how does this inform your circumstances? How does it need to be adapted?
We need to start where people are, to figure out, collaboratively, how we can use ourselves in relation to people’s unique personal and cultural circumstances. The training process is never just a process of teaching abstract information—although it does involve that in part, and then how to apply it through skill-building exercises. We’re modeling harm reduction in the training style itself.
People frequently get really fired up because what gets created in the training space is a sense of a collaborative work group. Dr. Jenifer Talley, who has been increasingly working with me in training, and I are nominally the leaders, but we’re also working to invite, empower and engage all of the participants to collaborate as co-constructors. I’m facilitating a process that is designed to empower the expertise in the room.
How optimistic are you that the harm reduction paradigm will continue to grow worldwide?
I have this “one-person” theory. When a paradigm is moving across the globe, in each organization, community, country, it takes just one person to recognize the new paradigm, to see its possibilities and become impassioned and committed and courageous enough to try to bring that into their setting.
And there are these people who get this new vision, and commit to bringing it into their settings. I’ve met these amazingly wonderful people around the world, beginning with Marek in Poland and then people like Alexander Tikhonovich in St. Petersburg, Dr. Li in Yunnan, China, and Paolo Egana in Santiago, Chile. They and others are part of this growing international community of like-minded people who are now getting networked up through integrative harm reduction psychotherapy. I now feel that they are my colleagues, and we have a growing community.