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HARM REDUCTION AND WOMEN
EXPERIENCES OF HARM REDUCTION
AMONG WOMEN WITH ALCOHOL USE PROBLEMS
CATRINA G. BROWN,
School of Social Work, Dalhousie University, Halifax,
SHERRY H. STEWART,
Department of Psychiatry and Psychology, Dalhousie University, Halifax
and
SARAH E. LARSEN
Department of Psychology, St. Mary’s University, Halifax
ABSTRACT
This paper explores women’s choice of controlled drinking or abstinence
goals in harm reduction treatment programs for alcohol use problems. Situated
within debates about controlled or abstinence goals for alcohol use, this research
project provides a specific focus on women’s treatment needs. We explore evi-
dence which reveals that women in treatment for alcohol problems often hold
deeply internalized dominant social ideologies on addiction. Results demonstrate
that while offered the choice of abstinence or controlled use goals, most women
defined themselves as “addicts,” adopted a disease metaphor of “addiction,” and
chose abstinence. The findings here raise questions about whether or not clients
receive sufficient education about harm reduction and controlled drinking and
make adequately informed choices.
Practiced in western Europe for over twenty years, and supported by the World
Health Organization (Room, 1997;
WHO, 1996), harm reduction strategies have only
recently become a viable alternative for women struggling with alcohol use problems
in North America. Harm reduction philosophy appeals to women-centered practi-
tioners because it departs from dominant deficit-based, abstinence-focused, disease-
model interpretations of addiction (Denning, 2000). Harm reduction approaches offer
strategies toward change that are harmonious with those of women-centered practice,
emphasizing client empowerment, self-determination/choice, and the necessity of
clients’ setting their own goals (Bepko, 1991; Pasick & White, 1991). Harm reduce-
tion is defined by leading proponent, Tatarsky (1998) as “a pragmatic approach that
accepts active substance use as a fact and assumes that substance users must be en-
gaged where they are, not where the provider thinks they should be. It recognizes that
substance use and its consequences vary along a continuum of harmful effects for the
user and the community, and that behaviour generally changes by small incremental
steps” (p. 10). The essence of harm reduction philosophy reflects non-moralistic
values and centres on individuals making their own treatment choices, practice prag-
_____________________________________________________________________________
This research was supported through a generous grant from the Nova Scotia Health Research foundation to
the first and second authors. The authors would like to acknowledge the assistance of Health Services
Director Tom Payette (Capital District Health Authority), Program Managers Paul Helwig (Core), and Jean
McClelland (Matrix) as well as service providers at each of these programs for their assistance in recruiting
participants for the study. We would also like to thank Jennifer Theakston for her research assistance. And of
course, we extend our thanks to the women receiving services at these programs for their participation in the
study.
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matism and compassionate strategies to minimize harmful consequence (Blume, An-
derson, Fader, & Marlatt, 2001; Denning, 2000; Erickson, Riley, Cheung, & O’Hare,
1997; Inciardi & Harrison, 2000; Tatarsky, 2002). Thus, clients are not required to
give up existing coping strategies without having alternative tactics in place. Harm
reduction offers an alternative to the “just say no,” “zero tolerance,” and “war on
drugs” public policy, programming, and treatment approaches (Marlatt, Larimer,
Baer, & Quigley, 1993). Similar to a client-centred approach, harm-reduction philos-
ophy and treatment is collaborative in setting goals and determining interventions.
Heather (1993) outlines four central approaches in applying harm-reduction
principles to the treatment of alcohol problems. The first approach he calls “drinking
but improved,” referring to the status of clients who continue to drink and
demonstrate related problems following treatment, but whose alcohol intake levels
and the severity of the problems are reduced. The second approach he identifies as
“the wider criteria of treatment outcome” which emphasizes the client’s overall
quality of life. The ultimate objective of treatment is not total abstinence or harm-free
drinking but simply an improvement in the client’s overall quality of life. Third,
Heather describes “controlled or ‘harm-free’ drinking.” He notes that “this is in fact
what most people think of when they apply the idea of harm reduction to the alcohol
problems field” (p. 174). Within this approach, controlled drinking can be an out-
come category following abstinence-oriented treatment or a goal of treatment itself.
This approach involves the complete elimination of alcohol-related harm and thus it
can be argued involves harm reduction in its most extreme form. Last is “harm
reduction from a societal perspective” which refers to reduction of the total number
of problems caused by alcohol in a given society. These approaches are not neces-
sarily mutually exclusive; neither are harm reduction strategies for treatment separate
from an overall philosophy of harm reduction.
In this paper, we explore women’s choice of controlled drinking or abstinence
goals within programs that use harm reduction to treat alcohol use problems. This
paper emerges from the portion of our community-based research which explored
women clients’ views on harm reduction based treatment for women in alcohol
treatment (Stewart, Brown, Theakston, Devoulyte, & Larsen, 2004). We will begin
by reviewing the debate on controlled use of alcohol among those with alcohol
problems, and then present the study and its findings. We explore evidence revealing
that women in treatment for alcohol problems often hold deeply internalized
dominant social ideologies on addiction (Sanders, 1998; Winslade & Smith, 1997).
Results demonstrate that while offered the choice of abstinence or controlled use as
treatment goals most women defined themselves as “addicts,” adopted a disease
metaphor of “addiction,” and chose abstinence. Consistent with Heather’s (1993)
observation, most women in this study understood harm reduction only to mean
adopting controlled drinking goals. The implications of these findings is that current
harm reduction based treatments need to provide sufficient information to women to
empower them to make truly informed choices.
CONTROLLED DRINKING VERSUS ABSTINENCE
Harm reduction emerged in the 1980s, most notably in the Netherlands and
Britain, as a public health response intended to reduce HIV risks associated with the
use of drugs (Denning, 2000; Inciardi & Harrison, 2000; Tatarsky, 1998). The Dutch
policy alternative, situated between the “war on drugs” approach and legalization, is
one of “normalization” (Dorn, 1989; Engelsman, 1989). With a co-emphasis on the
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HARM REDUCTION AND WOMEN
needs of the individual, and the goal of minimizing of all forms of harmful impact,
normalization avoids stigmatizing and labelling (Dorn, 1989). In contrast to
American policy, which continues to promote zero tolerance despite international
trends, the Canadian government redirected its drug-policy position to one which
emphasized harm reduction in 1987 (Fischer, 1997). Moving beyond a “one-size-fits-
all” model and responding to poor efficacy in traditional approaches, harm reduction
seeks to be more flexible, comprehensive, and inclusive (Miller, 1983). Harm reduce-
tion or low-threshold treatment approaches signify an important public health direc-
tion because what they offer may be a more attractive option to reticent individuals
(Englesman, 1989; Marlatt et al., 1993). Requiring clients to commit to abstinence
before they are adequately equipped not only sets them up for failure, it may prevent
them from seeking help at all (Tatarsky, 1998). This research project is situated
within debates about controlled or abstinence goals for drinking outcomes (Marlatt,
1983), but provides a specific focus on women’s treatment experiences. Women’s
addiction research demonstrates that research about men cannot necessarily be
generalized to women (Greenfield, 2002; Najavits, 2002; Plant, 1997). This study
contributes to filling a significant gap in the research on harm reduction in women’s
treatment programming.
A debate among health professionals working with alcohol addictions began to
emerge in the 1960s over abstinence or controlled-drinking goals (Miller, 1983).
Early research findings by Davies (1962), Sobell and Sobell (1973, 1976), and the
Rand report (see Armor, Polich, & Stambul, 1978) challenged the traditional
foundational assumptions guiding alcohol addiction research and service delivery,
calling into question the deeply contestable nature of “alcoholism.” These researchers
argued that controlled drinking was possible among certain problem-drinking popula-
tions, confronting the core belief that addictions are a primary and progressive chron-
ic disease (Fingarette, 1988; Marlatt et al., 1993; Peele, 1985a, 1985b). According to
the disease model, alcoholism is characterized by impaired control over alcohol use,
meaning, according to Marlatt and his colleagues, that “alcoholics have one of two
options: to abstain or to continue drinking in a progressively deteriorating manner”
(p. 464). Addictions are thus conceptualized as an all-or-nothing phenomenon where-
by one either has, or does not have, the disease of alcoholism and from which less
severe forms of drinking, such as problem drinking, or binge drinking/episodic drink-
ing are indistinguishable (Marlatt et al., 1993). From this traditional deterministic
perspective, alcoholism is a genetic or biologically caused disease outside of individ-
uals’ control, necessitating abstinence-based treatment. Additionally, when con-
sidered a primary disease, alcohol use as a secondary response, to the trauma of sex-
ual violence or to depression, for example, is discounted. By definition, the alcoholic
within this framework is unable to moderate or control alcohol use, and therefore a
controlled or managed approach to drinking is not only unacceptable, it is also un-
thinkable.
Collectively reporting on over twenty years of research findings, Miller (1983),
Sobell and Sobell (1995), and Marlatt et al. (1993) agree that moderated or managed
drinking is as achievable a treatment goal as abstinence among those with less severe
drinking problems. Of 22 research studies surveyed, 21 demonstrate the effectiveness
of controlled drinking (Marlatt et al., 1993; Miller, 1983). Although generally more
effective for less severe dependence, a minority of heavy drinkers have been suc-
cessful at controlled drinking, suggesting potential for controlled drinking as a
treatment option for all types of alcohol abuse (Finney & Moos, 1981; Heather,
1995). Some speculate that the establishment of more effective forms of intervention,
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including training in moderation, could increase success in controlled drinking
among heavy drinkers (Miller, 1983).
For decades, research has supported the effectiveness of the controlled-drinking
approach, consistent with predictions of the philosophy of harm reduction. However,
the debate about the utility of controlled-drinking verses abstinence approaches
continues, and the disease model for understanding and treating addictions remains
dominant especially in the United States (Marlatt et al., 1993). Recently the con-
troversy surrounding controlled drinking has been defused by reframing it in the
context of public health, shifting the focus from the politics of defining addiction to
early intervention and prevention. The debate is hardly over, however; ideological
differences remain entrenched in North America (Anderson, 1995; Weisner, 1995).
Research offers some important predictors of a successful moderate drinking
outcome. Women are found to have greater success with a moderate-drinking ap-
proach than men and this is significant for women’s treatment programming (Con-
nors & Walitzer, 1997; Marlatt et al., 1993; Marlatt, 1998; Miller & Joyce, 1979;
Rosenberg, 1993; Sanchez-Craig, Leigh, Spivak, & Lei, 1989; Sanchez-Craig,
Davila, & Cooper, 1996). Investigation of the controlled-drinking research (see
Heather & Robertson for review, 1981; Ogborne, 1987) suggests the following are
predictors of successful controlled drinking: lower dependence severity, younger age,
regular employment, a person’s confidence in his/her ability to abstain, a shorter
history of drinking problems, post-treatment social support, and “less contact with
Alcoholics Anonymous, and more ideological flexibility about treatment” (Heather &
Robertson, 1981, p. 478). In contrast, successful abstinence was predicted by prior
efforts at abstinence, greater involvement with Alcoholics Anonymous, physician
referral, and self-definition as an alcoholic. These findings suggest that the more in-
dividuals are exposed to and internalize dominant/traditional notions of addiction
through abstinence-based treatment, the more they are likely to develop alcoholic
identities. Those individuals less influenced by the dominant disease discourse appear
to have better success with the controlled-drinking approach. In other words, if
clients believe controlled drinking is possible, they are more likely to succeed. Orford
and Keddie (1986) suggest that success at either abstinence or controlled use is
directly linked to personal ideology and confidence in the approach (cited in Marlatt
et al., 1993).
Research suggests that when clients’ treatment reflects their goal choice of
abstinence or controlled use, they are more likely to have favourable treatment
outcomes (Booth, 1984; Marlatt et al, 1993; Marlatt, 1998). In a Canadian study by
Ogborne (1987), it was demonstrated that those with more severe drinking problems
tended to choose abstinence while younger people with less severe alcohol problems
chose controlled drinking.
RESEARCH OBJECTIVES
This paper focuses on women’s experiences and perceptions of harm reduction
treatment and is part of a larger study.
1
The purposes of the larger study were
twofold. First, we attempted to understand the mechanisms underlying the co-
prevalence of binge eating and binge drinking among women receiving treatment for
alcohol use problems, the results of which are presented elsewhere (see Stewart et al.,
2004). Second, we explored perceptions and experiences of harm reduction with the
intent of contributing toward improvement of current harm-reduction models for
treatment. In particular, there is a lack of harm-reduction programming deliberately
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HARM REDUCTION AND WOMEN
designed to address the specific needs and experiences of women (Marlatt, 1998). It
is the second objective that we address in the current paper.
METHOD
Data were gathered through multi-method research which included standardized
questionnaires, semi-structured qualitative interviews, and a focus group.
2
Fifty-eight
adult women (aged 18 years or older) seeking treatment for alcohol abuse or
dependence at Addiction Prevention and Treatment Services of the Capital District
Health Authority in the Halifax Regional Municipality, Nova Scotia were recruited
for this study. In order to be eligible, women had to be in treatment for a substance
use problem, self-identify with an alcohol use problem, and screen positive for a
clinically significant alcohol use problem using the 10-item Brief Michigan Alcohol-
ism Screening Test (b-mast; Pokorny et al., 1972). All of the women who self-
identified as problem drinkers by appearing for the study met criteria for a likely
alcohol use disorder on the screening test. Following completion of the question-
naires, women who identified as both binge eaters and binge drinkers, and who were
interested in participating, were interviewed and subsequently invited to participate in
the focus group. This paper focuses specifically on the data that emerged on harm
reduction from qualitative interviews among 18 women service users, and a focus
group of three women service users.
Qualitative Interviews and Focus Groups
3
Qualitative interviews and focus groups emphasize women’s own perceptions of
their behaviours and the meanings they attached to them (Mies, 1983, 1991; Stanley
& Wise, 1990). Interviewers sought to establish rapport with the research participants
in order to evoke richer accounts of their experiences (Finch, 1984; Oakley, 1981).
These two-hour-long qualitative, semi-structured, audio-taped interviews focused on
women’s perceptions. Women’s choice of abstinence or controlled use of alcohol,
and their perceptions of harm-reduction approaches to treatment were investigated by
exploring women’s own stories.
Data analysis identified dominant themes and narratives that emerged from these
interviews around reported treatment choices. We looked for both commonalities and
disjuncture in women’s narratives to examine transferability of the stories across dif-
ferent women’s experiences. Data were collected until no new themes emerged. The
focus group provided an additional layer of data beyond that obtained with the
individual interviews (Connors & Franklin, 2000; Kitzinger, 1994; Morgan, 1998).
Data Analysis
Data analysis identified dominant themes and narratives that emerged with
respect to women’s alcohol use and treatment choices. Data from the service users’
interviews and focus group were seen to represent women’s stories. A hermeneutic or
interpretive approach was used to explore the meaning of women’s stories. Thematic
analysis involves “a search for and identification of common threads that extend
throughout an entire interview or set of interviews” (Morse & Field, 1995, p. 139).
Attention to diversity is a critical component of all feminist research, thus this
research explored the differences and commonalities in women’s narratives
(Reinharz, 1992), and determined transferability of these stories across different
women’s experiences.
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The data analysis on harm reduction involved overlapping techniques of
thematic analysis and grounded theory, axial and selective coding. Drawing upon
grounded theory (Glaser & Strauss, 1967; Hurst, 1999; Strauss & Corbin, 1990; Stern
& Pyles, 1985), open coding initially generates categories, axial coding makes con-
nections between identified categories, and selective coding integrates the categories
through uncovering the dominant story, or “explicating the story line” in the stories
told (Strauss & Corbin 1990, p. 119). Because stories cannot encompass the richness
of lived experience, selective coding enabled us to note gaps, contradictions, and
notable omissions in the women’s stories (White & Epston, 1990). Taken together,
these strategies allowed us to unpack, contextualize, and interpret the narratives
produced in this study. By exploring narratives in this manner, we determined how
stories were organized to give meaning, structure, and coherence to the events or
experiences in the participants’ lives. This is highly congruent with the social
constructionist and hermeneutic foundation of this study, whereby one explores the
social construction of meaning through the stories told. Since stories only emerge
within available social discourses, the data analysis attempts to situate women’s
stories about problem drinking within the larger social discourses on drinking
behaviour and addiction discourse. Specifically, the choices women make between
abstinence and controlled use within harm reduction programming are situated within
the influence of dominant addiction discourse.
FINDINGS
This study explored views of women receiving harm reduction based treatment
for alcohol use problems on harm reduction as a treatment strategy. The mean age of
the 18 women participating in the open ended interviews was 38 years of age.
Women interviewed had an average education level of 14 years. Most described
themselves as Caucasian. Limited income and unemployment were a concern for 13
of the 18 women. Within their local treatment programs, clients could choose
between abstinence or controlled-use goals. All of the women interviewed for this
study were part of harm-reduction-based programming offered through Addiction
Prevention and Treatment Services, Halifax Region, Nova Scotia. All of the women
were also part of a women-specific program (Matrix), or one that had women-
specific components (Core). Although both Matrix and Core provide an initial
orientation to harm reduction, many women were unclear about what harm reduction
was. When asked about harm reduction, Jane
4
said, “What do you mean?” She
continued, “No, I’ve never had that attitude . . . It was always all-or-nothing.”
Similarly, when asked about harm reduction, Chelsea asked, “Which is what?”
Most of the women interviewed confused harm reduction with controlled
drinking, not understanding that harm reduction emphasizes clients’ choice of
treatment goals including abstinence. Based on this assumption, they often concluded
that they didn’t believe in harm reduction. While the women didn’t suggest people
shouldn’t be given the choice between controlled-drinking or abstinence goals, most
were sceptical that controlled drinking as a choice was really possible. Although the
women interviewed adopted either an abstinence or a controlled-drinking goal, we
will begin by presenting findings from the most common group, women who chose
abstinence and who reported that they did not generally support a harm-reduction
approach to alcohol use problems.
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HARM REDUCTION AND WOMEN
Totalizing Identity Conclusions: “I’m an Alcoholic”
Women who disagreed with harm reduction often concurrently believed that
they were “addicts,” and must abstain from alcohol use. Such totalizing identity con-
clusions tend to be rooted in the belief that they have a chronic primary disease
which, by definition, requires abstinence. Molly-Anne stated, “I think ‘once an
alcoholic always an alcoholic.’ I can’t see going back to being a social drinker.”
Mary adopted these same conclusions: “An alcoholic will find liquor. It doesn’t mat-
ter where,” and “addicts do things differently. . . .” According to Sarah, “I knew for a
long time that I was an alcoholic. It was just a matter of facing it.”
In addition to adopting totalizing and often pathologizing identities, some wo-
men framed awareness of underlying motives for drinking as “an excuse,” failing to
see the value in exploring drinking motives. Because these women defined harm
reduction primarily in relation to the concept of abstinence, they often focused on
establishing absolute behavioural control of their drinking. This approach tended to
minimize more introspective or self-reflective components of harm-reduction practice
such as increasing awareness of underlying motives or emotional needs and discov-
ery of new coping strategies in order to make different choices. Self-reflection sets up
a dualistic choice for women: they can either become more aware of the underlying
motivations for behaviour, and thus be more in control of their choices and behave-
iours around drinking, or they can simply abstain which may not involve attending to
these motivations at all. Framing the development of greater understanding or self-
awareness as an excuse for drinking illustrates this dualism. When asked about her
underlying reasons for drinking Mary established that she didn’t have any legitimate
reasons: “They are all just excuses.” She states emphatically,
No, none [referring to reasons for drinking]. Like I say, I’m an alcoholic. I use
any excuse. . . . I can have any reason. . . . I can stub my toe. Any reason. I’m an
alcoholic. Any reason at all. I can be mad. I can be happy. I can have a good day.
I can say: “you know, I’m feeling good. I’m going to have a couple drinks.” You
know? I can be doing housework. Any reason. I’m an alcoholic. I don’t need an
excuse or reason. I just do it.
Mary’s thinking about her drinking behaviour is unhelpful to her in four ways.
First, the belief that she has no control over her drinking denies her agency, choice,
and self-determination. Second, she denies that she has any reason for her actions
(i.e., benefits of drinking). Third, it reveals a lack of compassion toward herself
through the minimization of the importance of her needs and feelings. She is only
able to see her needs and feelings as impediments to abstinence. And fourth, this
thinking does not require her to be self-reflective, an important step in avoiding
relapse itself. This client stance raises significant questions about harm-reduction
strategies which emphasize choice as though all choices were equal or had equal
effect. In this instance, Mary’s choice to abstain seems to be conflated with a refusal
to enter into a dialogue about her emotional needs.
Most women were adamantly opposed to the use of controlled drinking and the
philosophy of harm reduction for alcohol use problems primarily because they were
committed to the idea of abstinence as evidence of recovery and because they didn’t
believe they had control over making the choice to drink. Describing a local harm-
reduction program, Shelley said, “. . . you’ll find that . . . anybody that takes groups
seriously are in abstinence and aren’t using.” She was very positioned on the issue of
abstinence: “If you want to stay clean, you have to give up the habits that make you
use.” She had no confidence in a local program that was “. . . an ineffective pro-
gram . . . because [it] was not a . . . program where you had to abstain from use.” For
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Shelley, being serious about addressing an alcohol use problem necessarily meant
abstinence. Mary also held onto the idea of abstinence: “I don’t want it [alcohol]
having any more control over my life—period. And once I take that first drink, I
don’t have control anymore.”
Experiences of Control
Abstinence is often the preference for women with drinking problems because
they believe they have very little, if any, control over alcohol. Jane felt that drinking
wasn’t a choice once she had started: “If I start up again, then it starts all over again
and it’s almost like I don’t have control. But before I take that first step to drinking
yes, there is a choice.” Similarly, Taylor reported difficulty controlling her drinking:
“. . . of course one drink leads to another to another.” Claire agreed, “I know I can’t
have any.” For, Sarah, like many of the women interviewed, the goal was to “get
sober.” Sarah, an Alcoholics Anonymous member, has also experienced a lack of
control over her drinking: And every time I drank, I’d binge drink. I couldn’t have
just one. I don’t think personally one drink for me is ever going to work. I know that
I’ll never be able to drink socially.”
Regarding controlled drinking, Sarah said, “God no. It doesn’t work for me.”
Perhaps more strongly, Paula said, about controlled drinking, “That’s a joke.” Ginnie
stated, “For me, control means I don’t ever want to do it again.” While she has tried a
controlled-drinking approach, she has never felt that drinking was actually in her
control. In agreement Paula said, “The alcohol takes a hold of me. I have no control
over it anymore. . . . The drinking I can’t control.” Mary didn’t perceive herself to
have any control over alcohol either:
And I know when I sit down to drink that . . . and I can use any excuse . . . I can
give you any excuse in the book. I’ve tried them all. I can be mad. I can be
happy. I can be upset. I can be nervous. I can be scared. I can be whatever I want
to be. But it’s because my mind . . . whatever chemical is released in your brain
when you get to that certain point . . . once you think about that first drink and
you’re fighting that first drink, you’ve already lost the battle. You’ve got to stop
fighting an enemy that you can’t win. And start running from it instead. Which I
find to be true. I mean, if I’m going to continually think about a drink, then I’m
going to drink it. I’ve already lost the battle.
This thinking encourages binge drinking: if having one drink is perceived as failure,
it makes no difference whether one has one drink or many.
Contradictions, Gaps and Uncertainties
Most of the women interviewed adopted an either-or position on choice and the
possibility of control over alcohol use. Shelley stated:
Like, I take one drink, I lose control . . . Because I’ve tried . . . controlled drink-
ing. You know, I did real good at controlled drinking for about three years. But
sooner or later, you don’t do it anymore. . . . But I was going out and having three
more often. And I was looking forward to the three. It was just an illusion of
control. Do you know what I mean? It’s an illusion. . . . I was talking myself into
going out and getting drunk. . . . But you know what? It’s a disease. It’s not a
social issue, it’s a disease.
Contradicting this position, however, she later states:
I made a conscious decision to drink. Because now I make a conscious decision
not to drink. I always said I made a conscious decision to drink. It’s like in our
program people will say: “I relapsed . . . I went out drinking and it just
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HARM REDUCTION AND WOMEN
happened.” It never just happens. You make a decision to do it. I make a decision
not to go to a liquor store.
Thus, on the one hand Shelley stated that she has no control over drinking (i.e.,
she has one drink and she loses control), and on the other, she stated she does have
control (i.e., she makes a decision to drink and a decision not to drink). Although she
was able to engage in controlled drinking for three years, she interpreted her
difficulty to continue to do so as evidence that controlled drinking is not possible. An
equally plausible interpretation is that controlled drinking is possible for her. Contra-
dictory positions on whether women did or did not have control over their choice to
drink were not uncommon among the women we interviewed in this study and are
suggestive of the need to address this in harm-reduction programming.
Shelley’s further statement highlights the contradiction around whether her
drinking problem is a disease or about underlying psycho-social mechanisms which
motivate the need to drink. While she referred to herself as an addict, and her
drinking problem as a disease, she also revealed unmet emotional needs that she
addresses through alcohol use: “I don’t know how to take care of my needs, because
my needs were never taken care of. I don’t have any role models.”
Similarly, Mary does not believe in harm reduction and her absolutist thinking
about alcohol use is evident here. Mary shared that she felt her desire for alcohol may
become so out of control that she needed to put herself in someone else’s hands.
So I’ve signed a consent form and she has my permission to do whatever is
necessary to get me out of the house. Because I can’t stay there. They have liquor
there. And, you know, I don’t think its right that they should have to get the
liquor out of the house because I’m there. Or, lock the cabinets or anything. . . .
[T]here’s liquor everywhere in the world, and if not there, I’ll go get it someplace
else.
However, while Mary talked about not believing that harm reduction works for her,
she does adopt a harm reduction approach with her medication. She has decided to
take control over medication that doesn’t mix well with alcohol.
This time leave them in your purse . . . you control them . . . you have control
over this. You leave them in your purse. But you go home, you tell your mother,
your sister, the lady you live with, your boyfriend, and whoever that they are in
your purse. So if you do start drinking take them from you. But you control this.
You put them in your purse and you control them yourself.
Although Mary repeatedly described her scepticism of harm reduction, she
proceeded to dispute the “cold turkey approach” and appeared to be a proponent of
“weaning off” which constitutes a step-down strategy within the harm reduction
approach. It is possible that her contradictory stance may stem from a lack of
information about what harm reduction is.
But I’ve tried all kinds of different ways. I’ve tried cold turkey. Cold turkey
doesn’t really work for me. Where, like you say, the weaning off part does.
Which I did do. A lot through my . . . through this last year of working the pro-
gram, I did do a lot of weaning off stuff.
Like Shelley, Mary views her use of alcohol as a disease, and as an addiction
and she is reluctant to explore her emotional life. Despite not wanting to analyze her
drinking motivations, seeing this as letting herself off the hook or providing herself
with excuses, she did actually provide an account of using alcohol as a method of
shutting down. She stated: “When I take that first drink . . . I want to shut down. I
want to be left alone. I want everybody to leave me alone.” Given her description of
using alcohol as a way to “shut down,” the desire to avoid her emotional world may
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well be a primary motive of alcohol use. Therefore, although a significant theme for
Mary was that she drinks because she is an alcoholic—and, as such, doesn’t need a
reason—wanting to shut down, and using alcohol to do so, was a competing,
although less readily acknowledged, central theme. When asked about whether she
uses alcohol to enhance her mood or as a coping strategy to deal with conflict,
anxiety, or depression, however, Mary stated:
No, no, I don’t have a problem coping with things in my life. I actually am
stronger when I’m coping with things in my life and other people’s problems. I
don’t think to any extent no [re: using alcohol to cope]. But like I say, I use any
excuse. I can say I drank because I was depressed. I drank because I was anxious.
I drank for many reasons. I’m an alcoholic. I can’t say that I drink for any one
particular reason.
It was pointed out to Mary that she referred to needing to shut down several
times during her interview and reported using alcohol to do so. She subsequently
identified that she is usually focused on taking care of others’ needs, rather than her
own, and that when she drinks she wants to be alone; she doesn’t want to have to be
nice or take care of anyone else. Unlike her claim that she will drink for any reason
or excuse, because she is an alcoholic, and further, that she doesn’t drink for
emotional coping reasons, she did articulate some reasons for her unmet needs which
appear to resonate with her use of alcohol.
. . . And I think that in my everyday life, I need to back off . . . Being the way that
I am with helping other people. And doing things for other people. And putting
my own needs and my own wants aside to do for other people. So that I don’t get
to that point.
Despite her addiction story, competing stories emerged through exploring
questions about Mary’s needs. These included taking care of others at her own
expense. The way that she deals with her needs is to shut down and isolate herself.
Both Shelley’s and Mary’s stories reveal themes about unmet needs and feeling ill-
equipped to meet them. For both women, alcohol appears to provide one means to do
so. Yet, their dominant stories of being “addicts” have rendered competing stories of
unmet needs.
Shelley and Mary moved in and out of conflicting discourses in their attempts to
find explanations that fit. However, one explanation for this slipperiness is that it
allows them to avoid holding onto a position for which they are accountable or have
to address head on. This may be a known, or practised, way of being and thus com-
fortable. An advantage of not staying with a position, not holding still, is that it offers
the capacity to escape or sidestep emotions posing emotional threat, danger, or dif-
ficulty. Further, their belief (like other women’s in this study) that they have no
choice over drinking is in many respects also about not claiming responsibility or
accountability for their actions. They do not acknowledge their own agency.
When asked about what she might like about drinking, Mary responded, “But
now I don’t want to like any part of drinking,” having difficulty seeing the difference
between what she would like to be the case and what she actually feels. She imposes
on herself what she wants to like, rather than acknowledge what she actually does
like. Without recognition and awareness of what she likes about drinking, it will be
difficult to find alternative, less harmful, behaviours that meet the same needs. These
shifting discourses—gaps, uncertainties, and contradictions—should not go unex-
plored in harm-reduction treatment strategies, otherwise nothing much will change or
be resolved.
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HARM REDUCTION AND WOMEN
Although on the surface, many of the women seemed to emphasize a disease
model, the presence of contradictions in their stories suggests it is possible that some
women are trying to acknowledge the complexity of their experiences. They may
actually be trying to transcend the either-or position that alcohol-related problems are
either shaped by one’s body (i.e., disease) or one’s life (i.e., social-emotional con-
text). Thus while they may be influenced by the dominant-culture stories of drinking
problems as disease-based addictions, they may also know that their life experiences
have played a significant role in their use of alcohol. It may be that the contradictions
evident in their stories reveal an unresolved effort at holding onto the idea that their
alcohol problems are related to women’s bodies and women’s lives (see Stoppard,
1997, 2000; Stoppard & Gammell, 2003; Stoppard & McMullen, 2003; Wiens,
2003). While at first glance these accounts appear contradictory, they may offer the
possibility of greater complexity. However, by themselves, such contradictory stories
do not appear to make much sense, and are suggestive of confusion, ambivalence,
and uncertainty not atypical of the change process.
Alternative Self-Definitions and Choices
In contrast to most women in this study, some felt that controlled drinking was
possible, and the harm-reduction strategy was their preference. Iris revealed that,
“. . . to me that model sounds ideal, and it fits, most of how I see myself. . . . It is hard
to say no forever. . . . I don’t think it would be hard to moderate. . . . I harm-reduced
myself basically.” Molly said about harm-reduction strategies: “I think it’s grand. I
really hate AA because of the attitude—I’m an alcoholic . . . It’s kind of a defeatist
attitude to me. I’m more than that . . . they put you in a box.” Morag was very
articulate about the importance of harm reduction, particularly about what she
described as dealing with the issues that may be causing the drinking, rather than
simply abstaining. She said:
And so by addressing the whys, by empowering the person with skills, lending
the thought that you won’t need to drink next time . . . I see that they do harm re-
duction that way. By dealing with the actual issues that may be causing the
drinking rather than—okay drinking is bad . . . That’s useless. And I think
they’ve realized that it is useless. It’s about addressing and identifying your own
issues prior to picking up that glass . . .
These women valued and appreciated the opportunity to engage in the ongoing
process of self-awareness necessary for small-step changes and increased control
over one’s alcohol-use choices. However, aside from this important dimension of
harm reduction, they did not report receiving any formal training in controlled-
drinking strategies. While programs for understanding change processes and
strategies for gradual change are implemented, an organized or formal opportunity
for training in controlled drinking does not exist in these programs.
DISCUSSION
These findings have implications for the continued development of harm-
reduction treatment strategies. Consistent with the philosophy of harm reduction, the
emphasis in the program of the study is on individual choice between goals of
abstinence or controlled use. Clients received an initial orientation to the program-
ming which provided some description of the harm-reduction philosophy. While
offered treatment choice, most women defined themselves as addicts, adopted a
disease metaphor of addiction, and continued to choose abstinence. These findings
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raise questions about whether clients make adequately informed choices, or receive
sufficient education about harm reduction and controlled drinking.
Given the desire of some women to gain greater control over their alcohol use,
and the fear many others hold that it isn’t possible, it seems even more compelling
that organized efforts at controlled-use training be made widely available. Women
afraid of the idea of controlled use may especially benefit from skills provided in
such training, skills that are necessary for managed use. The provision of these skills
may aid in making an informed choice, prompting more women to try controlled use.
Because the approach within harm-reduction programs focuses on individual
choice, there appears to be minimal direct challenge to the disease model, and to the
underlying conceptual assumptions of addiction, relapse, detox, and abstinence, most
women have clearly internalized from the dominant culture even prior to treatment.
To some extent, however, offering controlled-drinking goals as an alternative to
abstinence is an inherent challenge to the belief that alcoholism is a primary disease.
Drawing on Stoppard and Gammell’s (2003) research conclusions on women and
depression, we concur that medicalized approaches can result in women’s disem-
powerment, by shifting the focus away from social contexts which produce distress in
women’s lives. In addition, women in this study also reported that even though they
are participating in harm reduction based programming, both the legal system and
child welfare typically demand abstinence. Wild (1999) reports that the attitudes
which condone compulsory treatment and attitudes which condone harm reduction
are incompatible. While compulsory treatment may have the effect of reducing
individual or social harm it does not offer individuals the right to choose treatment, or
the form of treatment. Moreover, its punitive approach is not consistent with the
philosophy of harm reduction.
Influenced by ideas generated within contemporary feminist and narrative
theory, we argue that dominant disease-based addiction discourse is at odds with a
harm-reduction philosophy (Bordo, 1993; Brown, 1994, 2003a; Butler & Scott, 1992;
Foucault, 1980a, 1980b; Gormond, 1993; Haraway, 1988, 1990; Nicholson, 1990;
Madigan, & Law, 1998; Sands & Nuccio, 1992; Scott, 1988; 1992; White & Epston,
1990). For example, Alexander and Van de Vijngaart (1997) describe the intensity of
moralistic and judgmental attitudes which often correspond with an absolutist belief
in abstinence as a “temperance mentality.” In their research, they found that when
people were educated about harm reduction these kinds of attitudes were minimized
and that they were subsequently more open to harm-reduction approaches.
Narrative theory influenced by postmodernism recognizes that while women
often internalize dominant social stories about addiction and its treatment, many of
these stories do not work well for them (Adams-Westcot, Dafforn, & Sterne, 1993;
Hare-Mustin 1994; Sanders, 1998; White 1991, 1994, 2001; Winslade & Smith,
1997). A blended feminist narrative approach provides a framework to explore the
ways that dominant stories of addiction help or hinder women in harm-reduction-
based treatment. This critical lens of inquiry enables an analysis of the context of this
discourse and its potential impact on women seeking treatment. It draws our attention
to how dominant addiction discourse can become taken for granted and unquestioned
within everyday life, obscuring potentially beneficial interpretations and possibilities
for women. While the emphasis on individual women’s choices within harm-reduc-
tion programming appears to be neutral, it doesn’t take into account the social dis-
course which often predetermines or shapes choosing abstinence.
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In their review of the effectiveness of treatment programming for substance
abuse in women, Ashley, Marsden, and Brady (2003) report that women experience
gender-specific barriers to treatment including health risks, biology, social contexts in
which addictions occur, and the social consequences of having a drinking problem
(i.e., having one’s children placed in care). Subsequently, their treatment needs are
markedly different than men’s. In addition to developing drinking problems with
lower alcohol intake than men and experiencing greater health risks, overlapping
issues of eating disorders, depression, sexual trauma or abuse, and domestic violence
suggest the need for comprehensive and overlapping treatment for women (Brady &
Randall, 1999; Brady et al., 1993; Greenfield, 2002; Herman, 1992; Kaplan 1991;
Najavits, 2002; Pirisi, 2000; Plant 1997; Stewart & Israeli, 2003). Dominant addic-
tion discourses ignore these contexts, situating alcohol use as the only problem that
needs to be addressed. It is these gender-specific differences which have lead to
women-centered and women’s-only programming. Since little is known to date on
the effectiveness of harm reduction based programs for women, this study contrib-
utes to knowledge in this area.
Abstinence-based approaches (cold turkey) often focus on absolute behavioural
change with less attention to why one is drinking. The assumption is that one drinks
because one is an alcoholic. This paradigm inherently restricts a whole range of
questions about drinking behaviour, and its meaning and purpose which are critical to
finding less harmful alternatives. Of significance is the degree of contradiction about
these concepts within women’s stories themselves. For instance, a woman may be
opposed to harm reduction because she believes she is an addict who has no control
over drinking alcohol and, as such, she must abstain from it. She may simultaneously
provide psycho-social explanations of her drinking behaviour by connecting binge
drinking to a history of trauma or abuse. She may additionally describe a history of
depression, and a desire to numb or remove herself from difficult feelings through
drinking. Stories like this provide competing and complex accounts of drinking
behaviour.
This is fertile ground for further development in harm-reduction programming
and from a therapeutic perspective the results are suggestive of an entry point for
potentially valuable clinical exploration and discovery. While ambivalence and
uncertainty are common aspects of the change process, they need to be acknowledged
and explored if treatment is to be effective. Harm-reduction programming may then
need to deliberately attend to contradiction, ambivalence, and uncertainty, rather than
move people too quickly into the either-or position of abstinence or controlled use.
This also suggests that psycho-education and awareness training may need to be
further emphasized during the initial treatment choices clients make, reflecting the
assumption that they may be more uncertain than definite about what will work for
them. It is helpful that harm-reduction services in this study encourage service users
to move between these two positions.
This research suggests that without providing education and training in
controlled drinking, the focus on individual choice is limited and fails to adequately
educate women on the ideological assumptions and practices of medically-based
abstinence models. Perhaps further investigation will determine whether these prac-
tices occur across Canada, and provide exploration of the role of the therapist/
program in the process of clients’ treatment choices. Thus, while programs offer
alternatives to the disease metaphor such as the possibility of controlled use,
abstinence-based women’s treatment within harm-reduction programming doesn’t
actually dispute the disease metaphor. The significance of continuing to reinforce the
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disease model with harm-reduction programming is an issue that may also require
further investigation. We need to ask what the implications are of theoretically
offering alternatives to the disease metaphor while most women do not choose these
alternatives.
Admittedly, while there is a desire not to overly influence the choices
individuals make, findings here suggest that the choices currently made are overly
influenced by pre-existing dominant social discourse about addiction. To balance the
effects of this dominant ideology, more sustained effort at educating women about
the full range of possibilities and formal training in controlled drinking are needed.
Only by systematically providing this balance can it be said that women have made
an adequately informed choice. Further, if more education and skills in controlled
drinking need to be provided in order to offer women an informed choice, the role of
therapists and programming itself need to be examined (Hore, 1995). These findings
reveal potential tensions and ambivalence centered around the choice of controlled
use or abstinence which are likely to effect the implementation of harm reduction.
CONCLUSION
Research findings discussed in this paper suggest that psycho-education on harm
reduction may need to address internalized dominant discourse such as the
medicalization of addiction. Also, training in controlled drinking may advance the
delivery of harm-reduction services for women. Findings suggest a more proactive
approach to harm reduction by including education on harm reduction and more
purposeful integration of these principles into treatment practices, specifically, skills
training for controlled use. These findings lend support to the argument that feminist
approaches to working with women’s use of alcohol and other substances need to
challenge discourses which may be harmful to women. Women’s dominant addiction
stories need to be unpacked to discover competing stories about their lives which
may be valuable in making well thought-out treatment choices. Stories which con-
textualize women’s pain, suffering, and trauma, for instance, may be discounted
under the weight of the powerful story of addiction as disease. Future research in this
area needs to explore, in further depth, the sources of exposure to dominant addiction
discourse including previous medical treatment, Alcoholics Anonymous, history of
alcohol treatment, media and the culture at large, and should aim to determine the
impact of this exposure on women’s treatment choices and outcomes. Findings in this
study suggest that for harm reduction to work most effectively there needs to be
greater emphasis on ensuring that clients’ choices are well-informed. This will
involve balancing the dominance of disease-based abstinence approaches with both
the psycho-education and skills training needed to allow for the full range of choices
that harm-reduction services are well positioned to offer.
NOTES
1. The larger study explored the relationship between binge eating and binge drinking among
women in treatment for alcohol use problems. Thus all of the women participating in the
interviews had a co-existing problem of binge eating and binge drinking. Participants were
recruited through Addiction Prevention and Treatment Services and provided well-informed
consent at each stage of the research.
2. Ethical approval was attained through the Capital District Health Authority Research Ethics
Board. Written informed consent was obtained from the research participants prior to data
collection.
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HARM REDUCTION AND WOMEN
3. Focus groups generate additional information beyond the individual interviews. The group
interview structure of focus groups provides an interactive approach, likely to yield rich data,
and deeper discussion may be stimulated by varying positions and opinions (Kitzinger, 1994;
Morgan, 1998). The focus group revisited the themes of the individual interviews. While this
allowed for the possibility of new themes emerging we did not find that to be the case in this
study. The focus group conversation between women also highlight similarities and differ-
ences in women’s perspectives.
4. Names associated with quotes from participants are not real. All participants’ names have
been changed to pseudonyms that they chose for themselves.
RÉSUMÉ
Cet article traite des objectifs choisis par des femmes participant aux pro-
grammes de réduction des méfaits reliés à l’usage d’alcool, en termes de consom-
mation contrôlée et d’abstinence. Les auteurs situent leurs recherches dans le
contexte des débats entourant les objectifs de contrôle ou d’abstinence et
abordent principalement les besoins des femmes en matière de traitement. Des ré-
sultats révèlent que les femmes en traitement pour des problèmes de consomma-
tion d’alcool sont souvent caractérisées par une profonde intériorisation d’idéo-
logies sociales dominantes concernant la toxicomanie. Les résultats tendent à dé-
montrer que dans le cas où elles ont le choix entre des objectifs d’abstinence et de
consommation contrôlée, la plupart des femmes se définissent comme « toxico-
manes », adoptent une métaphore reliée à la maladie pour définir « la toxico-
manie » et choisissent l’abstinence. Ces constatations soulèvent des interroga-
tions sur la qualité des informations que reçoit la clientèle à propos de la réduc-
tion des méfaits et de la consommation contrôlée, ainsi que sur sa capacité d’ef-
fectuer des choix éclairés.
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