Total Abstinence or Harm Reduction. Which approach is right for me?

When working with clients, one of the most common questions I receive is, “do I have to give up using it completely?”

When starting to work with a client, it is crucial to identify the actual relationship that the client has with a particular substance or addictive “process” behavior. Addiction to substances can range from alcohol, cocaine, heroin, benzodiazepines, and even caffeine. Process addictions can include addictions to gambling, video games, internet, pornography, and sex. As with any relationship, there are ebbs and flows that can occur and addiction is no different. One of the most prevalent ebbs and flows that occur in addiction is the euphoria that one can feel when using but then the shame and regret that occurs when the “high” ends quickly follows.

Therefore, it is important to identify what use of a substance or process actually means for you and this could be something that is deep rooted in the past, a current struggle in the present, or a concern about the future. Continued use equates to escape from something, someone, or a particular life circumstance that is simply too painful in the moment to deal with without resorting to something to “temporarily fix it.”

When reflecting on the relationship that you have with your addiction, it is important to reflect on how the use has affected you and if it is problematic for you. For example, if you are struggling with pornography use and are finding that it is causing difficulties with your intimate relationships, then you may very well discover that its use is no longer sustainable. Another example would be if you occasionally find that you drink too much in certain settings or situations, you may want to ultimately curb your alcohol use, and this is something that you can define with the help of a therapist and through remaining accountable.

Therefore, the answer to this crucial question that comes up when a client starts therapy with me is that, “it depends” and depends on the consequences that a client has experienced because of their use. Consequences can range in severity and can include personal guilt and shame because of their use, depression, fear and anxiety over being caught, or even more severe examples of consequences where a client experiences legal involvement.

Importantly, both total abstinence or harm reduction approaches do in fact work and one is not necessarily better than the other, and would all depend on the individual goals that you have so that your relationship with that substance or process is healthy. Let’s explore further what total abstinence and harm reduction looks like.

Examples of Total Abstinence

Total abstinence involves stopping the use of a particular substance or process completely. In the case of substance use, it is important that you explore reduction with the help of a qualified health professional, such as a medical doctor or psychotherapist (i.e., mental health counselor, licensed social worker, psychologist, psychiatrist, or psychiatric nurse practitioner). For example, if you drink heavily or use intravenous drugs, you should seek out the assistance of a health professional that can appropriately reduce use safely and provide supportive medication (medication-assisted treatment) so that you can withdraw without complications. Additionally, you should begin to seek out therapy to help to explore the origins of your use and how that use has impacted you.

In the case of process addictions, this would look a lot more different. Support from a qualified health professional, such as a mental health counselor or social worker, would include engaging in therapy and working towards exploring the origins of your use and how this particular process has been impactful in your life.

With process addictions, the focus from the beginning is on the particular addictive behavior involved because it is the behavior that is leading to experiencing that “rush” of dopamine and other neurotransmitters that are contributing to that pleasant feeling you experience before, during, and after use. Before, because of the anticipation of use. During, because of that “rush” that occurs during the flooding of your brain with neurotransmitters, and after, because of the euphoria that remains and eventually ends.

Examples of Harm Reduction

Harm reduction is based on the idea that instead of living without a particular substance or process addiction, it is best to work towards moderating its use. Harm reduction can be an attractive option for clients looking to better regulate their use and where reduction of use is not always feasible or desired at the current time. Therefore, it goes back to the relationship that you have with a particular substance or process and how is it affecting you in your day-to-day living?

Harm reduction can be utilized in various ways in which a record of use is kept whether by hand or through the use of apps that are readily available for download. Some examples would include Party Safe, Brave and many others. However, logging use is not the only way that harm reduction can be approached.

An alternative approach within the harm reduction model would include the use of an alternative or less harmful substance. For example, a client who is struggling with a heroin addiction would be able to use a substance, such as marijuana, as an alternative to heroin use. The logic behind this is that a less harmful substance would provide for the client a means to be able to experience the euphoria of being high but without the possibility of overdosing. This approach, while well intentioned does come with risks which would include the possibility of the substance being laced with another substance, such as Fentanyl, which can be fatal. Therefore, an approach such as this is best utilized under the guidance of a medical doctor or addictions team, to reduce the likelihood that you will experience an adverse event resulting from suddenly stopping use.

With process addictions, harm reduction would look differently and can include approaches such as limiting use to certain hours of the day or even providing condoms for protection, as would be the case with some with a sex addiction. Ultimately it comes down to the relationship that you have with the particular substance or process and how it is affecting your life. If you are feeling a stirring within yourself that I need to stop completely to get everything back under control then a harm reduction model would not be right for you. However, if you feel that reduction is possible then a harm reduction approach is worth exploring. Importantly, is that this approach be explored through the help of a qualified health professional, such as a mental health counselor or social worker, who can help guide you through the process and help explore the underlying factors that have led to use.

The Abstinence Approach

This approach views addiction from a disease model and believes that it is important to completely stop using. The approach has worked for millions throughout the world and is one of the easiest to implement because of the lack of “gray areas.” In short, you stop using completely and ideally would receive assistance through the help of a qualified health professional in combination with receiving support through fellowship meetings such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Sex Addicts Anonymous (SAA), Porn Addicts Anonymous (PAA), and Gamblers Anonymous (GA). Links to these resources are provided at the end of this blog post.

Therapy for Addictions

For both substance and process addictions, various therapeutic approaches are available to help in the identification of a particular negative addiction pattern and working to change those patterns. For example, cognitive-behavioral therapy (CBT) is a very common and popular approach that is used to help a client to recognize certain behavioral patterns and work towards changing them. For example, a client could use an approach such as “putting your thoughts on trial” which helps to examine the supporting evidence for use and how this use has either negatively or positively impacted your life.

Another commonly used approach is called rational-emotive behavioral therapy (REBT) which helps to change the actual behavior itself and in recognizing exactly what is causing you to feel “triggered” to use. In this approach the “ABC model” is heavily used which helps to link the connection between what activates you to use, the behavior that occurs, and the consequences as a result of use. This will allow you to see the connection and to decide for yourself if a harm reduction approach or an abstinence approach is best for you.

Important to note is that for total abstinence or harm reduction to be effective, psychotherapy should be an important component because therapy will help you to identify particular patterns that you may engage in and work towards changing those patterns. Therapy will also help you in resolving any resistance to change that may be leading you to still engage in the same patterns over and over again.

How about support groups only?

Support groups can be broken down into groups that are fellowship based or therapy based. Therapy based support groups have been shown to be an effective tool in helping clients to establish an identification with others which can lead to a reduction in use. However, group therapy for addictions does have its limitations. One major limitation is that support groups are not therapy and so a deeper exploration into the origins of use may not occur. Additionally, many contributing factors that lead to use such as deep-rooted trauma, depression, and anxiety will be difficult to explore in a fellowship group. However, please do not interpret my message negatively! Fellowship groups do work and attendance at them is something that I strongly encourage to all my clients who are working within an abstinence model, but it is important to be transparent and point out some limitations.

Therapy based group therapy on the other hand is run by a qualified health professional who guides the topics and maintains control of the meeting. In many settings a set curriculum is used to help guide the group members through the process itself and to help each member fully gain an understanding as to why their addiction manifested in the way that it did and what they should do to address it.

In short, we return back to the original message of the relationship with a particular substance or process of choice and how it is affecting your life today?

Should I choose Harm Reduction or Abstinence?

You have an important decision to make but you do not need to make it on your own. In helping clients discover how they can go about deciding for themselves which route of treatment they should pursue, we work together to identify the positive and negative aspects of using a particular substance or process, and discuss what they feel may be right for them. As a therapist, I also will provide the client with feedback on the spot to assist them. This can only occur within the therapeutic setting which is the most appropriate place for exploration of use and in working towards living the life that you envision for yourself.

Resources

Alcoholics Anonymous: https://www.aa.org/

Narcotics Anonymous: https://na.org/

Gamblers Anonymous: https://www.gamblersanonymous.org/ga/

Sex Addicts Anonymous: https://saa-recovery.org/meetings/

Porn Addicts Anonymous: https://pornaddictsanonymous.org/