Monday, February 2, 2009

Harm Reduction Part 2: How do we Define Success?

The dominant addiction paradigm makes some very strong assumptions about the nature of addiction. It assumes a one size fits all approach, stating categorically that the only measure of successful treatment is complete abstinence from psychoactive drugs. And it assumes that the best method for achieving abstinence is a confrontational model that forces the addict to accept that they are powerless to deal with their addiction. That only through dependence on a higher power, can their addiction be brought under control. This is the basis for the twelve step program for treatment of addictions.

What is truly remarkable about this paradigm, is that it encompasses over ninety percent of addiction treatment in the United States today. It is a multi-billion dollar industry and firmly entrenched in our educational system. Go to med school and you're quite likely to be taught that this is pretty much the end all of addiction treatment. Public policy is based firmly on these ideas. This is remarkable to me, because not only is there no evidence to support this confront/depend on higher power paradigm, there is a lot of evidence that it simply doesn't work for the vast majority of people. Because of the lack of reporting on the part of most twelve step programs, it's hard to come up with very definitive figures, but the estimates range anywheres from a five to thirty percent success rate. Most science based research tends to assume the low end of the spectrum.

This is absolutely insane. At the high end estimates, this means we are failing seventy percent of the addicts who seek treatment. And yet this is the treatment paradigm that we allow to dominate our society and public policy. Don't get me wrong, I don't believe there's some vast conspiracy out there, propping up a failed system for profit. There's very little profit to be had in all this. At it's heart, I think it has to do with the Us/Them dichotomy that makes non-addicts, and especially addicts who haven't accepted what they are, feel better at night. This dichotomy is also very conducive to reinforcing addicts who are sober, because they've beat tremendous odds and manage to stay clean. This makes it really easy to just say; "Screw the other seventy to ninety-five percent."

"They're weak." "They just don't really want it." "They just haven't hit bottom yet." And underlying it all; "I'm better than them." Which isn't to say there isn't a lot of "we failed them," intermixed in all that. But which is more likely to keep this failed system propped up, "I'm better than them," or "we're failing them?"

At the core of this are some important questions to be asked. The same sort of stark, realistic assessments, very much like the self assessments that are an integral part of any addicts quest for control over their own lives. For this post, I am going to focus on one of them; How should we define success in one's battle with addiction? To try to answer this, I am going to ask you to try for a moment to ignore that nagging voice in the back of your mind that insists that success can only be defined as abstinence. Please, just try to pretend you've never heard of AA and other twelve step programs. Open your mind to the understanding that black and white is a flawed, simplistic dichotomy - that life exists in the shades of gray.

Meet Steve. Steve is an alcoholic who drinks from the time he gets out of bed, until he passes out, later in the day. Catch Steve in a rare moment of lucidity and you'll discover that the man is absolutely brilliant, rife with penetrating insight into human nature and it's interplay with the people around him. Steve first got high when he was eight years old. His drinking was out of control by the time he was thirteen years old. Not surprisingly, he never graduated high school, though he did manage a GED. He managed to stay sober in the Marines, at least when he was on duty. Steve spent several years in LA as a gangster, existing in a very ugly frame of reference. When I met him, he had left LA to get away from it all - but the memories of what he had seen, the things that he's done, drove him into the absolute depths of alcohol abuse.

Now meet Allen. Allen is an alcoholic who drinks in the evenings. Allen has, over the years, built a great business. He's also raised one of the very least dysfunctional families I've ever met. He has four fantastic kids, who absolutely adore their parents and who all have the foundation for great success in life. Allen has wonderful friends and is a very well respected, highly regarded member of his community. Not that he or his business are perfect, but his failings are the human failings that everyone can fall victim to, rather than being the result of his drinking. And make no mistake, Allen can drink. He proves that nearly every day of his life. As often as not, he proves it by getting fairly drunk. And it is quite likely that ultimately, Allen's drinking is going to foreshorten his life, though probably by very little.

So lets explore these two people, both men addicted to alcohol, but with very different lives, very different relationships to their drug of choice. According to the dominant paradigm, the only measure by which either of them can be successful, is for them both to abstain from the use of alcohol and other psychoactive drugs. But I would argue that success is in the eye of the beholder, that rather than searching for absolutes, success is very much a relative concept.

If Allen stopped drinking altogether, stayed absolutely clean and sober, what benefit would he gain? Certainly, his health would be positively impacted, though I should be clear that his health is very reasonable for a man his age. As such, this can really be counted as a minor benefit. It won't improve his family life, which is already quite rich and fulfilling. It isn't going to do anything for business, which while less than perfect, is that way because of the economy, not because of Allen's substance abuse. It certainly wouldn't improve his social life, which is largely focused around his brewing of great beers and appreciation for the. To be sure, he does have more to his social life than these, but a lot of his social activities are centered on his appreciation of fine drink.

Ultimately, we need to take into account Allen's relationship with alcoholic beverages. Why he drinks, what he drinks and the circumstances in which he drinks. Allen is a beer hobbyist. He belongs to beer a couple of beer clubs and has even taken classes for judging beer. He and his wife both take part in these activities together. He's taught his son to brew beer, along with a number of friends. He doesn't drink alcoholic beverages that aren't pretty much top of the line. And he never seems to drink alone. For Allen to quit drinking altogether, would require a major shift in how he lives and how he interacts with his friends and family. Since his drinking causes minimal harm to himself and no harm to others, I would argue that there is simply no reason for him to change.

Now lets look more closely at Steve. At first glance, Steve seems to be the typical, at the bottom alcoholic. It would be easy to make the assumption that Steve simply must either quit drinking altogether, or die an alcoholic. Honestly, that may well be the reality of things. The question becomes; Is abstinence from any psychoactive drugs the only measure of success we can use on Steve? What if Steve quit the destructive drinking, but took up smoking pot in the evenings and on weekends? How about if Steve was able to get help from a therapist and get a handle on the problems that have pushed him to drink to such destructive excess and started drinking only in the evenings? Could it not be said that some level of success has been achieved, if Steve is able to functionally work and take care of his family - even if he isn't completely abstinent from alcohol?

While I think it is safe to assume that in Steve's case, abstinence is the underlying ideal, helping him reduce his drinking and become more functional can be considered a success. This is not to say that when he's reduced his drinking and become more functional, that the work is done. Steve has goals that will ultimately require he quit drinking altogether at some point. Taking the step of reducing the drinking would be huge for him and more importantly, his family. Being able to hold down a job and support his family would also make a major difference. But ultimately, Steve wants to be in a position to ensure that he never gets this bad again.

Steve runs into a few problems with our dominant paradigm. One, it requires that he get sober now, instead of letting him take steps to get there. With the exception of his stint in the Marines, Steve hasn't managed to get to sleep without alcohol in almost twenty seven years, since he was thirteen years old. And even in the Marines, it was tough for him to sleep without it. After busting ass all day in training and maneuvers, he was still having trouble with sleeping. And the haunting memories of being a gang banger are still there, even if he gets the drinking to settle into a more functional pattern. But if he can manage to reduce his drinking and work with his therapist to deal with the underlying issues that push the hard drinking, it is likely that he will get there in the end. The other problem that Steve faces in the current paradigm, is that he simply cannot contend with the notion of a higher power. He believes that either god doesn't exist, of if he does, hes "one evil motherfucker," as he put it to me.

It is really easy to stick with the status quo. It doesn't take any work to assume that people who use drugs are out of control and simply cannot get through it on there own. To paint addicts as powerless to deal with their addictions. It's also very easy to create an us/them dichotomy. To assume that "us" are somehow better people, even as we recognize that addiction is a disease and not necessarily the fault of the addict. We all have a mix of feelings about addiction and addicts that just make it really easy to denigrate substance abusers. From equating the worse of substance abuse behaviors, such as driving while intoxicated, or destroying one's family, with everyone who has substance use issues.

Harm reduction, on the other hand, is a good way to get past the black and white and embrace the gray areas. Because most addicts and people with substance use issues live in the gray. Simplistic dichotomies rarely apply. But even harm reduction isn't the end all that some would assume, or at least hope it would be. There is balance that must be struck and there needs to be a tacit understanding that while it fails most people, the current paradigm has it's place as well. In the next post, I will be exploring this, as well as the shortcomings that I see in the harm reduction approach to substance use and abuse. I will be trying to get back into this and posting links to various sources of information, but I am mostly using these posts to try to lay down the information I want to put into my paper. That way I will have all the information in front of me and ready to organize.

I am also thinking on discussing some of my other friends with substance abuse issues, from time to time. Having been a very voracious abuser of substances, I spent a lot of time around abusers of substances and there are several I want to write about. In every case, I am renaming the people involved and trying to change as many details as possible to protect their identities. I am more than happy to post stories with the actual name of the person and more pertinent details about their situations, but will only be doing so with their permission. The thing about harm reduction, as I mentioned in my last post on this topic, is that it is very natural for some people to engage in it. The problem is that the current paradigm assumes that if they don't abstain, they are just deluding themselves. More to go in; Harm Reduction Part 3: Where I Digress or Harm Reduction Falls Short


Neill Neill said...

A very thoughtful article!

You make the point very well that the us/them view just doesn't cut it. I work with men addicted to alcohol and drugs, and I work with the wives of alcoholics. I've seen the range.

I had a serious alcohol addiction at one time in my life. I was consuming the equivalent of about 18-20 oz of pure alcohol per day. I never got drunk. I quit because it was seriously affecting my health. So I don't drink and haven't for many years. Basically, I cannot drink.

Yet I know others who had serious problems who now take a drink or two with no problem.

I know others who have chosen to never deal with addiction, because they cannot abide the AA doctrine, but have bought into the myth that AA and the twelve-step program is the only way.

A man said to me, "I don't want to be in recovery the rest of my life." My response is, "Then don't. Do whatever you need to do to deal with your problem, possibly including getting help, and then get on with your life."

Even though I had a serious addicton to alcohol in the past, I am not "in recovery." Alcohol is not part of my identity.

Neill Neill

DuWayne Brayton said...

Hey Dr. Neill, thanks for stopping by. I hope you get a chance to look at some more of my blog, especially part one of this discussion. I will be posting the third part soon.

I have a fair amount of personal experience with substance abuse and decided that I would go to school for psychology and focus on addiction issues. If all goes well, I will finish school with a Phd in neuropsychology and go into addiction research, as well as clinical work.

I look forward to checking out your writings as well.

JLK said...

DuWayne, I have a mad, mad crush on you that just won't quit. ;)

Mid-afternoon confessions aside, my father is very much like Allen. He drinks every day. He's retired now, but when he was working he would come home at night and drink 3 or so vodka martinis on the rocks because without them, he couldn't sleep.

On the weekends, he'd drink beer in the afternoon, followed by a bloody mary while preparing dinner, then have his martinis before bed.

No one in my family has ever questioned whether my father is an alcoholic. We just accept that he is. My grandmother used to say that everyone on that side of the family had a strong genetic predisposition toward alcoholism, and that us kids should never drink because we'd "get addicted from the very first sip."

But I have only seen my father drunk ONCE in my entire life, and I was an adult. It was at his house, late at night, when he was up and having conversation with my husband and I. I had never seen him drunk prior to that, and haven't since.

He worked every day of his life from the time he was 16, always provided for his family. He was, in every sense of the phrase, a functioning alcoholic. I have never felt there was anything wrong with that. As you said about Allen, what would be the point of quitting drinking? Some health benefits, sure, maybe. But what else? Some extra money in his wallet?

A topic that I would love for you to discuss in your substance abuse posts is binge drinking. Where is the line between going out with your friends and "accidentally" getting trashed and being a so-called binge drinker? It seems to me to be an entirely different category of substance abuse that is not subject to the same motivations and treatments. But I would love to get your thoughts on it.

DuWayne Brayton said...


Between you and Juniper, my head isn't going to fit in the room much longer....

As far as binge drinking goes, I honestly haven't focused much on it. I will try to go there at some point, but I have a lot to get to first. I'll actually put a post up to explain exactly what I'm doing with the writing I'm doing about addiction now, but suffice to say that there is a very express purpose to the direction I'm going.

Although I am going to have to fill in between these posts some, because I'm getting credit for writing here and variety is important.