First Do No Harm

By Kenneth Anderson 03/27/13

What can alcoholics do when AA doesn't work? And what can therapists do for these clients? A new harm-reduction program for alcoholism focuses on safety while supporting treatment goals.

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I have seen many people with alcoholism succeed with AA, including many colleagues who work in needle exchange programs. I have also seen many people whose drinking got worse while attending AA. I am one such person: During my time in AA, I nearly died of alcohol withdrawal. I created an alcohol harm reduction program to save my own life. I decided to share it with others, and in 2007, HAMS—Harm reduction, Abstinence from alcohol, Moderation and Support—was born.

Harm reduction is not a magic bullet to allow everyone to drink safely. HAMS is an option—a third way—for people who have been unable or unwilling to achieve either abstinence or moderation. We offer people a choice of goals—from safer drinking to reduced drinking to quitting altogether—and support for any positive change in drinking habits. For therapists seeking an alternative to AA and other programs for certain clients, we can be a valuable resource.

There is a common misconception that harm reduction and abstinence are two completely different, even opposite, paths. HAMS includes abstinence as a treatment option because anything that reduces or eliminates harm is beneficial. We don’t just pay lip service to abstinence, either—but we also don’t hold it up as the only or the ultimate goal. The ultimate goal is to encourage the natural recovery process, to decrease alcohol-related dangers, and to achieve health—or stay alive—to keep working toward that goal.

In the therapeutic relationship, a safe environment is essential in order for treatment to work. Safety is what harm reduction is all about. If someone is trying to quit but not succeeding, they should make it a priority to remain safe until they are ready and able to succeed. This may mean leaving an abstinence-only program like AA that is not working. It may also mean joining such a program if a goal of controlled drinking is not being met.

About one fourth of the people who come to HAMS choose to quit drinking entirely while still using the group as support for abstinence. Some also choose to get additional support from another abstinence-based group such as Self-Help Substance Abuse and Addiction Recovery (SMART) or Women for Sobriety (WFS). Others choose to leave HAMS and participate solely in an abstinence-focused group. However, for the many others who do not succeed at abstinence or moderation, harm reduction is the safety net to catch them when they fall. A drinking plan that eliminates, say, drinking and driving is better than no plan at all; a commonly repeated HAMS slogan is "better is better."

A frequently heard piece of folk wisdom holds that people with drug or alcohol dependence have to either abstain as a result of “hitting bottom” or else they will die. However, much recent research does not bear this out.

A 2009 landmark study of 43,000 US adults conducted by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) found that about half of all people who recovered from alcohol dependence did so by quitting completely and the other half by reducing their drinking. And research by William R. Miller, PhD, of the University of New Mexico Center on Alcoholism, Substance Abuse and Addictions, found that of the 70% of subjects whose alcohol dependence improved, 30% quit drinking completely; 18.5% became moderate drinkers; another 18.5% reduced drinking without achieving full moderation; 25% remained the same; and 5% got worse.

For daily drinkers even one day of abstinence can be a significant victory; likewise, practicing safe drinking by planning transportation before drinking. 

So, yes, abstinence is the road to recovery for many problem drinkers, but not everyone—and not even the majority. The rule is, different strokes for different folks.

Also, outcomes improve when you have a choice about which stroke. Research by Martha Sanchez-Craig, PhD, of the Addiction Research Foundation in Toronto, Canada, compared two groups of problem drinkers: those who were given a choice between abstinence and moderation, and those who were assigned abstinence alone as the goal. The result? The group that had a choice produced more successful abstainers than the abstinence-only group.

An alcohol harm reduction program is different from a moderate drinking program. Moderation programs are aimed at early-stage problem drinkers trying to achieve moderate drinking limits. Miller's research found that the more severe your alcohol dependence, the less likely you were to achieve moderation. However, severity was not correlated to either harm reduction or abstinence: those who were more severely dependent were no less likely to succeed at either goal than those whose dependence was less severe.

In its workings, HAMS is much like AA: a support group led by its members; no fee; open to anyone. We only have two in-person meetings: one in Brooklyn, New York, the other in Paducah, Kentucky. All other groups are online. Our email support group currently has over 1,000 members; we also offer daily real-time chats at 9 pm (EST). (HAMS is funded primarily through book sales. We also receive contributions from members and other individual donors as well as harm reduction psychotherapists and agencies. Our online advertising is funded through a Google Grant.) 

HAMS offers numerous evidence-based tools to help drinkers achieve their chosen recovery goal. These include a Cost/Benefit Analysis, Drink-Tracking Worksheets and Risk-Tracking Worksheets. HAMS members support one another in making small steps toward their goal. 

The straightforward Cost/Benefit Analysis, for example, is intended to help people think seriously about why they drink and what may be the best plan for reducing harm. The exercise is simple: on separate pieces of paper you list the pros and cons of both your drinking habits and the change you want to make. Research suggests that it is important for someone deciding about alcohol treatment to give equal attention to the costs and the benefits. Listing only the costs can relegate the benefits, particularly the personal needs that drinking seems to meet, to the unconscious, perhaps increasing the chance of relapse. Recognizing these needs brings them into awareness so that they can be dealt with. For example, if a person knows that they reach for that first drink in order to relax, they can attempt alternatives, such as exercise or yoga.

At HAMS most people with a harm reduction plan choose to pursue both safer and reduced drinking goals at the same time. We also offer tools for those who are choosing abstinence, whether permanently or for a set period of time, such as 30 days. These tools range from “drink refusal strategies” to “cognitive behavioral techniques” for dealing with cravings to “medical cannabis substitution therapy.” 

HAMS recognizes that for daily drinkers even one day of abstinence—or even one drink less per day—can be a significant victory; likewise, practicing safe drinking by planning transportation before drinking. Recognition for small successes can encourage you to build toward bigger ones. We have found that tearing people down for their failures and telling them that a single slip means that they have lost all their abstinence time can lead to despair and benders. 

But ultimately we measure success less in terms of days of abstinence or drinks consumed than in terms of overall happiness and life satisfaction, and the attendant reduction in negative consequences. Success comes when people feel that they are living better lives; when they eliminate threats of job loss, expulsion from school or divorce; and when they gain control of high-risk behavior such as drinking and driving. But it is up to each individual to define what a better life is and decide how much alcohol is too much. 

People who are working the 12-step program to their satisfaction presumably do not need an alternative like HAMS. But even when someone is not doing well in AA, we do not necessarily recommend that they start a controlled drinking program. As Miller’s study showed, people who had the least success controlling their drinking were those who had the most involvement with AA. If AA is not working, a harm reduction program like HAMS may offer an alternative path to what will work, including eventually returning to AA if abstinence is the right fit. Harm reduction can offer a new way of thinking seriously about their struggle with abstinence. Sometimes a change in thinking is enough.

Kenneth Anderson is the founder and CEO of The HAMS Harm Reduction Network and the author of How to Change Your Drinking: a Harm Reduction Guide to Alcohol.

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Kenneth Anderson is the founder and CEO of HAMS: Harm Reduction for Alcohol and the author of How to Change Your Drinking: A Harm Reduction Guide to Alcohol as well as the book series The Untold History of Addiction Treatment in the United States. He is a regular presenter at the National Harm Reduction Conference and holds a master's degree in addiction psychology from the New School for Social Research as well as a master's degree in linguistics from the University of Minnesota. You can find him on Linkedin and Twitter.