On March 25, 2000, Moderation Management founder Audrey Kishline killed two people while driving drunk on I-90 in Washington State. The press had a field day proclaiming that this was proof that moderation programs do not work and that what alcoholics need is AA. However, in the interests of getting a good story the press tended to leave out some of the facts.
On January 20, 2000 Ms. Kishline had resigned as Executive Director of Moderation Management and had begun attending AA and adopted a goal of abstinence from alcohol. However, Ms. Kishline was not successful at AA. During her stint in AA Ms. Kishline was frequently binge drinking. The final binge led to her arrest for vehicular manslaughter and a four year prison sentence.
Was Ms. Kishline a freak or an oddity for binge drinking while attending AA? This is actually not the case at all. Although AA is a good fit for some people it has proven to be a poor fit for many others. In a 1980 study by Brandsma et. al. it was found that drunk drivers remanded to AA for treatment were more likely to binge drink than a control group receiving no treatment at all. The results were statistically significant.
Should we blame Moderation Management for Ms. Kishline’s auto crash? Not at all. Moderation Management is an evidence based program which has been successful for quite a number of people. The Moderation Management limits are no more than 14 standard drinks per week and no more than 4 per day for men, and no more than 9 standard drinks per week and no more than 3 per day for women. Moderation Management suggests that people who fail to remain within these limits leave MM and pursue another program instead. Many people are successful at maintaining these limits and Moderation Management is a good fit for these people.
However, Moderation Management was not a good fit for its founder Audrey Kishline. In a Dateline NBC interview aired September 1, 2006 Ms. Kishline admitted to secret binge drinking during her last five years as executive director of Moderation Management. Ms. Kishline had put herself into an untenable position where there was no way to come clean about the struggles she was having with alcohol.
Since neither AA nor Moderation Management was a good fit for Audrey Kishline, what else could she have done? Commenting on the Kishline tragedy Stanton Peele said “[T]here is a therapeutic approach that applies in such situations–harm reduction.” In the year 2000 there were no harm reduction-based support groups for people who drank alcohol. Fortunately this is no longer the case. The HAMS Harm Reduction Network emerged in 2007 to offer support for drinkers based on the principles of harm reduction.
Audrey Kishline’s real demon was perfectionism–a perfectionism which could only view perfect abstinence or perfect moderation as a possible goal. Harm reduction is an approach which avoids perfectionism. The following is a paraphrase of the UK Harm Reduction Alliance’s definition of harm reduction which has been adopted to fit alcohol use:
* Is pragmatic: and accepts that the use of alcohol is a common and enduring feature of human experience. It acknowledges that, while carrying risks, alcohol use provides the drinker with benefits that must be taken into account if responses to drinking are to be effective. Harm reduction recognizes that containment and reduction of alcohol-related harms is a more feasible option than efforts to eliminate alcohol use entirely.
* Prioritizes goals: harm reduction responses to drinking incorporate the notion of a hierarchy of goals, with the immediate focus on proactively engaging individuals, targeting groups, and communities to address their most compelling needs through the provision of accessible and user friendly services. Achieving the most immediate realistic goals is viewed as an essential first step toward risk-free drinking, or, if appropriate, abstinence.
* Has humanist values: the drinker’s decision to drink alcohol is accepted as fact. No moral judgment is made either to condemn or to support use of alcohol. The dignity and rights of the drinker are respected, and services endeavor to be “user friendly” in the way they operate. Harm reduction approaches also recognize that, for many, dependent drinking is a long term feature of their lives and that responses to drinking have to accept this.
* Focuses on risks and harms: on the basis that by providing responses that reduce risk, harms can be reduced or avoided. The focus of risk reduction interventions are usually the drinking behavior of the drinker. However, harm reduction recognizes that people’s ability to change behaviors is also influenced by the norms held in common by drinkers, the attitudes and views of the wider community Harm reduction interventions may therefore target individuals, communities and the wider society.
* Does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drinking, it neither excludes nor presumes a treatment goal of abstinence. Harm reduction approaches recognize that short-term abstinence oriented treatments have low success rates, and, for many lead to binge drinking.
* Seeks to maximize the range of intervention options that are available, and engages in a process of identifying, measuring, and assessing the relative importance of alcohol-related harms and balancing costs and benefits in trying to reduce them
What we can learn from the Audrey Kishline tragedy is that neither abstinence-based programs nor moderation-based programs are enough in and of themselves to deal with the problem of alcohol abuse. In addition to such programs there is also a necessity for harm reduction-based approaches.