Heather Evans Editorial

When you search ‘addiction’ online, you are overwhelmed with the many different definitions that come up. Some sources say that ‘addiction’ is ‘a treatable, chronic medical disease’ whereas others say it’s simply ‘a strong inclination to do, use, or indulge in something repeatedly’. The only two qualities that these differing definitions seem to agree on is that 1) the addictive behavior leads to negative consequences and; 2) the factors behind each person’s risky behavior is unique to them.

With statistics showing a yearly increase of US citizens who are addicted to substances, it makes you question whether the treatment for those struggling with compulsive behavior is working. Historically, addiction treatment has been based on a disease model, idolizing abstinence as the only acceptable goal. 

I spoke with Andrew Tatarksky, PhD, who thinks differently. As the developer of Integrative Harm Reduction Psychotherapy (IHRP), he believes treatment for compulsive behaviors should be rehumanized. The goal should be to work collaboratively with clients on their positive change journeys to be the healthiest versions of themselves. Surprisingly, this doesn’t necessarily mean abstinence.

How does that work, you might say? Andrew goes through the what, why, and how of IHRP in our enlightening conversation.

What is Integrative Harm Reduction Therapy?

Integrative Harm Reduction Psychotherapy (IHRP) is a therapy that I developed as a radical alternative to the disease based model used for treating addictive behavior. The disease-based model, which promotes abstinence-only treatment, has dominated the helping professions. However, this approach has failed to help the overwhelming majority of people who struggle with problematic and addictive substance use.

IHRP is based on a paradigm shift away from the disease model toward a psycho-bio-social model of addiction. IHRP views addictive experience and behavior as meaningful responses to suffering, and an individual’s behavior reflects a dynamic interplay of psychological, biological, relational and social factors that is unique to each person. 

By applying harm reduction principles to substance use treatment, such as relational, psychodynamic, cognitive-behavioral and mindfulness strategies, IHRP tailors the therapy to the unique needs, strengths, values and relational/social context of the client.

Harm reduction has been defined by the National Harm Reduction Coalition (1996) as, ‘a set of ideas and strategies that aim to reduce the harms associated with drug use without requiring abstinence’. I see this as a paradigm shift away from the traditional assumption that abstinence is the only acceptable goal regarding addictive behavior. 

I believe that this shift includes that the provider be committed to not imposing, a priori, one’s values, agendas, presumptions and theories (including one’s internalized, conscious and unconscious countertransference) on the person being helped. This commitment helps to facilitate a safe space to support the person in discovering their truth as well as what approach to healing, growth, and positive change best serves them. 

The harm reduction frame opens the door to the entire spectrum of people who struggle with substances, including the vast majority who are not willing to embrace abstinence for a wide variety of complex reasons and have been denied effective care. Harm reduction engages and welcomes people into therapy wherever they are on their positive change journeys, in all motivational stages of change (Prochaska, Norcross and DiClemente’s Transtheoretical Model), and with all positive change goals including safer use, moderate, controlled, non-problematic use, and abstinence. 

IHRP facilitates collaborative therapeutic relationships. The clinician and client work together as a therapeutic team (Patt Denning) to support the patient in clarifying the nature of their problematic relationships to substances, and what positive change goals and approach to change best suit them. The goal is to support people in creating their ideal, healthiest relationship to substances as they define it.

IHRP has mapped the therapeutic process in Seven Therapeutic Tasks, each with specific associated skills and strategies:

• Establishing and maintaining the therapeutic alliance
• The therapeutic relationships heals
• Enhancing self-management/regulation
• Assessment as treatment
• Embracing ambivalence
• Harm reduction goals setting
• Personalized planning for change

How does using an IHRP framework enhance the treatment of addictive, compulsive, and/or risky behavior? 

IHRP approaches the patient with curiosity, empathy, and respect. The clinician is committed to not presuming to know the nature of the patient’s problem, or impose their agendas and values on the patient. This stance is conducive to creating a safe therapeutic alliance and safe relational space. Here, the client is supported to explore their relationships to substances and discover their own personal truth. 

Traditional treatments that presume to know the nature of people’s complex relationships to substances, i.e. “it’s a disease”, and how it needs to be treated, “start by accepting the disease and commit to abstinence”, are authoritarian and prescriptive. They seek to impose the helper’s view on the patient, require the patient to submit to the clinician’s authority and disconnect from themselves and, thereby, risk traumatizing the patient. 

This approach often sets up treatment failure. This “treatment trauma” has been experienced by many substance-using people, leaving them more disconnected from themselves, in more psychic pain, using more substances, and blaming themselves for the failure of the treatment. 

The IHRP stance of curiosity, respect, empathy, and support is conducive to a new relational experience. The “corrective emotional experience” disconfirms the client’s negative views of self resulting from previous ‘treatment trauma’ and supports the internalization of a positive view of self and others. This experience of being accepted and respected as a person who uses drugs can set the therapeutic stage for an exploration into the meaning and function of the substance use, leading to discovery, clarification and resolution of the suffering being addressed by the substance use. As a result, it becomes possible to find and/or create less harmful ways of expressing or addressing the issues that drove problematic use. 

What are the main principles of IHRP? 

Core harm reduction principles constitute a frame for helping. These include:

• Risk is part of life. We can never eliminate risk but can take measures to reduce risk and harm in our lives.
• One size does not fit all. Clinicians must understand drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors, from severe use to total abstinence. They must acknowledge that some ways of using drugs are clearly safer than others
• People engage in risky behavior for many complex reasons that are life and self-affirming that are not necessarily pathological. 
• “Compassionate pragmatism” (Marlatt, 1998), or doing what works!
• “Starting where the person” is, or radical acceptance with empathy, curiosity and respect.
• “Any positive change”. This means embracing all steps in a positive direction with the problematic behavior and other relevant personal, relational and lifestyle issues.
• Affirming small, incremental, gradual positive changes as the most realistic expectation for how complex behaviors generally change as opposed to the traditional expectation of abstinence as the only measure of success; an expectation that is often a set up for failure. We don’t need to know the destination to begin the journey.
• Working collaboratively to empower and support the client/person/patient on their positive change journey. 

Why do you think there should be a shift away from treating patients with addiction or compulsive behavior using the abstinence framework?

To be clear, harm reduction and abstinence as a goal are not two separate paths or approaches. The harm reduction umbrella supports strategies that “meet people where they are” in terms of their goals and motivation. Many people need and want to pursue abstinence, so this includes abstinence-focused or oriented strategies, such as self-help groups like Alcoholics Anonymous. The abstinence-only framework is a one-size-fits-all approach that presumes that abstinence is the only acceptable goal for all who are severely struggling with substances. This approach has been an abysmal failure to help the overwhelming majority of people who struggle with substances. You can see this from the statistics below:

• 48 million people in the US struggle with substance use disorder (SUD)¹
• 110 million people with substance abuse issues have significant negative consequences don’t meet the SUD criteria²
• About 13 million are in specialty addiction treatment³
• Substance Abuse and Mental Health Services Administration (SAMHA) says less than half complete treatment, and we know many who do complete don’t maintain abstinence.⁴
• Between 2003-2023, more than 100,000 people have died each year in the USA from overdose and drug poisoning, over one million over the last 20 years⁵

From this, it is clear that people who struggle with substances are an underserved population that would benefit from harm reduction-informed treatment. Most people do not want standard addiction treatment because it doesn’t “meet them where they are” in so many ways. It fails so many individuals that the definition of success is complete and total abstinence, and that those suffering have to commit to total abstinence as a prerequisite to get into and remain in treatment! These have been major barriers to so many ‘addicted’ individuals looking for help.

What advice would you give to patients and therapists new to the IHRP framework?

If substance use/addiction treatment has not worked for you as a client or therapist, don’t be too quick to blame yourself. It is likely that the treatment was not a good fit. 

Question everything you have learned about the nature of what we have called ‘addiction’. The traditional one-size-fits-all addiction/recovery narrative is wrong, both in its assumptions about addiction as ‘disease’ and the abstinence-only treatment approach based on that model.

Effective therapy begins with the “right fit” between the unique person who is struggling and the therapeutic approach. IHRP seeks to create a therapeutic approach uniquely tailored to the person. 

Educate yourself about harm reduction by picking up my book (https://www.andrewtatarsky.com/book) and reading my more recent papers that are available for free under my bio at Freedom Institute’s website, https://www.freedominstitute.org/team-gallery/andrew-tatarsky-phd.

There is also a wonderful growing literature on harm reduction therapy by Alan Marlatt,  Patt Denning, Jeannie Little, Jennifer Fernandez, Debbie Rithschild, Sheila Vakharia and Maia Szalavitz.

Therapists can learn the foundations in an upcoming three day in person training in September at Silver Hill Hospital: Integrative Harm Reduction Psychotherapy Essentials, https://ihrpprograms.carrd.co/.

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If you found the information in this article helpful, you can read more about IHRP and Andrew’s work on his website and in his book, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems

Andrew is also hosting an in-person training on IHRP Essentials across three days from 19th September at Silver Hill Hospital, which you can see more about here.

In December, Andrew is also co-training a ketamine-assisted retreat for professionals on healing addiction through Accelerated Experiential Dynamic Psychotherapy (AEDP) and Integrative Harm Reduction Psychotherapy (IHRP). You can see more here.

About Andrew

Andrew has worked with people who struggle with drugs and their families for over 40 years. Andrew developed Integrative Harm Reduction Psychotherapy (IHRP) for treating the spectrum of risky and addictive behavior. IHRP brings relational psychoanalysis, CBT, and mindfulness together in a harm reduction frame.The therapy has been described in his book, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, and a series of papers. The book has been translated into Polish, Spanish and Russian. 
He holds a doctorate in clinical psychology from the City University of New York and is a graduate of New York University’s Postdoctoral Program in Psychoanalysis and Psychotherapy. He is the Director of Clinical Programming at Freedom Institute in NYC where he oversees harm reduction-informed addiction treatment services and a harm reduction psychotherapy training program. He was the Founder and Executive Director of the Center for Optimal Living in NYC, a treatment, education and professional training center based on IHRP. He is a member of the Medical and Clinical Advisory Panels of the New York State Office of Addiction Services and Support. Andrew has trained individuals and organizations in 20 countries. His writing, teaching, clinical work and leadership aim to promote a re-humanized view of problematic substance use and a harm reduction continuum of care that will extend help to everyone who needs and wants it wherever they are ready to begin their positive change journeys.

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Hi, I’m Heather – an award-winning book editor and content writer specialising in mental and sexual health. If you enjoyed this post, you can support this series by contributing to a coffee, or hiring me for my blog writing or editing services:

1.  Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). ↩︎
2.  Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). ↩︎
3.  Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). ↩︎
4. Substance abuse treatment drop-out from client and clinician perspectives, Rebekka S. Palmer, Ph.D., Mary K. Murphy, Ph.D., Alessandro Piselli, B.S., and Samuel A. Ball, Ph.D., Subst Use Misuse. 2009; 44(7): 1021–1038. ↩︎
5. CDC, National Center for Health Statistics, Office of Communication, Press Release, May 15, 2024 ↩︎