I often surprise new graduate students on the first day of my substance use disorder (SUD) treatment course. Students come with a variety of ideas about what to expect in the course. Many indicate they are there because it’s a mandatory course, and they have to take it. Others have heard about motivational interviewing and are eager to learn how to “do MI”. Most are open and curious about what might happen in our 15 weeks together — even if they have no idea what to expect.
What students do not expect me to say is I love working with folks dealing with substance use issues — regardless of how they might show up along the substance use spectrum (from experimental use to severe SUD). I tell them that working with SUD is an opportunity to meet people where they are in a way that allows me to learn all about their true essence and how their use of substances or processes have enabled them to survive. I speak about how I am privileged to help them sort this all out and partner with them in a way that allows us to figure out together what is their next best step. I find such work joyous and lifegiving, and I would not be having this conversation with students — who anticipate this work to be painful and terrifying — without having adopted a harm reduction approach to care.
The harm reduction approach allows me the flexibility, openness and curiosity to work in a way that is empowering, respectful and life-affirming — for me as well as the people I am grateful to serve. These are my comments at the beginning of class, which set the tone for the entire semester, and it is important to elaborate so the promise and potential of harm reduction can be fully understood.
“The harm reduction approach allows me the flexibility, openness and curiosity to work in a way that is empowering, respectful and life-affirming — for me as well as the people I am grateful to serve.”
What is harm reduction?
Harm reduction is exactly what it says it is: anything that helps reduce the dangerous impact of any of our behaviors. It is not a binary of harm reduction (typically reduced substance use) vs. abstinence (no use). This is an important distinction to make as some treatment communities, media articles or online spaces frame the recovery discussion as “harm reduction vs. abstinence”, often with an implication that harm reduction is not effective and/or harm reduction is useful only as a path to abstinence. This perspective is an unfortunate misunderstanding of harm reduction. In fact, abstinence is harm reduction; anyone who is abstaining from a substance or a behavior is certainly protecting themselves from harm.
What the typical harm reduction approach provides is a continuum of options. Many providers, researchers or theorists consider harm reduction an umbrella term under which falls a variety of interventions that help reduce the impact of problematic behaviors (Denning & Little, 2024¹; Marlatt, 2011²). I use the image of a basket and speak to how this “harm reduction basket” provides us with so many options and opportunities to explore with people seeking care. I also speak to how each person is unique and has their own special and meaningful path to recovery or wellness, as they define it. Recovery is a highly individualized and nuanced process of selecting options from the basket. Choosing from the basket of many care options allows help seekers to define their own recovery and defines our therapeutic process together that will be a collaborative, respectful and thoughtful journey. Such a definition of harm reduction is important as it creates some significant changes in how the business of SUD or addiction treatment work has historically been performed.
“Choosing from the basket of many care options allows help seekers to define their own recovery and defines our therapeutic process together that will be a collaborative, respectful and thoughtful journey.”
Key elements of harm reduction
Choice: A continuum of options means that individuals will not have to choose between making current substance use less dangerous and abstinence. The status quo for many treatment programs historically has been that there is one correct choice, and the correct answer is abstinence. Harm reduction as a continuum of options positions itself as a place in which there is freedom and autonomy to choose between a variety of options and then evaluate and change what is needed. For instance, I might not be going into treatment right now, but I am willing to exchange needles and make a commitment to obtain and carry Narcan and do my best to use with others.
If you are a provider and you are reading this, notice what reactions you might be having to the idea of choice when speaking about substance use or process-based compulsive behaviors. You might feel compelled to make sure that someone is moving toward abstinence. What do you think is the reason for your reaction? Is it based on your morals and values? A fear of risk? A need to be following regulations? There is no shame when coming from any of these perspectives, but there is a need to sort out what might be our values, fears and concerns and how our thoughts and feelings impact the autonomy of people we serve. Many providers are well aware of reducing risk through following regulations, but collaboration is also aligned with ethical practice because it demonstrates respect toward help seekers and supports their autonomy (Swift et al., 2021³).
Therapeutic stance: Related to choice is the therapeutic stance providers adopt when we initiate therapeutic relationships. Motivational interviewing (MI), which is often the skills practice used to provide harm reduction services, is defined as “a particular way of talking with people about change and growth to strengthen their own motivation and commitment” (Miller & Rollnick, 2023⁴). Motivational interviewing (MI) is a person-centered approach to care that is embedded in a therapeutic stance that seeks to increase individual autonomy and reduce power difference between provider and patient. The “spirit” of MI are the broad values and attitudes that create the conditions for psychological safety and empowerment needed for truly open exploration of one’s change, and this spirit shapes the harm reduction therapeutic stance.
The MI Spirit consists of four components: the willingness to partner (collaborate) with help seekers; acceptance of their dilemmas, perspectives and personhood; compassion toward their challenges, with an intention to reduce suffering; and a desire to find ways to help empower individuals to find and use their own strengths and abilities. By adopting the Spirit of MI, the provider must take on a therapeutic stance that is not controlling or over-prescriptive. For practitioners working with substance use or process disorders, the basket of harm reduction options are essential because we cannot be collaborating in a compassionate manner that supports autonomy and empowerment if we are insisting on one outcome (abstinence) with a defined pathway to that outcome.
For providers, the above questions about choice, collaboration and autonomy are central to having an appropriate stance to offer harm reduction care; the provider facilitates the change and growth, but they are careful to not be prescriptive about the process and they do not define the outcome.
Setting limits: “But what if someone is really addicted or their behavior is too problematic?” The concern with this question is an assumption that some people will never get better, and they need to stop using to survive; they will keep “working the system” and continue to “not be held accountable,” or their behavior is especially problematic for those around them.
In the harm reduction approach, we do not prescribe the outcome, so it might be possible that we work with some people who never stop using. What the harm reductionist cares about is keeping people alive and improving quality of life. While we are not concerned about having abstinence as the ultimate outcome, we can still set limits on behaviors that impact others, even when we are supporting someone who has no intentions on quitting.
Setting limits with compassion can be a way of engaging in a conversation about change and growth. Again, using a motivational interviewing approach, providers can begin a meaningful conversation and engagement process even when such a conversation might not seem feasible.
Engaging in harm reduction with clients
Some questions to ask yourself when engaging in harm reduction conversations:
1. What are the providers or organization’s assumptions about the person seeking help?
First of all, are they seeking help? If clinical engagement is seen as part of a mandate, how can the conversation be shifted to helping clients explore what might be useful in their time together? Although some individuals do benefit from counseling mandates, the dual relationship providers find themselves in when required to both control and care for participants can create complications in the clinical relationship (Hachtel et al., 2019⁵). The more providers can find ways to work together that promote the relationship over compliance, the more they are prioritizing the individual care over controlling the individual.
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Does the provider see the person as “too far gone” or immediately want to pass on to a higher level of care? The person might need a different type, intensity or frequency of support, but they likely need to be thoughtfully linked to such support. Also, many organizations can review their resources and practices and with some shifting of protocol, expertise or resources can provide care within their scope of practice to more individuals in the community.
2. What are the assumptions providers have about their services?
If staff believe their job is only to get someone to embrace abstinence (or “get” anyone to do anything), they will likely be stressed and overwhelmed working with most individuals as change is a complex process.
3. What kind of flexibility do the providers have regarding their work and their role in the work?
If providers see their role as helping someone be safer in their life and find ways to move toward vitality and growth, and they have a bottomless basket of options from which to choose and customize for each person, then they will likely have a far more enjoyable and meaningful career.
4. What is the help seeker’s life like outside of their substance or process use issue?
Are they physically/emotionally not well? Malnourished, sleep deprived, traumatized and grieving people do not necessarily have the cognitive or emotional capacity to engage in discussions about change and growth. They need their basic needs met, so good case management including linkage and follow up to resources is often the best first step. Linkage also builds trust through demonstration of respect and compassion.
Do they have safety and support in their daily lives? Living in unsafe housing and/or communities or being hassled and bullied at work and school are serious issues that often need to be addressed before an individual can truly engage in care.
“Working with someone’s problematic substance use or process issue is complex. It does not have to be unduly painful for help seekers or providers when it is approached with compassion, openness and flexibility, which is what the harm reduction approach offers.”
Working with someone’s problematic substance use or process issue is complex. It does not have to be unduly painful for help seekers or providers when it is approached with compassion, openness and flexibility, which is what the harm reduction approach offers. For those of us who have been in the field for many years as well as for new clinicians, it offers an opportunity for meaningful engagement with community members who often are eager for shame-free support and guidance. Being able to offer such emotional support and a basket full of endless options for care makes it all worthwhile.
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References
1. Denning, P., & Little, J. (2024). Practicing harm reduction psychotherapy. Guilford Publications.
2. Marlatt, G. A., Larimer, M. E., & Witkiewitz, K. (Eds.). (2011). Harm reduction: Pragmatic strategies for managing high-risk behaviors. Guilford Press.
3. Miller, W. R. & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow. (4th Ed.). Guilford Press.
4. Swift, J. K., Mullins, R. H., Penix, E. A., Roth, K. L., & Trusty, W. T. (2021). The importance of listening to patient preferences when making mental health care decisions. World Psychiatry, 20(3), 316.
5. Hachtel, H., Vogel, T., & Huber, C. G. (2019). Mandated treatment and its impact on therapeutic process and outcome factors. Frontiers in psychiatry, 10, 219.