Harm Reduction Within ABA Practice

What Harm Reduction Means in Behavioral Terms

Harm reduction (reducing risk without demanding abstinence) is usually filed under drug work. This talk puts it in plain behavior terms instead. Harm reduction changes the antecedent (what happens just before behavior). It changes what follows the behavior too. It opens up safer access to reinforcement (things that make behavior repeat). And it teaches the skills that lower risk. None of that is new to our field.

The key clinical point is about support. Support is not the same as consent. Support is also not a prize for quitting. It does not hinge on abstinence (giving up the substance for good). It does not hinge on any goal we picked in advance. That is the line that splits harm reduction from older treatment models.

Foster framed the rest as competing reinforcement (a reward that competes with drug use). Some people in a rough patch with drugs touch very little else. The drug may be the only thing paying off. So small moves matter. A support group. A dose of medication. A phone call to a friend. Those stack up over time. Later the person may see family again, or make new friends. Syringe service programs (places that hand out sterile needles) work the same way. They raise access to the safer option.

support is never contingent on abstinence.

From the talk — Hal Foster

Two Roots: Free Medical Clinics and the Needle Exchange Era

Harm reduction has two roots. One is philosophical. The other is institutional. The philosophical root runs through the Black Panther Party. Their People's Free Medical Clinics ran from about 1968 to 1970. Care did not depend on quitting drugs first. The clinics served mostly Black communities. They gave real medical care while naming unfair gaps in health care.

The institutional root starts in 1984. The first formal needle exchange opened in Amsterdam that year. It came from a group called the Junkie Union. That group was run by and for people who used drugs. Foster flagged the dated language in the name. The point still stands: values turned into organized practice.

Then the story moves to the United States. The HIV and AIDS crisis hit while the war on drugs ramped up. Black and LGBTQ activists led the American movement. A harm reduction working group formed in 1992. It later became the National Harm Reduction Coalition. Much of that work ran against federal policy, which backed abstinence only. Foster named one book for readers who want more: Saving Our Own Lives, by Shira Hassan.

Why keep both roots in view? The philosophy gives us values. The history shows how those values hold up in real practice. Both shape our ethics and our scope.

meet people where they are or move with barriers and center dignity and immediate health outcomes.

From the talk — Hal Foster

Harm Reduction Past Substance Use

Most published work on harm reduction centers on drug use. The philosophy behind it does not. Foster pointed to writing in the Harm Reduction Journal that made this gap clear. The same ideas now show up in other places. Tobacco. Alcohol. Domestic violence. Safer sex and sex work. By the close of the talk, the list also held eating disorders and general health care.

Then came a question for the chat: where do you use harm reduction in daily life? Foster started with sunscreen. The chat filled in fast. Seatbelts, helmets, condoms, baby gates, birth control, masks. Personal protective equipment in health care. Elbow pads for skateboarding. A harness at the climbing gym. Leather for riding a motorcycle. We do not plan to crash. We buckle up anyway.

Foster also highlighted the Chicago Recovery Alliance. It has run outreach since 1990, and Dan Big was a co-founder. Its model asks for no abstinence to take part. For us, that lands in familiar territory. Reinforce movement toward the goal the person picked. Not the goal we handed them.

any positive change as a person defines it for themselves

From the talk — Hal Foster

Contingency Management Is ABA's Own Contribution

Contingency management (rewards tied to checked behavior) is the hinge of this talk. Foster paraphrased a 2020 HHS report to define it. It is a behavior-based clinical treatment. Tangible rewards such as gift cards, vouchers, or prizes go to the client. They are given only on objective proof of a target behavior. That proof comes from a standard, unbiased measure. Someone else can verify it.

Strip it down and you get three parts. A target behavior. A reinforcer. A contingency that ties the two together. That is the operant model Skinner described (behavior shaped by what follows it). Foster made the point without hedging.

So this is not an import from some other field. It is our own technology, and it bends to fit. The size of the reward can change. So can the schedule, the target behavior, and the shape of the program.

contingency management which is ABA's own tool

From the talk — Hal Foster

Inside the VA Fishbowl Program

The VA fishbowl program shows contingency management, or CM, at scale. Veterans working on stimulant use disorder (trouble controlling stimulant drug use) check in at VA sites. They come two or three times a week. Staff run a rapid urine test. Results land the same day.

Each negative test earns one draw from a fishbowl. The bowl holds about 500 prize tickets. About half just say good job and carry no cash value. Most of the rest are small. A few are worth more. One is a jumbo prize. Draws go up with each negative test in a row. So the payoff schedule climbs instead of staying flat.

The numbers Foster cited are not small. As of 2019, the program ran at more than 100 VA medical centers. More than 6,300 veterans took part. Among about 82,000 urine samples, over 90 percent were negative for the target drug. That drug was most often a stimulant. This is a running federal treatment program, not a research artifact. It sits on operant principles we already teach.

What the Evidence Shows for Stimulant Use Disorder

For stimulant use disorder, there is no FDA approved medication. There is no methadone or suboxone to reach for. CM is the only treatment with significant evidence on its own. CBT (talk therapy that targets thoughts and habits) has some support. So do relapse prevention, community reinforcement (building rewards into daily routines), and motivational interviewing (guided talk that builds readiness to change). Those look best when paired with CM.

CM also travels well. It does not need a bowl in a clinic. Foster cited a 2024 cohort study of app-based CM. Patients used the app alongside medication for opioid use disorder (trouble controlling opioid use). They used opioids on fewer days than people on medication alone. They also stayed in treatment longer. One caveat matters here: that study looked at opioids, not stimulants.

Foster pushed back on urine tests as the target. A clean test is the absence of behavior, not a behavior. Call it the dead man's test (a dead person could pass it). Giving a sample is also nobody's idea of a good time. Foster would rather reinforce what the person chooses to do. Picked up my medication. Went to counseling. Showed up at group. Called a friend. That sits closer to the harm reduction philosophy.

Building a CM Plan: The Parts You Can Change

Every piece of a CM plan can be tuned. Start with the target. It has to be observable and objective. 'Stay motivated' or 'work on my recovery' will not do. You cannot apply a contingency to those with any accuracy. Abstinence checked by a drug screen is one option. So is a breath test or a hair test. But other targets work too, like group attendance or taking medication as prescribed. That covers methadone, suboxone, and naltrexone for alcohol use disorder (trouble controlling alcohol use).

Next is the reinforcer. It has to be reinforcing to that person, not to us. Do not assume everyone wants coffee and donuts. It also has to be legal and ethical. No drugs, no alcohol, no weapons, nothing banned in a treatment program. And it has to be easy to hand over, every time. Gift cards and vouchers are common. Some programs skip cash over worry about diversion (rewards traded for drugs). Foster would rather give people what they want. Other programs use privileges, like take-home methadone doses. Social and experience rewards are harder to deliver reliably.

Then there is size, schedule, and structure. Fast feedback beats slow feedback. That is why the VA reads tests the same day. Same-day testing takes more resources and is not always possible. Structure is open too. A plan can run one on one with a therapist. It can use a bowl. It can run through an app. The person can even manage their own voucher system.

When a plan stalls, change one part. If adherence drops, raise the reward or shift the schedule. If attendance slips, add a bonus. If the goal is met, raise the bar: one group a week becomes two. If the reward is not working, go find out what is. Low motivation is not a reason to rule CM out. It is a sign the contingency needs care and more clinical support. A functional assessment (finding out why behavior happens) helps here. Is the use about relief, escape, social reasons, or pain? Treat the function. Do not just push the behavior down. CM can also pair with acceptance and commitment therapy (values based talk therapy). Keep dropout low with no waitlist, flexible scheduling, and a reward on the first visit. And write the plan down. Clear protocols and a defined target keep staff drift out and help new staff run it right.

instead of don't use, we could probably reinforce attending counseling.

From the talk — Hal Foster

Staying in Scope: Harm Reduction in ABA Service Coordination

Foster split the work into what a BCBA (board certified behavior analyst) can do and what we cannot. In scope: helping a family spot risk and teaching them how to get help. Raising access to housing, health care, caregiver support, and respite. Teaching safety behaviors you can see, down to which household items are safe to keep around. Out of scope without added training or a certificate: diagnosing or treating substance use. We are not housing providers. We are not medical or infectious disease providers.

The talk closed on a composite case. It blends about six families across several states, so no single case is real. A grandparent had custody and also cared for a sibling. The parent was in the picture and using substances. Housing felt shaky. Money and food were tight. The family knew about overdose prevention but had no way to reach the local harm reduction program. They wanted care that fit their culture. The grandparent asked for help.

Foster treated resource navigation as clinically relevant work. A calmer home makes our behavior plans run better. With consent, the list came together. It covered housing help, behavioral health care, and the local harm reduction group. It also covered where to get naloxone (a drug that reverses overdose). Foster called a few places first to confirm they existed, and asked only what they do and who they serve. No client details went out. Foster never mentioned being a behavior analyst or having clients at all. Medical, housing, and substance use needs got referred out. Then came the follow up: did you call, and did it help?

One note on mandated reporting (required reports of suspected harm). A caregiver using substances is not usually reportable on its own. Flag it when client safety is in play. The through line is trust. Build it with no preconditions. Celebrate any move toward the client's own goals. Trust comes before you ask for behavior change, not after.

we're not going to be presenting ourselves as a medical provider.

From the talk — Hal Foster