Harm Reduction Psychotherapy for Addiction & Compulsions

Rethinking addiction beyond the disease model: use exists on a continuum, has functions and meanings, and is met with curiosity and individualized goals rather than prescription.

Beginning treatment as an ally rather than an expert: what the patient likes as well as dislikes about their use, what it does for them, and goals that may include abstinence, moderation, reduction, or experimentation.

The alliance as a mechanism of change: trauma and mistrust, countertransference as clinical information, co-regulation, and Andrew’s “loop of awareness” — attending to the patient, yourself, and what is happening between you.

When abstinence helps — and when requiring it backfires into shame, secrecy, and the abstinence violation effect — keeping it available as one patient-chosen goal.

Staying genuinely engaged when a patient is doing something dangerous, without becoming permissive or taking authoritarian control: collaborative safety planning, overdose education, and the clinician’s own anxiety and limits.

When someone arrives intoxicated: investigating what the use is doing for the person — regulating anxiety, testing the therapist, making therapy tolerable — while still assessing actual safety and impairment.

Slowing down a single episode of use and mapping the sequence — circumstances, feelings, urge, debate, decision, consequences — to find exactly where small changes are possible.

Mindfulness that inserts space between urge and action: grounding, the window of tolerance, watching intensity rise and fall — adapted for trauma, where inward attention isn’t always safe.

Going beyond resisting an urge to asking what it means: what it wants, what it protects, and which need or disowned part is speaking through it.

Treating ambivalence as an accurate description of how people work, not resistance: engaging both the part that urgently wants to stop and the part that deeply values using.

Turning exploration into an experiment rather than a pass/fail contract: subjective and objective goals, alternatives, high-risk-event planning, and continual revision.

When reducing use means losing something that genuinely mattered — a companion, a regulator, an identity — the sadness has to be grieved, not pathologized.