Zero Tolerance or Harm Reduction?

A Reading of The Urge: Our History of Addiction, Part IV

My very first client when I began my career as an intern at a VA Medical Center’s Chemical Dependency Unit, confessed to me that he couldn’t stop thinking about having sex with little girls. He explained that heroin was the only thing that helped him resist that urge. Now that we were telling him to stop using heroin, he didn’t know what he was going to do.

When I told my supervisor what the man had said, she said he was just making excuses. He was at the unit to stop using heroin, so that’s what we were to focus on. I passed the message on to my client and the next morning he had disappeared. I hope he scored some smack.

This was in the days when addiction treatment was very simple. In twenty-eight days, residents of the unit would withdraw completely from all the drugs we didn’t want them to use, and we would convince them to never use them again. This was the same goal for every inpatient unit, every outpatient clinic, and every self-help group I knew of. It was the goal for every addict, no matter the reason they used the drug, the consequences of using it, or how many times they had attempted that goal. We could not countenance anything but total abstinence. We had zero tolerance.

I couldn’t even refer my client to mental health care. If they knew he was using heroin, they’d send him right back to us, saying they couldn’t do a thing with anyone addicted. I could have sent that man to a methadone clinic, where he could get something that could control his urges, but with considerably less risk than if he continued with heroin. Methadone clinics existed then, but my supervisor would not refer anyone there because Methadone is a drug and she believed people had to go entirely off drugs.

This is just the thing addiction psychiatrist, bioethicist, and assistant professor of clinical psychiatry at Columbia, Carl Erik Fisher, writes about in his book, The Urge: Our History of Addiction. Fisher is a recovering addict, as well as a leading professional in the field. He spends a lot of pages in his book detailing the origins of abstinence-based thinking, starting with the Surgeon General of the Continental Army, Benjamin Rush, onto the paradoxically intemperate temperance movement, prohibition, to today’s zero-tolerance policies. We are only just beginning to be more realistic about what to expect from people in the throes of addiction.

No everyone would enjoy Fisher’s book. It you read it to get a simple answer about what addiction is and what we should do about it, you’ll come away frustrated. There are no simple answers, but the history of treatment is filled with examples of people thinking there are.

The error my supervisor made was in thinking that addiction is about drugs. Drugs are sometimes involved, but, if I had to encapsulate what addiction really is, I’d say it’s about rigid, inflexible thoughts, of which my supervisor was as guilty as my client. Of course, when I try to say what addiction really is, I’m guilty, too. I’m oversimplifying. As Fisher would say, I’m guilty of reductionism.

My client had some very rigid thoughts. He had disturbing thoughts of having sex with little girls, and an inflexible thought that the only thing he could do was get high. Certain chemicals intensify rigid, inflexible thinking. Once you get addicted to heroin, for instance, your body may go into withdrawal after a little while and make you think you want it again. Our unit might have been the perfect place to confront and change all his thoughts, as well as his attachment to heroin, but my supervisor had rigid, inflexible thinking of her own. She thought, the only thing people needed to do was stop using drugs.

In fairness to her, there is a place, in the range of therapy options, for abstinence-based treatment. An inpatient unit such as hers, is the perfect place. But there needs to be other options for the people who are not ready for abstinence, if only to prepare for abstinence.

There were other issues that complicated my client’s dilemma. I imagine, if his world was one in which all his basic needs were cared for, then disturbing thoughts would not have been so powerful. If he had no traumas that were playing a part, and if he knew what to do with anxiety besides act on it, and if he were not so depressed about his situation, he would have been able to generate more choices. If he had other forms of recreation, he would have had other things to do. If he was accepting of grace and trusting of God, he would not have had to endlessly replay the morality play he was enacting, where he is faced with a temptation and turns it away by an act of self-sacrifice and abasement. If he had nurturing people he could talk to about his disturbing thoughts without judgement, he would have been able to talk through his thoughts without acting on them. If he had been able to identify what he really wants when he thinks he wants sex with little girls, he might have been able to rescue it from capture by his perversion. 

There are a lot of things that lead to an addiction. It’s never simple. The ultimate goal is never just to stop using drugs. Being clean is never enough, we must also develop a personally meaningful life.

I’m happy my experience did not deter me from going on with my career. It didn’t because I remember thinking that no matter how green I was, I could never be as bad a counselor as my supervisor. If I had to do it over again, I would affirm he had a good reason to use heroin, but heroin may not be the best he could do. Can we come up with an alternate plan when he is having these thoughts? Then, together we would look at his life and see how we could make it better, starting with the low hanging fruit. Are his basic needs met? Does he have something fun to do and someone to be with? Does he know what to do with anxiety and depression? Does he know what he really wants and what’s making him want it? Can we resolve some traumas? If we answer those questions and he tries some new things, sometimes intrusive thoughts and the use of heroin take care of themselves. If he is still struggling, then would he consider using something different, some safer, prescribed drug, other than heroin?

No matter if you’re the addicted person, or someone trying to help one, the task is the same. Can you stop putting your faith in a single, silver bullet that’ll solve all problems, and just look at what you and others need?

Other posts in this series

Part I: The Spectrum of Addiction

Part II: The Origin of Addiction

Part III: Is Addiction a Disease?

Next in the Series: The Reflective Eclectic Treatment of Addiction

Published by Keith R Wilson

I'm a licensed mental health counselor and certified alcohol and substance abuse counselor in private practice with more than 30 years experience. My newest book is The Road to Reconciliation: A Comprehensive Guide to Peace When Relationships Go Bad. I recently published a workbook connected to it titled, How to Make an Apology You’ll Never Have to Make Again. I also have another self help book, Constructive Conflict: Building Something Good Out of All Those Arguments. I’ve also published two novels, a satire of the mental health field: Fate’s Janitors: Mopping Up Madness at a Mental Health Clinic, and Intersections , which takes readers on a road trip with a suicidal therapist. If you prefer your reading in easily digestible bits, with or without with pictures, I have created a Twitter account @theshrinkslinks. MyFacebook page is called Keith R Wilson – Author.

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