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S.H. Kellogg / Journal of Substance Abuse Treatment 25 (2003) 241–247
The strength of the harm reduction approach is in its
ability to connect and form relationships (Tatarsky, 2003;
Westermeyer, 2003b). There is certainly something quite
striking and quite noble about the outreach workers who go
into potentially dangerous and unpleasant situations to make
contact with societal ‘‘outcasts’’ (Springer, 2003). There is
also something compelling about the creation of centers or
subcultures for drug users in which they receive acceptance
and welcome (Mechanic, 1996), and where they are greeted
with the attitude of, ‘‘What can I do to help you’’ rather
than that of ‘‘Here is what you must do’’ (Westermeyer,
2003b, p. 1). The warmth of this approach may be a
manifestation of what Dean James Parks Morton (1996)
referred to as a spirituality of being ‘‘radically welcoming,’’
and these interventions could also serve as an entry point to
a life-change process.
Some harm reduction advocates might argue that gradualism
is not necessary because harm reduction already
includes abstinence as part of its continuum of care. This
is not the case for two reasons. While some do believe that
abstinence is a part of harm reduction (Marlatt et al., 2001),
others do not. Roche et al. (1997) have clearly made the
case that abstinence-oriented approaches should not be
included under the harm-reduction umbrella.
The mixed feelings about the incorporation of abstinence
in the model may also reflect some confusion and lack of
clarity about the ultimate goal of the harm reduction
enterprise. For example, Westermeyer (2003a, p. 1) argued
that, ‘‘small reductions are better than no reductions ...[and]
a ...small improvement can pave the path for further
reductions of drug use.... eventually to the point of abstinence.’’
Tatarsky (1998), while acknowledging the desirability
of abstinence as an ideal, maintained that, ‘‘the ideal
outcome of this approach is to support the user in reducing
the harmfulness of substance use to the point where it has
minimal negative impact on other areas of his or her life.
Whether the outcome is moderation or abstinence depends
on what is practically realistic for the client, and emerges
from the treatment process (p. 12).’’ Single (1997, p. 8), in
turn, goes a bit further and writes that, ‘‘Harm reduction is
simply neutral about the long-term goals of intervention.’’
The Harm Reduction Coalition, in their list of principles,
sees the ‘‘quality of individual and community life and wellbeing—not
necessarily cessation of all drug use—as the
criteria for successful interventions and policies’’ (Harm
Reduction Coalition, 2003, p. 1).
This neutrality about the ultimate goal of treatment also
separates harm reduction from gradualism. The problem with
neutrality is that it runs the risk of encouraging stagnation, of
not fostering a kind of therapeutic or healing momentum.
This opposition to making abstinence the ultimate, if not
the immediate, goal may well be connected to some of the
social origins of the harm reduction approach, and it may be
consistent with what Pearson (1991) called the ‘‘Orphan’’
archetype. In this vision, addicted people are seen as an
oppressed and disenfranchised group. Not infrequently, they
have been the victims of emotional, physical, and/or sexual
abuse (Springer, 2003). The result is a network or community
of wounded people who seek to care and nurture each
other, while sharing contempt for the forces and symbols of
authority. In this light, traditional drug-treatment programs
are certainly seen as authoritarian and punitive.
4. Building the continuum
Perhaps one way to understand how a gradualist continuum
could exist would be to see it in terms of a
developmental model involving child and parental images.
The high level of acceptance of addicted people found in
harm-reduction settings is likely to be experienced as a
form of unconditional positive regard, of caring without
demands. It is well reflected in the harm reduction emphasis
on meeting the patient ‘‘where they’re at’’ (Denning, 2001;
Denning & Little, 2001, p. 1; Harm Reduction Coalition,
2003). This open nurturing may do a great deal to help
build relationships and get these addicted persons reconnected
again. The harm reduction site becomes something
of a ‘‘holding environment’’ (Greenberg & Mitchell,
1983; Winnicott, 1965). This may well work because, in
my opinion, there is, among many of these patients, a deep
longing for good, nurturing, affirming authority—perhaps
especially for good fathers (Bly, 1992; Thompson, 1991).
However, the good parent does not simply love unconditionally.
And while it may be important to meet the patient
where he or she is, it may not be such a good idea to leave
him or her there (see also Gelormino, 2002). As Goethe
wrote, and Viktor Frankl (1985) affirmed, ‘‘If I accept you
as you are, I will make you worse; However, if I treat you
as though you are what you are capable of becoming, I help
you become that’’ (quoted in Mayo, 1996, p. 240). The
good parent not only nurtures, but also affirms the possibility
within the child. Within the context of the harm
reduction classification schemes, this affirmation means
working to keep them alive, to protect their health, and to
help them to heal and get better. The parent that does not
take action to help a child who is in pain or in danger may
not be felt to be a good parent, and, since the patients
themselves, for the most part, do not think that the use of
drugs is a good or life-affirming activity, there is a question
as to what kind of message the psychotherapist is giving if
he or she does not ultimately (even if not immediately)
direct them toward abstinence.
From this perspective, the eventual emphasis on abstinence,
within a context of seeing both the woundedness and
the potential within these individuals, also becomes a form
of nurturing. The next step, then, would be for people to
make a successful transition to an empowering, recoveryoriented
treatment, and, hopefully, to a healthy, productive,
and drug-free life. The comprehensive needle exchange
program described by Majoor and Rivera (2003) appears
to embody many of these dynamics.