Introduction
This weeks lesson was centered around substance use and mental illness. It covered a brief history of mental illness, followed by a brief history of substance use. The remainder of the chapter was aimed at educating students on the defining characteristics, treatment settings, philosophy of treatment, and some current social issues related to SUD. I chose to give my interpretation of the philosophy of treatment. The text notes that there are two basic philosophies of treatment when addressing SUD: abstinence and harm reduction. I hope to explain each of these, based on the brief explanation provided by the textbook. I also intend to provide some explanation of the deeper nuance of each, based on further reading that I did.
Abstinence
Abstinence, in the case of SUD, is defined as complete restraint from accessing or using a substance. The text notes that some treatment programs champion this philosophy. An example that is presented is Alcoholics Anonymous, with the sobriety tokens that are synonymous with their program. Treatment programs and facilities the employ the philosophy of abstinence report relatively low success rates of 5.9% for females and 9% for males, according to the text.
Abstinence appears to be the most frequently utilized philosophy of treatment, at least in the United States. While skimming through online articles, I noticed that it is mentioned as the “gold standard” and the “most effective,” in terms of SUD treatment. From personal experience, I know that it can be very effective in ameliorating SUD symptoms, in the right setting; It has even proven itself effective for non-chemical addictions, like sex and codependency. But I also noticed a few articles that were critical of abstinence. Some articles noted that the time spent in active recovery was far longer for individuals being treated under the philosophy of abstinence. Another common criticism of abstinence is that it is too rigid to be effective for everyone. For instance, an individual experiencing SUD, may not recognize that they have an addiction and therefore might be extremely resistant to abstaining, as they do not feel that their substance use is out of control. Nevertheless, the years upon years of outcome data associated with abstinence proves its efficacy, though I would argue that it is not the best approach for everyone.
Harm Reduction
In the textbook, harm reduction is described as meeting a person “where they are at,” and working with them to reduce their substance use, rather than outright cease it. The philosophy of harm reduction requires a clinical worker to understand that drugs are part of society and that attacking or condemning a drug user, may not have the most positive results. Minimization of drug use and its effects is the focus, so that the symptoms can be addressed more easily.
Harm reduction seems to be a more gentle philosophical model of SUD treatment. One might even venture to say that it is the philosophy that better aligns with the values and ethics of a social worker. “All or nothing,” is rarely the approach that yields the best results, based on what I have learned in previous lessons and chapters. Harm reduction appears to have a strong focus on therapeutic rapport, based on what I have read. It is not, however, free from criticism. The most common criticism of the harm reduction model was that individuals being treated under the philosophy may become addicted to other substances. It is noted that as an individual reduces their intake of one substance, they may begin increasing use of another; The individual may even start using a substance that they would not have used otherwise. I found this to ring true in my personal life. As I began to stop drinking, I started using marijuana, something I had not used in ten years. Another common criticism was that individuals experiencing SUD may have trouble thinking clearly, and therefore may struggle to engage in other clinical services. This is extremely relevant, as many people experiencing SUD also experience a co-occurring mental illness, for which they may seek clinical services for. Much like the philosophical model of abstinence, harm reduction is an effective, yet imperfect, practice.
Conclusion
The philosophy of treatment section of the textbook was brief, and required some extra research to grasp completely. In the context of the rest of the chapter though, it was a good primer for its content. Something that I noticed in my extra reading, was that there appears to be a more recent push toward the harm reduction model. In some cases, there was even evidence provided that showed how the abstinence model may contribute to the perpetual institutionalization of people experiencing SUD. I will include links to some of the articles that I read below. To me, both of these are useful tools. I could see the abstinence model being more useful for short term substance users or for individuals in a residential setting. The harm reduction model seems that it might be more useful when working with a long term substance user in an out-patient setting, or someone who has a general distrust of people in the mental health and substance use fields. Both models have their function, it seems that clinical judgement and the needs of the individual, are the true deciding factors.
Further reading:
https://ophelia.com/blog/harm-reduction-guide
https://www.pyramid-healthcare.com/harm-reduction/
https://metaaddictiontreatment.com/why-abstinence-is-so-important-during-recovery/
“A Brief History of Vice: How Bad Behavior Built Civilization” By Robert Evans
*Images were taken from Ophelia.com and AA.org*
Alex Beaudouin
Hi Josh,
Thank you for your blog. The philosophy of drug abstinence is rooted in the belief that complete avoidance of all psychoactive substances is the most effective way to prevent the negative consequences associated with drug use, promoting the idea that individuals should refrain from using drugs altogether, regardless of their legality or perceived harm. I would go deeper to say that the philosophy of drug abstinence is grounded in several principles. Health and well-being by abstinence protect one’s physical and mental health, as well as preventing health risks and complications associated with substance abuse. Abstinence is considered a proactive approach to addiction, to eliminate the risk of developing drug use conditions. Self-control and personal responsibility through the encouragement for individuals to make conscious choices to avoid drugs and take ownership of their actions. I think it is essential to consider individual circumstances, personal goals, and available resources when making decisions about drug use.
Michelle Dunham
Very well said Josh! I agree with the Harm Reduction model myself, although abstinence does have its short term place as you said, such as in residential detox centers. I work at the VA in Mental Health, and the abstinence route is required prior to our inpatient rehab program. In fact, I would say the majority of Veterans come through our doors with one addiction or another, hence our onsite RRU (Rural Rehabilitation Unit) that runs 30-45 day programs with our Social Workers/Addiction Therapists and RN’s that can provide injections of buprenorphine for opioid/meth users.
The best part? Is that they are there. Asking for help. Sometimes over and over and over and over again. Round and around they go. Until they stop for help. And that is what we get to do as Social Workers. Be there when they get off that ride and be that someone to advocate for them until they are able to advocate for themselves.
Josh Fine
Thank you for your input Michelle. My GP is through the VA clinic in Fairbanks and I spend a bit of time there. They have never mentioned an inpatient program, is that available in Fairbanks? Just curious, I spend most of my work day connecting people to resources in town and I’m always looking to add one to my bag.
When you say the abstinence route is required, does that mean that clints need to provide a clean UA before they enter the program? If so, that is requirement that I have seen with many residential facilities, even the rescue mission. It frustrates me when a resource that is aimed at helping people has requirements that create barriers specifically for the people they are responsible for helping. That is why I feel advocating for clients is so important. Thank you for what you do, and again, thank you for your input.
Michelle Dunham
Sorry! I am working at the VA in Walla Walla, WA. The Jonathan M Wainwright Medical Center, which is also the same General from Fort Wainwright in Fairbanks, AK.
And yes, they need clean UA’s before they can take part in the inpatient program and are usually admitted post detox inpatient programs out in the community. We also have the Suboxone injections to curb withdrawals for some.
And yes, it can be frustrating, but I have to agree with the rescue missions requirements. Granted, there should be a difference in “clean” vs. walking in completely drunk or high creating potentially dangerous situations.
John Da Broi
Wow Josh your blog this week about abstinence from the use of drugs is very informative especially you going beyond the given information and finding more on this topic. OF course the most safe and useful method for drugs abuse if never having or giving yourself the option of using the drug have a solid surrounding and a positive community that supports you when it is needed so you don’t get the need to fulfill that empty void with something else that will only do damage to you.
Sharla Huckabey
Josh, thank you for the informative blog you shared this week. I have a lot of faith in the abstinence practice. I have a very close loved one who went to rehab for alcohol, where this practice was used. He has been alcohol-free ever since, so I am a firm believer in it. I also believe his drive to quit greatly affected his recovery.
I appreciate that you did some of your research to find more information for your blog.
Josh Fine
Hi Sharla, thank you for commenting. I am glad to hear that your loved one was able to benefit from rehabilitation. I also went to rehab for alcoholism, and abstinence was the law there as well. It was effective for me as well and I am now completely alcohol free. I will say, based on what I read, the harm reduction model boasts some very impressive numbers regarding recovery, as well. I feel that both definitely have their place in the world of substance use/abuse recovery.
Sammy Rivera Munoz
Thanks for your blog, Josh. I know people who have gone to rehabilitation due to different addictions and the abstinence method was used. I am not sure, but I believe this is the first time I have heard about the harm reduction model and I find it quite interesting. I know they are two totally different approaches, but I have a hard time thinking there could be a better approach to fighting any addiction than abstinence.
Neveah Reese
I love how this blog was easily understandable, yet packed full of information. I agree with you that both abstinence and harm reduction treatment can be successful depending on the person, the situation, and other defining factors. One way I have been thinking about harm reduction is in relation to dieting. Often times, it is not wise to partake in a strict diet that limits foods you like. This is because once you are off the diet, you are likely to binge on those foods and gain weight back quickly. In comparison, creating healthier habits with “bad” or unhealthy foods by having them in moderation will allow for pleasure and results. This idea is very similar to harm reduction and I can see how this option might be better for some individuals, such as those who have been dependent on substance for a long period of time.
Mel Maendel
Hi Josh
I liked the layout and information you provided. It was easy to follow and understand. I appreciate the extra research for the topic and how you included some critiques from different sources about this type of approach and how you included a new type of approach that is being used for people with substance use disorders. I believe that they are both effective but are to be used for different people who have different needs for their situation.
Robi Naranjo
Thanks for your blog! I came through treatment that was initially abstinence-based and did well for 9 months and kept relapsing every 9 months until I got on MAT. I was able to keep from going back from the streets and life and eventually got off MAT and have been clean for 5 1/2 years. From my own experience and what I’ve seen, some people are not ready for complete abstinence and/or keep relapsing, and MAT can change lives by keeping people from turning completely back to old life old friends old ways to maintain addiction, extremely dangerous prostitution, stealing, etc. but being part of some recovery program or outpatient while on MAT. At this point with so many people dying and overdosing its really needed to have different routes to recovery.
Jaelynn Anderson
I’ve seen harm reduction play out in TV shows and movies, but I’ve never seen it in action in real life. After some brief Google searching, it is so nice to see that there are not only abstinence-based practices here in Alaska but harm reduction as well. I know last week we talked about prevention programs (like DARE), but they aren’t working as much as we all would like to see. So, to invest money on the back end to harm reduction, I think we are moving into a better direction. However, when looking at it in the eye of a revolutionary social worker, how can we further improve these programs? What can we do on the macro level to make the road to recovery easier or the path to addiction even more unappealing? Side note: I am glad all of those in the comment section are doing better! It takes some serious hard work and integrity to do what you did!
Jillian Bowman
Hi Josh,
I really loved the way your blog was put together and how it read. I think the most long term solution is the best solution and that appears to be harm reduction. I know that as a child I would have given almost anything for my parents and brothers to be abstinent but perhaps anything that made it a little better would have been a life savor. I don’t think I have ever actually seen the harm reduction model in real life. The only recovering addicts I’ve encountered have been those who completely stay away from an substances.