Harm Reduction or Abstinence, Who is to say?
I recently was involved in a mini-debate about harm reduction and abstinence, and both sides had their pros & cons, but from who’s perspective.
Where I am coming from:
I am an alcoholic in recovery for over 15 years and an addiction counselor for 12. Now I have worked for the past 12 Years in a 12 Step Treatment Centre, and being in recovery myself, I would lean towards the abstinence model.
I am open minded though and through my own experience have seen that the clear pathway for people to get help has not been that direct. Let me explain:
At one time I would have been an orthodox abstainer or an all or nothing person, and that is what applied for me. I came to a stage where I didn't want to drink anymore, but could not stop drinking, you could call this my rock bottom. When I eventually got sober, (My Bio), I was ready to stop as I was sick and tired of being sick and tired. It was totally liberating for me to be a sober alcoholic.
There are many out there just like me, just so grateful to not be imprisoned by a chemically warped mind anymore, who embrace the 12 Step and other abstinence-based models and are very happy and content with life.
Most of us hit our own rock bottom, at whatever level, and had a bad enough experience or experiences that created the internal shift necessary to change. Some went into rehab, some directly through AA or NA, some even on their own.
The problem I see
Now in my line of work, we get a majority of our referrals into treatment from the Health Service, which is a statutory body. Many of these people are “Crisis Motivated”, either a situation has occurred that has involved the law, employment, family intervention, or child services.
I have found that people who are “Crisis Motivated” had little to no intention of stopping their drinking or using. Their motivation is to literally get the “monkey off their backs”. Once the crisis situation is over, then a vast majority relapse and return to their old ways. Their motivation to stop permanently was never there, and deep down they knew and in most cases could not wait to resume their old habit.
How dare you!!, I hear many AA’s saying, it is not a habit, it is a disease. I agree, chemical dependency is a disease, as the whole body, cells and all become addicted. The habitual part of addictions are the behaviors, and especially the routine or rituals that occur even before and after drink or drugs are taken are dysfunctional.
When someone is detoxed and is physically sober, the old behaviors do tend to continue, why? Habit or Habit Dysfunction. Why does this happen? Well, my belief and experience in working in this field for 12 Years, is motivation, or lack of it.
If someone doesn’t want to change and is temporarily only being obliging, then they are not going to change. Why should they?
If someone doesn’t want to change then no one can make them. You can work with them and work through ambivalence, in collaboration.
If they are not willing, should they just be dropped and left to get on with it? That would be irresponsible to leave someone who is in a distressed situation, depressed or even suicidal. Interventions are necessary, but what kind of intervention is needed?
People who have dual disorders or co-morbid, and are high risk do get admitted into Psychiatric Units, again a crisis intervention.
People are referred to the statutory health services when alcohol & drug abuse is flagged up.
Harm reduction leading to abstinence makes sense
So to get back to my introduction, harm reduction should be the first intervention. Telling someone who is in a crisis, is chaotic, an emotional wreck full of anxiety that they can’t drink or drug again will not work.
It will only cause more stress and anxiety & unless they are highly motivated will not return for another appointment. People want the crisis & chaos to go away, with as little stress or change as possible.
Everyone, especially the young, should be given the opportunity to initially try to control their alcohol and drug consumption, and if they can manage that, then the problem behavior could be down to something else-college stress, right of passage.
Not everyone who abuses alcohol & drugs is an alcoholic or drug addict and not every alcoholic or drug addict abuses alcohol or drugs.
The Health Service here has a 4 Tier system of intervention for alcohol & drug interventions.
Tier 1 is normally an intervention from a family member or significant other, maybe creating awareness that there is a problem and it has been noticed and needs to be addressed.
Tier 2 is an intervention from a Doctor or health care worker.
Tier 3 a specialized substance misuse worker/counselor/treatment. Approaches like CRA (Community Reinforcement Approach) & SMART ( Self-Management and Recovery Training) Recovery, with are both harm reduction approaches can be applied here.
Tier 4 is usually an abstinent based residential treatment programme.
Backward not forward
It sounds great, but unfortunately, it is not followed and the clear-pathway has many forks and people are still being referred from Tier 1 straight to Tier 4, bypassing tiers 2 & 3. They land in a 30-day intensive treatment programme and don’t even know why they are there.
The other situation is that they go from a Tier 4 treatment programme, have embraced abstinence and then are referred to a Tier 3 “Harm Reduction” programme.
This causes a lot of confusion with the person in recovery. People who are only getting used to the necessary changes they need to make now and in the future to have a good recovery.
At the end of the day the whole revolving door of addiction and recovery, relapse continues and is facilitated by a system that is supposed to help. Politics and ticking a box has a lot to do with this dysfunctional system, but at the end of the day, it is the person with the addiction and their families who continue to suffer.
It has to be up to the individual
Addiction is very complicated and as complicated as each individual who suffers from it, whether the harm reduction or abstinence models are adopted, the underlying issues will remain the same and have to be worked through. Each individual does deserve the right to do that for themselves without being dictated to by statutory bodies, who want bums on seats or them away from the view of society.