So Where Are We Now? Working with the Six Projects in Harm Reduction Psychotherapy
Scott Kellogg, PhD
This article outlines six Harm Reduction Psychotherapy strategies that can be used when working with patients who are wrestling with addictions or problematic substance use. They can each be used as stand-alone interventions or they can be understood within a Gradualist or developmental framework. A core idea is that the forces driving addictive behavior can best be clarified and addressed when there is a violation of intention - when a patient makes a conscious choice and a commitment to do something yet has difficulty doing it. This then becomes an opportunity to engage with the Horizonal interventions - those that are focused on managing the substance use - and Vertical interventions - those that are focused on addressing the underlying pain and psychopathology (Wurmser, 1978).
Out of my work as a Chairwork-Centered, Harm Reduction Psychotherapist (Kellogg, 2024), I have developed a Six Project Model that guides my work with patients who are wrestling with addictions or problematic substance use. Each of these projects can be used either as a stand-alone intervention, or as a part of a Gradualist or developmental framework (Kellogg & Kreek, 2005). With patients who want to work on and change their relationship with substances, I outline the Six Projects and invite them to choose the one with which they would like to engage. When we feel that we have moved through and progressed with one of them, I again present them with the different options and ask them how they would like to proceed.
Harm Reduction Psychotherapy, as I understand and practice it, is rooted in the Scientific/Humanist Model (Kellogg, October 10, 2014), and it is built on a number of core premises:
(a) People use substances for reasons – reasons that often need to be addressed before the individual will be willing to make changes in their drug and alcohol use.
(b) Addictions are complex in nature. This means that some will seek to change their relationship to substances in rapid and dramatic ways, while others will want to do so more gradually – perhaps through a series of small steps.
(c) Many drug users are filled with ambivalence – that is, there are parts of them that want to continue to use and parts of them want to change. These different motivational forces can be conceptualized as voices, modes, parts, or selves. Each of these will be invited to speak throughout the therapy process.
(d) While drug use is often rooted in inner pain, confusion, fear, and trauma, the addiction process does take on a life of its own. This means that the work needs to place on two axes: the Horizontal, which is concerned with changing the pattern of drug use, and the Vertical, which is focused on addressing the underlying pain and disturbance that drives it (Wurmser, 1978).
(e) The Horizontal treatments that I favor are Substance Use Management (Bigg, 2001), Relapse Prevention (Marlatt & Gordon, 1985), and Contingency Management or Positive Reinforcement interventions (Kellogg, Stitzer, Petry, & Kreek, 2007).
(f) In order heal in deeper ways, patients may be challenged to: (i) resolve inner conflicts; (ii) address stories, memories, and experiences from the past that are unresolved; (iii) confront fears and experiences of inner attack or criticism that dominate the present; and (iv) envision and take courageous action to create a new and better future. The Vertical approaches that I have embraced for this work include Chairwork Psychotherapy (Kellogg & Garcia, 2021), Schema Mode Therapy (Rafaeli, Bernstein, & Young, 2011), Voice Dialogue (Stone & Stone, 1989), Cognitive Therapy (Burns, 2006), and Heroic Existentialism (Kellogg & Triffleman, 1998).
(g) Lastly, all of this takes place with the context of a good therapeutic alliance or relationship; without this no work is possible (Tatarsky & Kellogg, 2010).
While all of this may seem complex or abstract, it all comes into focus with the slip, the lapse, or the breaking of an intention (Marlatt & Gordon, 1985). For the most part, the Six Projects are different ways for a patient to wrestle with a boundary of their own creation. If they are able to stay within its confines, they are increasing their capacity for freedom (Kellogg, 2016, 2024); if not, then the clarity that this provides will allow for the efficient use of the horizontal and vertical interventions. The Six Projects are:
(1) Let’s talk. Here, the patient and the therapist discuss and explore the patient’s experiences with their substances. Using a gentle touch, the goal is to not only get a feel for the contours of their use, but also to get their perception or sense of both the positive and negative experiences they have had with their substances in the last week or so. This can include creating Chairwork dialogues in which the patient sits in one chair, imagines the substance in the chair opposite, and talks to the drug about the positives and negatives of their relationship. As an additional step, the patient can be invited to do a role reversal – to switch chairs and become the substance – and to respond from the perspective of the drug. This kind of dialogical exploration is therapeutic as it can provide an emotionally informed clarity to both the patient and the therapist. The patient can then decide what, if anything, they would like to do in response, but there is no need for either the patient or the therapist to feel pressure to go beyond this.
(2) Tracking. The intention here is to get greater clarity about the specifics of a patient’s experience. To this end, the patient is invited to track the frequency of their engagements with the substance (of note, it could also be the frequency of certain type of behavior or method of use). Typically, this would be the number of days they used in the past week or the number of times per day. They can use paper, their phone, an app, or some other method of tracking. Since it is very important that this be as simple as possible, I usually only ask for frequency. Since I do not treat this as a scientific study, any form of consistent tracking is beneficial; this experience is then debriefed in the session. Some patients are quite surprised at the frequency of their use, while for others it is no surprise. Reviewing these experiences to not only ascertain if some were positive while others were negative or disappointing, but also to see if there were periods of higher and lower use can serve to deepen the exploration. Strikingly, not only is tracking useful, but not-tracking is helpful as well. Examining what happened on the days that they did not track can also reveal a great deal about the forces underlying their use. This, again, speaks to the utility of a patient becoming knowledgeable about their own patterns of using (Marlatt & Gordon, 1985).
(3) Setting an Easily Attainable Limit. This stage is built on the previous one. The patient and the therapist work together to set a goal or a limit that is easily achievable. For example, if a patient reports that their alcohol consumption was 35 drinks the previous week, a mutually agreed-upon goal of 40 drinks could be set for the next week. The aim is to set a limit that virtually guarantees success. This means that if they have 40 drinks or less over the next seven days, there is cause for celebration, but if they go over that limit, then the patient and the therapist will both agree that something significant has happened – something that is worth examining. I always integrate the Relapse Prevention philosophy that if this occurs, it is not a failure; rather, it is an opportunity for learning. The “failures” will begin to reveal whether the patient is facing issues with parts or motivation, with coping skills and empowerment, or with the emergence of inner pain and disturbance (Marlatt & Gordon, 1985).
Strikingly, patients sometimes want to set a low limit to start; I discourage this because I am very focused on making success relatively easy. This will also provide us with greater insights into what is going on, as it is at these “borders” where things are learned.
(4) Harm Reduction/Substance Use Management. Substance Use Management (Bigg, 2001) is a key intervention here. A central goal of Harm Reduction is to keep people safer when they use drugs; another goal is to begin to change the relationship between the person and their substances. This can be done by focusing on reducing the amount consumed, changing the methods of use, reducing the time of involvement, altering the context of use, and substituting on drug for another. Each of these are methods of disrupting the use pattern. The more the patient can break the automaticity of their use, the more power that they are claiming. Here, the violations of intent are likely to be very meaningful.
(5) Moderation. This involves a consciously structured approach to alcohol or drugs; for this to be effective, the individual has acknowledged that their substance use is definitely causing them problems, and they are now actively seeking to change their use pattern. Taking alcohol as an example, some patients want to create a high frequency/low quantity framework. This is typically the case with those who want to use alcohol in social settings where drinking is seen as an amplifier of an experience rather than the centerpiece of the experience itself. These patients are committing to very controlled amounts of alcohol (e.g., two drinks at a dinner). Other patients will want to take a low frequency/high quantity approach. This group seeks a more intense experience; they either do not want to forgo the experience of intoxication and/or they find low-level use to be frustrating and unpleasant. This group is committing themselves to many drug-free days each week and to some limits on how much they will drink when they do drink (e.g., total number of drinks, number of drinks per hour, type of drink). As in the other projects, disruptions of intention may be connected to motivation (resentment at having to control one’s use), the further development of skills (How do I say no when offered another drink?), or underlying issues (“I feel anxious in social settings.” “I do not know how to be in a romantic situation without a lot of alcohol in my system.”).
(6) Abstinence/Drug-free Living. In some ways, this is the simplest – if not the easiest project. The individual chooses to abstain from or not use any substances or they choose to refrain from using a specific substance. This means that any use is significant. The ascertainment of the degree to which these slips or lapses are a horizontal problem – related to triggers, pressure by others, cravings – or a vertical problem – a way of coping with traumatic memories, Inner Critic attacks, grief, high levels of anxiety, or deep ongoing pain – is of crucial importance in the healing process. With this kind of clarity, the patient will be able to more effectively use the therapy to achieve the goals that they have chosen for themselves.
While much of what I have written is not new, I believe that dividing the transformation process into six clear projects – each of which can be chosen or rejected by the patient – is a difference that makes a difference. It not only brings greater clarity to the work at hand, but also it invites the patient to be a more active participant in the therapy and to make clearer choices about the direction of their life – both of which lead to greater empowerment and greater freedom. While I do not specifically work with behavioral addictions, I am hopeful that this model can be modified to serve patients who are wrestling with those challenges as well.
[Originally published in ADDIC/DIV, The Newsletter of the Division on Addictions of the New York State Psychological Association, March, 2025, pp. 6-10]
References
Bigg , D. 2001 . Substance use management: A harm reduction-principled approach to assisting the relief of drug-related problems. Journal of Psychoactive Drugs, 33, 33-38.
Burns, D. D. (2006). When panic attacks: The new drug-free anxiety therapy that can change your life. Harmony Books.
Kellogg, S. (October 10, 2014). A struggle for the soul of addiction treatment. Substance.com. https://psmag.com/social-justice/struggle-soul-addiction-treatment-95358/
Kellogg, S. (2019). On addiction, complexity, and freedom: Toward a liberation-focused addiction treatment. Journal of Psychoactive Drugs, 51, 85-92.
doi: 10.1080/02791072.2018.1564157.
Kellogg, S. (2024). Liberation-focused addiction treatment: A biopsychosocial model. New York: Chairwork Psychotherapy Initiative. https://www.chairworkpsychotherapy.com/blog/liberation-focusedaddictiontreatment
Kellogg, S. (2024). With love and intensity: Some reflections on Chairwork, Harm Reduction Psychotherapy, and the treatment of addictions. New York: Chairwork Psychotherapy Initiative. https://www.chairworkpsychotherapy.com/chairwork-and-harmreduction
Kellogg, S., & Garcia Torres, A. (2021). Toward a chairwork psychotherapy: Using the four dialogues for healing and transformation. Practice Innovations, 6(3), 171–180. https://doi.org/10.1037/pri0000149
Kellogg, S. H., & Kreek, M. J. (2005). Gradualism, identity, reinforcements, and change. International Journal of Drug Policy, 16, 369-375.
Kellogg, S. H., Stitzer, M. L., Petry, N. M., & Kreek, M. J. (2007). Motivational incentives: Foundations and principles. Promoting awareness of motivational incentive – An awareness campaign. https://gradualismandaddiction.org/wp-content/uploads/2024/09/Kellogg-Stitzer-Contingency-Managment-Foundations-and-Principles.pdf
Kellogg, S., & Triffleman, E. (1998). Treating substance-abuse patients with histories of violence: Reactions, perspectives, and interventions. Psychotherapy: Theory, Research, Practice, Training, 35(3), 405–414. https://doi.org/10.1037/h0087655
Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention. New York: Guilford.
Rafaeli, E., Bernstein, D. P., & Young, J. (2011). Schema therapy: Distinctive features. East Sussex, UK: Routledge.
Stone, H., & Stone, S. (1989). Embracing our selves: The voice dialogue manual. Novato, CA: New World Library.
Tatarsky, A., & Kellogg, S. (2010). Integrative Harm Reduction Psychotherapy: A Case of Substance Use, Multiple Trauma, and Suicidality. Journal of Clinical Psychology: In Session, 66, 123-135.
Wurmser, L. 1978. The hidden dimension: Psychodynamics in compulsive drug use. New York: Jason Aronson.
Dr. Scott Kellogg is an ISST-certified Advanced Schema Therapist who has also received training in both Gestalt Therapy and Voice Dialogue. He created the Transformational Chairwork Psychotherapy Project in 2008, and, in 2023, he and Ms. Amanda Garcia Torres, LMHC, launched the Chairwork Psychotherapy Initiative – which is the first international Chairwork Psychotherapy Certification Program. Together, they have introduced Chairwork Psychotherapy to thousands of therapists throughout the world. He is in private practice in New York City.
Dr. Kellogg received his Doctorate in Clinical Psychology from the Graduate Center of the City University of New York in 1994, and he has served on the faculties of New York University, the Rockefeller University, the Yale University School of Medicine, and Teachers College/Columbia University. He is also a Past President of the Division on Addictions of the New York State Psychological Association.
Email: info@chairworkpsychotherapy.com
Websites: