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Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems
This ground-breaking volume provides readers with both an overview of harm reduction therapy and a series of ten case studies, treated by different therapists, that vividly illustrate this treatment approach with a wide variety of clients.
Harm reduction is a framework for helping drug and alcohol users who cannot or will not stop completely―the majority of users―reduce the harmful consequences of use. Harm reduction accepts that abstinence may be the best outcome for many but relaxes the emphasis on abstinence as the only acceptable goal and criterion of success. Instead, smaller incremental changes in the direction of reduced harmfulness of drug use are accepted. This book will show how these simple changes in emphasis and expectation have dramatic implications for improving the effectiveness of psychotherapy in many ways.
From the Foreword by Alan Marlatt, Ph.D.: “This ground-breaking volume provides readers with both an overview of harm reduction therapy and a series of ten case studies, treated by different therapists, that vividly illustrate this treatment approach with a wide variety of clients. In his introduction, Andrew Tatarsky describes harm reduction as a new paradigm for treating drug and alcohol problems. Some would say that harm reduction embraces a paradigm shift in addiction treatment, as it has moved the field beyond the traditional abstinence-only focus typically associated with the disease model and the ideology of the twelve-step approach. Others may conclude that the move toward harm reduction represents an integration of what Dr. Tatarsky describes as the “basic principles of good clinical practice” into the treatment of addictive behaviors.
“Changing addiction behavior is often a complex and complicated process for both client and therapist. What seems to work best is the development of a strong therapeutic alliance, the right fit between the client and treatment provider. The role of the harm reduction therapist is closer to that of a guide, someone who can provide support an
Harm reduction is a framework for helping drug and alcohol users who cannot or will not stop completely―the majority of users―reduce the harmful consequences of use. Harm reduction accepts that abstinence may be the best outcome for many but relaxes the emphasis on abstinence as the only acceptable goal and criterion of success. Instead, smaller incremental changes in the direction of reduced harmfulness of drug use are accepted. This book will show how these simple changes in emphasis and expectation have dramatic implications for improving the effectiveness of psychotherapy in many ways.
From the Foreword by Alan Marlatt, Ph.D.: “This ground-breaking volume provides readers with both an overview of harm reduction therapy and a series of ten case studies, treated by different therapists, that vividly illustrate this treatment approach with a wide variety of clients. In his introduction, Andrew Tatarsky describes harm reduction as a new paradigm for treating drug and alcohol problems. Some would say that harm reduction embraces a paradigm shift in addiction treatment, as it has moved the field beyond the traditional abstinence-only focus typically associated with the disease model and the ideology of the twelve-step approach. Others may conclude that the move toward harm reduction represents an integration of what Dr. Tatarsky describes as the “basic principles of good clinical practice” into the treatment of addictive behaviors.
“Changing addiction behavior is often a complex and complicated process for both client and therapist. What seems to work best is the development of a strong therapeutic alliance, the right fit between the client and treatment provider. The role of the harm reduction therapist is closer to that of a guide, someone who can provide support an
- GenresPsychologyAddiction
396 pages, Paperback
First published June 30, 2002
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September 8, 2026
I didn't realize I've been reading so much Academese lately, but l feel a strange urge to describe this book as "paradigm shifting," which is a phrase I'm almost certain I didn't know a few weeks ago. I don't even know if you're supposed to hyphenate it.
Anywho, it really is quite telling that I have been to both inpatient and outpatient rehab twice (as well as many an Alcoholics Anonymous meeting; I like to think this all earns me some street cred) since 2020, yet my mind is this blown by a book originally released before the first episode of "That's So Raven." If I were going to be harsh I would say that must mean the modern treatment industry is 25 years behind, but I don't like to be harsh-- AA/NA and recovery centers have worked quite well for some, they have saved many lives and they are where I have made some of my most cherished memories.
However, as the book argues, the system is limited in some important ways-- including by many of the deep-seated gospels passed down from one generation of recovering addicts to the next-- and perhaps I'm a good case in point (in fact I recognized a lot of myself in the case studies included in this book):
I first entered treatment as a 26-year-old androgyne of sorts (I like to call this my pre-transition, "Boy George phase" 💅🫅) with a history involving parental suicide (my mother), parental drug and alcohol addiction (my father), severe identity-based social stigma and peer rejection (I was quite obviously #thatgworl from an early age) as well as a history of romantic experiences with exactly the kinds of men who tend to like someone who looks very androgynous and sufficiently pretty like a girl (which is apparently a lot of guys, btw. Ask me how many unsolicited eggplant pics I got from guys I met in rehab), but only in private.
The treatment industry in its current form is just not designed to deal with that, or so many other manifestations of existential trauma, if I had to guess. Somehow clinicians heard all of what I said about my life and concluded, rather matter-of-factly, that I was suffering from the "disease of addiction" and maybe some borderline personality (the latter claim was based on, and I cackle as I write this, rather insufficient questioning).
That's in large part because, as Andrew Tatarsky writes in the book, historically, "the prevailing view in traditional drug and alcohol treatment was an emphasis on the commonalities among drug users as the central focus in treatment... Differences between drug users were seen as unimportant or worse, as undermining distractions to the task at hand, which was to help people stop using drugs. The fact that one person might say he used drugs to relieve his depression about being HIV-positive and another said drugs might curb homicidal or suicidal tendencies would be considered beside the point. Individual considerations were interpreted as justifications of drug use and not relevant to the challenge of stopping. They were seen as evidence of the drug user's wish to see himself as unlike other addicts rather than accepting that all addicts have a common disorder or disease that requires the same treatment. The wish to be seen as special or unique was understood to be symptomatic of justification for continued use rather than a serious wish to address some important, relevant issues."
This rationale sounds perfectly reasonable and is probably correct in quite a few senses, at least for a fair number of people, but Tatarsky argues that this reasoning is applied far too broadly, and I'm inclined to agree. I'll admit that at one point, in the early years following my first rehab stay and introduction to AA, I wanted desperately to finally have a simple explanation for my suffering and a clear path to curing it, so I clung to and repeated the explanation that I had a "disease," or a beguiling "allergy," as the Big Book describes it, an addictive personality that was ultimately to blame for my deep-seated blues... but even back then I was experiencing some obvious cognitive dissonance, and the voice in the back of my head started to get a little louder during my second rehab stint after I inevitably relapsed. I kept thinking to myself: "it seems like I'm just depressed and I've been drinking to self-medicate the depression. The drinking seems like a symptom of a different problem."
Lo and behold, i'm apparently not the first person to have such a revelation. According to the book, some pointy-head Harvard professor named Edward J. Khantzian already thought of that years ago, back when the Delorean could still pass as a car from the future, and presented what he called the "self-medication hypothesis" (for which discovery I assume he was awarded with an esteemed "Captain Obvious" trophy). Tatarsky sums up Khantzian's hypothesis in the book as follows: "people use substances as an attempt to address inner difficulties that they are unable to resolve in other ways. In contrast to the earlier view that substance users are simply bad, morally deficient, or just thrill seeking, all of which may be true for some users, this idea emphasizes that people for whom substance use has become problematic, compulsive, and severe are trying to deal with some inner suffering that they are unable to heal in other ways... One of the most recent developments in Khantzian's work is a refinement of the self-medication hypothesis. Through his work with large numbers of people struggling with drug problems, he has identified a set of general aspects of psychological functioning that seem to make people particularly vulnerable to self-medicating with drugs... The four 'sectors of vulnerability' that he identifies are problems with self-esteem, problems in relating to other people, problems dealing with emotions, and difficulties people have in how they take care of themselves.'"
The more I read, the more that originally rather faint voice now wants to scream a quote I recently picked up from a BBC interview of Hillary Clinton answering a question about why President Trump's cabinet members seem so sycophantic (I can turn literally anything into an excuse to quote Hillary Clinton): "THIS IS NOT COMPLICATED! This is so obvious!!" ---My parents' neglect obviously created some level of initial abandonment and self-esteem issues, that was obviously exacerbated by repeated adolescent social ostracization and then the stigma that chronically affected my dating life in adulthood, which obviously explains why I felt like a raw nerve ending in my 20s and consciously chose to drink after work to numb those feelings. I even consciously thought way back then "this is gonna have long-term consequences, but I'll cross that bridge when I get there." Transgender women (and LGBTQ people in general) have a disproportionate risk for substance dependency. Do we all just have a "disease" or an "allergy?" Or do some people genuinely just have harder lives that they have to struggle more to than average to find healthier coping mechanisms to deal with?--
As the book goes on to clarify (and as Viktor Frankl suggested in "Man's Search for Meaning" when he compared human suffering to a gas that fills a room completely no matter how small the molecule of gas or how large the room), one does not exactly have to grow up in a war zone to still experience their wounds, especially their early life wounds, as a severe trauma. As Tatarsky argues in the chapter titled "Drug Use as Rebellion Against the Inner Critical Voice," simply learning early in life that expressing your true thoughts and needs is unacceptable and being pressured to conform to the wants of your caregivers (who themselves carry their own emotional baggage) can leave a person profoundly vulnerable to the disinhibiting effects of drugs and alcohol later in life, which humans have used for millennia in an attempt "to connect more fully with split-off feelings and needs."
For most people, including people with some degree of a substance issue or any number of "process addictions," Tatarsky argues that their pain tends to manifest as a general sense of emotional malaise that they can't remember the cause of and that they feel ashamed and alien for even having. He gives a really compelling case study example in the book of a young man raised by parents who were, in his view, always working or on vacation, leading the young man, as a boy, to conclude he must have been worthless all along. In therapy he concluded that his younger self, needing to believe his caregivers were competent and reliable, subconsciously agreed with and identified with their behavior by blaming himself in order to bond with them because his need for competent parental figures (a product of evolutionary biology) was stronger back then than his need for a positive self image. Predictably, he grew up to suffer from chronic negative self-talk, suicidal ideation and a tendency to redirect his anger at the world (and at his parents) back at himself instead. Even in therapy, the prospect of acknowledging that his parents were wrong all along triggered deep grief at the loss of his perceived caregivers.
Tatarsky also notes that people with a tendency towards depression (and self-medicating depression with substances) tend to also have a stronger inner critic, a product of early, painful experiences. That might explain why people entering addiction treatment have a strong tendency to align themselves, at least superficially, with even the most self-blaming dogma-- at least temporarily (he notes that most people who enter treatment do so during a crisis and are temporarily, earnestly more motivated to stop using until the immediate pressure from family, friends or coworkers abates and the desire to numb out returns. This explains a lot of post-treatment relapses, in my opinion)-- and perhaps even why I for a time believed a more self-blaming explanation.
In an early chapter titled "The Psychoanalytic Contribution," Tatarsky references Sigmund Freud's theory of a "dynamic unconscious," referring to "needs, wishes judgements, and beliefs" that our conscious minds deem unacceptable and that are kept out of our conscious awareness by what Freud called "ego defenses," and that this unconscious tug-of-war between our dynamic unconscious and our ego defenses often leads to "compulsive or impulsive behavior [that] gives rise to intense inner pressures and creates painful feelings of anxiety, guilt, shame, and despair, all for no apparent reason." Later in the book Tatarsky expands on Freud's theory, presenting the idea of a "false self" constructed in response to the internalized voice of mother, father or anyone else in our early environment who had the power to make us feel that we had to conform to their expectations in order to survive. He writes: "... out of deference to our survival instinct, we learned to suppress, hide, and deny true feelings, wishes, and needs that were deemed unacceptable. We created a 'false' self for public consumption. British psychoanalyst Winnicott (1965) said that this is an inevitable development in human socialization. The false personality can get along very well, achieving great safety and success in life. However, we pay a price in the maintenance of this persona... Our compensations, compliance, and the manufacture and artifice of outward success hides a stirring sense of worthlessness, shame, and fear of being discovered. The voice punishes transgressions by shaming and guilt-tripping. This punishment takes the form of self-hate and self-criticism that create shame, guilt, anxiety, and depression..."
These ideas come to bear in a few of the book's case studies: In one case study Tom, a gay man in his early 40s, relapses after successfully moderating his drinking through ongoing psychotherapy. He shows up quite tipsy to a session, which incidentally is the first time he brings up his fear that his presumably straight male therapist is judging him for his sexuality. In other words, Tom had to work through deep-seated shame about his sexuality (which, if you subscribe to Freud's theory, is otherwise kept at bay from his conscious awareness by hard-working ego defenses) that he would otherwise use alcohol to cope with. In another case study an amphetamine-addicted woman named Sally, who had a history of child sexual abuse and conflicted feelings about her sometimes loving and sometimes abusive mother, "believed that she needed her drugs to stay alive. [Drugs] took care of her like a 'good mother'; it countered her dangerous suicidal depression, and it helped her stay thin when she felt she couldn't live with herself if she gained weight." If her therapist had attempted to intervene in her substance use, especially if he'd declined to treat her until she sought successful drug and alcohol rehabilitation and came back sober, Tatarsky argues, "she very well might have perceived him as an enemy to her survival. This would have slowed down the therapeutic process considerably." In other words, perhaps Sally needed help working through the painful parts of her "dynamic unconscious" that her "ego defenses" were struggling to face while sober in order to be assisted in giving up drugs as a coping mechanism. Perhaps we are all somewhere on this continuum of mental suffering just by nature of being human, and we would do well to be a little more compassionate towards one another. That seems to be the core idea of this book, and perhaps harm reduction psychotherapy more broadly, in a nutshell.
Anywho, it really is quite telling that I have been to both inpatient and outpatient rehab twice (as well as many an Alcoholics Anonymous meeting; I like to think this all earns me some street cred) since 2020, yet my mind is this blown by a book originally released before the first episode of "That's So Raven." If I were going to be harsh I would say that must mean the modern treatment industry is 25 years behind, but I don't like to be harsh-- AA/NA and recovery centers have worked quite well for some, they have saved many lives and they are where I have made some of my most cherished memories.
However, as the book argues, the system is limited in some important ways-- including by many of the deep-seated gospels passed down from one generation of recovering addicts to the next-- and perhaps I'm a good case in point (in fact I recognized a lot of myself in the case studies included in this book):
I first entered treatment as a 26-year-old androgyne of sorts (I like to call this my pre-transition, "Boy George phase" 💅🫅) with a history involving parental suicide (my mother), parental drug and alcohol addiction (my father), severe identity-based social stigma and peer rejection (I was quite obviously #thatgworl from an early age) as well as a history of romantic experiences with exactly the kinds of men who tend to like someone who looks very androgynous and sufficiently pretty like a girl (which is apparently a lot of guys, btw. Ask me how many unsolicited eggplant pics I got from guys I met in rehab), but only in private.
The treatment industry in its current form is just not designed to deal with that, or so many other manifestations of existential trauma, if I had to guess. Somehow clinicians heard all of what I said about my life and concluded, rather matter-of-factly, that I was suffering from the "disease of addiction" and maybe some borderline personality (the latter claim was based on, and I cackle as I write this, rather insufficient questioning).
That's in large part because, as Andrew Tatarsky writes in the book, historically, "the prevailing view in traditional drug and alcohol treatment was an emphasis on the commonalities among drug users as the central focus in treatment... Differences between drug users were seen as unimportant or worse, as undermining distractions to the task at hand, which was to help people stop using drugs. The fact that one person might say he used drugs to relieve his depression about being HIV-positive and another said drugs might curb homicidal or suicidal tendencies would be considered beside the point. Individual considerations were interpreted as justifications of drug use and not relevant to the challenge of stopping. They were seen as evidence of the drug user's wish to see himself as unlike other addicts rather than accepting that all addicts have a common disorder or disease that requires the same treatment. The wish to be seen as special or unique was understood to be symptomatic of justification for continued use rather than a serious wish to address some important, relevant issues."
This rationale sounds perfectly reasonable and is probably correct in quite a few senses, at least for a fair number of people, but Tatarsky argues that this reasoning is applied far too broadly, and I'm inclined to agree. I'll admit that at one point, in the early years following my first rehab stay and introduction to AA, I wanted desperately to finally have a simple explanation for my suffering and a clear path to curing it, so I clung to and repeated the explanation that I had a "disease," or a beguiling "allergy," as the Big Book describes it, an addictive personality that was ultimately to blame for my deep-seated blues... but even back then I was experiencing some obvious cognitive dissonance, and the voice in the back of my head started to get a little louder during my second rehab stint after I inevitably relapsed. I kept thinking to myself: "it seems like I'm just depressed and I've been drinking to self-medicate the depression. The drinking seems like a symptom of a different problem."
Lo and behold, i'm apparently not the first person to have such a revelation. According to the book, some pointy-head Harvard professor named Edward J. Khantzian already thought of that years ago, back when the Delorean could still pass as a car from the future, and presented what he called the "self-medication hypothesis" (for which discovery I assume he was awarded with an esteemed "Captain Obvious" trophy). Tatarsky sums up Khantzian's hypothesis in the book as follows: "people use substances as an attempt to address inner difficulties that they are unable to resolve in other ways. In contrast to the earlier view that substance users are simply bad, morally deficient, or just thrill seeking, all of which may be true for some users, this idea emphasizes that people for whom substance use has become problematic, compulsive, and severe are trying to deal with some inner suffering that they are unable to heal in other ways... One of the most recent developments in Khantzian's work is a refinement of the self-medication hypothesis. Through his work with large numbers of people struggling with drug problems, he has identified a set of general aspects of psychological functioning that seem to make people particularly vulnerable to self-medicating with drugs... The four 'sectors of vulnerability' that he identifies are problems with self-esteem, problems in relating to other people, problems dealing with emotions, and difficulties people have in how they take care of themselves.'"
The more I read, the more that originally rather faint voice now wants to scream a quote I recently picked up from a BBC interview of Hillary Clinton answering a question about why President Trump's cabinet members seem so sycophantic (I can turn literally anything into an excuse to quote Hillary Clinton): "THIS IS NOT COMPLICATED! This is so obvious!!" ---My parents' neglect obviously created some level of initial abandonment and self-esteem issues, that was obviously exacerbated by repeated adolescent social ostracization and then the stigma that chronically affected my dating life in adulthood, which obviously explains why I felt like a raw nerve ending in my 20s and consciously chose to drink after work to numb those feelings. I even consciously thought way back then "this is gonna have long-term consequences, but I'll cross that bridge when I get there." Transgender women (and LGBTQ people in general) have a disproportionate risk for substance dependency. Do we all just have a "disease" or an "allergy?" Or do some people genuinely just have harder lives that they have to struggle more to than average to find healthier coping mechanisms to deal with?--
As the book goes on to clarify (and as Viktor Frankl suggested in "Man's Search for Meaning" when he compared human suffering to a gas that fills a room completely no matter how small the molecule of gas or how large the room), one does not exactly have to grow up in a war zone to still experience their wounds, especially their early life wounds, as a severe trauma. As Tatarsky argues in the chapter titled "Drug Use as Rebellion Against the Inner Critical Voice," simply learning early in life that expressing your true thoughts and needs is unacceptable and being pressured to conform to the wants of your caregivers (who themselves carry their own emotional baggage) can leave a person profoundly vulnerable to the disinhibiting effects of drugs and alcohol later in life, which humans have used for millennia in an attempt "to connect more fully with split-off feelings and needs."
For most people, including people with some degree of a substance issue or any number of "process addictions," Tatarsky argues that their pain tends to manifest as a general sense of emotional malaise that they can't remember the cause of and that they feel ashamed and alien for even having. He gives a really compelling case study example in the book of a young man raised by parents who were, in his view, always working or on vacation, leading the young man, as a boy, to conclude he must have been worthless all along. In therapy he concluded that his younger self, needing to believe his caregivers were competent and reliable, subconsciously agreed with and identified with their behavior by blaming himself in order to bond with them because his need for competent parental figures (a product of evolutionary biology) was stronger back then than his need for a positive self image. Predictably, he grew up to suffer from chronic negative self-talk, suicidal ideation and a tendency to redirect his anger at the world (and at his parents) back at himself instead. Even in therapy, the prospect of acknowledging that his parents were wrong all along triggered deep grief at the loss of his perceived caregivers.
Tatarsky also notes that people with a tendency towards depression (and self-medicating depression with substances) tend to also have a stronger inner critic, a product of early, painful experiences. That might explain why people entering addiction treatment have a strong tendency to align themselves, at least superficially, with even the most self-blaming dogma-- at least temporarily (he notes that most people who enter treatment do so during a crisis and are temporarily, earnestly more motivated to stop using until the immediate pressure from family, friends or coworkers abates and the desire to numb out returns. This explains a lot of post-treatment relapses, in my opinion)-- and perhaps even why I for a time believed a more self-blaming explanation.
In an early chapter titled "The Psychoanalytic Contribution," Tatarsky references Sigmund Freud's theory of a "dynamic unconscious," referring to "needs, wishes judgements, and beliefs" that our conscious minds deem unacceptable and that are kept out of our conscious awareness by what Freud called "ego defenses," and that this unconscious tug-of-war between our dynamic unconscious and our ego defenses often leads to "compulsive or impulsive behavior [that] gives rise to intense inner pressures and creates painful feelings of anxiety, guilt, shame, and despair, all for no apparent reason." Later in the book Tatarsky expands on Freud's theory, presenting the idea of a "false self" constructed in response to the internalized voice of mother, father or anyone else in our early environment who had the power to make us feel that we had to conform to their expectations in order to survive. He writes: "... out of deference to our survival instinct, we learned to suppress, hide, and deny true feelings, wishes, and needs that were deemed unacceptable. We created a 'false' self for public consumption. British psychoanalyst Winnicott (1965) said that this is an inevitable development in human socialization. The false personality can get along very well, achieving great safety and success in life. However, we pay a price in the maintenance of this persona... Our compensations, compliance, and the manufacture and artifice of outward success hides a stirring sense of worthlessness, shame, and fear of being discovered. The voice punishes transgressions by shaming and guilt-tripping. This punishment takes the form of self-hate and self-criticism that create shame, guilt, anxiety, and depression..."
These ideas come to bear in a few of the book's case studies: In one case study Tom, a gay man in his early 40s, relapses after successfully moderating his drinking through ongoing psychotherapy. He shows up quite tipsy to a session, which incidentally is the first time he brings up his fear that his presumably straight male therapist is judging him for his sexuality. In other words, Tom had to work through deep-seated shame about his sexuality (which, if you subscribe to Freud's theory, is otherwise kept at bay from his conscious awareness by hard-working ego defenses) that he would otherwise use alcohol to cope with. In another case study an amphetamine-addicted woman named Sally, who had a history of child sexual abuse and conflicted feelings about her sometimes loving and sometimes abusive mother, "believed that she needed her drugs to stay alive. [Drugs] took care of her like a 'good mother'; it countered her dangerous suicidal depression, and it helped her stay thin when she felt she couldn't live with herself if she gained weight." If her therapist had attempted to intervene in her substance use, especially if he'd declined to treat her until she sought successful drug and alcohol rehabilitation and came back sober, Tatarsky argues, "she very well might have perceived him as an enemy to her survival. This would have slowed down the therapeutic process considerably." In other words, perhaps Sally needed help working through the painful parts of her "dynamic unconscious" that her "ego defenses" were struggling to face while sober in order to be assisted in giving up drugs as a coping mechanism. Perhaps we are all somewhere on this continuum of mental suffering just by nature of being human, and we would do well to be a little more compassionate towards one another. That seems to be the core idea of this book, and perhaps harm reduction psychotherapy more broadly, in a nutshell.
January 13, 2024
A classic - still amazing event though it’s been out a while.
Displaying 1 - 2 of 2 reviews