*Note: This interview has been edited for length and clarity* 

 Dr. Andrew Tatarsky is an internationally recognized leader in the treatment of problematic substance use and a psychobiosocial process model for understanding it. He has developed Integrative Harm Reduction Psychotherapy (IHRP) as an effective treatment for the full spectrum of substance use issues. IHRP has been described in his book, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, and a series of papers. He is the founder and director of the Center for Optimal Living in New York City, a treatment and professional training center based on this model.

Substance use issues impact millions of Americans; not only individuals struggling with substances, but the friends and family dearest to them. Current models treat addiction as a disease, and abstinence is the primary goal in most treatment programs.  As Andrew’s work emphasizes, harm reduction may be a more compassionate and successful option for treating those struggling with addiction. In this interview, we explore the relationship between abstinence and harm reduction, and how they might fit together to support healthier outcomes for treatment of problematic substance use.

Chelsea Rose:  Do you feel that we can define abstinence as a tool that we can all keep in our harm reduction toolboxes?

Andrew: Harm reduction from the beginning has been a set of ideas as well as specific practices. If we think about the ideas as a set of principles that guides how we develop our healthiest, least harmful, or most beneficial relationships to substances, then it’s not about a particular practice. It’s about supporting people in discovering or creating practices that support them in achieving their ideal relationship to substances, which really then bridges the entire gamut of outcomes. So that includes abstinence. Abstinence falls under the harm reduction umbrella. I think that what has been in conflict is harm reduction and abstinence-only. Because abstinence-only is what dominates the addiction treatment field, there’s an abstinence only ethos that dominates our culture, which presumes that abstinence is the only acceptable goal, it’s the only measure of success.

Chelsea Rose: Are there cases in which you or your patients have found abstinence to be the most effective and healthy option, or an essential step in their healing process? 

Andrew: The way to rework an addictive relationship is to develop the capacity to sit with that urge [to use] and surf it. As Alan Marlett put it, “to ride the wave of the urge and not give in to it.” That capacity to put a pause around the urge is what makes it possible to rework a relationship to the behavior or to the substance. So if a period of abstinence could be a period in which one develops the capacities, the skills to sit with urges and not act on them, that might give somebody a space to reflect on what they want their longer term relationship to the substance to be. And it might also be that people discover what it’s like to not be using. And some people decide they really prefer not using a drug and may choose to remain abstinent indefinitely. 

From the harm reduction point of view, which we might think of as very much about meeting people where they are or working with affirming and honoring and respecting that whatever the positive change plan is, it really needs to be geared toward who that unique person is, what they really feel motivated and up for. 

Chelsea Rose: When people are using problematically, it seems that they often don’t realize the harm their use is causing to themselves or others.  How can a harm reduction approach help people to see some of these pieces that they have been unable to see?

Andrew: A central part of our work  with Integrative Harm Reduction Psychotherapy is mindfulness; and mindfulness supports a deep exploration into that urge, to unwrap the multiple meanings of that urge. But also, mindfulness supports becoming a keener observer of connections between thoughts, feelings, choices, behavior and consequences. The harm reduction framework creates a safe space to support people in making those connections. As people get better at noticing and learning about how it helps and when it helps and how it hurts and when it creates problems, that can naturally lead to healthier choices or strategizing about how you might change your relationship to the substance so that it would work better and minimize or eliminate the negative consequences. 

I think that this framework can really support people in developing their healthiest optimal relationships to substances of all kinds. For all purposes, whether it’s recreational self-medicating or psychedelic substances that people are using for healing and growth. 

Chelsea Rose:  Because health insurance companies or the judicial system refer people to abstinence based programs only, do you have any thoughts on the accessibility of treatments that are centered around harm reduction? 

Andrew: [There is a] sea change that’s happening right now.

The Office of National Drug Control Policy, SAMHSA and CDC have gotten on board supporting Harm reduction in a big way.

And, at the Center for Optimal Living, we are working on developing a whole new treatment service that will be insurance based, and many major insurance companies will be paying for harm reduction therapy for folks on their plans.

We have to dismantle the criminal justice approach and support more effective, comprehensive care for people who struggle with drugs on every level. We have to change the way that insurance companies pay for treatment to support harm reduction. We have to keep people out of prison and offer them help. And we have to retool the entire addiction treatment system, retrain it. So we have a lot of work to be done.

Chelsea Rose: What are some things our communities can do to begin to support a more human-centered harm reduction approach to chaotic drug use issues?

Andrew: People can educate their families and friends; and if they’re clinicians, they can raise questions in their medical practices and with their colleagues. People can educate their local politicians and criminal justice folks by bringing up questions from a compassionate, pragmatic standpoint. There are so many bizarre practices that need to be questioned, like: Why do treatment programs kick people out for using drugs when they’re in treatment for using drugs? I encourage people to raise these questions and be a leader in harm reduction, trailblazing to a better future; helping to create a better world.