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Harm Reduction: Making Way for Curiosity About Your Drug/Alcohol Use

I haven’t been writing as many articles recently. I guess it’s because I’ve been spending my free time in bars.

Ok, I realize that was a misleading statement. I have a new podcast, A Therapist Walks Into a Bar, for which I interview random people in bars about all kinds of human issues and then interview experts to round it out and create pieces that are entertaining, emotional, and informative. I’ve found strangers to be open in ways I never expected, from charged topics like white privilege to intimate relationships. I’ve heard some pretty amazing and vulnerable stuff. But asking a person with a drink in their hand about their substance use…well, that seems to get people’s guards up.


I was a DARE kid. I don’t just say that because the DARE program (Drug Abuse Resistance Education) came to my school in the 90’s. Unlike many of the kids who made jokes and goofed off, I’m kind of embarrassed to say I took it pretty seriously. When I was 12 and I realized my older brother was smoking and drinking like a lot of other 16 year olds, I was terrified of what would happen to him. Over many years I’ve been trying to untangle my black and white thinking about drugs and alcohol from the gray reality. At first glance, it’s surprising that I became a Harm Reduction oriented therapist, coming from some rigid views and deeply-seeded anxiety. But I think I’ve chosen this path because it feels like the courageous path for me, with that scared 12 year old still inside. How can I find patience and compassion when I feel afraid? How can I maintain an open mind and meet people exactly where they are? How can I sit with discomfort? When we’re scared we want to bring the hammer down. But Harm Reduction challenges us to do the opposite.

It’s hard to have an honest discussion about substance use when there’s so much stigma attached. What you’ll hear when my next podcast episode comes out are the voices of some of my interviewees who are quick to say “NO!” when I ask if they ever use substances to deal with emotions. I imagine at least some people who responded this way were afraid that if they said “yes” or “maybe” I would judge them or think they have a “problem”. The way substance use is often portrayed in our culture is extreme – either you’re an addict or you’re not. But in reality we do all kinds of things, including use substances to deal with feelings. Maybe to feel less of something or to feel more of something else. That’s kind of what they’re for.

In the United States, some substances, regardless of their relative harmfulness, have more stigma attached than others, especially if they’re illegal. But the reasons for one substance being illegal and another not is often much more complicated than evidence-based health and safety protocol. And what isn’t addictive for one person, might be extremely problematic for another.

So let’s start with a perfectly legal substance that many of you probably use – caffeine. I interviewed a couple about their substance use as individuals and how that impacts their relationship. The woman lovingly described her relationship with coffee while the man piped in.

Veronika*: I can’t wait to have coffee in the morning.

Me: What does coffee do for you?

Veronika: Wakes me up, makes me feel good.

Richard: What happens when you don’t drink coffee?

Me: Yeah, I’ll let you interview her. [Veronika’s partner Richard wants to do the interview…]

Veronika: No one gets fed.

Richard: How grumpy do you get?

Veronika: Mean – I get pretty mean. On a scale of 1-10, I’m like a 20.

Richard: Does it give you a headache?

Veronika: Yeah, well no – if I’m going without for a long period of time, yeah. I have to drink coffee before I leave the house.

Richard: The first thing in your system is coffee.

Veronika: Yeah, I wake up and I immediately boil water. My mom gave me coffee when I was 13 years old and it was so I could start getting up extra early in the morning to feed the chickens and the pot belly pigs and the ducks and all the other animals.

Me: So it’s a way to make yourself more productive?

Veronika: Well, now it’s just a way to survive. [laughs] It used to just be for productivity. Now it’s just so I can be a human being throughout the day.

Me: Do you wish it was different?

Veronika: No, I like –

Richard: She has a French press. [laughs]

Me: If you quit coffee you wouldn’t be able to use your French press!

Veronika: I like having the routine in the morning which is really comforting. And I like trying different coffees and I like the way coffee smells. But I guess some people who do crack like the way crack smells.

Veronika sounds pretty sure she wants to keep drinking coffee. She’s aware of some of the consequences – her dependence can lead to her being a 20 on the 1-10 meanness scale when she doesn’t get her fix. She’s also aware that her relationship to it may not be so different from a crack user’s relationship to crack except that coffee is legal and possibly not as harmful. Overall she feels coffee is working for her. It’s been a part of her life for a long time and it helps her feel good, feel productive, feed her son. It helps her survive. And there’s no huge incentive to stop. A doctor hasn’t warned her that coffee is having a negative impact on her health and she is rarely in a situation where coffee isn’t available to her.

So Veronika uses coffee to help her feel productive. And to help her not feel mean and tired. She has a handle on exactly why and when she uses her substance. A Harm Reduction therapist would want to know about all of that and exactly what her goals are – does she want to keep using at the same level, reduce, or abstain? Why?

I interviewed expert Harm Reduction therapist Cynthia Hoffman describes it like this: “What we want to do is get a realistic view of what people are doing, the substances they’re using, the behaviors they have, and try to help reduce any harm.” And she adds something, a core of Harm Reduction therapy that’s really important, “People are experts of their own lives and consciousness and we can help them, as therapists, navigate their way through that. But I’m not in charge of that and it’s not up to me to tell them where they’re going wrong.”

So how might therapists help us navigate our way to understanding and (possibly) changing our substance use? First, we move through a process of inquiry that helps us be more aware of what, when, where, why, and how we’re using substances. I asked Veronika “what does coffee do for you?” and “do you want it to change?” I came from a place of curiosity, not from an assumption that her coffee consumption was “bad” and should be confronted (I mean, her coffee consumption would literally kill me but it’s not about me; it’s about her).

Believe it or not, I would do the same thing if someone told me they were using heroin. I would have to put my own anxieties and DARE indoctrination aside to do it, but pushing someone to change, especially when neither of us fully understands the context of their use, is rarely effective or useful. In fact it often backfires.

One man I interviewed at the bar who was worried about his friend’s drinking said, “I took his bottle away and drained it down the toilet. And when I read about it afterwards, it said ‘Number 1: Don’t take their bottles and drain it down the toilet’.” His anxiety led him to try to bring the hammer down, to intervene. But this wasn’t a wake up for his friend. His friend probably already new he was drinking too much and didn’t yet have the ability/desire/resources to change it.

If you’re using alcohol to get a little respite from your high pressure job, perfectionism and an intense inner critic, beating yourself up for drinking or getting hounded for drinking by someone else likely adds to the feelings that you drink to cope with in the first place. Cynthia says, “I tell people almost everyday, what is the perfect remedy for shame and guilt? Additional substance use.” And right there, whatever problematic cycle you might be in with your substance ensues.

So how to break this cycle? Harm Reduction says inquiry, inquiry, and more inquiry. Along with conscious choices coming from you (with the help of your therapist) to experiment with incremental changes aimed at removing the most harmful aspects of your use from the equation. If you want to go “cold turkey”, Cynthia asks, “What are the resources that you need to be able to quit?” You’re using for a reason and if you take your coping tool away, you need other things in place to support you because likely you’ll be turning towards the things that are scary and painful for you like trauma, stress, social anxiety, and overwhelm.

If any of this sounds familiar and you’re interested in understanding how and why you use almost anything from chemical substances to food to sex or anything else they’ve got a 12 step program for, which is pretty much everything as this Lip Balm Anonymous (LBA) site will show you, tune in for the next episode of A Therapist Walks Into a Bar releasing March 14th, to hear more. Cynthia and I will dig deeper into what an organic process of change can look like and take a nonjudgmental approach to understanding why we use (because most of us use something).


You can subscribe to A Therapist Walks Into a Bar in iTunes, Stitcher and most other places podcasts are found. And you can follow on Soundcloud or listen directly from the website.

For more on Cynthia Hoffman, you can read her articles for Psyched in San Francisco Magazine here or visit her website. In addition to working one on one with substance users in San Francisco, Cynthia leads Harm Reduction therapy groups.

If you want to read more about Harm Reduction and start the process on your own, Patt Denning’s Over the Influence is a must read.

*Names have been changed to protect the identities of my interviewees.

Lily Sloane

Lily Sloane

Lily Sloane is a licensed psychotherapist in San Francisco. She sees her work as a dynamic interplay of science, art, and relationship, aimed at opening up wholeness and a sense of choice for her clients. She specializes in working with sensitive, creative young adults struggling with eating disorders, substance use/misuse, perfectionism, and relationships. (LMFT #84885)

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