An alternative to abstinence: Craving, care, and harm reduction

At the heart of the discussion about addiction and recovery lies a trilogy of questions: whether abstinence is necessary or even helpful, what “harm reduction” offers in its place, and what is the best way to deal with cravings. These questions are intertwined. In fact they merge into a single issue. Today I want to approach this issue from the perspective of part-selves, and look more closely at harm versus care.

You probably know the parts better than you think. My addict self comes out of nowhere and roars into life. She’s incredibly determined, so I end up giving in before I even know it. Twelve-steppers say she’s doing push-ups in the parking lot. That part seems so evidently not-self, and yet it obviously is a part of the self. Or: I give myself such shit the morning after. You’re just a fucking loser, addict, drunk. You don’t deserve sympathy. You don’t even deserve to be alive! Again, that voice comes at us, so it feels like not-self, yet it obviously is a part of the self as well. Who else could it be?

Those are “parts” we recognize most easily. But according to IFS, Internal Family Systems therapy, there can be many more parts to us. I wanted to be at an IFS workshop this week. I’d paid the fee, bought my ticket to Bristol, reserved an Airbnb, cleared my calendar. And then the coronavirus came along and dashed my plans, as it has obliterated plans, wishes, normalcy, for so many of us. So I won’t write about IFS today. I don’t understand it well enough yet. But I already practice a kind of psychotherapy that recognizes “parts” — so I feel an intuitive connection with this approach, and my reading on IFS continues to flesh it out. More on IFS later.

For now, here’s my take on the parts:

Clearly craving is the single biggest challenge to people who want to overcome their addiction. The recommended methods to deal with cravings are (1) urge surfing — watching the craving come, peak, and then dissipate, while maintaining a mindful objectivity, and (2) developing new thought patterns, usually with the help of others, that result in abstinence until the cravings subside over time (or, less optimally, “white-knuckling” until you can start to relax). If these work for you (or your friend, family member, client) then that’s just great. And sometimes, when the consequences of substance use are dire and immediate, abstinence may be the only sensible choice.

But abstinence has a huge drawback. It’s incredibly difficult! It can feel like turning your back on your best friend, on love and comfort, forever! It can feel like kissing goodbye to the one thing in your life you could control — changing how you feel. It can leave you staring into an existential void, facing an abyss of emptiness and meaninglessness. So, abstinence very often leads to “relapse.” We know this story well, and it provides a (false) rationale for defining addiction as a chronic disease.

Abstinence erects a steel fence around the part of us that wants and feels it needs to get high (or get full, in eating disorders). But what if we were to take that part and, instead of turning our back on it, telling it “No, never again!” what if we were to embrace that part, listen to it, and comfort it. What if, instead of banishing the needy part, we were to get to know it, maybe even get to love it, so that it doesn’t have to feel so walled off, shunned and hated.

The logic is simple: as long as we wall off this part of us, it not only continues to exist, it gets more desperate and determined. Now it has to weaponize and force its way through. In psychodynamic parlance, the more you suppress a powerful urge, the stronger (or more devious) it becomes.

So, instead of banishing that part, in IFS and other psychodynamically-oriented approaches (including ACT and my own cobbled-together approach), the idea is to listen to the craving and connect with it. Can there be value in this?

It’s such an outlandish idea in many people’s minds, that I’m not at all sure this approach gets tested very often. (Research on IFS is still in its early stages.) But I’ve seen it work with some of my clients. And obviously I’m still developing the relevant skills.

Little kids crave what they can’t have, and the cookie jar doesn’t lose its appeal by being placed out of reach. So we give the little kid something else to eat, maybe a piece of fruit or cheese (think methadone). And/or we create a bridge to the treasured outcome. We say, you can certainly have a cookie, in fact two cookies, when it’s dessert time. That’s after dinner, at 6:30. Do you think you can wait that long? Let me help you. Let’s get busy doing something else.

Connecting with cravings doesn’t mean you have to be stupid about it, run out of your apartment and score as much coke as you can snort. In fact, being smart about cravings is one way to hold and soothe the part-self that feels so needy.

But the benefit of accepting and embracing the needy part isn’t just scaffolding it and keeping it from tearing the house down. Its greatest benefit is the feeling of integration you foster in yourself. The craving part is young and wild, defiant, and very much alone. But it’s a part of you! Finding out where it comes from — in your growing up years, in your efforts to control troubling emotions, in your battles against depression and anxiety — allows it to relax and connect with the rest of you. This opens the door to self-acceptance and self-love, which often seem so elusive in addiction.

And when the need is no longer desperate and isolated, that’s when you can manage to count your drinks, call a friend, watch a movie instead, shift from whiskey to wine (my target these days — I’m down to one scotch and a glass of wine most nights) …and taper, gradually — develop a schedule of controlled use or stop entirely. Once you feel less fragmented, once the warring factions have laid down their arms, you might find that place much more accessible, and it’s a lot less likely to give way when life throws its next curve-ball…or its next virus.

To me, this is harm reduction. Specifically, a psychological approach to harm reduction that makes sense and feels right.

……………………..

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17 thoughts on “An alternative to abstinence: Craving, care, and harm reduction

  1. Dev March 30, 2020 at 5:25 am #

    desert is worse than dessert time.

    • Marc March 31, 2020 at 12:24 pm #

      Finally saw it!

  2. Annette March 30, 2020 at 5:38 am #

    I think all addiction is ultimately a craving for love, which if we didn’t receive the right kind (which is mostly unconditional and patient, isn’t it?) as kids, manifests as switching off the ‘scary’ feelings of understandable anger, helplessness and life feeling out of control.

    Throw in war, poverty, hunger, the West’s obsession with stuff and money and it’s the perfect breeding ground. My brother did well on harm reduction (methadone) when he lived with our mother = unconditional love. He fell apart after her death. He did well again on harm reduction when he met a wonderful man who was the caring dad we never had. And chocolate has replaced booze for me, along with helping others recover. Now down to 3 squares a night, from 2 bars, so progress!

    We all need and deserve love and comfort: it’s such a basic human instinct. Moderation can work if it’s done in a disciplined, ritualistic manner, as a small daily reward for tasks well done. That’s how my chocolate works for me, like your wine and whisky for you, Marc.

    • Marc March 30, 2020 at 5:52 am #

      The one thing these approaches have in common is their claim that addiction is a derailed search for the sense of being loved. This comes up all the time in ACT and IFS for example. But approaches that focus on “parts,” like IFS, see the craving self as a sort of subpersonality that grows over the years. This part-self can become increasingly isolated, embittered, and desperate, and THAT’S WHY its so difficult to accept it and make peace with it.

    • April June 18, 2020 at 2:07 pm #

      Great comment Annette! I too experienced love from family and friends as well as from a giant harm reduction community as a huge support for success!

  3. matt March 30, 2020 at 9:44 am #

    I hate the word “abstinence.” It doesn’t capture the dynamicity of the change process in intractable habit change. It’s a tight, occlusive, restrictive word along the lines of “constipation.” In addictive habit change we’re not just “stopping” a behavior. We are replacing it with a new rewarding behavior. It’s a simple idea that so easily gets lost in the shuffle of generic treatment programs. Helping guide a client to find purpose in their life, to replace the maladaptive reward. Not just stopping the unwanted behavior to re-engage, re-enter, reconcile there life

    • April March 30, 2020 at 3:24 pm #

      Hi Matt,

      I love the word abstinence because it isn’t “Sobriety.” Sobriety has so many moral connotations, many of them misogynist. I was taught in rehab (where women had a dress code requiring us to wear a bra at all times when outside our bedrooms, skirts no shorter than below the knee, and “If you’re wearing yoga pants, your shirt has to cover your butt!” in big letters on a sign. Men had almost no restrictions. My rehab taught us that emotional sobriety meant not having more than one sexual or even emotional/intellectual partner (with no sex involved) of the opposite sex. That was called an “emotional affair.” Women’s AA meetings I went to were full of slut-shaming. I wrote an article about it here: https://www.recovery.org/my-view-on-sexualitys-role-in-recovery-no-more-slut-shaming/

      AA did tremendous things to change society’s image of the “alcoholic” (another word I don’t use), and Bill Wilson was one of the greatest organizers who ever lived. I have fantasies of meeting him in a bar and having a nice, long chat, as he drinks fifteen cups of coffee and I match him in Diet Cokes. But if you read the Big Book and other literature carefully, you see that it is designed to integrate “alcoholics” into “normal” society. What is making amends but getting back the relationships that made you “normal?” What if those relationships were oppressive in the first place?

      Abstinence has the limitations that you point out. I wish there were a perfect, different word. Maybe we could work together to come up with one! Today, I am abstinent from alcohol. I am also abstinent from rice cakes, because I found I could not eat just one. I have no problem walking past a bar, but I walk a circuitous route around the grocery store to avoid the rice cake aisle! At one time I had a problem with bagels. I still can not go near a gummy bear. I watch my weight very carefully, not because I like being thin (though I do, and whose social construction of reality says that while the entire world values women for our looks, we are supposed to pretend we don’t care about them?), so I must avoid foods to which I have an addictive response. I don’t consider myself “nutritionally sober.” Hmmmm… not yet. You have given me much food for thought (pun intended.) And I’ve started, or restarted, my own blog, on the topic of food. I hope some of you follow it, because like all my writing, it’s never about what it says it’s about.

      • morgan machen March 30, 2020 at 9:52 pm #

        I had a coworker who used to say “I’m going straight-edge”. He would do that periodically and it seemed like he just saw it as a new challenge he was undertaking for awhile and that he didn’t consider his ‘partying’ to be problematic. I had the sense that he was more into exploring different states of being and ‘going straight-edge was yet another interesting life experience to explore.

        I have used that line a few times when I felt like partaking of some substance would only make me feel worse. It seems like a simpler way to literally ‘cut off’ someone’s offer of something than saying “No thank you I prefer to be abstinent”. It’s a word that implies some kind if deprivation, I think, whereas “No thanks I’m going straight-edge right now” has a decisive, strong quality that doesn’t imply that I’m trying to avoid something.

        That way I can accept that person’s choice to partake and I don’t give them the impression that I’m being judgemental about their choice.

      • matt April 3, 2020 at 9:43 am #

        Hi April,

        Thanks for your thoughtful and thoroughgoing answer. I agree with you that “sober” is another word that is an inadequate descriptor of the state I’m trying to achieve when I move to change my troublesome habit behavior. Who wants to be sober as a judge when we grow up? Any more than I aspired to be “addicted?” I wonder if it’s ever struck anyone that a reason that “addiction” terms often fall short is because the things they are trying to describe– states or phenomena that have so many uses and interpretations by lawmakers, families, the general public and many others who have no direct experience and understanding of these substances/experiences— the terminology may as well never have existed in the first place. These categories and labels like “sobriety”, “abstinence,” “addiction,” “recovery,” “relapse,” “slip,” “disease,” etc.. may be awkward and inaccurate because we are labeling a behavior something that it isn’t, just because historically that’s what people have always done, without much reflection. Slapped a label on it and interpreted what that label means however they want– without the rigor of science and evidence-based research.

      • Eric Nada April 8, 2020 at 11:55 am #

        April, I, too, like and use the word “abstinence” instead of “clean or sober.” I do so for two important reasons. First, “sober” belongs to the 12-step model of recovery. It has a particular (though somewhat nebulous and ever-shifting) meaning specific to on old recovery paradigm. But more importantly, abstinence is more accurate. I had horrific addiction problems and was traditionally abstinent for years (20). But I am not abstinent anymore. That said, I am almost always sober. It is very rare that either my emotional state or my alcohol use leads me from a state that I would say is sober–even though I may not be abstinent. Furthermore, I have met many people who are abstinent but so dysfunctional that I would not consider them very sober. For now, I have healed the underlying emotional problems that fueled my addictions. And I have found that alcohol no longer creates a craving for more. I feel more sober now in my non-abstinent lifestyle than I ever did when I was traditionally sober and involved in 12-step recovery. I guess that’s a long winded way of saying, I agree!

        • Dan July 12, 2020 at 11:12 am #

          Eric, Thanks for your comment on this topic. I am newly on my path towards figuring out what my state of being is going to be moving forward. It will be different than it has been because it needs to be. Figuring out the language I will use to think about it, and to describe it, is particularly important to me – I work with words and they are all we have to make our reality known. Your comment has helped me tremendously in conceptualizing that state of being. Thanks again!

          • Eric Nada July 12, 2020 at 12:11 pm #

            Dan, I’m very glad that you are examining these words. Words are fairly clumsy to use since we have such a limited number of them to describe an unlimited set of experiences–so it is important to choose them carefully. Every subculture adopts a particular vernacular, applying it in such a way as to help specify and teach their philosophy. In the case of 12-step, their vocabulary has been adopted into mainstream discussion surrounding addiction and recovery. This makes it harder to separate ourselves from, making it even more important that we assign our vocabulary carefully. Especially when we are specifically trying to divorce ourselves from a particular subculture, it becomes even more important that we challenge ourselves to use our words carefully. I’m so glad you related to my comment.

  4. April March 30, 2020 at 3:42 pm #

    Once again, Marc nails it. No one in the addiction field has managed to cut straight to the heart of the issue better than Marc, clinically but with empathy, unlike those whose hatred of those who disagree get in the way of their messaging.

    I think it was Alan Marlatt, arguably the founder of the concept of harm reduction, who said that you can’t expect people to replace their one coping mechanism without giving them another. AA/NA give people another coping mechanism that is appealing to some but not most – addiction to meetings, sponsors, steps, and the fellowship. I’ve found it very helpful at times, though for me the greatest stumbling block was a later day orthodoxy requiring 90 meetings in 90 days, immediate sponsorship, and the insistence that one define one’s life by a problem you once had. Other coping mechanisms that work for me are yoga, intense exercise, and tons of contact with people. But when those aren’t available, like now, it gets hard. And frankly, all that stuff about yoga and meditation and prayer (even though I am a Christian and even record daily online prayers for my old church during this time when people can’t gather to pray) just leads to the idea that when we stop drinking/using, we have to become perfect little good girls or boys.

    It has been my experience, and that of the thousands of people in the group I co-lead, HAMS (Harm Reduction, Abstinence and Moderation Support) that abstinence is usually taken up in a time of crisis, and as a form of punishment. “I binged/crashed my car/lost my job/spouse threatened to leave me/my parents forced me to go to rehab.” That burns the concept of abstinence as punishment into the brain, often if not usually forever. Even in the Big Book (which unlike almost anyone in AA I have actually read cover-to-cover) it says something to the effect of, We have lose the right to anger. We have lost the right to attempt to drink moderately. In other words, we are being punished by standards that “normies” do not have to adhere to.

    The people I’ve seen who are successful at living the life they want (normal is not a category I aspire to!) did not punish themselves with abstinence or a life long series of confessions of “character defects.” Whether they choose to drink or use or not, they embrace the part of themselves that is wild, young, free. While I used alcohol to medicate anxiety, I also used it to set myself free from lifelong pressure to be the perfect good girl. And I mean perfect. With the smallest misstep being treated as a crime.

    The most successful people I know have adopted their own style of living that may or may not involve a substance now classified as a drug. Kenneth Anderson, founder and executive directer of HAMS, drinks approximately one night per week, one bottle of whiskey. He does not drive, turns off his phone and computer to avoid drunk dialing or emailing or Facebook posting, and watches Japanese movies in Japanese without subtitles. His liver enzymes are perfect, he is successful and happy, and one of the sanest if strangest people I know. Marc has his whiskey and wine (I’m with you on the wine part Marc but I can’t stand the smell of whiskey!).

    I still seek a balance, and am far from finding it. My good girl, straight A, outwardly perfect to the point where you can get away with just about anything (don’t ask) side remains at war with my other, truer self. I have even gone by two names, now three. Right before I went to rehab in 2015, I didn’t clinically split into two, but I had the voice of Katy, my alter-ego, in my head, talking to April. I made a deal with her. I said that if she would let me live (instead of passing out in the street in Philadelphia on a regular basis), I would write in her voice.

    I still haven’t written in her voice, or at least not published it. Maybe it’s time.

    • Annette March 31, 2020 at 9:09 am #

      April, there are some great sobriety forums now, run and moderated mostly by women. There’s Holly Whitaker in the US of course. All want to avoid the ‘A’ word and the huge rules and regulations of the Big Book.

      We women are creative and independent now. We can live the life we want to, some of which requires discipline, others the joy of letting go and being spontaneous. I really recommend Club Soda, set up in 2015 – now with well over 50,000 members, and not just UK based. They have an app too; there’s also http://www.boozemusings.com, with many US and European members, who tend to be late 20s onwards, people with a penchant for photos and often long posts.

      We DO get to decide how we live our lives. Some can moderate successfully, many can’t. I choose an alcohol free life simply because booze almost destroyed my mental health. My genes include addiction and paranoid schizophrenia (both my dad and younger brother) I’m VERY happy to live this way – and certainly in the UK and much of Europe, we have a fine choice of alcohol free drinks, which provide dry and sophisticated tastes, without any buzz at all. My go-to at the weekends and 1/3 to 1/2 the cost of the real thing!

      I think the thing about perfection is innately US: we have a bit of it in the UK but a lot of Europe isn’t too bothered: they’d rather be human!

      I hope you get to publish in your 3rd voice. We all have a 3rd voice: that quiet, diligent observer whom we so often overlook. Sending hugs. xx

  5. Matjaž Horvat May 2, 2020 at 11:50 am #

    Great post. But I do have to ask, how much of that “rebellious” part is culturally contingent.

    For example, there have been several cultures where recreational opium use has been traditional, socially accepted and something done by almost the entire society, mostly in Asia. The idea of doing this as some kind of rebellion would be alien to these folks. What would they be rebelling agianst if it’s the norm?

  6. James July 4, 2020 at 9:39 pm #

    Thanks I believe I was using harm reduction however my usage was to much and I had a binge which usually happens every 3 months or so

  7. Rene September 21, 2020 at 7:53 pm #

    Thanks Marc for the work you do! I just came across this blog though I have read Biology of Desire…twice.
    Thank you for the clarity you bring to the neuroscience of habit/desire/mental loops (I tend to call it), the default mode network is maybe the same thing I believe.
    Changes take time and diligence to realize in practical ways far as I can tell.
    And letting go completely is daunting when pathways are well established.

    What I am experiencing is this kind of skirmish with the various aspects of my being. And that feels energy consuming. I know you address this concept with ego fatigue.

    I hope you keep writing!

    Much love,
    René

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