What Is Harm Reduction?

You may or may not have heard of harm reduction, but you have almost certainly practiced it. If you ever deliberately slowed down on your drinking across a night or across a week, or switched from shots to beer; if you ever skipped a social event because you wanted to cut back on your drinking or drug consumption; or if you ever decided not to take a bottle home with you because you knew it would call to you until you drank it, then you have already practiced harm reduction.

If you still can’t count yourself in, if you’ve ever used a condom, switched from regular cigarettes to low-tar, or strapped on a seat belt, you have reduced the potential harm of an activity that in some way has its dangers. And that’s harm reduction.

What Are the Principles of Harm Reduction?

Here are the ideas that underlie the philosophy of harm reduction:

There is a continuum of alcohol/drug use: Instead of seeing alcohol or drug use in black-and-white terms of using or not using, the idea of a continuum recognizes that there are different levels of use, from occasional, to regular, to heavy, and on to chaotic use. In general, the closer you are to the low-use end of the continuum, the more harm you are reducing. And any step towards greater safety is a step in the right direction.

Change usually happens in incremental steps: Not everyone makes an important change in one huge, dramatic gesture. In fact, there are psychological reasons why most human change happens in quite small increments. Asking someone who is in heavy/chaotic use to abruptly switch to abstinence is like asking the Empire State Building to take a walk down the block and pick out something nice to wear at Macy’s. It will probably be more of a step-by-step process than that.

Easy access is important: If you have to wait, as some addiction specialists require, until you are sober to work on your sobriety, hmm, that makes things difficult. It’s rather like having a pain clinic that turns away hurt people. In harm reduction we meet you where you are and work with you there in a non-judgmental way. For instance, you don’t have to stop drinking or doing drugs to start the therapy that will be part of your healing.

Harm reduction is pragmatic: There aren’t too many proscriptions in harm reduction. You just do whatever works to get yourself to a place of greater safety. Some people need to stay away from drugs or alcohol completely to control their bad habit. That’s understood. But others can do simple things to move down the continuum towards greater safety. They may drink lots of soda before they go out to a bar so that they get a feeling of being full much sooner; they may find that keeping a log of how much they take in helps act as a control; they might count their drinks and work towards keeping a nightly or a weekly limit. None of these measures works for everyone, but they are all very direct, simple strategies for keeping a bad habit in check.

Not everyone is ready at the same time: Change has its own rhythm, and this rhythm has to be respected. When people are motivated and ripe for action, it may be a struggle, but you have the sense that they will ultimately be successful. When people are more ambivalent and tentative, this has to be respected too. They need time to wrestle with their ambivalence and to struggle with the pros and cons of change, even though the issue may seem straightforward to others. A lot of people move to no drug/alcohol use, or into a zone where it is much less problematic by an intricate dance back and forth between using and not using, and that’s okay. The goal is to find a place you can stay at that works for you long-term.

Two researchers called Prochaska and DiClemente came up with the stages of change theory. Whatever the bad habit is, they see people going through several stages as they change. People begin in Precontemplation, meaning that they are not focused on change at all; they move into Contemplation, where they are weighing the pros and cons of change but doing very little about visibly altering what they do. Next comes a preparation stage, where they are gearing up to really make some changes in their lives, and then comes the action stage, where a person goes about making the change happen.

Maintenance: Sometimes we forget that the bulk of the work comes after you have put your change in place. Prochaska and DiClemente also point out that we often cycle through the stages of change a number of times before change sticks. So, I might be in maintenance today, keeping to my plan, but back in contemplation tomorrow. Normally this is stigmatized as a relapse, but harm reduction people are nice enough to call it a lapse, suggesting that things will be back on track soon.

Where Did Harm Reduction Come From?

Harm reduction evolved in the late 1980s in Europe, Australia, and Canada. It started as a response to treatment systems that was quite punitive and judgmental towards drug users and heavy drinkers. Amsterdam, for instance, created the “methadone bus” which traveled round the city to drug users rather than requiring that they come to clinics where would probably be stigmatized. Once the dangers of HIV among drug users filtered into our awareness, the harm reduction movement rallied around getting clean injection equipment to drug users. Harm reduction programs around America have done a great job of keeping people alive this way, and of linking them to treatment and to the basic services that make it possible for people to really believe that they can make a useful change.

Harm Reduction and Therapy

Harm reduction therapy is a funny concept, because it’s based entirely on what we don’t do: We don’t stigmatize you, we don’t require abstinence, and we don’t give you deadlines by which you have change. Harm reduction meets you where you are.

The type of therapy involved is whatever method the therapist happens to use. Brian uses Inner-Directed Therapy, a combination of EMDR and the Internal Family Systems (IFS) Therapy model. IFS recognizes how compulsive and self-destructive behaviors get very embedded inside of us as part of our inner dramas. IFS sees all compulsive activities as a way to cope with emotional pain that we just don’t know what to do with. And IFS has its eyes on the prize of healing the pain that has been the driving force of all our craziness. Then our compulsion – whether it’s drugs, alcohol, sex, gambling, food issues, tobacco, whatever – can calm down and be at peace. And it is you, the client, who decides exactly where your journey will take you.