If you know someone in recovery from addiction, you know that the thought of completely abandoning their addiction all at once feels daunting, crushing, and terrifying. After all, this addiction has been a go-to whenever they feel sad, angry, scared, shame, bored, or even happy. That’s where harm reduction psychology comes in. The harm reduction approach emphasizes incremental steps to recovery and wellness. So, for example, if someone does not feel ready to abandon alcohol dependence altogether, maybe they could try consuming less of it. Obviously the goal is to stop completely, but sometimes a person may not initially want that goal or be willing to pursue it wholeheartedly. The point of harm reduction is to reduce the harm their addiction causes while or until they’re ready to pursue recovery. With all that in mind, we’ll provide a brief history of harm reduction, list some examples of harm reduction, and discuss the pros and cons of the harm reduction approach.
A Brief History of Harm Reduction
You might recognize that harm reduction looks at things a lot differently than the “hit rock bottom” approach. And that’s important to the history of harm reduction. The approach first developed in the early 1980s, at the beginning of the AIDS epidemic in the United States, when scientists discovered that injection drug users suffered the most from the pandemic, behind gay and bisexual men. To address this, groups like the Harm Reduction Coalition provided clean needles to users, as well as the nation’s first safe injection sites (SIS). As a result, HIV and AIDS numbers began to drop.
Yet, the history of harm reduction is far broader than this. As time has gone on, these techniques have influenced numerous other fields. For example, there has been a long debate over treatment-first and housing-first programs to address homelessness. Housing-first programs often emphasize harm reduction. More recently, Naloxone treatment has become popular throughout the United States in addressing the opioid epidemic. Such an invention was born from the history of harm reduction.
Additionally, the harm reduction approach has influenced treatments for things other than substance abuse. For example, in the treatment of pornography addiction, dieting, people who self-harm, and others.
Harm Reduction and the Stages of Change
Before we move to examples of harm reduction or consider its pros and cons, we need to see its relationship to the stages of change. These include:
- Pre-contemplation – The person does not consider changing their behavior or lifestyle, and deny that it is problematic.
- Contemplation – The person begins to recognize that their behavior is harmful, but they may remain ambivalent to change.
- Preparation – The person recognizes the behavior as a problem and begins to take small steps towards change.
- Action – The person has taken concrete and continuous action to change their behavior in various ways.
- Maintenance – The person has changed their behavior, formed new behavior patterns, and plan on maintaining these changes permanently.
- Termination – The person no longer desires to return to their old behavior.
- Relapse – Although this can be seen as a step back in the change process, more recent work in the Transtheoretical Model recognize relapse as an organic part of this process. After all, once a person moves from one stage to the next, there’s no guarantee they’ll continue that trajectory.
Examples of Harm Reduction
The following examples of harm reduction particularly focus on people in the pre-contemplation, contemplation, preparation, and/or action stages. Consider the following:
- You work with someone who is addicted both to heroin and cigarettes. They want to quit both at the same time. However, numerous studies show that two simultaneous drastic life changes are exceptionally harder to begin and maintain than one. You encourage the person to focus on quitting heroin first.
- You work with a person who is addicted to sex and experiences 20 sexual encounters a day. They only use protection if the partner has a prophylactic. You connect this person with resources so that they can obtain prophylactics for at low cost.
- You work with an obese person who used to pass a McDonald’s on their way home from work and order several burgers. Now, they’ve stopped eating fast food, but they still feel overwhelmingly tempted as they pass the McDonald’s on the way home. By the time they get home, they’re so stressed that they eat a few candy bars to help them relax. You encourage them to take a different route home and to cope with a snack that is both sweet and healthy, like fruit.
In each of these examples of harm reduction, each person is at a different stage in their pursuit of change. In the first, the person seems to be in the contemplation or preparation stage for their drug dependence. However, if they pursue both goals at once, they might not progress in either. Since heroin addiction presents as an acute problem, they should focus on that alone first. Their risk of prompt death will decrease, creating an opportunity for them to quit cigarettes sometime down the road.
In the second, the person does not at all seem interested in addressing their sex addiction. Nevertheless, if they persist without any protection, they could die before they ever have an opportunity to change. By at least making a small change to protect themselves, they may seek change in the future.
Lastly, this person appears to be in the action stage. However, their struggles lead to continual relapse, albeit relapse in a different way. By changing their driving route, they can avoid the temptation. By offering a less harmful substitute, they can feel assured that some source of soothing and comfort remains available.
Principles of Harm Reduction
The Harm Reduction Coalition particularly focuses on employing the ideas of harm reduction when it comes to drug addiction. They list the following eight principles of harm reduction.
- Accepts, for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
- Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors
- from severe use to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
- Establishes quality of individual and community life and well-being — not necessarily cessation of all drug use — as the criteria for successful interventions and policies.
- Calls for the non-judgmental, non-coercive provision of services and resources to both people who use drugs and the communities in which they live, in order to assist them in reducing attendant harm.
- Ensures that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
- Affirms people who use drugs (PWUD) themselves as the primary agents of reducing the harms of their drug use and seeks to empower PWUD to share information and support each other in strategies which meet their actual conditions of use.
- Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
- Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.
Pros and Cons of Harm Reduction
Harm reduction techniques remain a hotly debated topic. And there are real pros and cons to harm reduction. Those for it point out its benefits:
- Lowers the risk of death and/or severe bodily harm
- For IV drug users, reduces the spread of STI’s such as HIV and Hepatitis C
- Helps people feel safe to begin the recovery process if total abstinence seems impossible
- Protects the general public from various negative consequences, such as drug users spreading disease to non-drug users, or preventing drunk drivers from taking the road
- Enables police officers to focus on crime rather than dealing with people high in public, people without homes living on the street, etc.
Those who resist harm reduction point out the cons, such as:
- Drug users using harm reduction as a replacement for treatment
- Enabling drug users in their addiction rather than finding ways to help them out of it
- Regarding safe injection sites, employing public funds to potentially foster drug addiction
- Providing people with a false sense of comfort within their behavior rather than challenging them to change
Although plentiful evidence suggests that harm reduction helps save lives, the debate ultimately revolves around priorities. On the one hand, if you believe that services should only focus on those who desire change, then you might see harm reduction as an obstacle to flourishing rather than an aid. Instead, you will want to focus more on addiction treatment. People should not be protected from the consequences of their poor decisions.
On the other hand, if you believe that services should exist to protect people’s lives, even the lives of those who are addicted to drugs, then you would probably support harm reduction. You may still believe that addiction treatment is important, but not as important as protecting lives. Negative consequences from poor decisions are inevitable, but death doesn’t have to be one of those consequences.
Master of Divinity| Westminster Theological Seminary
Bachelor’s of Social Work, Bachelor of Science, Bible | Cairn University