Wednesday, February 15, 2017

What about Moderation Management?


Popular wisdom tells us to be moderate in all things…except abstinence.



He came to see me on his own with minimal outside pressure. He very candidly shared his history with alcohol, cocaine, and heroin and his success at recovery. He was very high functioning for the population I serve. He worked almost full time and had never had a long stretch of unemployment. He worked low paying food service jobs but tended to keep them for years meaning he could show up on time for work and was productive. He paid his own rent and lived in a boarding house with “a bunch of Cambodian teenagers” who were in actuality all in their 20s. “They’re kind of like my kids.” An impressive attitude for a white man from his generation with little education who is barely scraping by. 

“Eight years of nothing and I was happy about it.” He had started drinking again after a manager he liked quit and his replacement an authoritarian type who often called him a “retard” increased his work stress. Most nights he drank a six pack after work but not every day but two blackouts in the last month had scared him and he had requested to meet with me individually feeling uncomfortable in groups. “It doesn’t look like things are too out of control” I told him. “The things that kept you sober for 8 years will likely help you now. What kind of support do you think you need to reach your abstinence goal? Assuming you want to be abstinent.” He paused. “Sometimes I have a beer in the summer on a hot day. Just the one. I sure would hate to give that up.” I asked him if his goal was to quit all drinking or did he want to try controlling his drinking. “Is that even possible?” he asked surprised. My answer  “I really have no idea.”

If you want to see a group of eyes roll walk into any 12 Step or SMART Recovery meeting and tell them you’re practicing Moderation Management. MM is considered pure nonsense by most people in the USA with any involvement in substance use disorders and the recovery from them. “Once an addict always an addict” the saying goes and it is accepted as fact from the highly educated doctors to the newest recovery coach. People struggling with substance use believe this because no one bothers to dispute it. Research doesn’t support this. Now I’m not going to site sources so you’re going to have to trust me on this. I looked very hard six years ago for information on how many people achieved moderation after being diagnosed and there isn’t much. What I could find was not reliable not using a random sample or control group and relying mostly on self-report. People who are problem drinkers and manage to moderate after treatment don’t come back to tell their counselors of their success. Why would they? They obviously don’t need our help and are like to be told what they have achieve is impossible. What little I could find on the subject put the success rate between 3% and 45%. In other words we have no idea. 

So it might work and it might not work so why was I who argues for research based treatment (at least in the professional setting) printing out drinking diaries and frantically reading the MM website after a session. MM is an unknown but abstinence is proven to work. Here’s a list of reasons I chose to make my first Moderation Management treatment plan as a professional.

1) Abstinence doesn’t always work: 
You quit and you stay quit until you learn to like it. What could be simpler than that? The problem is it’s not at all simple. The majority of people attempting an abstinence plan don’t make it a year, fewer still make it 3 years. If you look at the pattern of people who use while trying to abstain is it that different from people attempting to moderate? What’s worse is that each use can be seen as a failure you can almost see the weight of it on people who have attempted multiple treatments and find themselves back again. Being unable to moderate may not hold the same sense of shame and may increase the client’s motivation to change down the road. It might even work.

2) Many of the skills are the same:
People who try to moderate need the same skills as people. They need to learn to cope with their uncomfortable emotions, they need to overcome social anxiety, they need to address family issues, and they need to like themselves again. Above all they need to change their relationship with alcohol. Abstinence gives us a nice clear cut line moderation is a little blurry. We know a person is abstinent and when they are not but how do we know if they’re moderating? I suggest you look at something besides the tox screen to figure that out. Are they practicing the skills you teach? What about police interaction or ER visits? The world is rarely black and white and a moderation plan will require us to wade around in the grey and don’t forget, it might even work.

3) It doesn’t matter if it works:
If a client’s goal is to moderate I recommend the counselor begin with the assumption that moderation is possible. It could be the client will never be able to moderate even a little but think of the relationship you can build exploring that together. Supporting a client’s goal to moderate shows that you are respecting the client’s autonomy. The therapeutic relationship works best when it operates as two adults making choices together. The alternative is usually the counselor plays the role of a parent, the client a child and children rebel. Successful counseling is about connection and respecting a client’s choice to attempt moderation provides an opportunity to connect before the client is ready to attempt abstinence and that connection can be used to help the client with positive change whatever the level of success. Abstinence will always be there if moderation doesn’t work.

Stanton Peel has made the point that we have an “abstinence fetish” in the United States and it’s something we’ve successfully exported to much of the world. The problem is by focusing on abstinence we invariably become drawn into a moral judgement where using is a sin and the user a sinner. This judgement is poison to the therapeutic relationship and it closes our minds to new ideas. It may be that research will someday prove that moderation is impossible past some  point and on that day I will gladly retract all I have written today. However, if you find yourself drawn to treating people struggling with addiction you are entering  a field that is just coming  out of a dark age of mysticism and faith healing mascaraing as medicine and it will behoove you to keep an open mind.