What is harm reduction and what role can it play in navigating problematic substance use? Khesed Apprentice Brendan Caldwell shares his perspective.
Harm Reduction Psychotherapy encompasses a range of clinical practices used to minimize the harms associated with active problematic substance use, without assuming that abstinence from substances is the ideal goal for every person. This school of thought believes that people can engage with therapy, improve themselves, and heal while still actively using substances. As a feature of that process, their relationship with those substances will improve as well.
We are in the midst of the deadliest drug overdose epidemic in the history of this country. 110,000 Americans died of a drug overdose in 2021. It is now the leading cause of death for Americans ages 18 to 45 (CDC, 2021). Many of these deaths are from contaminated and unexpectedly potent street drugs like fentanyl (NY Post, 2022). Illicit drugs are becoming deadlier by the day and our current approaches to the issue simply aren’t working. While we wait, generations are being devastated.
Mainstream drug and alcohol treatment in the US has long operated under an “abstinence-only” ideology. According to this model, abstinence from all mood-changing chemicals is the only acceptable goal for those with problematic substance use. This must be accepted by the client in order to gain access to treatment and must be quickly achieved and maintained to remain in treatment.
These treatments work for some people, and those in the harm reduction community are in no way against sobriety. However, the reality is that a substantial number of people fail out or drop out of abstinence-only programs. Most people are unable to finish the treatment program and those who do often struggle to maintain abstinence. Many experience more extreme behavior and a higher risk of overdose when they resume using. Maybe these people aren’t ready for sobriety yet, or maybe this approach will never work for them.
Harm Reduction Psychotherapy is aimed at those looking for an alternative to abstinence-only approaches. The idea is to place the client’s goals around substance use, whatever they are, and work to support those without demanding abstinence at any time. Physical safety is prioritized. People cannot recover if they are already dead. Helping clients get access to drug testing services and clean supplies, for this reason, are crucial harm reduction interventions.
We then shift to examining the client’s ideal drug use patterns and explore the function that substance use plays in their life. Using moderation management skills to help clients achieve their ideal pattern, we explore the thoughts, emotions, and situations that drive the problematic substance use. At no point will treatment be terminated due to the client’s inability to achieve their desired substance use pattern. Healing takes time, and a positive relationship with substances only comes with healing.
Plenty of this work you can do on your own. If you are struggling with some aspect of your substance use, but are not currently wanting to quit, think about what an ideal relationship with that substance would be for you at this time. Write it down. Then you may want to try one or more of the following moderation strategies:
Create ‘barriers’ to interrupt compulsive use. Examples include only buying one pack of cigarettes per week or asking a loved one to hold onto your stash except for at agreed upon times or keeping your stash at some other location. In all these cases, you would have to make a plan and execute it to access your drugs, which makes the behavior easier to control.
Journal. Track your substance use daily along with your feelings before and after use. Try not to be harsh on yourself in this process, it will not help. The goal here is understanding, not shaming.
Try tolerance breaks. Try committing to some significantly reduced use for some period of time - whatever feels achievable. If physical withdrawal is an issue, try taking smaller doses to reduce these symptoms and transition into the break slowly. Journal throughout this experience - notice how you think and feel.
Programs with a harm reduction lens have had impressive success across the world at treating substance use problems. Switzerland, for instance, started providing prescription heroin for those dependent on opioids over 20 years ago. They’ve seen rates of problematic use plummet and, most importantly, have essentially eliminated fatal opioid overdoses (EAR, 2014).
If you or someone you know is using drugs, you can obtain access to harm reduction services at the Harm Reduction Action Center in Denver, CO. Protect your loved ones. Carry NARCAN.
Khesed therapists utilize a variety of therapeutic approaches to address problematic substance use, including but not limited to harm reduction and abstinence-based models. There is no one-size-fits-all approach, and we match clients with the therapist who is the best relational and therapeutic fit. If you’d like to explore your relationship with substances with the support of a mental health therapist, submit an intake form to get started.