Thank you, Sara McGrail

March 31, 2022
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The DrugWise Daily newsletter noted the passing of Sara McGrail.

I never met Ms. McGrail and I didn’t follow her work, but her name rang a bell. I knew I’d interacted with her years ago but couldn’t remember the details.

It turns out we interacted around some posts related to harm reduction in 2008.

I had posted a response to something she wrote, she respectfully and thoughtfully responded. A couple of months later, we had a similar exchange that resulted in my conceptualization of recovery-oriented harm reduction.

This was an outcome of her meaningful engagement in the face of our disagreements, and her challenging, vigorous, substantive, and good faith arguments.

We saw things differently, but her questions, assertions of her values, and her prodding challenged me to examine my convictions and made me more thoughtful.

As I said, my knowledge of her and interaction with her was limited, and I don’t know if it was typical of her. Whatever the case, I am grateful to her for challenging me to think more deeply about the intersection of harm reduction and recovery.

What is recovery-oriented harm reduction?

Recovery-oriented harm reduction (ROHR) seeks to address the historical failings of both abstinence-oriented treatment and harm reduction services. ROHR views recovery as the ideal outcome for any person with addiction and uses recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented treatment provider.

Addiction is an illness. The defining characteristic of the disease of addiction is diminished and/or loss of control related to their substance use.

Drug use in addiction is not freely chosen. Because the disease of addiction affects the ability to choose, drug use by people with addiction should not be viewed as a lifestyle choice or manifestation of free will to be protected. It is not an expression of personal liberty, it is a symptom of an illness and indicates compromised personal agency.

All drug use is not addiction. There is a broad spectrum of alcohol and other drug use. Addiction is at the extreme of the problematic end of that spectrum. We should not presume that the principles that apply to the problem of addiction are applicable to other AOD use.

ROHR is committed to improving the well-being of all people with addiction. ROHR services are not contingent on recovery status, current AOD use, motivation, or goals. Further, their dignity, respect, and concern for their rights are important are not contingent on any of these factors.

An emphasis on client choice—no coercion. While addiction indicates an impaired ability to make choices about AOD use, service providers should not engage in coercive tactics to engage clients in services. Service engagement should be voluntary. Where other systems (legal, professional, child protection, etc.) use coercive pressure, service providers should be cautious that they do not participate in the disenfranchisement or stigmatization of people with addiction.

For those with addiction, full recovery is the ideal outcome. People with addiction, the systems that work with them, and the people around them often begin to lower expectations for recovery. In some cases, this arises in the context of inadequate resources. In others, it stems from working in systems that never offer an opportunity to witness recovery. Whatever the reason, maintaining a vision of full recovery as the ideal outcome is critical. Just as we would for any other treatable chronic illness.

The concept of recovery can be inclusive — it can include partial, serial, etc. While this series argues for a distinction between recovery and harm reduction, Bill White has described paths that can be considered precursors (precovery) to full recovery.

Recovery is possible for any person with addiction. ROHR refuses cultural, institutional, or professional pressures to treat any sub-population as incapable of recovery. ROHR recognizes the humbling experiential wisdom that many recovering people once had an abysmal clinical prognosis.

All services should communicate hope for recovery. ROHR recognizes that hope-based interventions are essential for enhancing motivation to recover and for developing community-based recovery capital. Practitioners can maintain a nonjudgmental and warm approach with active AOD use while also conveying hope for recovery. All ROHR services should inventory the signals they send to individuals and the community. As Scott Kellogg says, “at some point, you need to help build a life after you’ve saved one.”

Incremental and radical change should be supported and affirmed. As the concepts of gradualism and precovery indicate, recovery often begins with small incremental steps. These steps should not be dismissed or judged as inadequate. They should be supported and possibly even celebrated and they should never be treated as an endpoint. Likewise, radical change should not be dismissed as unrealistic or unsustainable pathology.

ROHR looks beyond the individual and public health when attempting to reduce harm. ROHR wrestles with whether public health is being protected at the expense of people with addiction, whether harm is being sustained to families and communities, and whether an intervention has implications for recovery landscapes.

ROHR should aggressively address counter-transference. ROHR recognizes a history of providers imposing their own recovery path on clients while others enjoy vicarious nonconformity or transgression through clients. These tendencies should be openly discussed and addressed during training and ongoing supervision.

ROHR refuses to be a counterforce to recovery. ROHR seeks to be a bridge to recovery and lower thresholds to recovery rather than position itself as a counterforce to recovery. Recognizing that addiction/recovery has become a front in culture wars, ROHR seeks to address barriers while also being sensitive to the barriers that can be created in this context. When ROHR seeks to question the status quo, it is especially wary of attempts to differentiate from recovery that deploy strawmen, recognizing that this rhetoric is harmful to recovering communities and, therefore, to their clients’ chances of achieving stable recovery.

ROHR sees harm reduction as a means to an end. ROHR views harm reduction as strategies, interventions, and ideas to reduce harm. As such, it is wary of harm reduction as a philosophy or ideology, which sets the stage for seeing harm reduction as an end unto itself. Back to Scott Kellogg’s point, “at some point, you need to help build a life after you’ve saved one.” The end we seek is recovery, or restoration, or flourishing. Seeing harm reduction as a philosophy or ideology risks viewing it as “the thing” rather than “the thing that gets us to the thing.”

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