What is Harm Reduction Therapy and How Do I Practice It?

Harm reduction therapy is based on four principles:

  1. While absolute abstinence may be preferable for many or most substance abusers, very few will achieve it, and even that small group will take time to do so and may relapse periodically;
  2. Ordinary medical treatment readily accepts and practices ameliorative therapies, which preserve health and well-being even when people fail to observe all recommended health behaviors;
  3. Therapists should present accurate information to clients and may even express their own beliefs, but they cannot make judgments for clients;
  4. There are many shades of improvement in every kind of therapy—this improvement may be all that people are capable of and should be encouraged and nurtured.

In Europe, the concept of harm reduction is taken for granted. Except for the United States, every national government in the Western world endorses or provides needle exchange programs. And harm reduction has had a certain impact in the U.S. as well, where many cities and states tolerate, or even encourage, clean needle programs. Moreover, there are methods for counselors to deal with addicts and alcoholics which are consistent with the harm reduction ideology. These often require counselors to develop whole new ways of thinking about addictions, clients and the therapeutic relationship. These new ways of thinking offer important tools for reaching clients and for improving treatment outcomes.

Following are key harm reduction therapy attitudes and techniques in relation to addictions:

Accept and respond to improvement. The standard addiction treatment in the U.S. requires the individual to instantaneously and totally give up all use of the problem substance, and rejects anyone who fails to do so! This is cherry-picking of clients, by working only with those who are immediately able to get better. But who then will deal with the vast majority who are not capable of immediate cessation? Substance abuse counselors who wish to work with this large majority need to define intermediate goals, and to recognize such positive steps when these occur.

Improvement includes any lessening of harms the person experiences. What if a man regularly, while out drinking, got into fist fights or committed crimes? If, while drinking no less, that person stayed at home, he might significantly reduce the harms his drinking causes. Or, if another man got drunk at home and then fought with his wife, he might improve his life by simply drinking at a safe place outside of his home. It is a strange kind of perfectionism which says, “I won’t accept any kind of drinking or drunkenness, and if this man continues to drink this way, I wash my hands of him.” This is reminiscent of former New Jersey governor Christie Whitman, who rejected the recommendation of the AIDS Commission she appointed when it listed provision of clean needles as the top step the state could take to prevent new HIV infection. New Jersey now has the highest rate of injection-based HIV infection in the nation, many of them children of drug users.

Humility (versus perfectionism) is a clinical skill. When people say, “I will not tolerate any kind of drinking in therapy, and therapists who do endanger the lives of their clients,” their own patients must surely have perfect compliance. Not! It’s just that they insisted on abstinence, so that any failures were those of their clients, and not their own. While this may assuage therapists’ consciences, it is not effective therapy.

Anticipate and incorporate continued harms in therapy. Among the delusions of therapists is that clients depend solely on their therapists for any advances they make. In fact, most people get better on their own. In part, this involves experiencing and learning from the pain of their mistakes. When we consider that most alcoholics have spent years, even decades developing their habits, we may begin to understand that positive changes may likewise take some time (although hopefully not as long as it took to develop the problem), and trial and error. This means recognizing that continued drinking will occur, while continuing to work with clients towards fulfilling life goals and reducing harms.

Learning to take care of oneself is a skill, a value, and an attitude. To say one accepts that human beings are imperfect does not mean that you endorse their imperfection. You want to encourage those you are helping to greater heights and larger successes. But it is the recognition and encouragement of smaller successes that lead to such progress. In particular, helping people to think about how to take care of themselves, even if they continue to drink and take drugs, may be an entirely new attitude for some people. When they first start getting medical care for health problems, or eating well or avoiding infection, or staying out of legal trouble, or getting a place to live, or accumulating money, etc., this new attitude can grow so that it crowds out all problem drug use or drinking.

What we consider substance abuse therapy in the United States consists largely of exhortation—”quit drug taking and drinking!” Real therapists must know how to improve the conditions of a range of clients, from those who are ahead of the therapist in curing themselves, to those who merely need encouragement, to those who need help to avoid falling off the edge, to those who may have given up and who are waiting —or helping themselves—to die.

For more information on Harm Reduction, please visit the following:

Stanton Peele

Dr. Stanton Peele, recognized as one of the world's leading addiction experts, developed the Life Process Program after decades of research, writing, and treatment about and for people with addictions. Dr. Peele is the author of 14 books. His work has been published in leading professional journals and popular publications around the globe.


  • Yves Zwyssig says:

    The drinking and drugs are not the problem…in the beginning. then they became the problem.
    If you start eating better, or at least you intent, this will take you to the root, you may start observing your thoughts ” I don’t deserve it”, or “what is the proposed” not deserve it etc. because when you started the bad habit you were not observing. Observing is the key together with your Intent. That takes you to the root.

  • Catharine says:

    My addiction started at age 11. Incidents in my past left me with the knowledge that I was a piece of garbage, and that people could do anything they wanted to me, and there was nothing I could do about it. I had to abstain for my mind to recover enough to absorb therapy. The longer I abstained, the more my life improved, and the more I shed my “victim” mindset and took control of my life. I had relapses, but I didn’t give up. I was blessed by those who didn’t give up on me. Today I am working and no longer a burden on society and a source of fear and misery to those who care about me. I do what I can to help people who are still struggling. I hope this gives you something useful. Non-addicts don’t understand why we just can’t stop.

  • Dean B. says:

    “When they first start getting medical care for health problems, or eating well or avoiding infection, or staying out of legal trouble, or getting a place to live, or accumulating money, etc., this new attitude can grow so that it crowds out all problem drug use or drinking.”

    The drinking and drugs are not the problem. This statement presents them as a problem when they are a symptom. Simply “crowding out” or “continuing to stuff or deny” is doing nothing as well to benefit the person. Yes, learning skills is important, but one MUST address the ‘root’ problems of their pain and suffering, otherwise they will simply continue to look for other coping mechanisms. Who wants to cope? Tolerate? The goal is to heal mentally thereby reducing the pain and suffering, thereby reducing the brains needs to ‘crowd out’, stuff, deny,etc and the need for the drug is diminished and becomes an unwanted, unhealthy choice (not taken).

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