If moderation is what harm reduction means, should we have tolerance for continued or moderate use of addictives among clients in treatment? Again, the question is too broad. The answer for individual outpatient clients might be Yes, if the therapist understands that heavy use of any addictive such as gambling may lead to an ongoing altered state from which what is learned in treatment may fail to generalize to a non-altered state. Then, of course, the answer in individual outpatient work would depend on the degree of involvement with other addictives and the client’s inner resources for making important changes in life. We simply do not yet know who may or may not be a good candidate for controlled use of addictives, or any other dangerous behavior, as a treatment goal.

So, is the client to be the final judge of his or her own of treatment goal: abstinence or moderation? Of course—the choice is always theirs. They will do whatever they wish in the end, but as teachers, we should have a lesson plan of our own. What therapists call positive transference is a kind of hero worship, a love/respect feeling the client seems to develop toward a personal therapist. Like it or not, any good therapist becomes a moral authority in the eyes of the client when the magic dust of positive transference is scattered about. When we accept and encourage whatever goals the client sets, we surrender some of that moral authority and discard much of what makes therapy work.  

Should we allow outpatient members of therapy groups in addiction treatment to continue gambling, drinking or abusing drugs during treatment? Pragmatically, will our peer counselors be tolerant of addictive use during treatment? Would the National Council on Problem Gambling certify gambling counselors who encourage moderation and who, themselves, may continue to gamble? Will insurance companies be willing to pay for sessions if members continue to use addictives? Will family members find the treatment credible if we tolerate other addictions? Only someone with firm moral principles could thread a path through such pragmatic considerations, but, in the eyes of some harm reduction writers, the moralist is evil.

We desperately need research on the value of total abstinence as opposed to limited use in clients with different personal characteristics. Obviously, one size does not fit all, but can we work effectively in group therapy with mixed goals? The fact is, we do, and it does work. Group members who use and confess to it actually provide the abstinence-oriented members with a chance to practice their Twelfth Step work. But perhaps, with such a mixed group, in a mistaken effort to make everyone comfortable, therapists might bid the abstainers be silent so the others will feel more comfortable.

Marlatt writes that the harm reduction movement is pragmatic, but he is not the only one to discover that pragmatism is invaluable in designing treatment. A major source of referrals in the early days to our gambling treatment programs was Gamblers Anonymous. To work comfortably and effectively with Gamblers Anonymous, a group that gave endless acceptance to our low bottom gamblers in the Veterans Administration, we stressed eventual abstinence as a treatment goal. That is what our best customers told us they wanted. But members of Gamblers Anonymous, like those in Alcoholics Anonymous, are incredibly accepting of human weakness. Champions of harm reduction like to vilify what they see as traditional, hide-bound opposition to any goal other than abstinence, and yet I have never in my life found any groups as tolerant, loving, accepting and patient with backsliders as Twelve Step groups. You will find more compassion in those groups than in most professional circles.

In two published follow-up studies we looked at many quality of life issues aside from relapse and abstinence and did find, in fact, that absolute abstinence is not necessarily indicative of improved overall quality of life. Many gamblers and alcoholics following treatment reported limited use and improved financial, family and vocational life. Also, most of those doing well were attending self-help groups whether or not they made slips back to use. I think the same results are true for drug abusers. 

With respect to alcohol use, age restrictions on buyers and limits on sales to intoxicated individuals seem to work well, but prohibition has generally failed by causing worse problems than those we sought to solve. Warning labels may or may not prove useful, but they certainly can’t hurt. Although moderation training for alcoholics has been with us for nearly thirty years, the lack of a reliable and valid treatment strategy, not dogmatic opposition from mental health workers, has discouraged widespread use. One suspects that those problem drinkers for whom moderation training would work best are those least in need of formal treatment. Natural, unaided recovery is probably the most effective solution to the majority of alcohol problems found in younger people, and maturational moderation can arise from personal and self-imposed psychological restraints gained through experience. 

Members of Overeaters Anonymous have a very special definition of abstinence. For them, abstinence is not total food abstinence. It consists of avoiding certain food substances completely such as sugars, fats and refined starches. Restrained eating—controlled eating if you will—is still the best solution for obesity, and I think we would all have a great deal to learn in working with problem eaters. Some social policies such as food labeling have helped a great deal, and members of Overeaters Anonymous have learned many self-control tricks that work well. As with all addictions, pharmaceutical products may eventually help alleviate the dark feelings behind addiction, reduce craving, and make abstinence easier.

If we were discussing clients with poor sexual impulse control, what harm reduction measures would we recommend? In terms of social policy we have, as we do with drug abuse, a plethora of legal restrictions on sexual behavior, most of which seem to have little effect. Prohibition of prostitution, for example, is certainly a disaster serving only to create busy work and easy arrests for police. In those Nevada counties where prostitution is legal, rates among prostitutes of sexually transmitted disease (STD), assault, drug abuse, and depression are almost zero. In Clark County, home to Las Vegas, prostitution is illegal due to pressure from the casino industry, and among prostitutes there, alcoholism, STD, assault and suicide rates soar.

If you were working with clients with disorders of sexual desire would you recommend harm reduction, and what form would that take?  It has been argued that oral sex is not sex. Would you recommend feathers instead of whips and chains? Would you risk the fate of a recently fired Surgeon General and recommend masturbation as a safe, universal, and harmless outlet for the young? Should the errant husband be limited to one extramarital encounter per month? 

Hard questions all. These questions remind us of the need for a consistent, compassionate morality and a clear code of professional ethics. Harm reduction is a powerful tool when used in making social policy, and as concerned citizens we ought to support efforts to protect addicts and their families from the disastrous results of addiction. If we again look outside of our narrow specialty, we see that driving is a potentially dangerous or risky behavior as is hunting, the practice of medicine or psychology, piloting an aircraft, building a building, or selling intoxicating beverages. Like gambling, these behaviors are privileges, not rights. Privileging risky behavior by granted formal certification or licensing works extremely well in many areas to reduce harm to the individual and to the public at large. The single most powerful harm reduction method I can think of would be licensing gamblers to gamble, drinkers to drink and drug addicts to use certain drugs if they prove they can do so in controlled moderation. A few simple questions, answered subject to perjury, would go a long way in protecting all of us from irresponsible addicts. It would make it illegal for vulnerable people to use in any amount.