In her two-part series clinical psychologist Jessica Katzman writes about a way of managing addiction that is grounded in scientific research, human rights, compassion, and common sense. Click here to read part two.
I was trained in and practice from a harm reduction perspective, so I’d like to provide some background and information about what this means, as well as invite some conversation around alternative ways to approach alcohol and substance use.
Though we can trace its roots back for several decades, harm reduction largely became visible in the 1980s as an international public health movement that recognized HIV as a larger health risk than drug use in and of itself, and aimed to reduce transmission via the distribution of condoms and clean needles.
The primary principles of this health movement are an acceptance of the reality that people do engage in high-risk behaviors, and a commitment to helping them reduce the harm associated with those behaviors, without requiring that the behaviors themselves stop. Out of these principles grow many of our well-known public safety regulations and health education programs, such as seat belt and helmet laws, minimum drinking age requirements, nicotine replacements, safer sex practices, and designated driver programs.
Harm Reduction is a pragmatic stance, rather than one based in moral idealism, and is grounded in scientific research, human rights, compassion, and common sense. It is consumer-oriented, maintaining a low threshold for participation; providers are committed to meeting people where they are rather than requiring abstinence before treatment begins.
Harm Reduction is collaborative, rather than punitive; people are encouraged to participate in setting their own goals for treatment, and to work together with their providers towards those goals. This stance represents a major shift in how we approach individuals with high-risk behaviors, opening the doors of treatment to many more people than ever before.
Moving Away from the Moral and Disease Models
The full history of drug and alcohol use in human society obviously lies way outside the purview of this post, since we would have to track back at least 10,000 years. Additionally, these substances are always inextricably bound up in the cultural, social, economic, political, religious, agricultural, and medical developments of a people.
The United States, in particular, has always struggled with a highly conflicted set of attitudes regarding drinking. The Puritanical roots of the colonial people, and later temperance organizations, had a hand in shaping the Moral Model seen in the 19th and early 20th centuries. This model can be characterized by these beliefs:
- Addiction stems from a weakness of character, and is the result of poor choices. It is naturally associated with crime, poverty, sin, domestic violence, and laziness.
- The appropriate response should be punishment, not sympathy. (For an example of how this principle continues to impact our political policy, look no further than the War on Drugs.)
This was gradually (and perhaps only partially) replaced by the Disease Model, which has been viewed as our standard approach since the inception of Alcoholics Anonymous in 1935. The precepts of this model are:
- Addiction stems from a biological disease, which follows an inevitable progression from use, to dependence, to extreme consequences, to death.
- It is a black-and-white issue (either you’re an addict or you’re not) and is incurable (once an addict, always an addict). This malady is marked by loss of control and powerlessness, as well as the addict’s denial of the severity of the problem.
- The only way to arrest the disease process is total abstinence, ongoing participation in 12-step community, and turning one’s life over to a higher power.
In contrast, the Harm Reduction Model of substance misuse holds that:
- There is no one single cause—it is as complex as any human behavior, and often multi-determined (vs. a biological, inherited disease).
- It is not a black-and-white matter, but rather a continuum of use that flows from abstinence to dependence. (Additionally, people may skip around on this continuum, depending on their life context and emotional state.)
There is actually a diversity of outcomes for substance misuse (vs. the “inevitable progression”). For example, it has been shown that most people stop using drugs by age 29 (and few start after this age), a process Peele calls “maturing out”, which reflects how competing values and goals can have an affect on our choices.
The most common outcome of chemical dependency treatment is relapse and continued abstinence is the exception. The typical, black-and-white perspective overlooks a substantial amount of improvement in those who do not maintain perfect abstinence.