Mid-week Musings – “The Harm of Harm Reduction”

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4 thoughts on “Mid-week Musings – “The Harm of Harm Reduction”

  1. First I read the article followed by the title of your blog and I’m in conflict. Is this satire or commentary? Should I even respond?

    Firmly believing that my “A Dog’s Breakfast of Social Justice and Politics” isn’t any more clear, I’ll I respond to what I assume is your commentary.

    We have very different understandings of harm reduction (HR) and its implementation.

    The implementation of HR strategies in Canada didn’t necessitate the closing of non-medical detoxes. They have always been in short supply, with long-waiting lists, and the resistant emergence of HR alongside these closures seems to be more a sign of neoliberalism than a diversion of funding to HR. HR, for example, is largely accepted in urban centers and is almost completely absent in rural areas. The closure of rural facilities have not not provided an increase of HR programs, and the relative stability of these non-medical facilities have been marked by programmatic match in urban centers with an increase of HR. How can you justify these differences?

    Harm reduction counselors also use motivational interviewing (MI) as a technique so drug users reflect on their actions and make decisions to their benefit. You see the elimination of this technique where I see its proliferation. But I am weary of MI on other grounds. Primarily that MI has a goal to alter behavior the therapist wants to achieve, but they do so in a way that makes the drug users come to the decision the therapist wants. This strategy, in my view, undermines one of the main principles of user autonomy in HR. HR models, at least theoretically, acknowledge that drug users are wholly capable of making their own decisions without the help of experts. Rather “experts” are there to provide help if help is solicited by the drug user.

    Your understanding of AA, NA and 12 Step programs – and we can add abstinent-based treatment to the mix – is fairly standard. The success of any program is dependent on the motives of the drug user. If they want to stop using drugs they will, but this can be very hard to do. Many people have to go through treatment many times before they succeed. And these kinds of abstinent-based programs have a high failure rate. It’s cult-like to suggest the drug is more powerful than the person. And this spiritual form of recovery – though i admit it works for some folks – confirms that addiction is a disease of the will and not the body.

    I think you overstate the degree to which counselors want to be that unconditional friend because they have issues with power and control. In fact, I think it’s the opposite. If a counselor doesn’t judge a person for their actions, they become more open and honest. Counselors who demand certain changes – changes that are hard to achieve – encourage dishonesty to breed for feeling guilty for failing to live up to expectations.

    HR counseling says I’ll be here to talk whenever, if ever, you want to talk. Abstinent-based counseling says that if you don’t work your program you fail.

    To this extent abstinent-based counseling and NA say “if you fail you have to start from scratch”. HR models, on the other hand, say: “people screw up. maybe you’ll get it right the next time. The former stigmatizes drug users if the fail to live up to expectations, and the latter says: “don’t feel guilty because this is a process. Maybe you’ll achieve your goals the next time around”.

    Another infrequently evaluated impact of AA and NA is that the success of the program makes false equivalencies by saying things like: “Once your an addict you are always an addict as if it was a verifiable disease. Ex-users are always in the process of recovery, yet they can never recover”. A HR model might say: “You know what works for you and doesn’t. It might not be wise to go back and using X or drinking alcohol because it might lower your inhibitions”. The former is a directive while the latter regards an autonomous choice..

    Finally, and again I acknowledge that they work for some folks, the success of NA and AA depends on helping people formal how much they despise who they were last week when they were using. A sound strategy to be sure, but such things have consequences, such as intensifying the stigma of that person they were last week. A stigma that fuels the use of drugs.

    In general I am sympathetic, but critical, to HR. But i also recognize that it, too, is part of a neoliberal strategy that makes individuals responsible for mitigating harmful behaviors rather than asking experts to come up with solutions.


    • Thank you for your comments.

      However I will stick to what I said.

      And no it was not satire.

      As the government of Ontario was in the process of “medicalizing” addiction treatment under the guise of harm reduction, I was confronted by a researcher from what was then The Addiction Research Foundation. He asked why abstinence treatment and harm reduction/medicalized treatment couldn’t coexist.

      My response was that there was not an inexhaustible fund of money and the government wouldn’t fund competing programs. Neither would the proponents of harm reduction allow the legitimacy of abstinence-based programs. We were unsympathetic dinosaurs lacking in professionalism and compassion.

      And so the programs in effect ceased to be..

      A couple of years ago, HR/medicalization proponents in B.C. and in Ontario mused that maybe non-medical detoxing might be worth a shot. Duh? They didn’t act on those passing thoughts.

      It’s interesting how little people know about Twelve Step programs and how they actually operate before dismissing them as cults who reject and stigmatize the non-believer, They accepted the notion of relapse way before the professionals latched on to it. Their motto is keeping coming back, it works when you work it. They are in effect glowing examples of both narrative therapy and solution-focused counselling without even knowing it.

      And the stuff I said about the counsellors stands.

      What I would allow is that there are Harm Reduction techniques that can be effective as long as you are not actively offering to get drugs and drug paraphernalia for people.

      But then that’s just what people in recovery taught me.


  2. And I thank you for a speedy reply!

    My overall interest of drugs and their treatments is gleaned from observing the extent to which the theory of abstinent-based or harm reduction programs translate into actual practice. What are the logics of operation in these programs? How is the problem of drugs understood by each camp?

    It is definitely most accurate to say I am critical, yet sympathetic, to the aims of HR, including enabling the user to access drugs – a decision that might occur on a personal relationship level (like parents for example) but not carte blanche without boundaries, or paraphernalia – distributed on a professional level through programs.

    That said, I recognize that some HR programs have a tendency to replicate paternalisms they profess they are intent on dismissing. I also recognize that abstinent-based programs do work for some people, but am mindful of the ways they contribute to the production of stigma of persons who still use. To this end, I’m not categorically dismissing anything by saying: ‘We should be mindful of how these programs operate and be mindful of their their effects’.

    What is interesting is the way personal experience is invoked in your closing line, and using “just” as a smug way to say you know and speak the Truth because of your relationship to people in recovery. This sounds like a wholesale dismissal.

    It remains unclear if your relationship to “persons in recovery” refers to your recovery and people you know in recovery, your position as a counselor working with people in recovery or some other reason, but the dismissal operates in the same way.

    I, too, could claim this Truth through claiming I speak through this experience, whether those are my personal experiences with recovery/NA, personal experiences with friends in recovery/NA or drug counselors, professional experiences people in NA/recovery and drug counselors, policy makers, politicians, nurses, doctors, active drug users and the list goes on. But dismissiveness isn’t conducive to conversation.

    I submit that I am new to blogging and haven’t even created a post. When I manage to get some up, I’ll be thankful if even one person reads them and filled with excitement if they respond. I hope to have expressions of agreement and dissent. I also submit that I don’t know everything and it’s really gratifying learning new things or having someone change your mind.

    Nonetheless, I appreciate you taking the time to impart your knowledge on the subject.


    • Welcome to the Blogosphere.

      And yes, keep posting.

      That’s how you develop your “voice”, your unique style of presenting your thoughts.

      While I try to keep it civil, progressive and inviting in my posts, you can see that the direction that addiction services has been going bothers me to no end.

      It’s not my life that they are messing with.

      However, I realize that my focus needs to be on providing help to people who want and benefit from my sharing what I have learned.

      Happy posting.


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