Harm reduction, lack of stigmas in treating substance use disorders help them learn to advocate for future clients
By Abbey Goers, UW-Stout
Menomonie, Wis. – Fourteen master’s students in the clinical mental health counseling program at University of Wisconsin-Stout traveled to Lisbon, Portugal, in August to learn firsthand about the nation’s coordinated public health model in treating substance use disorders.
During the new, nine-day study abroad course, A Public Health Approach to Addiction in Portugal, led by Professor Julie Bates-Maves, students witnessed how Portugal’s policy on drug decriminalization has helped its people, and how it differs from policy and stigmas in the United States.
Portugal’s health-oriented approach, the National Plan on Addictive Behaviors and Dependencies, is based on five pillars – harm reduction, reintegration, treatment, prevention, and dissuasion, with goals to empower, care for and protect its citizens.
Bates-Maves is an ardent supporter of harm reduction. “The ease of access to support and deep sense of humanity that people with substance use disorders experience in Portugal is remarkable,” she said. “It makes me so happy to know it exists and a little sad that it isn’t likely to be achieved at this level in the U.S. I am thrilled our students were able to see there’s more than one way to do things clinically and that reducing barriers to care can be done — politically and socially.
“In the U.S., there is still debate around adopting this model with open arms,” she added. “Researchers have attributed this slow adoption to low public support for harm reduction, outdated attitudes that approach drug use as a moral failing, and stigmatizing attitudes toward populations who use drugs.”
Bates-Maves was excited to develop the course with UW-Stout’s Office of International Education in partnership with Academic Programs International.
“I’m proud that our program extends the learning outside the classroom. Seeing what’s possible elsewhere makes it feel more possible here at home. This experience inspired hope as clinicians as much as it inspired academic learning,” she said.
She is working with OIE to plan a course in Lisbon for CMHC alumni next summer, giving working mental health professionals new perspectives on how to care for their clients. The course for graduate students will run every other summer, with the next course held in August 2025.
Advocating for their future clients
One of UW-Stout’s 24 Graduate Studies programs, CMHC prepares competent and ethical counselors for service in the mental health counseling profession. Graduates are prepared to conduct individual, group and family counseling to restore mental health and to promote human development and growth.
Three of the master’s students, Ashley Barry, Alyssa Belling and Tiffany Johnson, have concentrations in alcohol and other drug abuse counseling, as well as crisis and trauma. Johnson also has a concentration in child and adolescent counseling. Before the trip, they studied U.S. and Portugal drug policies and were aware of the differences in stigmas regarding addiction and recovery.
“Learning Portugal’s approach to harm reduction and having awareness of their care will help me advocate for my future clients,” said Barry, of Morgantown, W.Va. “In Portugal, they have nothing but compassion for their people. It’s a night and day difference from the policies and stigmas in the U.S. Here, we’re not given that grace. We’re made to feel shamed and are judged as we’re trying to get sober.
“There’s none of that in Portugal. It’s so beautiful. I want to be a part of the solution. There are so many people who struggle with addiction, with the stigma and misinformation. I want to give people the help and support they need,” she added.
Belling, of Dodgeville, studied addiction during her undergrad in psychology, where she first learned about Portugal’s policy. “When the opportunity presented itself to study abroad, I knew I had to go because it would be a ‘full circle’ moment for me,” she said.
“It was really cool to be in a society that had significantly less stigma and misinformation around mental illness and alcohol and other drug abuse as compared to the United States. I love that my understanding of these brain diseases allows me to educate others, encouraging acceptance and empathy toward folks who struggle.
“After visiting a country where everything related to mental health care is so different, it was hard at times to imagine how I could possibly make any difference in America,” Belling said. “My classmates and I shared our sadness in this but will use our hope to propel us to be better clinicians. Although we might not be able to change the world, we have the privilege of playing a large role in the worlds of our clients. We have the power to provide a positive experience with mental health care.”
Johnson, of Suring, enrolled in the class because she wanted to see something new and “because it can be frustrating when you’re working within a system that sets people up to fail. I wanted to see in person a place where there are programs that work for the people.
“This experience gave me a new stance from which to advocate from professionally. I have a new approach for my future clients. Harm reduction makes sense in the classroom, but to see in person how it works and how accessible it can be was really cool to see,” Johnson said. “Unfortunately, in the U.S., we’re not at the point where we can offer that. There are people who don’t believe in decriminalization; people who believe in the stigmas surrounding drug use.”
A social service system devoted to harm reduction
In Lisbon, the class visited SICAD, the National Institute for Preventive Behaviors, which helps craft policies, maintenance and change. Students spoke with Elsa Maia, director of Intervention on Addictive, Behaviors and Dependencies, in the Ministry of Health.
Maia presented on Portuguese policy, its approach to harm reduction and the history behind the policy, which decriminalized drug use in terms of practice with less than a 10-day supply. “But that doesn’t mean it’s legal,” Bates-Maves added.
“Above all, a person with a substance use disorder is considered as a person in need of health and social care,” she said.
When someone is found with less than a 10-day supply, they are given an administrative citation to meet with a dissuasion committee of social workers, physicians and counselors, who determine if the person’s possession is for medical or recreational use. They then determine what care the person may need and if they opt in for counseling support, their care is paid for by government health care. Those found with more than a 10-day supply are arrested as a dealer/distributor and criminal proceedings take place, Bates-Maves noted.
When Portugal’s’ policy was enacted in 1998, illicit drugs, from heroin to cocaine to meth, impacted people from every walk of life. Its jails were overflowing, and 1% of its population had a substance use disorder, a high percentage for a nation of only 10 million people, Bates-Maves explained.
Since then, substance use disorders have dropped to 0.33% of the population. Of that percentage, heroin use went from 98% to 16% of users, and overdoses went from 350 deaths to 63 deaths this past year. Problematic users went from 100,000 to 33,200, and new cases of HIV dropped from 56% to 3%.
Compared to the opioid crisis in the U.S., the Centers for Disease Control and Prevention reported more than 75% of the nearly 107,000 drug overdose deaths in 2021 involved an opioid. And 13% of people used an illicit drug in 2019.
The class visited the Centro de Acolhimento de Santa Bárbara, temporary housing for homeless individuals and those struggling with addiction. The facility is in a renovated police barracks and offers a safe place for anyone in need.
“It’s a beautiful facility. It could be a postcard,” Bates-Maves said. “And pets are allowed, which is so important for so many homeless people. They may not accept help if their pets aren’t allowed to be with them. The facility even provides veterinary care and food for animals.”
The class also visited a supervised drug consumption room, which offers clients clean needles, swabs and needle exchange kits to use drugs safely and reduce disease transmission. While clients bring their own drugs, they are monitored by medical care providers in case of an overdose. Case managers are also available for clients.
“There is a whole social service system every time you go in,” Bates-Maves explained. “This is another aspect to their harm reduction policies – to reduce disease, reduce overdoses and offer greater access to care.”
The students met with guest lecturers Catherine Moury and Rui Coimbra Morais, who spoke on European Union drug policies and harm reduction in addictions. Moury is associate professor of political science at NOVA FCSH University of Lisbon; and Morais is a psychologist specializing in deviant behaviors and a member of the Order of Portuguese Psychologists.
A powerful experience, professionally and personally
The most powerful experience for the class was a visit to a mobile methadone unit, where Bates-Maves and students talked with the nurse and staff, who drive the unit – a visibly marketed van – to scheduled stops at stations in the city. Methadone is a medication used in medication-assisted treatments to help people reduce or quit heroin or other opiates.
At the mobile unit, clients drive or walk up, check in, receive their medicated dose, and meet with a counselor if they choose.
Bates-Maves has worked in a methadone clinic and called the visit in Lisbon “one of her best days as a professional counselor.”
“Methadone is very effective in treating opiate addictions, but it’s very stigmatized in the U.S.,” said Bates-Maves. “Because of the stigma, it’s often very secretive – a hidden service regulated by the DEA, and there are so many barriers for treatment. But in Portugal, it’s accessible and is widely accepted as a valuable treatment.”
During their visit, a work truck pulled up and a man stepped out. He checked in to the unit, received his dose by a professional health care provider and continued on his way. The process took three minutes. Fees are covered by government health care.
In the U.S., a similar visit might take a half hour to an hour waiting in line to see a nurse and perhaps a therapist. Limited hours of operation, few facilities in a region and cost of coverage hinder accessibility and add barriers for people on their way to recovery, Bates-Maves said.
Johnson was amazed to learn that the worker’s employer was involved and supported his recovery. “In the U.S., people feel that they could be putting themselves at risk and looked at differently by their employer for their past drug use or recovery,” she said.
For Barry, the course was an academic, professional and personal opportunity. She has been in recovery from alcohol for seven years. She celebrated her anniversary of sobriety with her cohort on their trip.
“Seeing the mobile methadone unit in person was very emotional for me, in a good way. With my lived experience, it was very profound to witness a country that can go so far to help its people,” Barry said.
Careers in counseling and compassion
Johnson will graduate with her master’s this December. “You learn so many amazing things in the clinical mental health counseling program,” she said. “You’re learning knowledge of counseling, but it’s also a journey of personal growth. I think of who I was coming into the program and now as I’ll be graduating. To counsel someone else, you have to have that moment of vulnerability yourself. It’s about personal development.”
Johnson, who has a bachelor’s in criminal justice rehabilitation from UW-Stout, is currently interning with Lutheran Social Services in family therapy and children with high needs and worked as a residential treatment worker with Arbor Place, in Menomonie. During her undergrad, she interned with Cedar Ridge, a dual-diagnosis residential treatment center in Stillwater, Minn.
Barry is completing her practicum with Park Avenue Center, a drug and alcohol use facility in Minneapolis, with a goal to continue working with this population. She plans to earn dual licensure in substance abuse counseling and mental health. She will graduate in May 2024 and has her B.S. in psychology.
“I would move to Portugal in a heartbeat if I was able to work for them,” Barry said.
Belling is in her practicum at Dunn County Behavioral Health Services and will graduate in August 2024. She is most interested in working in trauma counseling but is keeping an open mind.
The course also included cultural immersion and sightseeing opportunities such as a Portuguese language lesson, a cooking class and visits to castles and palaces in the Lisbon area.