The Challenge of Harm Reduction Toward Addiction Treatment

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January 5, 2026 

Andrew Tatarsky, PhD, Author & Psychotherapist

Tom O'Connor, Publisher

Author Andrew Tatarsky has worked with people who struggle with drugs and their families for over 40 years. He developed Integrative Harm Reduction Psychotherapy (IHRP) to treat a wide range of risky and addictive behaviors. IHRP integrates relational psychoanalysis, CBT, and mindfulness within a harm-reduction framework. It meets individuals wherever they are on their journey of positive change and works collaboratively to help them discover their truth and identify goals and strategies that best suit their needs. 

Andrew's therapy approach is described in his book, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, on Amazon. He holds a doctorate in clinical psychology from the City University of New York and completed the Postdoctoral Program in Psychoanalysis and Psychotherapy at New York University. 

According to Andrew Tatarsky

Peter

In our first session, Peter, a successful lawyer, told me that he'd been smoking crystal meth for the past two years. "I know it's dangerous," he said. "But it's like I'm having a love affair with meth, and I'm nowhere near ready to let it go." 

Indeed, his drug use was connected to sex. Every few weeks, he'd go on binges, drifting in and out of people's apartments or hotel rooms, smoking meth and having sex with men: some he knew, most were strangers. He looked almost blissful as he described sex scenes that lasted for hours. "But in the last few months, it's gotten a little rough,"

He said, taking a breath. "I started slamming it," meaning he'd been injecting the drug intravenously. He pulled up his sleeve to reveal a red, swollen arm marked with scars, scabs, and infected puncture wounds. The damage was so alarming that I gasped in astonishment.

Sarah

Another client, Sarah, drank alcohol and smoked marijuana every night to the point of blacking out. With no memory of how she'd gotten herself to bed, she'd wake up groggy with a splitting headache, take aspirin, drink a cup of coffee, and drive to a job that she hated. In her view, she hadn't killed herself yet, but probably would. 

Her doctor had been trying to persuade her to stop using substances for seven years with no success. Sarah didn't want to stop, but she didn't want to die, which is why she was working with me.

Drew

Drew was a 20-year-old man who'd taken a year off from college to recover from a life-threatening staph infection. During that time, his drug use had gone from an occasional beer or having a joint to near daily use of some combination of marijuana, alcohol, Xanax, heroin, pharmaceutical opiates, and cocaine. 

He prided himself on being well-educated about the risks of drug interactions and knowing how to stay safe. He loved getting high but wanted to "fine-tune" his drug use, now that he was back in school. 

During a phone session, I became alarmed at how intoxicated he was. He reassured me that he'd only used "a little" heroin and drunk one beer. Opioids and alcohol can be a lethal combination. I told him I'd call back in 15 minutes and that if he didn't answer, I'd alert school security and his parents. When I called back, he didn't answer. Security found him passed out under his bed. He was brought to the hospital and revived from a possible overdose.

Peter, Sarah, Drew

What would you have done if they were your clients? Many therapists

would've referred them out immediately, likely to a treatment center where abstinence is a prerequisite for therapy, and likely not one of them would've gone there for help. The therapists, nonetheless, could've wiped their foreheads —phew!—believing they'd dodged a dangerous, messy, and wholly untreatable liability of a client.

Throughout my career, I've had the privilege of working with individuals who use drugs in risky ways. It's often felt like navigating a minefield, but my decades of experience have taught me that our assumptions about these clients are usually wrong. Peter, Sarah, and Drew all demonstrated remarkable resilience and benefited from psychotherapy, ultimately achieving positive outcomes. 

Can Active Drug Users Benefit From Psychotherapy?

While the dominant thinking in the field is that active drug users can't benefit from psychotherapy until they've stopped using, I've come to view this perspective not only as backward but harmful.

For many people, their drug use serves a function that's vital to their psychic survival. It's a meaningful response to the psychological impact of the conditions in which they live. Although they may be in intense pain and worried about their behaviors, many don't want to stop using.

It's crucial to meet clients where they are in their journey, especially when they're not yet ready to consider curtailing their drug use. Until they've done the challenging and sometimes painful work in therapy, many people can't even begin to imagine stopping. 

Therapy, in this case, is a before, not an after, and the challenge of harm reduction.

Their engagement in therapy, rather than their abstinence, is the primary goal of treatment. Is this an incredible challenge for the therapist to focus on engagement, creating safety, and trust while risky behavior continues?

Yes. People with these behaviors tend to look outside for relief, and often hold others responsible when things don't go well. They frequently have deep attachment wounds due to early trauma, and might leave therapy at any moment. An acute sense of shame, guilt, and vulnerability contributes to secretiveness and lying—to themselves and others. Trust can be difficult to develop, and even the strongest therapeutic relationships are repeatedly tested. 

But isn't this what we do as therapists? We heal shame, treat trauma, build trust,

repair the therapist–client relationship, repeatedly.

Addiction is a Complex Issue

Addiction is a complex issue, often frightening and mystifying. However, I view it as part of the universal human experience. Who hasn't felt compelled to do something over and over despite negative consequences? Eating foods you know are harmful, calling an old lover when you know it's a bad idea, and making an expensive purchase when money is tight? 

Drug users engaging in behaviors they know are dangerous are at the end of this spectrum, where deeply cherished people, possessions, and values often get jettisoned in the addictive process.

Addiction is the experience of losing control over oneself, and helping clients explore this reality without judgment is critical. Uncertainty and danger are central to this work. Each session might be the last time I see a client. I don't always know whether clients are being truthful with me. Even if I'm certain I know what's going on and have accurately assessed their risk, circumstances can change dramatically from one session to the next. 

I've felt incredibly frustrated, disappointed, exasperated, anxious, and angry. 

At times, I've woken up in the middle of the night worrying about a client, which is generally a sign that there's something I need to address with that person

right away. I might call them the next morning to check in. The more involved in therapy a client becomes, the more emotionally invested in their well-being I become, and 

I have not lost a single client to a drug-related death.

The Social Context and the Traditional Model

There's no doubt that, on the whole, we've been doing a terrible job of helping people who struggle with substance use. Addiction has become one of America's most urgent humanitarian crises. 

Forty-eight million Americans suffer from serious alcohol and drug use disorders, and 100 million suffer from less severe problematic substance use that has a significant public health impact!!!

The Challenge of Harm Reduction

Over the last 20 years, overdose deaths have steadily increased. Our society is saturated with dehumanizing, stigmatizing narratives about addiction as a

disease and a moral failing. Ask anyone—even many therapists—what comes to mind when they think about "addicts," and you'll likely hear: weak, selfish, sick, pathetic, manipulative, criminal, dangerous, filthy, and so on. 

This common perception, of course, contributes to drug users' reluctance to seek help and tendency to be secretive and withdraw from potentially supportive relationships. If people use drugs when they feel bad, isn't it obvious how this internalized and institutionalized stigma would contribute to increasing it? It's a vicious cycle.

For the Client's Substance Use Disorder, here are six (6) Core Principles:

1. Forging the Therapeutic Alliance. The foundational principle of IHRP is meeting clients where they are, even if they're actively using. Presume there is intense vulnerability and likely trauma present. Identify and challenge generalizations about drug users, and get clear about your own tolerance for risk, extreme frustration, uncertainty, and fear. 

2. Offering Corrective Emotional Experiences. Accepting and respecting lying, hiding, intoxication in session (to a point), and other behaviors that are frustrating and scary are where the therapeutic action of corrective emotional experience happens. Self-hate, guilt, and shame are healed gradually over time through a therapist's patience and ability to stay accepting, respectful, and calm, even when provoked.

   
   

3. Teaching Self-Regulation. As with all clients, you can help those with problematic drug use to strengthen their ability to sit with complicated feelings through mindfulness, breathing, self-talk, and the specific technique of "urge surfing."  

4. Assessing Risk. Risk assessment is part of an ongoing, collaborative conversation that's only possible with a strong alliance and near-constant tracking of how comfortable the therapist feels supporting the work. The therapist must be willing to do a microanalysis of scary events, feelings, thoughts, urges, and choices.  

5. Affirming the Client's Ambivalence. There's much work to be done before many clients can stop their drug use, if they ever do. As with all clients in therapy, welcome the part of them that doesn't want to change; otherwise, that part will sabotage positive, healthier change efforts.  

6. Setting Positive Change Goals. Work with both the part that wants to use drugs and the part that wants to use more safely, cut back, or stop. Affirm whatever clients feel they can take on, and empower them to be in the driver's seat in creating a personalized vision for ideal use and a plan to achieve it.

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Andrew Tatarsky, PhD, is available at https://www.andrewtatarsky.com. You can also email Andrew at atatarskyphd@gmail.com/

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