The Differences Between Moderate Drinking Programs and Harm Reduction Programs, Pt. 1

The Differences Between Moderate Drinking Programs and Harm Reduction Programs

Part 1: Moderation Drinking Programs and Moderation Management

By Kenneth Anderson, MA

Moderate drinking programs and harm reduction programs start from opposite assumptions and wind up in very different places. This doesn’t necessarily make one type of program better than the other–different people will find different programs to be a good fit.

A Brief Overview of Harm Reduction Programs

Harm reduction programs start from the assumption that the more harm there is associated with behavior such as the use of a substance, the more the person who engages in that behavior can benefit from harm reduction services. Harm reduction services are low-threshold and are provided unconditionally. For example, needle exchange programs recognize that the more heroin a person injects, the more clean syringes that person needs. Likewise, an alcohol harm reduction program recognizes that the more alcohol-related harms a person has, the more that person needs to mitigate those harms. Whether the substance is heroin or alcohol or anything else, any positive change is considered to be a success.

A Brief Overview of Moderation Management Programs

Moderate drinking programs, on the other hand, are highly conditional and have set drinking limits. An example of a professionally delivered moderate drinking program is William R. Miller’s Behavioral Self Control Training (BSCT) program. Miller deemed people who failed to maintain moderate drinking limits after completing the program to be failures, despite the fact that many had achieved significant reductions in their alcohol consumption. Rather than recognize this as a success, Miller et al (1992) concluded that therapists needed to find a means to force abstinence on the people who had fallen short of perfect moderation. Moderation Management (MM) is also highly conditional and exclusive: MM states that it is not for “alcoholics” and states that people who fail to maintain moderate drinking limits need to join Alcoholics Anonymous (AA) or another abstinence-based program. This would be like a needle exchange program which only supplied clean needles to moderate heroin users and referred all heroin “addicts” to NA.

History and Roots of Both Programs

The HAMS alcohol harm reduction program was an outgrowth of the MM program. I developed the HAMS program during the time that I worked at MM and simultaneously worked in needle exchange. Therefore, what follows is a history of MM and of HAMS, which explicates the differences between the two.

Moderation Management (MM) is a free-of-charge, lay-led support group founded by Audrey Bea Kishline nee Conn (Nov 9, 1956 – Dec 19, 2014) in 1993 in Ann Arbor, Michigan. The first MM meeting was held in December of 1993 in Ann Arbor. MM was incorporated as a nonprofit named the Moderation Management Network, Inc. in Michigan on October 29, 1993. The initial board of directors was comprised of Audrey Kishline, her husband, Brian Gene Kishline, and psychologist Jeffrey Schaler, PhD.

The Moderation Management program was based on a number of moderate drinking training programs which had been developed for use by professional therapists by Martha Sanchez-Craig, William R. Miller, Mark and Linda Sobell, etc., as well as the self-help books How to Control Your Drinking (1982) by William R. Miller and Ricardo F. Munoz and DrinkWise (1993) by Martha Sanchez-Craig.

An Influential Ideology

These books and programs were very heavily influenced by the ideology of Alcoholics Anonymous and 12-step treatment programs, as was the MM program itself. Kishline herself had had gone through a 28-day, residential, 12-step treatment program in 1986. AA, MM, and the other moderate drinking programs all bought into the idea that there is a sharp binary distinction between problem drinkers and alcoholics, although contemporary science has found this binary distinction to be untenable.

Kishline spent 1993 and part of 1994 writing Moderate Drinking, the MM handbook. Moderate Drinking was published by See Sharp Press in October of 1994. See Sharp Press is a small press operated by Charles Bufe in Tucson, Arizona. See Sharp Press focuses on publishing books on anarchism, atheism, and music, as well as anti-AA criticism. In writing Moderate Drinking, Kishline consulted with Schaler, Bufe, the Sobells and Sanchez-Craig, as well as other moderate drinking/alcoholism experts, including Vince Fox, Frederick B. Glaser, Ernest Kurtz, Herbert Fingarette, Stanton Peele, Fred Rotgers, and G. Alan Marlatt.

The book Moderate Drinking repeatedly stressed that MM is only for mild to moderate problem drinkers and not for alcoholics. The nine steps of MM were all mandatory and to be done in order. Anyone who failed to stay within MM’s moderate drinking limits was to leave and join AA or some other abstinence-based program. MM’s moderate drinking limits were quite strict and taken from the Canadian limits for healthy drinking. The MM limits are no more than 14 US standard drinks per week and no more than four per day for men, and no more than nine per week and three per day for women.

Additionally, anyone who failed to complete MM’s step two, a mandatory 30-day period of abstinence from alcohol, was to leave and join AA. Kishline said that the intent of this step was to weed out the “true alcoholics.” AA was treated as a magic wand which could be waved at people, and which would result in immediate and perfect lifelong abstinence from alcohol. However, AA, despite being very successful at self-promotion, is not always successful at helping people to stop drinking.

MM, in its insistence on perfect moderation or perfect abstinence, embodied all the perfectionism of AA. Interestingly, AA has a slogan “progress not perfection,” but when one looks at the actual AA literature, one finds that this is in reference to spiritual perfection, not drinking (Big Book, p. 60, 12 by 12, p. 91). In fact, if one drinks again after joining AA, it is mandatory to show the proper contrition and shame at the next meeting, or else one will be completely ostracized by the group. MM’s insistence on perfect moderation was a bit like a diet that never allows you to eat a pork chop or a cheeseburger for the rest of your life.

By the end of 1996, Kishline had appeared on Oprah Winfrey, Good Morning America, and numerous other mainstream media venues.

Junkiebond and Harm Reduction as a Grass Roots Movement

Whereas the first moderate drinking programs were created by academics and self-appointed experts and handed down from on high to the unwashed masses with no input from drinkers themselves, and no consideration of their lived experiences, harm reduction programs had quite a different origin story. In 1979/1980, the mayors of the four largest cities in the Netherlands decided to use the insanity laws to forcibly commit heroin users to abstinence-based treatment. Not only did civil liberties groups push back against this proposal, but the Dutch heroin users themselves formed a drug users union named the Junkiebond to fight back. The movement was headed up by Nico Adriaans, himself an injection heroin user. The first issue of the Junkiebond’s newsletter, Dope, proclaimed:

Suddenly, like a bolt from the blue, there is the Junkie Union. An initiative from users themselves, users who are fed up with having their life decided by psychiatrists, lawmakers, aid providers etc. without these users being involved with decision-making about drug policies themselves.

From the outset, harm reduction was a grassroots movement of social justice and civil disobedience operated by drug users to protect the rights and lives of drug users. Nico Adriaans established the world’s first needle exchange in Rotterdam in 1981 in response to an epidemic of hepatitis B among injection drug users. AIDS had not yet raised its ugly head in the Netherlands and was only beginning to appear in the United States.

As Maia Szalavitz documents, the first clean needles in the US were handed out in 1985 by the National AIDS Brigade, headed by former injection drug user Jon Parker. This was done in the face of opposition by all the academic drug “experts,” who stated that drug “addicts” were incapable of rational thought and wouldn’t use clean needles if they had them. Possession of a syringe was a crime in most states at this time, and Parker and several others known as the “needle eight” deliberately got themselves arrested in New York City by handing out needles on March 6, 1990, in order to get the laws changed. This was a turning point that helped kick off a national harm reduction movement.

In Part 2 of The Differences Between Moderate Drinking Programs and Harm Reduction Programs, I will present how harm reduction has been applied to alcohol problems.