Harm Reduction Therapy Isn’t What You Think It Is by Perri Franskoviak, Ph.D.

When I was in school training to be a therapist, I learned about various models related to how humans develop. I learned about the different theories that inform our conceptualization of how mental illness develops and what to focus on when working with individuals and groups. I learned about the importance of empathy, and that no therapy can take place without the formation of a trusting relationship with a therapist. I was taught how to assess intelligence, personality, and mental health disorders using standardized instruments that leave little room for factoring in the impact that environment has on our developmental capacities, much less the artificiality of the test setting. Finally, I learned how to calculate a linear regression (by hand!) to understand how multiple variables might predict a particular outcome. Hmmm.

It was only when I graduated and began working full-time as a clinician, over a quarter of a century ago, that my education really began.

Early on in my career I had the good fortune to work as a psych assistant for Patt Denning, a co-developer along with Jeannie Little of Harm Reduction Therapy. Working with Patt was a master class in coming to appreciate how we humans approach change. Whether it’s a decision to change jobs, to end a relationship, or slow down on our cannabis use, we are ambivalent about change. And nowhere is this truer than if we think we’re not. We are always of at least two minds when it comes to letting go. One part desires change and is hopeful about the possibilities of a different life, while another part (or parts!) may feel hopeless about our capacity to carry out a change, as well as find the patience to keep trying rather than blaming ourselves or others when our change does not succeed our first time out. Fantasy is powerful, and who among us has not fantasized that we’ll forgo that pint of ice cream and in no time have the body we want. Still another part of us resists change, the part of us that can’t imagine feeling as stable doing anything other than what we’re doing right now. It’s amazing the  situations we humans can talk ourselves into settling for.

The ensuing years have helped me become a better listener, to lead with empathy and curiosity rather than a need to know, and have taught me how powerful context and culture are in understanding human behavior. I have a much better sense for how our earliest relationships endow us with resources and challenges; early relationships and their impact on us create a continuum with trust on one end and protection on the other. 

Throughout all my training, the ace in the hole, the shining beacon on the hill, was the finding, replicated through many iterations of psychotherapy outcome studies, that what matters most in determining a successful therapy is the quality of the therapeutic relationship. It’s not that other elements, such as the type of therapeutic model or the type of psychic distress the client has been experiencing, aren’t important. It’s just that the quality of the therapeutic connection relegates those factors to a supporting role, uplifting instead skills such as active listening, attuning to our clients’ emotional states, reflecting our clients’ experiences so that they know they’re being heard, and making eye contact and dropping it when it feels like too much for our client. Most of all, it means respecting and appreciating clients’ protective behaviors, such as the choice to use drugs. In other words, what’s needed are the qualities that make us sensitive and aware members of the human community. Harm reduction therapy isn’t about tolerating behavior we don’t understand or don’t agree with, it isn’t about knowing how drug use impacts the brain and body, although that information is helpful to know, and it surely isn’t about creating programs that require people to behave as if they’ve already received the treatment they’re seeking as a requirement to participate in that treatment! If you follow that last sentence, then you can appreciate how convoluted our treatment system is.

Being a harm reduction therapist is about being curious about other people’s experiences. It’s about developing the courage to not know and remain open to what is. It’s about paying attention to our responses to the people we work with, especially the folks whose behaviors really activate us, and being willing to explore how our response relates to the therapeutic relationship rather than collapsing around an interpretation that our clients are attacking us or aren’t interested in change. It’s about creating systems where we can support and take care of each other rather than feeling isolated and burned out. It’s about respecting people’s autonomy and the right to choose what’s best for them. And most of all, it’s about learning to be aware: of ourselves, our impact on others, and their impact on us, and sitting still with that knowledge before acting on it.

Really, being a harm reduction therapist is no different than being a therapist who works with anyone. It’s about continuing to imagine that our clients, like us, are human and fully capable of all kinds of choices and behaviors that make us more alike than different. None of us is without a desire to feel different than we do at any given moment given the challenges we all face in our lives. Letting that truth in and living as if it matters is what the harm reduction therapist is up to. So, you see, harm reduction therapy is just good therapy. Nothing added.

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