Shifting the Addiction Counseling Paradigm: Starting with Harm Reduction

November 22, 2019 

I can think of no other field in the mental health world where counselors regularly predetermine goals for clients and threaten the counseling relationship if the client doesn’t comply. Unfortunately, in the addiction treatment world this is a common reality, one that sets people up for failure through the use of negative reinforcement (i.e. loss of take-homes, probationary status), including termination of services. In this field it is even common to immediately distrust clients, requiring embarrassing and disempowering urine screens to ‘prove’ one’s compliance. As counselors we share the desire to help, we want positive outcomes. We need to learn to let go of thinking we have the right to determine what that outcome should be.

Research from the World Health Organization and the United Nations Office on Drugs and Crime reveals that 90% of people who use drugs do not have a substance misuse problem, their use is primarily recreational and nonproblematic[1]. They also suggest that countries move away from the notion of compulsory treatment as it is not best practice, and can be indeed be harmful. For those who use, but do not misuse drugs, as counselors why do we accept such mandated individuals on our caseloads? Where is our advocacy? If an individual does not want to engage in counseling and does not have a substance misuse diagnosis (illicit use does not equate DSM V diagnostic criteria), why do we participate in the facilitation of compulsory treatment?

When people do misuse drugs they do so for various reasons, most commonly there is a history of trauma. Mandating that people with trauma histories cease their coping strategy without new skills in place is contrary to everything we are taught as counselors. It is akin to throwing someone in a pool in order to teach them to swim and throwing them in jail if they start to drown and grab on to a life-preserver. It is essentially choosing someone’s stage of change for them without their input.

The Harm Reduction Model (HRM) incorporates a series of practical strategies targeting the reduction of the negative consequences of drug use. It acknowledges that drug use is a part of our world and works to keep people who use drugs safe rather them to ignore or condemn them. HRM meets a person where they are in that moment and supports them, keeps them safe and develops a connection. Reducing harm for those who have a substance misuse diagnosis provides time to engage drug users until they are treatment ready, and if they do not have a substance misuse diagnosis, it helps to keep people and the community safe. Primum non nocere (First Do No Harm).

As a professor of counselor education I bring my students to Prevention Point Philadelphia (PPP), perhaps the largest harm reduction center in the US, to spend the day watching what we all learn our first day in our counseling/social work programs, ‘meet your client where they’re at’. Here my students work the needle exchange, distribute Narcan and Fentanyl testing strips, hand-out food, water and condoms, and simply engage in conversations with people who are actively using drugs. This is a place where there is no shame, no compulsory participation, everyone is treated with dignity and respect and truly cared for. When someone who uses their services is ready for treatment, they immediately get help. Until that point, PPP helps keep people alive, because dead people cannot recover. This rehumanizing of the addiction paradigm from one of disease to one of public health, away from compulsory and towards self-determination is necessary in the addiction counseling field. Although we learn this in class, it is the opportunity to both watch and engage in harm reduction work where this shift in perspective among students solidifies.

I can honestly say that the hours we spent with the people in Kensington struggling with drugs, and the people of Prevention Point that have dedicated their time to this effort, changed my outlook on addiction as a counselor. I can see that a person does not choose what happens to them in their life, probably all the people that walked through those doors experienced things that I will never be able to comprehend. Our system failed them in providing adequate and accessible resources, so the ones that are the most easily accessible (drugs) are the ones they accepted. Could I say if I were in their shoes that I would have made any different decisions? Absolutely not.” Abigail Emmert

“Many people who use drugs want to use clean needles, they want a safe space, and want to get help on their own terms, rather than be punished for a problem they are struggling with.” Student

“Harm reduction is an amazing concept. I liked how they described harm reduction at Prevention Point as “meeting them where they’re at” since drug use is on a continuum.” – Student

We need more harm reduction counselors in the addiction counseling world. Imagine if people who misuse drugs could seek local counseling services and receive the guidance and support they need without being distrusted, forced into immediate abstinence and given goals that are not consistent with their own desires. Harm reduction efforts are critical at this time in our country when such elevated rates of opioid use and overdose are deemed a national public health emergency. Heroin use among those ages 18-25 has doubled in the past 10 years. From January through June of 2017 there was a 50% increase in overdose deaths (n=1,314) from the same time the previous year in Philadelphia and its surrounding counties (Sapatkin, 2017) with an additional 30 nonfatal overdoses for each fatal one[2]. Many of these nonfatal overdoses were nonfatal due to harm reduction initiatives, and how many of the fatal ones could have been nonfatal if we had more?

Sapatkin, D. (October 12, 2017). Philly region’s drug deaths are soaring faster than ever, new data show. Philadelphia Inquirer.



– Dr. Sandy Gibson


Dr. Gibson is a Professor and Clinical Coordinator in the Department of Counselor Education at The College of New Jersey (TCNJ). Prior to her time with TCNJ she was a community-based addiction counselor in the Washington DC area for five years, followed by seven years writing addiction-related grants and directing research studies for Temple University, and four years directing her own social research company. She joined the TCNJ Counselor Education faculty in 2011.

Dr. Gibson co-directs the Intoxicated Driver Resource Center with Dr. Stuart Roe, serving Mercer County community members who are convicted of a DUI. This program allows Counselor Education students the opportunity to provide community-based psychoeducation, as well as clinically screen IDRC attendees to referrals for assessments. She recently developed new curriculum for this program that will now be used statewide in all IDRC programs.

Her current scholarly activities focus on harm reduction strategies to reduce overdose deaths, with a specific focus on safe injection rooms, fentanyl testing strip and needle exchange use. Dr. Gibson frequently includes students in her research, co-authoring publications and co-presenting at state, national and international conferences.

The Ammon Foundation believes that when individuals are holistically and strategically supported to build purposeful lives, the likelihood of them maintaining their recovery substantially increases. We provide this support via our two core programs – Ammon Recovery Scholars Program and Ammon Empowerment Workshop Program. To find out more about our programs, or to apply for an educational scholarship, please click here.