Harm Reduction is a philosophy that is surrounded with a lot of controversy, confusion, and intrigue. What is it? What does it really mean? I would like to briefly describe my understanding of this term and how it can help our understanding and treatment of addiction.
I was watching the Today Show the other day and Meredith Viera was interviewing a psychiatrist who has written a book on addictions and works at a treatment facility. They were discussing Lindsay Lohan’s numerous stints in treatment and ensuing relapses. The psychiatrist said that the treatment community is in a crises and part of the problem is they are stuck in an old, purely abstinent model. She explained that it would be more helpful to have a Harm Reduction model because relapsing is so much a part of addiction and the recovery process. Meredith rebutted, “so, can someone just be a little bit of addict? Is that really helpful?”
Harm Reduction (HR) is not about being a little bit of an addict. It is a common sense way of approaching a very complicated issue that does not have an easy and simple answer. Many people think that HR just lets people keep on using. This is a gross oversimplification. HR mostly has the same goal of abstinence but incorporates the reality of slips and relapses into its philosophy of treatment. It also incorporates the reality that some people take a while to fully reach abstinence so any amount of cutting back is seen as success. It’s not the end result desired for a chronic addict but it is progress. For those that just aren’t going to stop cold turkey, any other approach just exacerbates shame, moral judgment and self-hatred. These are not helpful to anyone who wants to change.
Let’s look at some analogies. Addiction is the only behavior problem that we expect people to stop before we will help them. It is the only behavior addiction that will cause a counsellor or a treatment centre to discharge someone or refuse treatment because they are still having “their problem.” Isn’t this ridiculous? How would you feel if you went to a counsellor for depression and he/she asked you to come back after you stopped whining about your sorrows, to come back after you were done being depressed – then they’ll help you with your depression? Or let’s look at weight loss. Weight loss programs or gyms do not tell you to leave and come back when you’ve lost weight. What would be the point of those programs? What is the point of a treatment center if they are discharging people for having the problem for which they are seeking help? There really does need to be a paradigm shift in addiction treatment. It is stuck in the stone ages and very unwilling to change or look at growth. This isn’t about anti-12 Step philosophy because I believe if one wants to, they can incorporate working the 12 Steps into an HR philosophy.
HR is really about applying common sense to the reality of how people change. It is evidenced based and shown to be important to meet someone where they are and move from there. People change when they feel they are accepted first. People change when they are ready and given the free choice to decide to do so. People change when they are given the resources and tools from the place they currently are. You cannot ask someone to change before they know how. People often move through stages of thinking about changing, deciding to change, and actually doing what is necessary to change. Working with those who have addictions is about walking next to them on that path and helping them see the right next choice. Ripping away their addiction, which to many is security, can cause way more problems that it can solve.
HR treatment sees substance use/abuse as a continuum and if you look at all the people you know and their relationship to substances, you will see the reality of this continuum (I will use the word “use” to mean the use of drugs/alcohol/gambling/sex/what have you). Some people use a little, some heavier on the weekends, some heavier once a month, some everyday, and some all day everyday – and many in between points. Further, many might fluctuate back and forth on this continuum of severity at different points in their lives.
Addiction is a process, not an event therefore, changing that process is about entering a new process. THAT is a process. Change is a process. It takes time and failure. It takes hard work and failure. Therefore, HR is about honoring this process realistically and helping people reach their goal of eventual abstinence. See, those who get quite angry at the type of HR that would help people to control their drinking, feel this way when they think of chronic addicts. But not everyone who uses and abuses substances is a chronic addict. Some people do move on to a more healthy use of whatever it was they were abusing. Others, like chronic addicts, need to eventually be abstinent. HR is about having a more comprehensive understanding and treatment for the use and abuse of substances (or any addiction for that matter). It is about understanding the entire continuum of human relationship to addictive behaviors and finding pragmatic and helpful ways for clients to no longer be oppressed by their urges, cravings, use, or abuse of addiction.
Harm Reduction says you cannot help someone if they are dead so intervene and help wherever/whenever you can. Obviously some people don’t want help but they might later, even sooner, if they feel accepted and know where to go to get help. If they want help but feel they have to be ready to give it all up in one second, discouragement at that idea becomes too much for some and they keep on using. It actually amazes me that people with chronic addictions can actually dig themselves out (although many don’t) and get help with the kind of rejection they feel socially and the lack of support for the reality of changing addictive behaviors. We don’t expect that of anyone else in our society who is trying to change. Again, this needs to change. The good news: it is. The bad news: very, very slowly.
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