Meeting people with drug and alcohol problems “where they’re at” is commonly viewed as “harm reduction,” a term that often refers to using less alcohol or fewer drugs—as opposed to quitting completely. It can also refer to practices having to do with lowering hazards caused by drug use, including offering clean needles to people addicted to heroin.
This is not a discussion of returning to or learning how to use substances such as alcohol or marijuana moderately or socially for a person who once met the criteria for addiction, even though that happens more often than most people think and can certainly be an acceptable goal for certain individuals, particularly those with less serious substance problems.
As suggested in Part 1, the “disease model” of addiction espoused by traditional treatment programs in the U.S., which incorporates the 12 steps of Alcoholics Anonymous, advocates abstinence as the only acceptable goal. Mark Willenbring, M.D., former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism and currently director of the comprehensive Alltyr addiction practice in St. Paul, MN, said, “To many treatment practitioners, ‘harm reduction’ implies ‘giving up’ on the person. They truly believe that A.A. is 100 per cent effective if you follow their directions and that if you continue working with someone who isn't totally abstinent, then you are ‘enabling’ them.”
Does Rehab Prepare You if You Can't Remain Abstinent?
The truth is that among people completing treatment, about half will have a recurrence of the alcohol or drug problems that took them to rehab within the first year. However, rehab often doesn’t prepare clients for this. One woman I interviewed for Inside Rehab told me of her experiences at a prestigious 12-step-based program, “You learn how to prevent relapse—but they’re afraid to say what happens if you do relapse. Even the workbooks are all before it would happen; they’re not, ‘Where’s your plan if you do relapse?’ The counselors are trained to not let clients fail.”
She advised that a good question to ask programs before choosing one is “How are you going to prepare me if I do have a relapse?” Having first been to a non-twelve-step program that taught her what to do if she did drink again, she said, “There was acceptance of relapse and working through it. At the nontraditional program, you weren’t one step out the door if you used, as in a conventional program. Being prepared was more than just ‘call your sponsor.’”
How Meeting Clients “Where They’re At” Works
Another woman who long-struggled with a serious alcohol problem first went to an outpatient program and then AA but resumed heavy drinking for a decade until, at the age of 31, she found an addiction psychologist who specializes in individualized approaches. Of her experience with him, she said, “It took eight years to get to a life of happy abstinence. It was gradual, small goals sometimes achieved. I was drinking the whole time, sometimes not drinking for a few days.” At times she saw the psychologist weekly; then there were big gaps in their visits. But when she saw him, she drank less.
Finally, after a night of excessive drinking, she decided she never wanted to feel that way again, and she just quit. She lost 80 pounds, and her health improved markedly, as did her relationships. “This was the path I had to take,” she told me, “And I had to take it with someone who was going to allow me to do it my way. I’m very convinced I’m where I am because of the long, often winding and genuine path of self-discovery and acceptance led by a very wise and patient facilitator.”
A list of alcohol harm reduction therapists can be found here, but there are many others who are not on the list and/or who may not describe themselves as such:
Times may be changing in that a 2012 survey of more than 900 addiction counselors from across the U.S. showed that about half of respondents said it would be acceptable for clients who abused alcohol to limit their drinking but not totally give it up. That's about double the number of treatment program administrators who said this 12 years earlier.
While I found that there was often a difference between what was said and what was done at the treatment facilities I visited for Inside Rehab, some outpatient program administrators told me that while the program goal “on paper” is abstinence, it’s different in reality. One said, "We preach abstinence but there are times when all we can hope for is harm reduction." Another said, “To be licensed, we have to be say our goal is ‘drug-free’, but we don't kick people out if they lapse. To a degree, whatever it takes to get you where you want to be, we'll work with you.”
Should We Do Away With the Term, “Harm Reduction”?
The following professionals prefer alternatives to “harm reduction”:
• Bob Muscala, R.N., director of Chemical Health Concepts in Minneapolis, prefers to use the term, “chemical health improvement.” Indeed, when it comes to other medical problems, such as lowering blood cholesterol to a level that’s short of ideal, we call it “improvement”, not “harm reduction.”
• Dr. Willenbring said that while the ideal for all patients having severe substance use disorders is abstinence, he recognizes that’s not possible for many of them and added, “It's best to call the way we help them, ‘treatment’ or ‘chronic care management.’ That's what we do with every other condition or disease.”
• Alan Wartenberg, M.D., a consulting physician with addictions expertise in Attleboro, MA, maintains he’s “sick to death” of hearing, "harm reduction," adding, “It presumes that some kinds of treatment are more successful in getting people into ‘recovery’ and others are just allowing them to hold down the fort. ALL treatment is harm reduction. This dichotomy between ‘recovery’ orientation and ‘harm reduction’ is a false one, divides clinicians, and is of no help to our patients.”
Since only about 1 out of 10 people with a substance use disorder seeks treatment, it’s high time that we offer more inviting approaches, regardless of what we call them and whether clients are willing or ready to be abstinent. Andrew Tatarsky, Ph.D., director of the Center for Optimal Living in New York City, explains, “When many ‘unmotivated’ people hear about non-abstinence-only harm reduction therapy, they become motivated.”
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