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Barry Lessin Barry Lessin

Harm Reduction Made Me a Much Better Family Therapist

As an abstinence-based therapist, I assumed that failure and frustration came with the territory. When I adopted the values and strategies of harm reduction, I was finally able to offer my clients real help.

16 Substance

When parents lead their teens with a light but stable hand, staying engaged but allowing independence, their kids do better. Photo via

When parents lead teens with a light but stable hand, staying engaged but allowing independence, kids do better. Photo via

I chose to work in the addiction field because I care about people who struggle with substance use and felt that maybe I could make a difference. I was aware of the difficulty of the work because of the complex nature of problematic drug use and the interaction with mental illness. For decades, I shrugged off the difficulty, assuming that the frustration and pain involved in providing effective treatment came with the territory.

About four years ago, though, my career took a dramatic turn after I was profoundly affected by a combination of my personal experience with drug misuse and mental illness in my family and my new awareness of public health policies that criminalize substance use and stigmatize drug users.

These experiences shone a glaring light on how the traditional treatment model was failing my clients and their families and led me to incorporate harm reduction approaches into my work. As I learned about harm reduction, it quickly became apparent that the tenets of harm reduction parallel those of effective parenting.

Harm reduction and effective parenting

The philosophy of harm reduction is based on our knowledge that human beings engage in behaviors that carry risks. Harm reduction values each person’s dignity and respects their right to make choices. This shifts the focus from attempting to restrict or prohibit risky behaviors to reducing the negative consequences associated with them.

This premise parallels psychological theories of normal adolescent development, during which taking risks and challenging authority help children establish independence and a unique identity.

Harm reduction approaches empower people by collaborating with them in making behavioral changes and by viewing people as much more than their substance use. Empowerment helps counter the shame and stigma of substance use and thereby lowers a common barrier to engaging in treatment.

People in emotional pain, when shown compassion and given a stigma-free environment, are more willing to open up and share their worries. Teens, especially, engage in treatment when shown respect by allowing them to collaborate in their own care.

Effective parenting involves similar values: compassion, flexibility, mutual trust, creating safety, encouraging children’s individuality and ease of communication. This makes harm reduction therapy a natural fit with for working with parents and teens.

Unfortunately, harm reduction remains a “dirty word” in traditional addiction treatment due to the misconception that it condones substance use. In reality, harm reduction embraces the uniqueness of the substance user, thereby avoiding the stigma- and shame-inducing approaches of one-size-fits-all treatment.

Initially, I was somewhat apprehensive about whether parents would be willing to have their child see a therapist using a more flexible, non-abstinence-based approach. My concerns quickly evaporated as I began working with families. Virtually all of my teen clients were more willing to work with a therapist who viewed them as a student, a peer, a sibling and a person with unique skills and personality—who also happens to be using drugs.

Harm reduction in practice

Harm reduction teaches us several important lessons: (1) “Hitting bottom” isn’t required for lasting change; (2) people use drugs for reasons; (3) helping people change is easier when we start “where they’re at”; and (4) change includes taking small positive steps.

My work with my client Matt illustrates these lessons. (My client’s name and some details of his story have been changed to protect his privacy.)

Matt was a month from his eighteenth birthday, during the summer before his senior year of high school, when his father called me about Matt’s marijuana use. Matt’s father reported that he and Matt’s mother were extremely worried about their son’s seemingly depressed mood, insomnia, underachieving in school and lack of motivation about making a decision about his future. They had lost the ability to trust him since he had been lying about his marijuana use.

Effective parenting involves similar values: compassion, flexibility, mutual trust, creating safety, encouraging children’s individuality and ease of communication. This makes harm reduction therapy a natural fit with for working with parents and teens.

Three months prior to the initial call they grounded him and limited his cell phone use after they caught him smoking in the house and driving while high, following repeated warnings to him to stop smoking. They feared that his marijuana use was a “gateway” to other drug use. They doubted that they could persuade him to come for help and that if he did, he would participate. Their belief that he would need to “hit bottom” before responding to any offered help contributed to them feeling helpless.

They had already called another addiction treatment provider, who refused to see them because Matt was “not ready” for making a change and advised that forcing him to come to treatment would be fruitless.

No need to “hit bottom” or use “tough love”

Initial calls from parents wanting help for their child’s substance use are naturally filled with much uncertainty. Popular myths about everyone with a severe substance use problem needing to “be ready” for treatment or “hitting bottom” reinforce irrational fears and fail families who could otherwise benefit from help.

Psychological research shows that people predictably move through stages of change. Most people enter treatment or make positive changes in their substance use without hitting bottom.

Overall, harm reduction approaches conform to research that shows that when parents lead their teens with a light but stable hand, staying engaged but allowing independence, their kids generally do better throughout life. The concept of “tough love,” which embraces the “hitting bottom” myth, can damage or even destroy a child’s life-sustaining connection to the only people who truly care. In the absence of violence or abuse in the home, kicking a child out of a family can be disastrous.

In fact, a child’s refusal of treatment is an opportunity for parents to benefit from learning about their role and to be offered a road map of next steps to take. I encouraged Matt’s parents to tell him that they had made a decision to consult a professional for some guidance, that I would like to meet him if I am going to give his parents guidance, but that it was his choice to attend or not.

People use drugs for reasons

I was pleasantly surprised that Matt attended the session. We discussed my collaborative approach and agreed that he would decide what his goals were in treatment, if he chose to continue working with me.

I discussed with them the harm reduction view of substance use: that people use drugs for reasons such as to relax, sleep, have fun, improve creativity and help cope with the pain associated with mental health issues, and that people “form a relationship” with substances.

Once these guidelines were established, Matt was motivated to talk about his life. He loved playing basketball, hanging out with friends and earning money from his part-time job. Academics came easy for him, requiring little studying to maintain good grades. He was protective of his younger sister and kind to his grandparents.

But he was furious at his parents for grounding him and for demanding abstinence from marijuana use before he would be “trusted” enough to be granted his freedom. He admitted being depressed since middle school; not being able to see his friends now made him feel more depressed.

He said that he was extremely overwhelmed about not knowing what he wanted to do after high school. He said his struggle with insomnia began at the start of high school. He felt unable to share any of these worries with his parents because they thought smoking marijuana was the cause of all of his problems.

We explored his relationship with marijuana (and his other substances, alcohol and nicotine) in terms of the pros and cons of use. We discussed the continuum of substance use and when safe use, managed use or abstinence might be appropriate to deal with his use.

He admitted smoking marijuana almost daily for two years. He denied that it was a problem for him; he actually saw it as a benefit because smoking pot had become the only way he could fall sleep.

Matt felt that the only negative consequence of his use was his parents’ disappointment and disapproval. He admitted that his lying to them about his drug use made things worse, and realized that parental trust was an area in which he definitely wanted to improve.

Meeting people “where they are at”

With the focus on issues that were important to Matt and on change as a process, he expressed some hope and was willing to attend therapy with the goals of sleeping better and improving his relationship with his parents.

But he was frightened to reduce his marijuana use because he didn’t think he would be able to fall asleep. He was open to thinking about changing his use when I reassured him that insomnia is a common problem and that we could discuss ways he can improve his sleep. He also agreed to have his parents involved in family sessions as needed.

His long-term daily marijuana smoking was a concern to me partly because the developing adolescent brain is vulnerable to potential cognitive problems associated with pot use. Obviously, the child’s safety trumps treatment goals and every teen therapist must incorporate safety as part of any treatment plan. I don’t condone smoking marijuana but try to educate my clients about the research and the risks when they are making informed decisions to reduce any consequences connected with their use.

Family involvement

When I was an abstinence-based therapist, teens were rarely comfortable with involving their families in treatment. Collaboration, empowerment, respect and avoiding stigma are values of harm reduction therapy that make it more conducive for teens to agree to family therapy.

My current work with families is now informed by CRAFT: Community Reinforcement and Family Training, a research-backed approach that relies on non-confrontational methods to encourage loved ones to enter addiction treatment. I encourage the families I work with to use the “The 20 Minute Guide,” a free, user-friendly online guide to CRAFT.

Reflecting on their own teenage experiences can help parents better understand some of the unintended negative consequences of zero-tolerance approaches. If kids want to get high, they will find ways to do so, and the harder we make it for them, the more risky behavior they will tend to engage in.

Matt agreed to share his treatment goals with his parents and have them join us for sessions. His parents were very relieved that Matt was able to share his feelings of depression and anxiety. His father admitted battling depression and insomnia throughout his life and was able to support Matt mood’s difficulties. His mother admitted smoking marijuana a lot in her youth and said that she eventually stopped smoking as her life responsibilities increased.

Parents are often reluctant to share their own substance use history, fearing that their children will use it to justify their own use. I encourage parents to look at their own history; adults often forget that they were teenagers once and struggled with the same developmental challenges. Kids can tell if parents are being transparent with their history, so it’s best to be honest, not only self-reflective.

Reflecting on their own teenage experiences can help parents better understand some of the unintended negative consequences of zero-tolerance approaches. If kids want to get high, they will find ways to do so, and the harder we make it for them, the more risky behavior they will tend to engage in.

Once Matt’s parents were able to view his use as self-medication for his anxiety, depression and insomnia, they were more willing to look at alternative approaches for intervening with Matt. Unbiased information about substances is essential, so I offered resources including information about marijuana and the myth of gateway drugs.

Small positive steps

Harm reduction therapy incorporates motivational interviewing techniques that include “meeting the person where they are at” as well as building confidence by taking small positive steps.

Starting out of the gate demanding zero tolerance for substance use is misguided because small steps that lead to small improvements in behavior—and the experience of success—can give a teen confidence and hope, driving the process forward. Zero tolerance allows zero flexibility, keeping family anxiety high and often locking everyone into a destructive cycle.

The process of change is frightening and often feels overwhelming. Most people tend to resist changing all at once, and family problems that take time to develop need time to resolve. Because the self-esteem of even high-achieving kids is vulnerable, it’s important to allow them to experience success and to voice appreciation and encouragement to them for any positive change.

Harm reduction offers hope and healing

My treatment with Matt focused on his developing healthy strategies and tools to reduce anxiety and improve his mood. He used our sessions to explore career options; after speaking with a military recruiter, he decided that the military was a realistic option for him to get training in his mechanical interests, develop motivation and independence, and to help his parents pay for college when he was ready to enroll.

The requirement of the military for Matt to be drug-free at the time of his enrollment evaluation, together with his excitement about his newfound sense of purpose, motivated him to decide to “end his relationship” with marijuana at that point. He was able to fairly easily stop using; his treatment ended once he was accepted into military.

In my previous life as an abstinence-based therapist, Matt and his family probably wouldn’t have gotten past their initial phone call to me.

Harm reduction therapy allows me now to offer families like Matt’s some hope and a compassionate partner to walk with them through an often very difficult period. I didn’t have to “reinvent myself” as a psychologist. A recipe of compassion, collaboration, evidence-based treatments and a menu of options offers me the opportunity to be more effective with more people.

Parents don’t have to reinvent themselves, either. Harm reduction uses time-tested parenting principles and values, along with common sense, to offer parents some hope and the skills to cope more effectively with the challenge of their children’s risky behaviors. A more hopeful parent means a more effective parent and more opportunities for family healing.

Barry Lessin is an addiction psychologist in private practice in Philadelphia, specializing in working with teens, young adults and their families. His career has spanned 40 years as a clinician, administrator, educator and researcher. He is the clinical director of Broken No More and GRASP (Grief Support After a Substance Passing), where he works to advocate for drug policy reform.