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As a therapist, I have worked with countless individuals who fall somewhere on the spectrum of having a serious substance addiction to those who engage in alcohol or drug abuse but who may not quite have hit “rock bottom.”

My experience in this field of work took me from spending a few years as a case manager in an in-patient substance abuse facility at the beginning of my career to later working as a therapist in an in-patient center treating substance abuse, mental health, and eating disorders. In recent years, I’ve also worked in individual therapy with clients who suffer from problematic drinking habits, have significant substance abuse histories, or who use other substances recreationally.

The history behind substance abuse treatment has, until recently, almost exclusively focused on getting people to commit to and practice abstinence and total sobriety. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have been go-to referrals for many people seeking help with sobriety and are considered prerequisites in any recovery treatment model. Unfortunately, there is one glaring problem with these models — they don’t work, at least not for everyone.


There are several reasons why the AA and NA models don’t work universally, without falling into the label of “treatment failure,” which is often used as a label that inadvertently blames addicts. Instead, we must recognize that there is a range of ways to measure improvement, and other ways to help people improve their lives and therefore weaken the grip of addiction. I’m talking here about what we call “harm reduction,” a growing movement in the field of substance abuse treatment that is giving more people hope for a future free from addiction. Before getting into Harm Reduction, let’s look at why AA and NA programs are not working for everyone.

What’s wrong with AA and NA?

It isn’t that AA and NA are terrible models for recovery, or that they haven’t helped many, many people achieve sobriety. I always tell my clients that if they find something that works for them, and if it is helping them achieve their goals, they should keep doing it. I have no qualms with people using AA or NA as a support and structure system that helps them gain freedom from alcohol or substance abuse. The problem is that they are not magic formulas that work for everyone, for a variety of reasons. Here are a few:

Powerlessness

The first “step” in the 12-step AA model is that you need to admit that you are powerless over alcohol or drugs, and that you are unable to stop using on your own. This is useful to some people, because it helps them get into the mindset that they do really need help. For others though, it feels too disempowering. Some people do want power over their addiction, rather than frame their situation in a way that gives the addiction or substance all the power. From the outset, telling people that they are powerless over certain substances gets them in a mental framework that says they are not capable of controlling their own choices and behaviors, which may not be helpful to all.

Total sobriety/failure model

Another part of the AA/NA model is the “chip” system. When you walk in to a 12-step program for the first time, you get a “chip” that serves to commemorate your sobriety journey. As you progress through the program, you collect more chips upon achieving markers such as 30-days sober, or a year sober. If you pick up a drink or use again, you’re back to day one, and typically expected to come into the group and pick up a 1-day chip, which basically announces to the group that you “relapsed.”

The reality of the total sobriety/failure model of accountability is that it may work with some people to stay on track with their goals, but for others is actually a humiliating exercise which they may feel points to them as being a failure. This feeling can ultimately cause people to avoid returning to the group at all, because they don’t want to be seen by their peer group as having failed at sobriety. A different approach is needed for this group of people, who don’t want one drink to mean that their previous efforts at sobriety cease to matter and they’re starting over at square one.

Ultimately, it is not our place to tell people what their goals should be. Some people just don’t want to be completely sober.

Another problem with this total sobriety model is that in all honesty, some people just don’t want total sobriety. They want to be able to enjoy a few beers at a barbecue, or be able to toast on New Year’s Eve with the recognition that they don’t need or want to be getting fully drunk in these scenarios.

There are also people who may have been on some really hard drugs from which they do want sobriety, but who want to be able to go out to dinner and consume a couple drinks without being labeled as an “addict.” AA and NA do not provide any framework for a person who wants this, and thus they leave out people who do what want to change their habits, but who may not want total sobriety.

The “higher power”

The 12-step model originated with Christianity as its structure for recognizing a higher power. Though it has since evolved to be more inclusive as to how exactly people interpret their higher power, it still requires members to submit to one, even if of their own choosing. Needless to say, this leaves out everyone who considers themselves to be agnostic or atheist.

Once again, we find the same conundrum that there is a part of this model that works for some people (particularly those who want their faith to be a major factor in their road to recovery) and which just doesn’t resonate for others. It also brings into question the idea of powerlessness. In turning your personal power over to a “higher power” who will presumably help you stay sober, there is little room for those who want to feel that they control their use. I have found that for this group, the concept of turning it all over to a higher power just doesn’t fit with their idea of being in control of their drinking or use.

There are other criticisms of the 12-step or AA model of recovery, but these are some of the main points I have found that turn people off from this program altogether. Luckily, the concept of harm reduction is gaining traction in the recovery industry, and is helping to provide more options for those people who either have found that AA or NA don’t work for them, or who are interested in pursuing another path.

What is harm reduction?

Harm reduction is the concept that people who abuse alcohol and drugs can reduce their overall use of substances without committing to total sobriety, can reduce the negative effects that substance abuse has on their lives and the people in their lives, and can lower the risky behaviors associated with their substance abuse, that ultimately cause them to experience more severe consequences of their use.

It is the concept that one solution does not fit every individual’s needs, and that someone who drinks or uses should have access to a variety of choices when they are seeking help. Harm reduction also includes advocating for policies that do not punish people for being addicted, but seeks to help them in finding what they need to have healthier lives without insisting that people conform to our expectations. Further, harm reduction posits that we should meet people where they are on the road to recovery and stop insisting that they commit to 100% sobriety before we give them any help.

Harm reduction can encourage people to make the following changes in their lives and habits:

  • If the person struggles with drinking and driving, Harm Reduction can get them to a place where they may still drink, but no longer get in the car to drive in that state, and can make the decision to get a ride home when needed.
  • If the person shares needles with others in order to get high, Harm Reduction can bring about the shift for them to still use, but only through the use of clean needles that they don’t share, limiting the worry of transferring disease or infection from dirty needles.
  • If the person drinks heavily on a regular basis and verbally or physically abuses others during blackouts, Harm Reduction can help set a limit on the number of drinks they have at a given time, eliminating the abusive behaviors associated with their drinking.
  • If the person uses high addiction-risk substances, such as cocaine, meth, or heroin, Harm Reduction can help limit that, so the person shifts to engaging solely in marijuana use, and therefore no longer experiencing the damaging physical and addictive effects of those harsher drugs.

As you can see, there are ways in which someone who struggles with substance abuse can reduce the harm and associated risks that addiction or dependency plays in their lives without requiring that the person be completely sober before seeing an improvement in their condition. Advocates of harm reduction recognize that we don’t have to require people to be 100-percent sober before we can call these minimizing efforts a success.

This is helpful because, ultimately, it is not our place to tell people what their goals should be. Some people just don’t want to be completely sober.

We need to redefine what recovery means, because it really doesn’t look the same for everyone.

As a clinician, I have always been trained to start where my clients are and to let them define their goals, rather than defining what I think their goals should be. Harm reduction fits into that concept as a best practice because whether I think someone should stop drinking/using is irrelevant if they themselves don’t want to stop. If they do want to reduce their drinking, however, or feel empowered to make better choices about their drinking and, or minimize the negative effects that drinking has on their life, then as a clinician I should support them however I can.

The 12-step model is more useful to those who really do want and need total sobriety, often because the behaviors surrounding their addiction may be dangerous and harmful to themselves and to others, and because their personal efforts at moderation have not worked after multiple attempts. In my belief, most inpatient treatment centers use a 12-step model because, for many people, once they have reached the point where they require in-patient treatment, those behaviors are pretty out of control and dangerous.

In the meantime, we need to redefine what recovery means, because it really doesn’t look the same for everyone. At this time, when I have clients that want to learn more about harm reduction and learn strategies that focus on that goal, I refer them to Smart Recovery, which focuses on abstinence without some of the trappings of AA mentioned above. They also have groups and online meetings which may be helpful to some people, depending on their location and/or comfort with the group setting. Individually, finding a therapist or provider that is familiar with the concepts of harm reduction can be an important step in the recovery process as well.