Harm Reduction & 12-Step Recovery Natural Partners Sarz Maxwell MD sarzmaxmd @yahoo.com www. AnyPositiveChange.org
AA agrees with HR Progress not Perfection addiction is the only human condition, good or bad, in which we expect immediate, complete, and permanent perfection or it s no good!
AA agrees with HR Keep Coming Back, the quintessential phrase of AA, IS harm reduction. It does not state come back when you re really serious or you can come back after 90 days or any other nonsense
HR agrees with AA Ensure drug users have a voice in treatment; see that users have strengths as well as problem areas. AA: Each member uses the Steps in an individual way. The Steps are suggested as a program of recovery no AA member is forced to accept or even read them. It is up to the individual to decide when & how the Steps will be used. (from AA s Is There An Alcoholic in Your Life?, 1976.)
HR agrees with AA Calls for non-judgmental non-coercive services & resources for drug users. AA: There is no prescribed AA right way or wrong way. Each of us uses what is best for himself or herself without closing the door on other kinds of help we may find valuable at another time. And each of us tries to respect others rights to do things differently. Living Sober, 1975.
Treatment invades AA Minnesota Model Mandated AA Treatment Centers Hazelden et al Confrontational tx True Believers
When Treatment entered AA... AA became the only way to recover Abstinence became the only measure of recovery black or white, no middle ground Recovery became possible only with God Recovery came to mean that you were working the Steps of AA Use of medications was forbidden
AA / HR vs TT One day at a time only requirement is a desire Medication is between pt and doctor Progress not Perfection 30-day treatment plan wait till you hit bottom No meds, especially OST or benzos One strike, you re out
Self-Help vs TT Peer-based Reciprocal Supportive No fee Professionalbased Uni-directional Interventional Fee-based 12-Step Treatment is trying to make orange juice out of apples!
Sponsor vs Counselor Just Another Drunk Is chosen because his recovery looks desirable Has no power, no influence beyond strength of relationship May / may not be addict Is chosen because he s next up to get a new patient Has the power to change pt s life substantially
Tradition 1 No A.A. can compel another to do anything; nobody can be punished or expelled. Our Twelve Steps to recovery are suggestions; the Twelve Traditions which guarantee A.A.'s unity contain not a single "Don't." They repeatedly say "We ought..." but never "You must!"
Tradition 8 Alcoholics Anonymous should remain forever nonprofessional. We have discovered that at the point of professionalism, money and spirituality do not mix. Alcoholics simply will not listen to a paid twelfth-stepper.
More on AA and Treatment Bill Wilson testified at the first hearing of the Special Subcommittee on Alcoholism and Narcotics held in Washington, DC, July 30, 1969. He stated that AA should not be used as treatment when asked for his opinion.
HR Challenges Traditional Treatment Assumptions Abstinence-based All drug use is abnormal Drug users are deficient in knowledge and unmotivated Harm reduction-based Drug use is NORMAL. Drugs can be pleasurable and may have other benefits Denial -- Discomfort at inspecting one s behavior and its consequences is NORMAL
Neurochemical / Behavioral Schematic of Addiction Thoughts + = Cravings Feelings Cortex Limbic System >> Behaviors ALCOHOL COCAINE GABA HEROIN endorphins Dopamine Nucleus Accumbens Serotonin
Clinical Model of Thought Beliefs are based on empirical information New information leads to new beliefs Constant interplay of information & belief
Spiritual Model of Thought Beliefs are based on faith, and do not require empirical information Empirical information does not alter beliefs
Non-Medical Priorities Drug # deaths Tobacco 390,000 Alcohol 80,000 2 nd -hand smoke 50,000 Heroin 3,500 Cocaine 2,200 Aspirin 2,000 Marijuana 0 Source: NIDA research monographs
WHAT IS MI? A directive, client-centred approach for initiating behaviour change by helping clients to explore and resolve ambivalence. (Miller, 1996) am biv a lence (noun) 1. The coexistence of opposing attitudes or feelings, such as love and hate, toward a person, object, or idea. 2. Uncertainty or indecisiveness as to which course to follow.
MI is about: Being connected With self, others Personal responsibility Mindfulness Developing discrepancy Inner growth Ambivalence > changing > growing
AA practices MI This is by no means a comprehensive picture of the true alcoholic, as our behavior patterns vary. There is a Solution, p22, BB MI: individuality; no judgment
AA practices MI No one among us has been able to maintain anything like perfect adherence to these principles. We are not saints. The point is that we are willing to grow along spiritual lines. How it Works, p61, BB MI: Practice improves; it doesn t make perfect!
AA practices MI The point is, there is no prescribed AA right way or wrong way. Each of us uses what is best for himself or herself without closing the door on other kinds of help we may find valuable at another time. And each of us tries to respect others rights to do things differently. Living Sober, 1975. MI: Empathy, self-efficacy, individuality
AA practices MI We do not like to pronounce any individual as alcoholic, but you can quickly diagnose yourself. More About Alcoholism, p31, BB MI: labeling trap; evocation
Evocation People are generally better persuaded by the reasons which they themselves have discovered than by those which have come into the minds of others Pascal s Pansees, 17th Century I learn what I believe as I hear myself talk - Miller, 1995
Discrepancy & Ambivalence First step towards change is to become ambivalent Discrepancy makes use of it, amplifies it, increases it -- Until it overrides attachment to addictive behaviors vs Traditional Treatment model, where ambivalence is unmotivated, and discrepancy is denial
Motivation Change occurs within the client and doesn t rely upon external motivators or leverage Clients provide the arguments for change vs traditional treatment, where the counselor tells what to do
Dealing with Resistance Provide reflections Emphasis on personal control & responsibility Come alongside Shift Focus v.s. TT model of confrontation and abandonment
So what works? Peer interactions Evidence-based interventions Incremental improvement Flexibility Individualized approach Respect
What Works AA HR MM MI TT Respect + + + + - Individualized Approach + + + + - Peer Interactions + +/- - - - Evidence-based Interventions - +/- + + - Incremental Improvement + + + + -
New Things are often greeted with Suspicion