As a therapist, I have worked with countless individuals who fall somewhere on the spectrum of having a serious substance addiction problem, to those who have problematic substance use or drinking habits, but who haven’t hit the proverbial “rock-bottom” we so often hear about. I spent a few years as a case manager in an inpatient substance abuse facility at the beginning of my career, and later I worked as a therapist in an inpatient center treating substance abuse, mental health, and eating disorders. Since then I’ve also worked with clients in individual therapy with problematic drinking habits, those who have significant substance abuse histories, or who use other substances recreationally. The history behind substance abuse treatment has been until recently almost exclusively focused on getting people to commit to and practice abstinence and total sobriety. AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) have been the go-to referral for many people seeking help with sobriety and are considered pre-requisites in any recovery treatment model. Unfortunately, there’s one big glaring problem with these models… they don’t work. At least not for everyone.

There’s several reasons why they don’t work for everyone, and there’s other reasons why we blame individuals for “treatment failure” instead of recognizing that there is a range of ways to measure improvement, and another way to help people improve their lives and weaken the grip of addiction. I’m talking about Harm Reduction, and it is a growing movement in the field of substance abuse treatment that is giving more people hope for a future free from addiction. First, though, let’s look at why AA/NA programs are not working for everyone.

What’s wrong with AA and NA?

It’s not that AA and NA are terrible models for recovery, or that they haven’t helped many, many people achieve sobriety. I always tell my clients that if they find something that works for them, and if it is helping them achieve their goals, they should keep doing it. I have no qualms with people using AA or NA as a support and structure system that helps them gain freedom from alcohol or substance abuse. The problem is that they simply don’t work for everyone, for a variety of reasons. Here’s a few:

  1. Powerlessness: The first “step” in the 12-step AA model is that you need to admit that you are powerless over alcohol and/or drugs and that you are unable to stop using on your own. This is useful to some people, because it helps them get into the mindset that they do really need help. For others though, it feels, well, disempowering. Some people want power OVER their addiction, they don’t want to give the alcohol/drugs all the power. From the outset, telling people that they are powerless over substances gets them in a mind-frame that they are not capable of controlling their own choices and behaviors.
  2. Total Sobriety/Failure model: Another part of the AA/NA model is the “chip” system”. When you walk in to a 12-step program on your first day of sobriety, you get a “chip” that serves to commemorate your sobriety. Then you get more chips as you work the program and make progress, achieving markers such as 30-days sober, a year sober, et cetera. If you pick up a drink, or use again, you’re back to day one, and typically you’re expected to come into the group and pick up a 1-day chip, which basically announces to the group that you “relapsed”. Again, for some people, this model of accountability helps them stay on track with their goals; for others, it’s a humiliating exercise that points to them as being a failure and can ultimately cause people to not come back to the group at all because they don’t want to be seen by their peer group as having failed at sobriety. A different approach is needed for some people, who don’t want one drink to mean that their previous efforts at sobriety cease to matter and they’re starting over at square one. Another problem with this total sobriety model is that in all honesty, some people don’t want total sobriety. Some people want to be able to enjoy a few beers at a BBQ, or be able to toast on NYE, but they recognize that they don’t want or need to be getting blackout drunk every weekend. Or perhaps they’ve been on some really hard drugs, and want sobriety from those drugs, but want to be able to go out to dinner and feel like a normal person capable of having a couple drinks without being labeled as an “addict”. AA and NA do not provide any framework for a person who wants this, and thus they leave out people who want to change their habits, but don’t want total sobriety.
  3. The Higher Power part: The 12-step model requires members to submit to a higher power. While the 12-step program originated with Christianity as its structure for recognizing a higher power, it has since evolved to be more inclusive as to how people interpret their higher power but the requirement to subscribe to a higher power remains. Needless to say, this leaves out everyone who considers themselves agnostic or atheist. Once again, we find that there is part of this model that works for some people, particularly those who want their faith to be a major factor in their road to recovery, but it just doesn’t resonate for others. This aspect of the AA/NA program also relates to the concept of powerlessness. The idea is to turn your power over to a “higher power”, who will presumably help you stay sober. For those who want to feel that THEY control their use, not the other way around, the concept of turning it all over to your higher power doesn’t fit with their idea of being in control of their drinking or use.

There are other criticisms of the 12-step/AA model of recovery, but these are some of the main points that I have found that turn people off from working a 12-step program. Luckily, the concept of Harm Reduction is gaining traction in the recovery industry and helping to provide more options for those people who either have found AA/NA doesn’t work for them, or who are interested in another way.

What is Harm Reduction?

Harm reduction is the concept that people who are abusing alcohol and drugs CAN reduce their overall use of substances without committing to total sobriety, CAN reduce the negative effects that substance abuse has on their lives and the people in their lives, and CAN lower the risky behaviors associated with their substance abuse that ultimately can cause them to experience more severe consequences of their use. It is the concept that one solution does not fit every individual’s needs, and that someone who drinks or uses should have access to a variety of choices when they are seeking help. Harm reduction also includes advocating for policies that do not punish people for being addicted, but seeks to help them find the help they need to have healthier lives, without insisting that people conform to our expectations. Further, harm reduction posits that we should meet people where they are on the road to recovery, and stop insisting that they commit to 100% sobriety before we give them any help. Harm Reduction can encourage people to make the following changes in their lives and habits:

  1. Going from someone who drinks and drives regularly to someone who still drinks heavily, but no longer gets in the car and drives and is able to choose to get a ride home when needed, no longer risking their own life and the lives of others by being on the road while intoxicated.
  2. Going from someone who shares needles with others in order to get high to someone who still uses but accesses clean needles and no longer has to worry about contracting or transferring a disease or infection from dirty needles.
  3. Going from someone who drinks heavily on a regular basis and then verbally or physically abuses others during blackouts to someone who is able to set a limit on the number of drinks they have and eliminates the abusive behaviors associated with their drinking.
  4. Going from someone who uses high addiction-risk substances such as cocaine, meth, or heroin to someone who smokes marijuana and no longer experiences the damaging physical and addictive effects of those harsher drugs.

As you can see, there are ways that someone who struggles with substances can find ways to reduce the harm and associated risks that using substances or abusing alcohol has in their lives, without requiring that the person be completely sober in order to recognize those achievements. Harm Reduction advocates recognize that we don’t have to require people to be 100% sober before we can call their efforts a success. For one things, it is not our place to tell people what their goals should be. Some people want to be 100% sober and the truth is that some people don’t. As a clinician, I have always been trained to start where my clients are and to let them define their goals, rather than defining what I think their goals should be. Harm reduction fits into that concept as a best practice, because whether I think someone should stop drinking/using is irrelevant if they don’t want to stop drinking. However, if they want to reduce their drinking, feel empowered to make better choices about their drinking and while they’re drinking, or minimize the negative effects that drinking has on their life, then as a clinician I should support them in those efforts however I can.

Some people really do want and need total sobriety, because their behaviors surrounding their addiction have gotten so dangerous and harmful to themselves and to others, and because their efforts at moderation have not worked after multiple attempts. I think this is why most inpatient treatment centers use a 12-step model, because once you are at the point where you need inpatient treatment, your behaviors are probably pretty out of control and dangerous. However, as with all treatment, what one individual needs is not going to be the same across the board. In the meantime, we need to redefine what recovery means, because it doesn’t look the same for everyone. At this time, when I have clients that want to learn more about harm reduction and learn strategies that focus on that goal, I refer them to Smart Recovery. Smart Recovery does focus on abstinence, but it does so without some of the trappings of AA that have been problematic that I mentioned earlier. They also have groups and online meetings, which may be helpful to some people depending on their location and/or comfort with the group setting. Individually, finding a therapist or provider that is familiar with the concepts of harm reduction can be an important step in the recovery process as well.

To learn more about harm reduction, visit HarmReduction.org.

To learn more about Smart Recovery, visit SmartRecovery.org.

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