Harm reduction approaches to treatment are any strategies or methods that help a client or patient gain control over their drug or alcohol use in ways that reduce or mitigate potential harm in their lives. Controlled, social or recreational drinking approaches generally encourage patients to reduce the frequency of drug or alcohol use, the amount of use, the time someone is drinking or drugging and the strength of a substance. For example, a first attempt might be to limit drinking to weekends or to limit the amount of drinks to 4 or 5 over a long evening. That might seem like a lot to some, but it’s far better than drinking 18. Switching to beer from liquor is a harm reduction technique. Laying off the hard drugs and only drinking and smoking pot is a harm reduction technique. For many people, a harm reduction technique is the first step to the recognition that their behavior is having very real detrimental consequences.
A surprisingly small percentage of clients in our practice come with the expressed desire of stopping their drinking altogether. Most people seeking treatment for alcohol dependence, misuse, or abuse have experienced consequences due to their drinking and just want to minimize or stop those consequences but do not want to give up their drinking entirely. In essence, they want a harm reduction approach to their treatment.
For many drinkers, controlled drinking or moderate drinking is definitely an option but for a small portion of the population, approximately 5%, controlled drinking is nearly impossible. While many people believe “once an alcoholic, always an alcoholic,” some patients diagnosed with alcoholism can learn to control their drinking and become moderate or recreational drinkers again. However, if you have been diagnosed with an alcohol use disorder that is moderate or severe, most addiction psychologists, psychiatrists, physicians, social workers, and addiction counselors would clearly recommend abstinence. This is obviously a personal decision that should be made with careful consideration of the risks and benefits of drinking versus abstinence.
We recommend two basic procedures that may differ in numerous ways but have the same central premise. First we suggest you cut back your use of alcohol or drugs in whatever way you decide and then pay attention to what thoughts and feelings come up as a result. Alcohol serves to mediate feelings by numbing, suppressing, enhancing or changing them entirely, and when you reduce or stop your use feelings will come back. Keep a journal or talk to your friends, family, partner, or therapist about these thoughts and feelings, ask for feedback and sit with them. No one ever dies from feelings. The only way through them is through them. We have feelings for a reason and you may learn a lot about yourself from experiencing these heightened feelings.
The acronym “HALT” captures this. HALT stands for Hungry, Angry, Lonely, and Tired. This refers to the types of feelings people experience as they reduce their alcohol or drug use. We are reminded to “halt” or stop, and pay attention to what we need or want, whatever we are craving. We have to learn to cope with these feelings or risk relapse. If you are hungry, then eat. If you are angry, then vent, exercise, talk about your feelings, pound a pillow, or express your anger. If you are lonely, get with people or start the process of finding new friends and if all your friends drink then recognize that you may have gravitated towards people who drink over time because drinking has become very important to you. If you are tired, rest. Individuals with substance use disorders suffer from an inability to take care of themselves, and learning this new skill in recovery is essential.
Another basic approach to drug and alcohol counseling which we recommend and help people craft from a recreational or controlled drinking standpoint is to pick an amount of alcohol that you will not exceed and to stick with it. The National Institute on Alcohol Abuse and Alcoholism recommends in an excellent pamphlet here https://www.rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Is-your-drinking-pattern-risky/Whats-Low-Risk-Drinking.aspx – that “low-risk drinking,” for men is defined as consuming no more than four drinks per day and no more than 14 per week. For women, the number is no more than three per day and seven per week. We generally believe that this is generous. For example, a man can drink 4 beers while at a party on Friday or Saturday night, 3-4 during the football game on Sunday, 3-4 at bowling or poker night with the guys, and still have two or three drinks with his partner on another day during the week.
Another very helpful guideline would be to learn to “stop at the buzz.” For most people, 3 or 4 drinks make them feel tipsy or buzzed. Alcohol is a CNS depressant, yet the initial effects of alcohol in these amounts are more stimulating and euphoric feeling. Most individuals don’t get into serious trouble from these amounts, but since the initial effects feel good, many people continue to drink past these amounts. The problem is that it takes time for alcohol to be absorbed into the body, so people don’t realize how drunk they are, and in larger amounts alcohol has a dampening and depressing effect. The alcohol you drink today can make you feel depressed days and weeks later, and these small amounts can contribute to depressive-like symptoms over time.
To stick to the above drinking goals, there are other specific drinking techniques that you can use with the help of a therapist who specializes in drug and alcohol counseling and mental health. One small example would be avoiding hard alcohol and sticking to beer. Beer has lower ethanol content, and the carbonation fills you up, so it tends to take longer to drink. Switching from alcohol to nonalcoholic drinks and back can slow you down as well. Holding a drink with lime or lemon may deter others from thinking you are not drinking an alcoholic mixed drink, and they may be less likely to offer you another drink. Remember, you are more aware that you are not drinking your normal amount or that you have reduced your consumption, and others probably aren’t even thinking that you made any changes at all.
One technique we suggest to help you be honest with yourself is to take four coins (or as many coins as you are planning to have drinks that night) and place them in your back pocket. Each time you take a drink, move one of the coins into your other pocket. This may be more important if you are planning on drinking larger amounts of alcohol, and many of the people we work with start out reducing their drinks per setting with numbers more like from ten to five or six, for example, so counting drinks becomes essential. This way, when your coins run out, you can be sure not to exceed the previously determined limit. Remember you have set this limit and not anyone else. You are doing this to learn about yourself and determine if you might be happier in the long run. Stick to your predetermined limit and if you can’t then keep trying or you may have to lower your limit so that you are less buzzed or drunk and more likely to be thinking clearly and more able to stick to your limit. There is an acid test here which is that if you can’t control your use ultimately you may have to concede that you are alcoholic or have an alcohol use disorder.
One method which we use with some clients is to recommend one drink per hour as another way of controlling or moderating one’s use. Since alcohol leaves the bloodstream at about .02 blood alcohol content (BAC) per hour, this will most likely keep your BAC at a reasonably safe level. In using this technique, it is recommended that you discuss your upper limit with a licensed professional counselor or psychologist. It goes without saying that it’s important to pay attention to drink equivalents. A typical shot equals one five-ounce glass of wine, which equals one 12-ounce standard beer. If your favorite bartender is pouring your drinks and she knows you are a big tipper who likes to drink, you might need to have a brief conversation with her. Bartenders are used to these conversations, and they will not hold it against you. In fact, most bartenders will be very respectful and discreet and will keep an eye out for you thereafter. If your girlfriends are trying to get you drunk, that’s another story. Watch how much they pour. A Long Island Iced Tea counts for three drinks, not one!
We strongly recommend that you do not drink when you are experiencing strong emotions like sadness, anxiousness, loneliness worry or any negative feeling states. These are times when you should figure out healthy ways of coping. If you drink during these times, you are at high risk for using your drinking as a crutch. Furthermore, estimates of the numbers of individuals in treatment for substance use disorders suggest that between 50-85% of folks in treatment have some sort of mental illness in addition to their alcohol or drug problems. It is very common for the negative feelings to be both a symptom and a cause of drinking. Depressive and anxiety disorders are very treatable and should be screened for and addressed early on in your efforts to consider making changes.
After exploring these techniques with your therapist and determining your level of success, you should be able to assess whether you can be a controlled or social drinker. To the extent that you break any of the rules that you set up as an experiment and exceed these drinking limits with resulting consequences, then it is time to readjust and lower your upper drinking limits and decrease the frequency, quantity, intensity (alcohol content), or duration of your alcohol use. If you aren’t able to be successful then take some time to learn the research into percentages of normal people who have alcohol and substance use disorders. About five percent of the population can be diagnosed with a substance use disorder and the current belief is that it is mostly genetically and biologically determined. So it is not our fault. Be kind and compassionate with yourself if this is the case. If you were diagnosed with diabetes or asthma you would be disappointed but you wouldn’t beat yourself up and you wouldn’t fight it, deny it or lie about it. There is no shame in not being able to control one’s alcohol use. The more we learn the more we seem to believe that biology, genetics, heredity and evolution determine our fate.
Resources for controlled, recreational or moderate drinking include the following:
Center for Optimal Living NY – http://centerforoptimalliving.com/ Model practice for Harm Reduction in NY.
Practical Recovery CA – https://www.practicalrecovery.com/ – Model practice for Harm Reduction in CA.
Moderation Management http://www.moderation.org/ A not for profit lay person led web site with meetings, links to therapists and support for individuals seeking a harm reduction approach.