To Moderate or to Abstain? That is the Question!
By Tom Horvath, Ph.D., ABPP
Practical Recovery’s policy is not to give advice about whether to moderate or abstain. Unfortunately, this approach has sometimes been interpreted to mean that we “advocate” moderation. We neither advocate nor oppose any specific level of addictive activity, including cutting back (to something short of moderation) or focusing on safety without reducing quantity and/or frequency (e.g., “I won’t cut back my drinking, but I’ll stop drinking and driving”).
The term for this broad position, which follows the client’s lead on what changes to make, is harm reduction. Harm reduction has been a fiercely debated concept. However, as noted in last month’s article, harm reduction is identical to motivational interviewing in its focus on helping clients to identify their own goals. It is striking that motivational interviewing is so widely endorsed in the treatment industry but harm reduction is not.
To clarify another point, residents in Practical Recovery residential and sober living facilities are required to abstain throughout their residency, even when off property. As with other facilities, this requirement is enforced with drug testing and searches of rooms and possessions. We believe such facilities have an important place in the recovery continuum. Individuals unwilling to accept this requirement are welcome to use our outpatient services.
Rather than advising clients on their consumption goals, we focus on assisting them to make good decisions about these goals. We consider all such decisions as experiments to be observed over time. Furthermore, such decisions typically need to be made many times, not once. The decision may evolve over a long time. To look at someone only after unbroken abstinence has been achieved is to ignore all the back and forth that most likely occurred before that last stage.
How Could the Harm Reduction Approach Affect Addiction Treatment in the US?
We believe the US addiction treatment industry would improve substantially if all clients were greeted with a harm reduction perspective, as they are in many other countries. One way to manage assessment and treatment would be to separate them, with freestanding assessment facilities referring clients to treatment facilities suitable to their goals. Clients could check back with the assessment facility when their goals change. A somewhat similar system is emerging now, with some interventionists and organizations offering outcome monitoring for extended periods. However, these providers appear to be focused only on abstinence.
Are clients able to make good decisions about their own substance use? From the self-empowering perspective, yes! Even from the powerlessness, 12-step perspective, at least one decision is needed: to “become willing to turn it over” to a sponsor, the fellowship, and one’s Higher Power. For recovery to occur, there is no escaping decision making.
The powerlessness approach requires one big decision at the beginning (and many subsequent smaller decisions to support that initial decision). The self-empowering approach does not require one big initial decision but rather one or more smaller decisions that may be easier to make. For this reason the self-empowering approach is more likely to be attractive. It demands less at the beginning. We complain in the US that most people who might benefit from treatment will not seek it. If we did not insist on major change right away, more might show up.
The Role of Psychological Reactance
Regardless of whether you think clients are able to make decisions about their goals, the reality is they will make them. Furthermore, if you appear to be limiting choice, the client may focus more on fighting you than on making a decision and implementing it. The psychological term describing this tendency to fight is psychological reactance. Would it not be better for clients to focus on following through with a self-selected goal rather than fighting with you over a goal they don’t want?
One advantage of residential treatment for severe cases is that it leads to abstinence for a period of time and to better decision-making. Many clients will not attend (or do not have available to them) residential treatment, but even severely addicted individuals are capable of deciding to improve their lives. Again, the reality is that, except perhaps for brief periods of time, we cannot force them to change.
Helping the Client Decide
How do we help clients decide about their level of involvement with substances and activities? We encourage clients to consider the following factors, many of which they may not have considered sufficiently. These are the primary factors but, depending on client circumstances, not the only ones.
We aim to function as true experts, bringing experience to decisions that others are making perhaps for the first time. We do not make decisions for them. You want your doctor, financial advisor, and other professionals to be this kind of expert. The remainder of this article is an adaptation of Chapter 7 (“You have choices”) of Sex, Drugs, Gambling & Chocolate, first published in 1998.
1) What are you motivated to do? This factor is perhaps most important. “Where there is a will there is a way.” SMART goals have no definitive list of terms, but they are sometimes mistakenly listed as “specific, measurable, attainable, realistic and timed.” In that version, attainable and realistic are redundant. Instead the “a” could stand for agreeable. If you don’t agree with a goal, it is pointless to adopt it. To clarify, although SMART goals are sometimes discussed in SMART Recovery meetings (Self Management And Recovery Training, the mutual-help group), the two uses of the term SMART are otherwise unrelated.
2) How will your current circumstances support or hinder you? Can you change them to achieve better support? Do you need to limit your time with certain people, places, things, events, etc., to avoid them temporarily, or even to remove them from your life?
3) How confident are you in your capacity for self-control? Do you accept that craving is time-limited, won’t harm you, and won’t force you to use? Do you need to search your own history, or have exposure experiences now, to strengthen your belief that you are ultimately in control? Would a powerlessness approach be better for you?
4) If you decide to attempt reduced use or moderation, are you ready for the effort involved? Abstinence is straightforward, and generally easier. Moderation often requires planning, recordkeeping, and coping with cravings for a longer time. With abstinence, craving will die away or greatly diminish within weeks or months. Craving may persist much longer with moderation.
5) Is the substance or activity legal? If not, are you prepared for the legal risks? To clarify, Practical Recovery does not recommend engaging in illegal activity. If a client intends to use an illegal substance, we inquire about the potential consequences.
6) What does your past history suggest about what is likely to happen now? If you typically go on a binge each time you use, might a substantial period of abstinence be in order before attempting reduced use?
7) How much trouble might a significant slip or relapse cause? Is your health already at risk? Are your finances, emotional well-being, or other aspects of your life at significant risk?
8) What would people close to you prefer? Although the decision is yours, is a moderation decision worth damaging these relationships (if it would)? Is your partner on the verge of leaving you?
9) What about those with authority over you? Your probation officer, judge, boss, licensing board, etc., may have a clear requirement for you to abstain. Such a requirement does not prevent you from making your own decision. However, are you prepared for the possible consequences of not abstaining? If you intend to conceal your use, how realistic is this plan? To clarify, we would not help anyone plan how to avoid detection, but we might provide information about how such plans fare in our experience (generally not well). These clients typically understand that once out of scrutiny they are free to do what they want. Can they find the motivation to abstain and avoid problems for now?
In a self-empowering approach the discussion about these factors might extend over many sessions. For us the default position is abstinence, because it is generally easier and for most clients less risky. However, many clients have already decided what they want to do. Our job becomes helping them think through the decision carefully. Even for clients pursuing abstinence, discussions about how to approach social situations and how to think about the self-imposed limitation (“does it mean I’m really weak?”) are often needed.
Strikingly, in nearly 30 years of specializing in addiction, almost no one has asked me for advice on this issue. As with other parts of their lives, many people want to make their own decisions.
Horvath, A. T. Sex, drugs, gambling & chocolate: A workbook for overcoming addictions (2nd ed.). San Luis Obispo: Impact, 2004