One of the most polarizing philosophical debates in addiction counseling is between abstinence and harm reduction. In general, Abstinence-focused addiction counseling believes that recovery only exists if the addictive substance is completely removed from the life of the individual it affects. The issue is seen as largely black or white: either you drink/use drugs and deal with the consequences, or you abstain and live a life in recovery. Harm Reduction-focused addiction counseling generally follows the belief that not everyone is in a place to completely abstain; and therefore, it is best to take steps to reduce the risks to the person and others when the individual chooses to partake in the addictive substance. The notion is that some people may not currently be willingly or able to completely give up the substance of their addiction.
Philosophy of Abstinence in Addiction Counseling
The definition of abstinence means refraining, or being free from, the unwanted behavior. Many people in the addiction world see abstinence as the only way to recovery based on the definition of addiction and the idea that the user has lost control. The abstinence model follows the science behind addiction. Science has shown that some people are genetically predisposed to addiction and are more likely to get hooked to substances or behaviors. It is estimated that 40%-60% of a persons predisposition to addiction is genetic. Evidence also shows that with continued use, alcohol and drugs can physiologically and neurologically alter the brain. The brain circuitry is forever altered, so if the individual starts using again, they will do so addictively.
This is the foundation for the disease concept and abstinence only philosophies. Someone who has become addicted to substances cannot undo the neurological and physiological alterations in a way that will allow them to use moderately in the future. For these people, abstinence is seen as the only way to regain control of ones life and effectively recover. Alcoholic Anonymous and other 12-step fellowships follow the abstinence-based approach. The only requirement may be a desire to stop drinking (or using) but the philosophy is rooted in this disease concept that the alcoholic has lost control over the substance and therefore treatment begins with sobriety. AA and other fellowships are actually behavioral and psychological modification processes, seeking to instill in the minds of those who attend that if they are addicted, they are powerless over alcohol and other drugs.
Due to the nature of addiction, alcoholics and addicts usually have intricate denial and rationalization systems to convince themselves they dont have a problem. These psychological defenses are worked on with the First Step: admitting that they are powerless over alcohol and other drugs. Cognitively, alcoholics and addicts need to retrain their minds that they are in fact powerless over alcohol and other drugs and therefore they cannot use them again. Successful sobriety via the 12-step philosophy occurs when an individual can take their unhealthy attachment to substances and redirect it to a healthy attachment to the program.
Philosophy of Harm Reduction in Addiction Counseling
The general focus of harm reduction is not whether an individual does or does not do a particular behavior, it is about reducing the potential problems associated with it. Substance use under the harm reduction approach is not black/white, either/or; it is the gray area in between. If a person chooses to drink or use drugs, the focus is on ways to reduce the risk from using. An important concept that some people and policy makers do not understand is that the harm reduction approach should not be seen as condoning risky or illegal behavior. Rather, it understands that risky behavior is inevitably going to occur, so it is more beneficial to curb the negative consequences incrementally as best as possible.
There are many types of harm reduction modalities including: drug replacement therapy such as methadone or buprenorphine (Suboxone), needle exchange programs, designated drivers, substituting less harmful drugs, testing illicit drugs for harmful additives and behavior modification to control intake. Because harm reduction philosophy and practice resides in the gray area of the continuum, research on the topic has been muddled, largely due to the lack of a consistent definition as to what harm reduction is and how it should be measured. This makes sense even if you only consider the expansive list provided above as types of harm reduction.
Some in addiction counseling use harm reduction as a way to motivate the client for change and incrementally work towards abstinence: a harm-reduction now, abstinence later approach to treatment. Others in addiction counseling implement the philosophy fully in its own capacity: the end goal is not abstinence.
Evolving Integration of Abstinence and Harm Reduction
The philosophies of each group may be separate. But in practice, the two philosophies are not as siloed as one might assume. There is an overlap between the two philosophies and they are merging closer together than many people are aware of. For people seeking help, total abstinence is an ideal goal but given their circumstances and motivation for change, that goal may be unreachable when they first seek help. Many abstinence-based facilities are moving away from kicking out a client after one positive urine screen, which was not always the case. Often the treatment team reassesses the situation and decides if the treatment plan is still appropriate and if the client is receiving the proper level of care. Similarly, abstinence-based facilities are also increasingly using or allowing pharmacotherapy as an adjunct to treatment. Many treatment facilities now work with clients who are on Suboxone, Vivitrol, Naltrexone, etc. In theory, allowing these medications is a harm-reduction approach to treatment, but in practice those modalities are becoming more acceptable across the board.
It is important to remember that the client and the clients specific needs comes first, not the ideologies of the treatment staff. There are no hard and fast rules that apply to all people trying to get sober and/or improve their lives. No client is a black or white case, it is essential to individualize treatment and recognize the unique characteristics of each client. The process should be a collaborative effort between the client and addiction counselor/treatment team. If we put the client first, then the philosophical debates fall to the background. The focus shifts to what is more important: being present and being an agent for change.
New Hope Recovery Center provides individualized treatment for all clients. We understand that each client is unique. If you or someone you love is struggling with an addiction to drugs or alcohol, you can reach us at 888-707-4673 (HOPE) or [email protected].
Written By: New Hope Recovery Center