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By Gwen Gruber, LCSW 
As a clinician, I have been tremendously inspired by Patt Denning, PhD, and her groundbreaking book:
Practicing Harm Reduction Psychotherapy:
An Alternative approach to Addictions, (2nd ed., 2004. Guilford Press).
Prior to learning about “Harm Reduction Psychotherapy,” I felt frustrated with the rigid and “black and white” way that addiction has traditionally been viewed by our society. From my observations, there seemed to be something punitive in the manner that addictions were perceived and treated. Consequently, I saw a large number of people falling through the cracks of our mental health and substance abuse systems. This was especially true of people that were dual diagnosed with a psychiatric disorder as well as an alcohol or substance abuse problem.
“Harm Reduction Psychotherapy,” also known as “Motivational Interviewing,” was initially designed to work with alcohol and substance abusers who were willing to explore changing certain aspects of their behavior. I have found that harm reduction can be applied to a whole gamut of issues and with many populations including adolescents and those suffering from eating disorders or other unproductive emotional and /or health problems.
For instance, harm reduction psychotherapy examines and utilizes the concept of ambivalence that many people wrestle with in their process of change. Oftentimes, harm reduction has been utilized with positive results with treating adolescents who tend to be struggling with many ambivalent factors that are an intrinsic part of adolescence. Frequently, by giving an adolescent the opportunity to figure out new ways of handling situations it empowers them as opposed to boxing them into a corner. Their positive sense of empowerment can lead to autonomy, a heightened level of self-esteem and new and productive ways for them to deal with the world around them.
The approach of “Harm Reduction Psychotherapy” incorporates techniques from both Cognitive Behavioral Therapy and the use of more in- depth assessments that are reflective of psychodynamic psychotherapy.
In my practice, I utilize the principles and techniques of both cognitive behavioral therapy and psychodynamic psychotherapy. I believe that by exploring the individual’s early experiences I can help them gain greater insight into who they are today. By exploring their thinking together, we can shed light upon some self-defeating thought patterns and work together to create more healthy and productive ways of thinking, feeling and acting.
As an individual and a therapist, I believe that for any real change to manifest itself it has to come from within the bounds of the person’s ability to choose and to be honestly motivated to change. As a therapist I serve as a catalyst in empowering my clients to set goals, make decisions and ultimately change.
According to Denning, “one of the most important parts of treatment planning is the mutual development of a needs hierarchy, a statement of what the patient considers most immediate and crucial to the resolution of other problems.” (pg 102) This is a vital tool, as both knowledge and acceptance of a person’s needs are crucial to understand them and to create a strong working alliance.
I see therapy like so many other things as a process that is continuous and each therapy therefore, needs to be tailored to the individual. There is no perfect exact treatment that is going to absolve patients from their demons, so to speak. Realistically during the process of change, people tend to vacillate and struggle with the ambivalence of change. It is hard to let go of patterns of behaviors and ways of life that we have incorporated over long periods. Even if these patterns were self-destructive and did not feel good to the individual, it is still very difficult at times to let go.
Some of the rewarding outcomes I have witnessed while practicing harm reduction therapy are based on the concept of accepting and achieving incremental changes. This is in contrast to the frequent concept of people setting themselves up by creating goals that are too difficult to achieve. When establishing goals incrementally a person is more inclined to achieve a smaller concrete goal. I have witnessed more progress and satisfaction when an individual is able to accomplish a tangible goal. This process of incremental progress helps to create more progress.
Change is then seen on a continuum based on an honest appraisal of the patient’s needs and their ability to accomplish what they set out to do. Accomplishing change can be viewed as series of small transitions. By breaking goals down to smaller incremental steps, progress is more tangible and leads to results that are more positive. I believe strongly in the premise that “a small change can have an enormous effect on a person’s life.”
Harm reduction theory as a model can be utilized in many areas of a person’s life. I find it to be very helpful in treating people with eating disorders by helping them create "incremental goals" to modify their thoughts, feelings and behaviors.
One of the most significant things about “Harm Reduction Psychotherapy” is that it begins “where the client is at.” In working with people with alcohol or substance abuse issues, I believe this a revolutionary approach. Unlike more traditional approaches, we are not requiring abstinence on the part of the person who wants to seek treatment.
For instance, someone may be a “functional alcoholic” and only drink in the evenings after work. For years, despite concerns from loved ones, he/she may have denied or downplayed their “alcoholism.” However, on their own they came to realize that their drinking is limiting them and they begin to question their dependence on alcohol as well as the serious health implications of long term heavy drinking.
Even though they have come to the realization of their dependency to alcohol, they are ambivalent about giving up drinking. They are fearful of what may happen when alcohol is removed from their lives. Will they have DTs, or seizures? What will they do to replace the very dysfunctional yet significant role that alcohol has played in their lives? They are not certain of what plan of action to take.
Sometimes, people become immobilized with their fear of change, especially when it comes to modifying or giving up something habitual. However, an empathic attuned therapist has the capacity to build an alliance with the person and, in open-minded way, help him/her to broach and explore their issues and accept that the fact that they have begun to acknowledge a problem is a way to initially decrease “harm.”
Although abstinence may be the ultimate outcome for treating alcohol and or drug abuse, I believe that if a therapist can be open and work with someone to help explore his/ her own decision, thus this can improve the prognosis. The harm can also be diminished by inviting the person into the therapeutic relationship to explore issues that may have been previously considered taboo.
By only accepting the abstinence model, we may be forced back into a “black and white” or “ultimatum” approach to dealing with clients. I do not believe that this rigid approach is best. Oftentimes, I have seen how ultimatums can cause people to become defensive and or rebellious. Consequently, they close up and choose not to explore their issues and terminate treatment prematurely.
In summary, I have found “Harm Reduction Psychotherapy” to be a wonderful tool in which to work with people dealing with a host of unproductive behaviors. About the Author...
Gwen Gruber is a Licensed Clinical Social Worker with over 20 years experience. She is presently in private practice in the Phoenix/Scottsdale area in Arizona. Some of her primary specialties are working with adolescents, alcohol and substance abusers and those suffering from eating disorders. Last Update: 11/17/2008
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