Harm Reduction Needs Guardrails: Balancing Compassion and Accountability

On a website created to allow treatment court practitioner to pose questions and engage in discussion with other practitioners, a member of a treatment court recently posted her frustrations about a lack of accountability in her program. She described a series of negative and problematic behaviors displayed by participants. While the behaviors themselves, repeated violation conditions, falsifying pay stubs, missing or diluting drug tests, testing positive, missing probation meetings or court appearances, etc. are not atypical for a treatment court population, particularly if the program is targeting high risk and high need individuals, as treatment courts are instructed to do, but the reported responses to those behaviors, raises questions.

The treatment team member describes that in following what her team understands to be new standards and guidance, she questions whether she and her team are helping their clients create “….real change.” The writer states:

“[W]e are starting to consider not holding probation violation hearings because we’re told there isn’t going to be any loss of freedom for most of these behaviors per new training guidance, we don’t need to. Dishonesty is to be ignored because its seen as ‘expected in addiction’ and consequences are minimal: verbal warnings, praise for rescheduled appointments and drug tests crafts and essays for a sanction and occasional increased testing or alcohol monitoring…”

The writer never uses the term “harm reduction,” but the “minimal” consequences and responses to the negative behaviors displayed by her program’s population is consistent with what could be described as a harm reduction approach. [Read the full post below.]

One definition of harm reduction is: a public health strategy designed to reduce the negative consequences of substance use, including overdose. In justice settings, particularly treatment courts, this means helping individuals make progress toward recovery. A critical question for the discussion is whether harm reduction eliminates expectations, in particular expectations to comply with programs rules, notwithstanding an expectation to at least reduce,  if not desist from ongoing substance use. What is harm reduction’s response to relapse, e.g., a new use after a period of sobriety? Does it tolerate dangerous or criminal behavior? If applied in treatment courts, harm reduction must mean responding to continued use, or use after a period of sobriety, and non-compliant behavior in ways that are clinically appropriate instead of reflexively punitive.

Harm Reduction and Accountability 

Accountability must still exist, purposeful accountability, based upon meaningful research, i.e., operant conditioning, towards a goal of behavior change and recovery. In other words, harm reduction must have guardrails.

Oregon’s Lesson:  In 2020, Oregon voters passed Measure 110, decriminalizing possession of small amounts of narcotics. Its goals aligned with harm reduction principles: reduce incarceration for drug use, reinvest in treatment services, and treat addiction as a public health issue.

But the rollout exposed a critical flaw: decriminalization came without accountability mechanisms or a functioning treatment system.

• Police could write citations, but individuals were not required to seek treatment.
• The promised treatment infrastructure lagged behind implementation.
• Overdose deaths increased while engagement in treatment remained low.
• Communities lost confidence in the system.

By 2024, Oregon partially reversed the law, reintroducing criminal penalties while attempting to preserve treatment funding.

Oregon did not fail because harm reduction is necessarily flawed, it failed because harm reduction without structure may be akin to  abandonment. Unlike Oregon’s broad policy experiment, treatment courts when applying best practices, including evidenced supported principles of behavior modification, contain the guardrails that make harm reduction effective. Purposeful accountability is integral in those guardrails. Treatment courts do not allow participants to disappear after a relapse; they use accountability to force treatment.

 Legal leverage is often what brings individuals to treatment, especially those with severe substance use disorders. Harm reduction should not remove that leverage but instead should channel it toward recovery.

As the National Institute on Drug Abuse (NIDA) noted in 2021: “Coerced treatment can initiate recovery; harm reduction sustains it.” Put another way once an individual is in a structured program, incentives are four times as effective as sanctions. However, meaningful, impactful sanctions are part of the structure. 

To avoid Oregon’s mistakes, harm reduction must include accountability safeguards. Treatment courts should:

• Maintain clear expectations and response matrices
• Employ collaborative case management practices
• Use best practices for incentives and sanctions following operant conditioning principles
• Provide immediate access to MOUD and treatment services
• Respond to continued use and relapse effectively
• Require frequent court review hearings
• Track outcomes and adjust plans individually

Conclusion

If employed, harm reduction should not be a retreat from accountability. Oregon’s experience reminds us of a simple truth: abandoning structure in addition to being ineffective, may also—as the lack of meaningful responses approach described in the email from the treatment court practitioner describes—be actually antithetical to the goals of recovery and prosocial behavior change. She closed her email by saying; “The same behaviors repeat every few weeks. I support a compassionate recover-oriented model but without meaningful accountability or structure, I am not sure we/re making a difference …. Because right now, it feels like we’re enabling more than we’re helping.”

Treatment courts should not enable harmful behaviors; they should change them. Incorporating harm reduction in the effort to facilitate that change with high risk and high need individuals requires practical guardrails that include compassionate support, and impactful accountability.

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