Earlier this year, Jane decided she was drinking too much. She would have a couple of brandies at noon and up to three glasses of wine at night.
Her drinking wasn’t causing problems with her husband. But Jane, 69, was disappointed with herself and worried about her health.
Jane, who lives in the East Bay and asked that her real name not be used, was no stranger to drinking problems. A retired nurse, she once worked in a substance abuse unit for a Bay Area hospital. And she had gone to rehab and participated in Alcoholics Anonymous for six years when her drinking was even more out of control. But she didn’t want to take that route again.
For one thing, Jane didn’t want to stop drinking. “I like the wine — the taste and the effects,” she said.
She thought it would be difficult to locate a program that would support moderation; an estimated eight in 10 treatment programs in the United States follow a 12-step, abstinence-based model.
But then she learned about the Harm Reduction Therapy Center in Oakland, co-founded in 2000 by psychologist Patt Denning. The center offers an alternative — and, to some, controversial — approach by giving its clients the choice to keep using alcohol while they set small, but achievable, goals to moderate their use or quit.
“We make the threshold as low as possible so that people don’t have to step over a big hurdle to get into treatment,” Denning said. “You don’t even have to want to change. You just have to be willing to talk.”
When Jane began to see Denning, she set her own goal: to gradually cut back to two glasses of wine at night. She also worked with Denning and in group therapy on pinpointing her triggers and managing the anxiety that fueled her drinking.
“Harm reduction allows people to choose their own direction and supports that direction,” Jane said. “If you don’t meet those goals, then you talk about the issues that came up. A big portion of harm reduction is not beating yourself up.”
The harm reduction movement has its roots in the needle-exchange and safe-sex campaigns that emerged in the early years of the AIDS epidemic. Just as in those public health efforts, Denning and other therapists believe it is unrealistic to expect people to “just say no” to alcohol and other drugs if they are not ready.
Empirical data and qualitative reports have vouched for harm reduction’s effectiveness as an treatment approach, according to the 2006 article “Overview of Harm Reduction Treatment for Alcohol Programs” in the International Journal of Drug Policy, co-authored by the late harm reduction expert, University of Washington professor G. Alan Marlatt.
The concept has become less radical in national policy circles. The National Institute on Alcohol Abuse and Alcoholism views “alcohol abuse disorders” across a spectrum from mild to severe, discourages a “one-size-fits-all” approach to treatment and focuses on getting people to use alcohol in healthier ways, whether that means abstinence or moderation.
“Our position is a kind of a hybrid for the treatment of alcoholism,” said George Koob, director of the NIAAA. Abstinence is the healthiest option for people who are severely dependent, but if the most people can do is cut back, he said, “we’re happy to take anything that comes along.”
The NIAAA launched its Rethinking Drinking website in 2009 in response to national epidemiological studies showing that about only 8 percent of the 17 million Americans with drinking problems seek help. Their reasons? According to studies, they don’t want to quit, they don’t want to be labeled as alcoholics or they can’t abide by the faith-based principles of 12-step programs.
“The tendency to see everyone who has a drinking problem as an alcoholic stops people from seeking help,” said Keith Humphreys, a professor of psychiatry and behavioral medicine at Stanford’s School of Medicine.
Humphreys has studied A.A. and Moderation Management, a national organization that uses harm reduction techniques to help people cut back or quit. While he has written that 12-step programs offer quality intervention, abstinence shouldn’t be required for early treatment, even among severely troubled people, he said. The harm reduction concept of “meeting clients where they are” offers a more inviting option to those who haven’t yet become addicted.
“I’m on a college campus, and there can be a lot of binge drinking,” added Humphreys. “But in a couple of years, a lot of these students will have jobs and families and will cut back on drinking and change, with no treatment at all.”
Jim M., Moderation Management’s Sacramento-based executive director, used the online tools and social support on the group’s website to “form positive habits” for himself — such as delaying when he drank, measuring the quantities and making sure to keep his blood-alcohol levels to certain limits.
To critics, harm reduction sounds like a way to let drunks keep drinking. It certainly runs counter to the common idea of how people beat alcoholism. In this narrative, originating with A.A. in the 1930s, a person hits rock bottom and turns his life and will over to a higher power. A lifetime of abstinence — supplemented by meetings — is the only path to recovery.
“The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker,” A.A.’s “Big Book” says.
A supporter of the A.A. path is Terry Arnold, manager of assessment and clinical services at Alta Bates-Summit Medical Center’s MPI Chemical Dependency Services, who doubts someone can overcome an addiction while still using. MPI requires patients to be alcohol- and drug-free while in treatment: “Your judgment is clouded, and you don’t see the true picture because you’re under the influence or trying to figure out how to use. And how can you be honest if you’re still using?”
But Anne Fletcher, the author of “Sober for Good” and “Inside Rehab,” disputes the idea that people need to be clean to succeed in treatment. For one thing, doctors don’t stop treating people with diabetes or other chronic conditions if they don’t stick to their diets or take their medication. Fletcher now works at Minnesota Alternatives, a harm reduction center outside Minneapolis. She overcame a drinking problem more than 30 years ago by working with a therapist who let her choose to moderate. Fletcher ultimately decided to quit.
Denning notes that people start and continue drinking because it makes them feel better, at least temporarily. Harm reduction uses motivational interviewing, a form of counseling, to help clients gauge their fears about change, their reasons for drinking and the pros and cons of continuing to use. It considers any step forward a success and discourages self-recrimination because people do better when they feel confident, Denning said.
For some, those changes come in a few weeks. For others, it takes months or years. Denning recalled a client, a successful attorney, who first addressed his drinking problem by making sure he didn’t drive after a night out at bars with colleagues. “He wasn’t sure whether he had a drinking problem, but he was sure he had a drinking and driving problem,” she said. He stopped drinking and driving after two weeks, but it took him another year to cut back on his daily drinking.
Denning denies enabling addicts. “Unless I’m sitting here doing drugs with someone, I don’t have the power to either enable or stop them,” she said. “What I’m enabling is for a person to stay in treatment.”
In her sessions with Denning, Jane felt she could be honest about how and why she drinks: It reduced her depression and anxiety, as well as eased pain from a spinal fusion surgery several years ago.
“As I told Patt, after I have some wine in the evening, I feel like I can breathe,” she said. “It’s a definite relaxer and pain reducer.”
By early September, Jane was down to a beer in the middle of the day and two glasses of wine at night. “It’s the best it’s been in a long time,” she said, happily. Then, after a difficult visit with relatives in Connecticut later in the month, she returned home deciding to stop drinking. “It was easy to just stop,” she said in late September. She wonders if a new antidepressant suppressed her cravings.
She won’t beat herself up if she starts again, but would like to see how long she can live alcohol-free. In either case, she believes she is developing the problem-solving tools to address whatever the future holds.
