Self-Reflections on Self-Determination in Harm Reduction

When I was a social work student in the early 1960s, I assumed that it was imperative, even obligatory, that I respect the right of client self-determination, but I certainly didn’t know how to put self-determination into practice. I was placed at Henry Street Settlement and worked with two groups of unruly children who had been referred to the agency by a school in the neighborhood almost as a condition of continued enrollment. Their behavior in school and in the community was unacceptable to everyone but themselves.

My second-year placement and my first job were at Jewish community centers where I continued to work with children. The only aspect of self-determination I encountered in those agencies was the ability of the children (or their parents, presumably in their behalf) to choose whether or not to participate in the programs that were offered.

My next job was as a social worker and, subsequently, as Director of Social Work at Hull House Association in Chicago. There, I worked with several treatment groups for children. My clients were like those at Henry Street Settlement, pressured to engage in treatment by their parents and teachers. However, by then, I knew I would get nowhere with them under such circumstances. Consequently, I developed six session preparatory groups that had three goals: help the clients (1) develop sufficient self-observation capacity to be able to look at themselves somewhat objectively; (2) identify and conceptualize an aspect of their behavior that they viewed as undesirable; and (3) develop motivation to deal with that problem. To accomplish this, we assigned social work students – one student for each child – to watch their assigned child during my group sessions from behind a one-way mirror. After each session, the students met individually with their child and verbally compared what they saw with the self-observations of the children. Through these interviews, the children were helped to identify problematic interactions during the sessions, generalize those behaviors to similar actions at home and school, and determine whether or not they wished to change. By the end of six weeks, most of the children were able to articulate problems they said they would be willing to deal with in the next phase of treatment. This clinical approach was strictly utilitarian. I knew that the kids would get nowhere in treatment unless they wanted to be in treatment. This had nothing to do with self-determination – at least not in my mind. But utilitarian or not, that experience was the closest I ever came to supporting client self-determination until 48 years later.

In the intervening years, I was a manager, a public official, and a management consultant. As part of my consulting practice, I had 7 interim management positions, the last of which, in 2015, was Interim Executive Director at the Lower Eastside Harm Reduction Center in Manhattan. For the first and only time in my career, I saw the ethical principle of self-determination put into practice.

At first, I was dismayed but subsequently enthralled by the live-and-let-live philosophy that is at the core of the provision of harm reduction services. Substance users who wanted to continue taking drugs were helped to do so safely by our offering sterile needles, a safe place to come down if they were too high, and access to and training to use an antidote in the event of an overdose. The choices of participants were respected although practitioners did not ignore or minimize the possible consequences of their lifestyles and certainly didn’t encourage drug use. If participants wanted to engage in risky sex, they were provided condoms, helped to have frank discussions with sexual partners in order to avoid pregnancy and sexually transmitted diseases, and those at high risk for HIV were given access to medications to lower their chances of getting infected. The agency facilitated various forms of mutual support and participants were able to utilize the services provided at their own pace or not accept them at all without recrimination. This was self-determination and the benefits were enormous, not only to the self-esteem of the participants, as might be expected, but also to their abilities to manage their precarious lifestyles.

It seemed odd that it took me this long to experience and understand the benefits of self-determination since it appears to be such a prominent value among social workers and some other helping professionals. But I don’t believe I am unique. It is well known that much of social work practice, such as in public assistance, child welfare, and protective services, operates within authoritarian structures. But even group and individual treatment are often coercive, not only with children, but, for example, when offered as an alternative to incarceration or other punitive measures.

Unique or not, I was excited to find that self-determination is respected in harm reduction. I loved both the idea and the application of it. If I were able to begin my career again, I would pay more attention to self-determination, not only as a value, but also as a means toward really helping people.

Dr. Eugene Aronowitz can be reached by email at or at

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