Increase Benefit, Reduce Harm

In my work teaching about community mental health and drug treatment, I’ve noticed that even more orthodox abstinence-only type students are fine with the concept of “gradualism” (harm reduction as a path to abstinence), and that’s often the way they can make the wide spectrum of harm reduction fit into narrower binary recovery models. I clarify that yes, this is totally true for some people, while others will never do abstinence, and many others will fall in-between. They usually just nod politely and then stick with their “path to abstinence” definition.*

Wherever a person we serve is heading on their way to making changes in their health, it’s essential to remain rooted in the present rather than cheerleading or otherwise promoting the fantasy of future benefits, including abstinence, because of two main things: first, we can’t tell the future so we can’t ensure that “we know you can make it” when that’s not true, and second, it’s the present where the potential for transformative experience lives. Regardless of where someone is heading, including abstinence, that’s how they will get there in the most authentic, sustainable ways.

These days I live by the very simple directive of “increase benefit, reduce harm” and apply it to everything. In finding paths through my own struggles and challenges, and toward healing, this really helps me problem-solve and make decisions throughout my day. I also love my colleague David Valentine’s joking but serious concept of “infinite flexibility” because it’s funny (there’s really no such thing since everything breaks eventually if flexed far enough) and, it remains an ideal when serving people, an aspirational ethic in harm reduction, even as we maintain healthy boundaries and sometimes even solid, unwavering stances. Or as I’ve heard Jeannie Little say (generally in frustration about people saying, “oh yeah, harm reduction, that’s letting people use drugs when we first meet them so we can then channel them into abstinence-based treatment [gradualism]”), “it’s not just meeting people where they’re at, it’s staying with people where they’re at.”  

To me, this is a bottom line– reinforcing people’s autonomy and supporting healing however we can. This requires acknowledgement though– that some people are not going to stop experiencing harm from what they’re doing/how they’re thinking and feeling– and the only real help we can offer is companionship, in the hope that it will somehow alter their perception enough that they’ll be able to reduce harm in ever greater ways in their life. And, at the very least, even if they go down in a blaze of harmful behavior, they had someone alongside them for a moment while they lived, and didn’t have to go down entirely alone. I have experienced this many many times in my professional and personal life, having lost people to the harms of their substance use, though I attribute it to their inner suffering– substances being one way to try to live with inner (and often outer) suffering– and that suffering making life so unbearable that eventually it takes them out. At the same time, I’ve experienced accompanying people “to the edge” of suicide, and seeing how my presence alongside them helped them explore it and choose to continue living. 

This is also the essence of harm reduction– partnership, companionship, community, guided by respect, support, compassion, kindness, love. We know from tons of research that most people we serve in behavioral health treatment have experienced disproportionate amounts of trauma and suffering, and we owe it to them to not punish them for how they are. Just as people in treatment are learning to not “act out” impulses around particular behaviors, in parallel we are always learning how to not “act out” our impulses on them. Instead, we remain mindful of our own reactions and judgements, noting them in their unpreventable glory, while simultaneously staying open and kind, accepting and affirming of how they are, remembering they have a lot of good reasons to be that way.

Harm reduction work means being willing to walk with a person through the swirly combination of self-help and self-harm, self-medication and self-destruction, with all the mushy grey areas that evade these binaries, and without taking power over them and pushing them be different. Even the pursuit of change, so much the focus of our work in research and treatment in harm reduction, must be secondary to unconditional acceptance (albeit paradoxically since this kind of joining usually increases feelings of agency, autonomy, strength, all precursors of making change).

As my friend Ken Tyler says, drawing from Thomas Metzinger’s discussion of mental models in his book The Ego Tunnel, binaries are the simplest mental models we can have, and take far less energy (a lower “metabolic price”) to maintain than spectrum/nonbinary models, which entail greater complexity of thinking and understanding (and thus require greater energy/metabolic price). (I’d add that this is also why we “collapse” into simple binaries when threatened and activated– they take far less energy and can be acted on immediately, with greater life-saving speed than a complex thought process. This response is used by autocrats to control whole populations– elevate the perception of threat and the resulting collapse into binary thinking makes it much easier to polarize people and direct them against each other.)

This makes harm reduction an even tougher sell, like the other spectrum models of human experience that are growing in popularity (the autistic spectrum, the gender spectrum, the “purple state” in US politics, etc.). Again, even though these may be more “real”– more accurate and authentic– models, they are more difficult to evolve and maintain because they require more energy/have a higher metabolic price for human brains than black and white thinking. 

Unfortunately for humans, changes around deep brain structure and chemistry don’t usually evolve very quickly, so “getting rid of” these ways we are probably isn’t going to happen anytime soon. In lieu of that, we’re working with becoming more conscious of these “ways we’re built” and learning to observe them rather than act them out. For thousands of years, contemplative traditions have been encouraging this way of developing ever-greater awareness of ourselves in the effort to reduce suffering. For me, harm reduction works well within this context and provides legitimate practical ways to operationalize it, all by practicing a very simple guideline: “increase benefit, reduce harm.”


*It’s not lost on me that collapsing into binaries is dialectical– that this discussion of “binary vs. spectrum-based thinking” becomes its own new binary– and that makes each evolution toward transcending a binary a new binary. This isn’t bad or wrong (as we said above, collapsing into binaries in the face of threat can be life-saving), though it reminds us that in a fractal way, spectrums can emerge from binaries and binaries from spectrums. Maybe if we think in this way, binaries and spectrums are interdependent and co-existent, and it is our work to better manage the ways we think about, and use, both of them (and the spectrum in between :).

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