Virtually everyone, like it or not, undergoes drug experiences within which they must learn to steer a sober course. This demands an understanding of the term “sober” that differs from the one commonly understood.

We are not living in a “dry” era.  Alcohol use is a widespread and increasingly high-end activity. Marijuana has been legalized for much of the country. Psychedelic therapies are newly reinvigorated. Tens of millions of us use opioids for pain, and many more for pleasure. And then there is the ever-growing use of psychiatric drugs in America, including by children and adolescents.

The Abstinence Argument

Abstinence is the traditional American treatment goal for substance use disorders. And while many therapists, particularly those with 12-step backgrounds, continue to tout abstinence as essential, several factors have challenged its position at the top of the treatment goal hierarchy.

Supporters and opponents of abstinence-only approaches argue along the following lines:

Point: Abstinence provides a clear and unambiguous treatment target.

Counterpoint: People will refuse treatment altogether rather than quit entirely.

Point: In order to participate constructively in therapy, the mind and body must be clear of intoxicants.

Counterpoint: While living in a monastery or being in rehab allows people to abstain, living in the real world constantly exposes people to substance use.

Point:  Some drugs create an intense rush that users must dissociate from in order to recalibrate their pleasure responses as a necessary step to sobriety.

Counterpoint: Since the majority of drug-dependent people cease their addictions on their own, without treatment, then obviously drugs don’t overpower people’s free will.

Point: Giving in to the urge to use one drug reduces overall willpower strength, according to Roy Baumeister and John Tierney’s best seller, Willpower.  

Counterpoint: While avoiding one substance may be called for, the user may have little cross tolerance or susceptibility to problems with use of other drugs.

Real life often blurs these polarizations, demonstrating that sobriety—like drug use itself—occurs along spectrums.

One point that illustrates the double-edged nature of drug use and reliance might be endorsed by both abstinence advocates and balanced harm reductionists reluctant to see pharmaceutical treatments as panaceas: People on antidepressant, bipolar and other prescribed medications often encounter problems with using the drugs, causing frequent dosage and medication adjustments, and including pathological withdrawal if they quit.

A Self-Labeled “Recovering Alcoholic” Smokes Pot

Joyce, who now lives in California, drank heavily as a teenager, quitting in her early 20s. She attended Alcoholics Anonymous, remade herself, and moved far away from her home state in the East. Over the years, she smoked pot and took medication as indicated for pain or sleep or anxiety, but with a wary eye on her penchant for addiction. She succeeded in not using any drugs other than alcohol excessively or addictively.

Joyce developed severe depression, which antidepressants relieved. Eventually, however, she worried that she had become dependent on the medication, so she stopped. Joyce is also prescribed and occasionally takes anti-anxiety medication, which she uses sparingly due to her fear of addiction.

Joyce does not avoid opioids, despite her wariness about her addictive tendencies. She finds them helpful for her moods, but understands that she shouldn’t rely on opioids for mood modification when she is prescribed the drugs for pain.

She navigates her use according to her mood, her life and her here-and-now reactions.

Although some cannabis advocates would say that she is using marijuana therapeutically, Joyce views her use of that drug as strictly recreational and only uses it at night. Using cannabis in this way doesn’t interfere with her work or other life functions, and she feels she can take it or leave it on any given night depending on her mood and what she’s doing.

Keep in mind that Joyce remains completely abstinent—and considers herself “sober”—with regards to alcohol, per her AA dictates. With other drugs, prescribed and recreational, however, she navigates her use according to her mood, her life and her here-and-now reactions.

Widespread Drug Use by Formerly Addicted People

As a self-described “recovering alcoholic,” Joyce is far from being sober by strict 12-step standards. According to her former AA cohorts, Joyce is living in dangerous territory. She uses mood-altering substances for fun and she continues to take a variety of psychoactive medications. She also no longer attends meetings. Yet she is solid in her conviction that she is now a sober individual, and proud of it.
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Joyce is in many ways a prototype of the modern American polydrug user. Her life calls into question the meaning of the terms abstinence, sobriety and recovery. Of course, even the most hard-core abstinence proponents often don’t include cigarettes and coffee in their sobriety calculus, although both are potentially addictive and can have serious negative health consequences.

The majority of formerly dependent drug users didn’t even abstain from their “drug of choice.”

And data suggest that Joyce’s case is very typical, even if it differs from the conventional American view of “recovery.” A well known 2012 survey from the New York Office of Substance Abuse Services and the Partnership at Drugfree, for example, indicated that 23 million Americans (10 percent of adults) were “in recovery.”

But here is the question those respondents were asked: Did you once have a problem with drugs or alcohol, but no longer do?

There’s nothing in there about abstinence in regards to their problematic drug, let alone all psychoactive substances. Evidence suggests that the number of “recovering” people who abstain entirely from all drugs and alcohol is quite low. According to Filter contributor Maia Szalavitz, writing from experience, “for some, recovery is a members-only club for people who are totally abstinent. That leaves most of us out in the cold.”

One oft-cited, major study, called NESARC, found that among the largest single category of formerly dependent drug users—alcohol drinkers—more than half of those who fully recovered drank at low-risk levels without symptoms of alcohol dependence. That is to say, the majority didn’t even abstain from their “drug of choice” (alcohol).

It is clear that for most Americans, contra the dominant recovery narrative, sobriety and abstinence are very different things.

Despite this reality, there is a heated debate among 12-step adherents about taking medications—allegiances to abstinence precepts range from rejecting all medication, including even over-the-counter drugs like Benadryl, Afrin and Sudafed, to accepting prescribed medications, to believing use of anything that isn’t your drug of choice is okay (like Joyce’s controlled cannabis use).

And this is before even considering the modern harm reduction movement’s scope, including moderate use of a substance to which you were formerly addicted, substituting a regulated drug like buprenorphine or methadone for heroin, and even continuing addictive or binge use under safe conditions—e.g., using heroin with clean needles or in a safe consumption site, or continuing to drink heavily but safely in “wet housing.”

How to Apply This Knowledge to Helping

True harm reduction-oriented therapeutic programs instead focus on underlying, fundamental factors in discussing continued substance use with people who have been diagnosed with—or who themselves believe that they have—a substance use disorder.

These six recommendations entail both clients and helpers:

1. Be open to, and consider all, substance use options: abstinence, substitution or replacement with other substances, moderation, safer use, occasional or regulated addictive or intense use—and the same person can have different goals with different substances.

2. Remain mindful of—and review—experienced outcomes (this opposes the idea of “denial,” taken to mean that clients cannot accurately report their substance-use experiences).

3. Measure the success of treatments against actual life functions—work, family and friends, and especially subjective client feelings.

4. Avoid labeling substance use pejoratively as addictive, bad, or equally as harmful in all forms or methods of use.

5. Consider first and foremost client values and preferences by using motivational techniques in use decision-making.

6. Change is continual—the person, their situation, and the interchange between them are always in flux. There is no perfect, fixed answer to substance use issues.

With the advent of the internet, we stand at a new frontier of almost infinitely available substances. It does no good to regret or bemoan this reality.

In a sense, we are at the final societal stage of what therapists should regard as the goal in all therapy: realizing the clients’ agency and freedom of choice in devising their best selves.

Help Illuminate a person’s best way—their unique path and purpose in life—with and without regard to their substance use profile.

Allowing people to feel safe in openly discussing their lives with drugs with their counselors and providers—to convey what it is they think they are doing rather than what their counselor thinks they should be doing—increases trust and allows for a truly collaborative helping relationship.

Such a therapeutic alliance encourages the client’s sense of agency. A path of empowerment through clients’ self-identification of their individual values and goals is the ultimate objective in this new conception of sobriety, as detailed by Stanton Peele and Zach Rhoads in Outgrowing Addiction: With Common Sense Instead of “Disease” Therapy.

It’s not a therapist’s or other helper’s job to identify how someone should live. Rather, it is to collaborate in exploring and helping to illuminate a person’s best way—their unique path and purpose in life—with and without regard to their substance use profile.

Perhaps we should celebrate the availability of a modern cornucopia of substances for driving the most important element of freedom, personal autonomy, home.

Photo by Joshua Eckstein on Unsplash

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