Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidence based background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.