Harm Reduction vs Abstinence

An abstinence based approach to problem alcohol use among the homeless would predict that treating or punishing men for problem alcohol use would result in decreased alcohol use and a resultant reduction in the problems that lead to increases in related societal service utilization. The current system that homeless men are engaged in is such an abstinence based system. This system uses both prohibitionist and medical models of intervention which focus on eliminating the use of alcohol. Among the homeless, use of alcohol is prohibited, punished and medically treated.

The prohibitionist and medical treatment approaches have a long history, are well established and are highly interconnected. Harm reduction is an alternative to the prohibitionist and medical model approaches to substance use. Harm Reduction theory would predict that focusing on the problems related to substance use rather than the use of substances will result in a net reduction in problems irrespective of substance use. This theory also predicts that this reduction in harm will be greater than that achieved through an abstinence-based system for those not ready to abstain.

A harm reduction approach that accepts difficult behaviors and cares for problems could result in decreases in time spent on the street with difficult behaviors. A reduction in the amount of time spent on the street exhibiting difficult behaviors results in reduced harms that result in acute hospital care visits, detox visits and correctional service interactions. In general, harm reduction supporters believe that the cessation of drug/alcohol use should ultimately be left up to the individual.

In this regard, practitioners/therapists work collaboratively and attempt to meet the drug user “where they are at” while providing access to services, psychoeducation and support. Under the harm reduction model, abstinence is seen as an option on a continuum of other options (Riley et al. , 1999). While abstinence may indeed become the desired goal, the harm reduction practitioner accepts the fact that some individuals do not wish to cease their drug use, and therefore reducing harm is the chief focus.

For nearly three decades, the harm reduction approach, has been a source of debate within the addiction community, creating a riff between those who accept its premise and those who criticize its aims. It appears, at present practitioners and professionals alike have taken an added interest in this model, as it provides an alternative approach to the abstinence-based model that dominates the nations drug polices and treatment programs. At the same time, some researchers note that it is a “high-risk strategy” that can have disastrous effects, when used inappropriately (Tatarsky, 2002).

Nevertheless, Marlatt (1998) report that due to the recent interest in this model, some centers are adding a “pre-treatment group” – for those individuals who are currently not ready to abstain from drugs, but are in need of services. As a result, one may now feasibly find a harm reduction practitioner and an abstinent based practitioner working together under the same agency. Proponents of harm reduction therapy, maintain that alternative approaches to substance abuse treatment are greatly needed. G.

Alan Marlatt, a psychologist and leading figure in the harm reduction movement, has been vocal in his aim of integrating harm reduction therapy with traditional services. In addition, increased interest has led to many harm reduction conferences, across the nation. However, to what extent harm reduction strategies are truly embraced remains to be seen. Summary This paper has discussed the origins of harm reduction and how harm reduction ideas have begun to inform substance abuse treatment in the US in the form of harm reduction psychotherapy.

Harm reduction psychotherapy takes an integrative approach to substance abuse treatment, incorporating techniques from cognitive-behavioral, psychodynamic, and relapse prevention based treatments. The main focus of harm reduction is in meeting the client where they are in terms of readiness to change substance use, and on reducing the harm in use. Providers of harm reduction based treatment work with the client to identify treatment goals as defined by the client, and work to enlist the strengths and motivation of the client for positive change.

The focus on enlisting the client as a collaborator in designing treatment has the benefit of allowing the client to feel more empowered in the therapy, increasing sense of self-efficacy and retaining the client in treatment. Harm reduction approaches use motivational interviewing to work with clients to establish treatment goals and determine how substance use interferes with the realization of goals. Also, relapse prevention strategies facilitate the discovery of triggers to use or relapse after a period of abstinence, and teach coping strategies as alternatives to substance use.

Mindfulness may be a useful adjunct in harm reduction practices such as self-monitoring, discovery of triggers, and development of coping strategies.


Alexander, W. (1997). Cool water: Alcoholism, mindfulness, and ordinary recovery. Boston: Shambhala. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (4th edition) Washington, D. C: Author Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice. 10(2), 125-143.

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