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The Silences of Our Work, Part III: Alternate Paths to Recovery

Updated: Aug 29, 2023

EDITOR’S NOTE: Today, Points brings you the third in a series of posts on silencing and substance use by Heather Sophia Lee, PhD, LCSW, an Assistant Professor of Family Medicine and Community Health at Rutgers’ Robert Wood Johnson Medical School. You can read the first installment here and the second installment here

For my dissertation, I conducted a qualitative study of two harm reduction programs. The purpose was to describe the experiences of participants in harm reduction programs given that “outcomes” of such programs were difficult to measure.

At that time evidence existed for the efficacy of harm reduction practices, like needle exchange programs, in reducing the spread of sexually transmitted diseases like HIV and hepatitis C. Less was known about the impact of harm reduction as a model for addiction treatment. Its broad focus made it unclear which “outcomes” were most important to measure. Coupled with political resistance, many agencies often avoided calling their work “harm reduction” to avoid scrutiny which might interfere with meeting the needs of their clients.

As a novice qualitative researcher, I was intuitively curious about how harm reduction was being integrated into twelve step recovery experiences. I was also interested in the extent to which one might be just as likely to come to abstinence through harm reduction as abstinence-only based treatment. Harm reduction and twelve step models were often cast as mutually exclusive, and I knew there was a deeper story to be known though I wasn’t yet sure what it was.

Asking harm reduction providers in the study to speak on how they viewed the relationship between twelve steps and harm reduction yielded some of the most interesting data. It resulted in a publication in Substance Use and Misuse, “Harm Reduction and 12 Steps: Complementary, Oppositional, or Something In-Between? ,” which can be read for greater detail.

For me, the major lesson in that part of the study was learning that many providers viewed harm reduction and twelve steps as entirely compatible. They argued that Alcoholics Anonymous in it its origin was harm reductionist as demonstrated in language such as “progress not perfection” and “everyone deserves a seat at the table.”

Some providers who spoke most eloquently about this relationship were those who also disclosed these experiences as part of their own recovery path. They also said the way abstinence-only policies are employed in some treatment centers is not what the original founders of AA would have intended.

I became more interested in this issue as I started to present my work at academic conferences. When I spoke about my work in harm reduction, there seemed to be an assumption that because I was talking about harm reduction I was also “anti-twelve step.” To speak about the potential benefits of harm reduction as a treatment model was by default condemning twelve step approaches.

My current writing focuses on how harm reduction providers conceptualize their work as centering around 1) a low-threshold service delivery model and 2) a compassionate attitudinal stance toward the client promoting “any positive change.” Another assumption about harm reduction is that the model means moderation or “cutting back” on one’s alcohol or other drug use. In reality, it promotes the approach which best meets the client’s needs through “any positive change”– including abstinence.

In the same ways that self-determination and traumatic experiences have been silenced in the clients with whom we work (as I’ve written about in my prior two posts), so have their nuanced approaches to recovery. The arbitrary divide between harm reduction and the twelve steps is something that limits our capacity to meet clients where they are. Our inclination to label, categorize, and “place” an individual is a barrier to our meeting them where they are. Giving space for diverse recovery narratives may help us to move past a “one-size-fits-all” approach, which fails to suit many but is ingrained in the American psyche.

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