Harm Reduction in Couples Therapy

"Substances serve a function for couples and in therapy it is important to find out what job the substances provide and see if there are other ways to achieve the same job.   Treatment can’t be a cookie cutter design and therapists now know that substance use and relationship discord can be inextricably linked and in more cases than not, treated at the same time."
-Cynthia Hoffman, Licensed Marriage and Family Therapist




Last year, I saw a couple who found me by specifically searching for a Harm Reduction Therapist after a negative experience they had with another therapist who could not help them with all of their goals for the therapy that included exploring the impact their substance use was having on their relationship.  Most of their goals for the therapy were common for couples entering therapy; they wanted to improve communication, talk about some possible value differences and try to figure out if they were in it for the long haul. But they also talked about a recent incident in which one of the women had too much to drink at an office function. That incident gave us a more complete a view of their goals and where the roadblocks were in their relating.  

Not unusual, in this couple, they both drank and wanted to explore their relationship with alcohol, how it affected the relationship and their communication.  But their previous therapist honed in on just one member of the couple as the problem drinker and decided she needed sobriety in order to be in couples therapy.  This therapist concluded this after very little assessment, no negative results from drinking – other than the one incident.  In good faith, the couple returned and told the therapist that while drinking was an issue on the table, it wasn’t a primary one. The therapist disagreed  and so the couple sought me out. This is not uncommon. Many therapists were trained to see substance use as very one dimensional.  Harm Reduction brings a much more expanded view of how to work with substance users before sobriety is even up for discussion, if it ever needs to be part of the treatment at all.  

It is important to note that this couple had two successful, highly functional professional people with lots of responsibility both at work and at home.  More importantly they were BOTH WILLING to look at their alcohol use.  It was clear that the old school adage of ‘first treat the substance use’ got in the way for the first therapist who could not see everything that was going on with this couple.  Also, the continued belief that abstinence is the only way to approach substance abuse actually hindered this couple’s ability to work with the therapist to make changes.  This is not how Harm Reduction therapy sees the world and the intention is to help clients be supported therapeutically at the exact same time they are  making changes to their relationship to substances.  

Substance use and abuse affects couples in a variety of ways:


The tasks of therapy blend the substance use with the broader patterns of relating that most couples therapy treats.  For example, tasks in therapy might be to help the couple find other ways to connect or learn relaxation or mindfulness techniques that can help foster communication. As a therapist who looks at family dynamics, I might look at the messages clients received growing up about honest and direct communication.  Was is discouraged? Scary?  Substances serve a function for couples and in therapy it is important to find out what job the substances provide and see if there are other ways to achieve the same job.   Treatment can’t be a cookie cutter design and therapists now know that substance use and relationship discord can be inextricably linked and in more cases than not, treated at the same time.


Cynthia Hoffman, MFT, is a psychotherapist in private practice with over 13 years of extensive experience in working from harm reduction, psychodynamic and cognitive behavioral perspectives. She can help you to identify what you want and what you don't want from your drug and alcohol use. She is an effective, compassionate and directive couple therapist. She sees individuals, couples and adolescents. www.cynthiahoffmanmft.com

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