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"The authors sufficiently demonstrate how such a program should be administered....Both the theoretical basis for this type of treatment and the corresponding choice of techniques are sound and appropriate tor the drug-using population. Furthermore, the book is written in a very clear and understandable manner, making it easy for the reader to incorporate this approach within his or her repertoire of therapeutic responses....Case illustrations provide clear and specific therapeutic suggestions....This book makes a very important contribution to the literature....The book is practical, realistic, and systematic in its approach. The authors demonstrate a keen understanding of human nature and clearly understand the drug-abusing population....For all those treatment providers who have desired options beyond the traditional orientations of treatment, this book is highly recommended."--Criminal Justice Review
"An all-around good book....Could conceivably be used as a supplemental text for a counseling strategies course. It would certainly be a useful reference book in a college or university library."--Journal of Teaching in the Addictions
"Although written primarily for people who have a substance abuse problem, or for those affected by another''s use, the book will also be of value to professionals working in this field....As someone with a number of years of experience working as an alcohol counsellor, I would certainly have found this book helpful, as I developed my own understanding of the impact of substances on the person and ways of working with the person to promote a more healthy lifestyle, and I feel sure many of my clients would have benefited from it as well."--Healthcare Counselling and Psychotherapy Journal
"This is a terrific book....I very much appreciated the respectful tone....I have read a number of self-help books, and many of them try to acheive this tone. Few manage it....the book is aimed at those who are using and those who have a relationship with someone who is using--family, friends and relatives....it would also be a valuable resource for professionals who are looking for a concise explanation of harm reduction....I found myself repeatedly nodding in agreement, grinning at new perceptions or surprised and intrigued by new information....very well written, informative, humane and kindly."--Metapsychology
"At last, a user-friendly guide to harm reduction! If you or someone you care about are seeking an alternative to abstinence-only programs, I highly recommend this book. It offers ample solace, support, information, and the skills you need to understand harm reduction and use it to make positive changes in your life. The authors are compassionate and pragmatic, and their extensive experience is reflected on every page."--G. Alan Marlatt, PhD, Addictive Behaviors Research Center, University of Washington, Seattle
"Over the Influence is not only the best-named book about recovery from drug and alcohol addiction, it is also the best written, most concise, and most emotionally real of all the books in the field. Denning, Little, and Glickman translate the controversial concepts of harm reduction into practical guidelines for people who want to improve their lives--whether or not they achieve abstinence."--Lonny Shavelson, MD, author of Hooked: Five Addicts Challenge Our Misguided Drug Rehab System
"This book will bring optimism and hope to readers with a range of addictive problems. Dr. Denning and her coauthors don't demand abstinence, nor attack the integrity of those who don't attain it. Instead, the harm reduction approach encourages people to make changes that improve their lives, no matter how long it takes or how many setbacks they encounter. A brave, caring, and radical book."--Stanton Peele, PhD, JD, author of The Truth about Addiction and Recovery
"Denning, Little and Glickman take the concept of harm reduction and apply it broadly and eloquently. This guide is sure to provide users, their families, their therapists, and their communities with tools to address the complexities that characterize drug use, misuse, addiction, and treatment. I highly recommend it to everyone who is, knows, or cares about a user of intoxicating substances."--Marsha Rosenbaum, PhD, Director, Safety First Project, Drug Policy Alliance, San Francisco
IS IT ALL OR NOTHING?
Do you know anyone with diabetes who has ever been refused insulin by his doctor because he won't stop eating ice cream or drinking alcohol?
Or any pro ball players who are told they have to quit playing forever before they can have yet another tendon repaired?
How many heart patients are denied bypass surgery because their last meal was a hamburger and french fries, and the one before that a pizza? Or because they still haven't gotten around to getting off the couch except to let the dog out, despite their doctor's instructions to get thirty minutes of aerobic exercise at least three times a week?
How many overweight fifty-year-olds are told they must lose weight before their doctor will perform knee surgery?
How many doctors demand that you quit smoking before they will prescribe oxygen for your emphysema?
Would your doctor refuse to set your broken arm just because you don't wear elbow pads when you skateboard?
The likely answers to all of the above are "not many," "none," and "no." Doctors may ask, they may plead, they may try persuasion and education, but they generally don't refuse treatment to people who aren't ready, willing, or able to stop doing the things that are harmful to their condition.
It is not so for people who use or abuse alcohol and other drugs. People who drink too much and people who use illegal drugs—those 20 percent, or thereabouts, of Americans who often get lumped into the category of "addict"—usually hear "I can't help you until you stop drinking [quit using]." This is most often the case when people try to find help for emotional or relationship troubles or for more severe problems such as depression, anxiety, or posttraumatic stress disorder. The mythology in some circles is that getting sober will take care of all your other problems or will clear the way for you to take care of them.
The Reality of Change
Sure, sobriety's nice. So are lifelong love, unlimited wealth, and perfection. But we don't go to sleep on Sunday wanting to be wealthy and wake up on Monday with tons of money. We don't even go to sleep in February wanting to be rich and wake up in June with a stock portfolio on which we can retire. It takes time. There are obstacles. First we get some training and a good job. Then we work hard, invest well, save some money. We improve our skills, we take a few risks in the stock market.
Nor do we dream of love and wake up to find Prince(ss) Charming beside us in the morning. We talk to friends about how they found good partners, date different people, get married. We mess up, we learn, maybe we divorce—we practice until we learn to have a good love life. Eventually, we find our way.
Even then, most of us never end up rich or with the person of our dreams. But we can be happy, comfortable, even satisfied. Perfection? That, we never achieve.
The same is true with drug or alcohol problems. Most of us don't go to sleep on Sunday hoping to stop drinking, snorting coke, or shooting speed or heroin and wake up on Monday "clean and sober." (We also don't go to sleep drunk on Sunday and wake up Monday an alcoholic, but that's a different chapter.) It takes time, and there are obstacles. First you try to get control of your drinking on your own. You decide to snort coke or smoke crack only on weekends. You are determined to quit heroin completely because it has become the habit you thought would never happen. You admit to a friend that you're struggling to control your drinking and he takes you to an AA meeting. You go into a twenty-eight-day treatment program and relapse a few weeks or months after you graduate. You find a therapist to talk to about the problems you think might be causing your heavy drug use, but she confronts your "denial" so vigorously that you decide drinking is the only cure for feeling beaten up by your therapist.
Or, if you've discovered this book, you consider practicing harm reduction. In this way, you begin by first making sure you always have a ride home from the bar so you're not driving drunk. Then you quit drinking gin and stick with beer because the piercing headache that accompanies your gin hangover makes you argumentative at work. Then you drink less beer. You realize you've been depressed for a while, and you start taking antidepressant medication. Maybe find a therapist who knows about harm reduction and doesn't say you have to quit before you can talk about your problems. You begin to deal with the depression that may have started your drinking in the first place. Maybe you stop smoking pot for a while, take a "drug vacation." You exercise. You talk to a friend who also does crystal meth (speed), and together you agree to go on a run no more than once a month, to quit by noon on Sunday, and to always have condoms in your pocket. Eventually you find your way.
There Are Other Choices Besides Quitting
This book is about harm reduction. It is not about "getting clean." It is not about quitting drugs or alcohol in the hope that simply not having these things in your body will be the solution, or the beginning of the solution, to all your other problems. It is not about determining, once and for all, whether you are an addict. It is not about an all-or-nothing attitude: drink or be on the wagon, use or quit. It is about reducing the harm done by alcohol and other drugs in your life. Less harm is the solution.
Hillary works in a busy cafe. She uses speed with her coworkers to keep up with the intense pace. Usually she uses only once a day, around the middle of her shift. Sometimes, though, it feels good to do a hit later because she's so tired. But then she has trouble sleeping. Which means she needs a hit the next day even more. She knows she can't go on like this forever. She has a child who needs attention, she's exhausted, and she'll burn out at this rate. She thinks about quitting speed or maybe getting a different job. She's already beginning to practice harm reduction just by worrying about the problem and thinking about solutions. She will have many options for taking better care of herself and her child.
If, for you, reducing harm means abstaining entirely, that's fine. But if it means beginning with tiny changes that move you in a positive direction, that's fine, too. If it means drinking, but for the first time in your life not driving drunk, that's wonderful—lives are no longer in such danger when you get in your car. If it means limiting your marijuana use to whatever is supplied by your most reliable drug dealer so that you know you're not getting a joint laced with PCP, that's wonderful—you're reducing your risk of a potentially violent, psychotic, or lethal drug experience. If it means getting more sleep on Sunday so you don't get so tired at work on Monday and can avoid that first hit of speed to get through the day, you're on your way. Even if it doesn't work out so well from Tuesday through Saturday. That's the reality of change for most of us. We do as much as we can the best way we can. And that's harm reduction.
Moreover, you are the expert. You know better than anyone what works and doesn't work. You are the only one with the power to choose what's best for you. Whether consciously or not, you always balance the risks and the benefits of using drugs versus quitting. Harm reduction merely helps you find more options between keeping on as you are and quitting altogether. And the most radical idea from harm reduction is that drugs work. The speed you use does, in fact, get you through the day; alcohol helps you enjoy your wife's office Christmas party; pot makes the music so much more beautiful; cocaine was around before Viagra; and heroin takes away all the pain. Drugs work; otherwise you wouldn't be using them.
The Reality of Harm Reduction
Since this book is about reducing harm, there will be times when you'll be invited to identify the harm you experience in your life, whether it's harm that has caused or is caused by your alcohol or other drug use. We appreciate the magnitude of such an invitation. If most of us had to strip down and look at our lives with brutal honesty, we'd climb into the nearest dark hole with as much of our drug of choice as money could buy and stay there till hell froze over. To some degree, we all avoid looking closely at the damage, pain, anger, sadness, loneliness, or depression in our lives. And we do this for an understandable reason: it hurts to live it, and it hurts to think about it.
We understand that you may begin reading this book feeling like you've failed at the only step usually accepted—total abstinence from all psychoactive substances. So when it comes time to look again at the harm incurred by your drug or alcohol use, go at the pace that's right for you. And if you do get into that hole, drink lots of water and get plenty of rest. This book is waiting patiently for your return.
We offer the plainest and most difficult advice: Be patient with yourself. Being patient with yourself means going at your own pace, no matter whose agenda is pressing you to DO SOMETHING NOW, OR ELSE!
Practicing harm reduction means taking an active interest in your own welfare and the welfare of those around you. It means being curious about why you drink or use. It means reviewing how you got here, why you started using in the first place, and how you got to the point of needing this book. It means examining, without harsh judgments, the risks of your drinking and the trouble you've gotten into because of it. It means accepting, without guilt, that you like things about your drugs, that they are helpful or pleasurable, even if they cause problems.
Harm reduction is not the easy way out. It's not an "excuse" to keep using. It is, in fact, very hard work. Harm reduction is based on the reality that most of us don't quit doing something unhealthy or start doing something healthy just because someone says so or just because it's the "right" thing to do. But that doesn't mean we do nothing at all.
When facing a problem, our first job is to think, not to do. Of course, if you have to quit immediately because you're a doctor and you've been threatened with suspension from your job ... or you're on parole and you'll be locked up for a violation ... or your wife has said she'll leave you and that's the last thing you want, then fine, quit. But it's hard to do and hard to maintain. Change is difficult, and it's stressful. If you can't or don't want to quit, even thinking is hard, too. Because so often what we have to think about is painful. On the other hand, you've already shown that you can tolerate pain, stress, or frustration. In everyday life, you have probably (at least once)
Gone without food, new clothing, or other pleasures when those around you were indulging.
Broken up with a partner when you were still in love.
Withstood humiliating lectures from teachers or bosses.
Endured a broken ankle and taken three months away from your favorite sport.
Having done any of those things tells you that you have the ability to do something painful, difficult, uncomfortable, or boring, even when you don't want to. You also have the ability to exercise control. If you've gotten into trouble drinking and using drugs, it could almost certainly be worse. You've already set limits on your use, or you wouldn't be reading this book right now. You'd be in the hospital struggling to live, living in the streets struggling to survive, or, worst of all, dead.
But What If People Say I Have to Quit?
So you wake up Monday morning. Whatever pleasures the weekend provided for you, you find yourself in pain now. Your head hurts, you're nauseous, anxious, and tremulous. You're late for work and your pockets are empty. This morning, the options are laid out, crystal clear and so depressing you can barely bring yourself to think of them. There's an NA meeting that starts at noon. Or an AA meeting at the church in half an hour. Insurance would probably cover a detox, maybe even rehab. The possibilities all jumble together in your head, and the only clear feeling you have is that nothing has ever worked. Either you go whole hog, quit, "join the program," suffer another detox, or keep on going the way you are. Either way, you're doomed.
The people around you believe you're suffering because of your use of alcohol or other drugs. The term they know for this is addiction—if you drink too much or use drugs, you must be an addict. The only solution they know is for you to quit—quit using all "mind-altering" drugs. It's the only way. That's what they've been told, and that's what they believe is best for you.
Kendra got laid off from her job at a large law firm and can't find another job. She's very worried. For the past five months she's been hanging out with other unemployed friends, watching TV, smoking pot, and occasionally snorting heroin. Some of her friends also drink a lot. But her brother had a big problem with alcohol, lost jobs and family, finally quit, and is much better off now. So she stays away from drinking. He says he was an alcoholic and that she's an addict. He tells her that the only way she'll ever get back on her feet and find work is to quit.
Addiction is a strong word, and we use it very freely in this country. It's a casual term that sometimes just means you're using a drug regularly and don't want to give it up. It's often used to peg a user with negative images. Because we have such a strong tendency in the United States to be puritanical about pleasure (pleasure is indulgent; being indulgent is bad), the word addiction denotes stigma. People who are addicted are seen as being weak and out of control. The word addiction really has no official meaning. Someone in your life who uses this term may not know whether you are "addicted" or not. He is just communicating to you that he's worried. Using an illegal drug doesn't make you an addict. Nor does drinking more than most other people around you.
The actual terms used by substance abuse treatment professionals are substance abuse and substance dependence. Substance abuse refers to continuing drug use even after it has begun causing problems such as legal, financial, or family trouble. Substance dependence refers to a number of things related to use, including possible physical dependence (see the special drug section in the middle of the book for more information about this aspect), craving, or seeking and using drugs to the exclusion of other activities. The term addiction generally refers to chaotic, compulsive use that can no longer be understood or controlled by the user. But this by no means describes most drug use.
Since addiction has become such a common term, it's likely that your friends and family use it freely. They see that you use drugs or alcohol, they see problems in your life, they experience problems in their relationship with you, and despite their requests, demands, or pleas for you to stop, you continue to use. Therefore, you must be an addict. As we explained in the Introduction, these ideas about addiction come from the disease model of addiction, known elsewhere in the world as the American disease model.
In reality, there are many types of problematic use patterns that are not described easily as "abuse" or "dependence" or "addiction." There are also many ways to use drugs more safely. The continuum of drug use is much more complicated than the disease model allows. To get an idea of the difference between the approaches of the disease model and harm reduction, consider this:
According to the
Harm Reduction Says ...
Disease Model ...
IF DRUGS AND
Your use of alcohol may be related to some
ALCOHOL CAUSE trouble in your life, but you are not necessarily
PERSISTENT addicted to alcohol.
PROBLEMS IN YOUR
LIFE, YOU'RE AN
ADDICTED TO ONE
You may be addicted to the heroin you use
THING MEANS every day but not to the marijuana you smoke
ADDICTED TO ALL on weekends.
ONCE AN ADDICT,
You can stop drinking and later learn to drink
ALWAYS AN ADDICT. moderately. Or you can stop drinking and just
be over it. You are no longer an alcoholic.
THE ONLY ANSWER IS Most people don't quit, or not forever. They
TO QUIT ALLMIND- end up moderating their use. And most people
ALTERING who quit one substance—like heroin, crack, or
SUBSTANCES. alcohol—don't quit everything, especially
alcohol or pot.
So What Do You Do?
You picked up this book because you or someone in your life is worried about your drinking or drug use. If you haven't been living under a rock, you've heard of, or even been to, Alcoholics Anonymous or drug treatment. The fact that you're reading this book suggests that they haven't been helpful enough so far. You are in the majority. Although, many people find extraordinary help through AA and its 12-Step cousins, most don't. That doesn't mean there is something wrong with these programs. Nor is there anything wrong with you. It just means that AA, or NA, or any other 12-Step program, with its disease approach to understanding and dealing with drug and alcohol use, is not a good match for you. But you're still worried and looking for help.
For the moment, you're willing to coast on the hope that this book might have a few new ideas for you. In spite of your searing headache, the unexplained bruises on your leg, or the zero balance in your bank account, you're willing to entertain the possibility that there's a way to make life better. It's a delicate thing, that hope you cling to, daring to try one more thing before you decide your life is going to suck from today until you die. Thus you invite harm reduction into your life.
Excerpted from Over the Influence by Patt Denning, Jeannie Little, Adina Glickman. Copyright © 2004 The Guilford Press. Excerpted by permission of The Guilford Press.
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