What we can learn from the tragedy of Audrey Kishline: the case for harm reduction
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 don’t work and that what alcoholics need is AA. However, in the interest of getting a good story, the press tended to leave out some of the facts.
On January 20, 2000, Mrs. Kishline resigned as Executive Director of Moderation Administration and began attending AA and adopted the goal of abstinence from alcohol. However, Mrs. Kishline was not successful in AA. During her time in AA, Mrs. Kishline used to drink heavily. The final binge led to her arrest for vehicular manslaughter and a four-year prison sentence.
Was Mrs. Kishline an oddball or an oddity for binge drinking while attending AA? Actually, this is not the case at all. Although AA is a good option for some people, it has been shown to be inappropriate for many others. In a 1980 study by Brandsma et. paraca Drunk drivers referred to AA for treatment were found to be more likely to drink excessively than a control group receiving no treatment. The results were statistically significant.
Should we blame Moderation Management for Ms. Kishline’s car accident? No problem. Moderation Management is an evidence-based program that has been successful for a large 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 do not stay within these limits leave MM and find another program instead. Many people manage to maintain these limits and moderation management is a good option for these people.
However, Moderation Management was not a good fit for its founder, Audrey Kishline. In a Dateline NBC interview broadcast on September 1, 2006, Ms. Kishline admitted to secretly drinking heavily for the past five years as CEO of Moderation Management. Mrs. Kishline had put herself in an untenable position where there was no way to clear up 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]There is a therapeutic approach that is applied 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. HAMS Harm Reduction Network emerged in 2007 to offer support to drinkers based on harm reduction principles.
Audrey Kishline’s true demon was perfectionism, a perfectionism that could only see perfect abstinence or perfect moderation as a possible goal. Harm reduction is an approach that avoids perfectionism. The following is a paraphrase of the UK Harm Reduction Alliance definition of harm reduction, which has been adopted to fit alcohol consumption:
* Is pragmatic: and accepts that alcohol consumption is a common and enduring feature of the human experience. It recognizes that while it carries risks, alcohol use provides benefits to the drinker that must be considered for responses to alcohol use to be effective. Harm reduction recognizes that the containment and reduction of alcohol-related harm is a more feasible option than efforts to eliminate alcohol use altogether.
* Prioritizes goals: Harm reduction responses to alcohol use incorporate the notion of a hierarchy of goals, with an immediate focus on proactively engaging individuals, target groups and communities to address their most pressing needs through the provision of accessible and user-friendly services. Achieving more immediate realistic goals is considered an essential first step toward safe alcohol use or, if appropriate, abstinence.
* It has humanistic values: the drinker’s decision to drink alcohol is accepted as fact. No moral judgment is made to condemn or support alcohol consumption. The dignity and rights of the drinker are respected and the services strive to be “user friendly” in the way they operate. Harm reduction approaches also recognize that, for many, dependent alcohol use is a long-term feature of their lives and that responses to alcohol use must 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 is often the drinking behavior of the drinker. However, harm reduction recognizes that people’s ability to change behaviors is also influenced by the norms shared by drinkers, attitudes and views of the wider community. Therefore, harm reduction interventions can be targeted at individuals, communities, and society at large.
* Does not focus on abstinence: Although harm reduction supports those seeking to moderate or reduce their alcohol consumption, it does not preclude or presuppose 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 evaluating the relative importance of alcohol-related harm and balancing costs and benefits in trying to reduce them.
What we can learn from the Audrey Kishline tragedy is that neither abstinence-based nor moderation-based programs are sufficient on their own to address the problem of alcohol abuse. In addition to such programs, there is also a need for harm reduction based approaches.