For people with co-occurring mental health and substance use disorders, abstinence-oriented treatment may do more harm than good

Dorothy Bond (not her real name) was a self-described methamphetamine addict living with bipolar and borderline personality disorders. Ten years ago, she found mental health treatment that did not demand sobriety—and for Bond, who had been struggling to manage her co-occurring mental illness and substance use disorder (SUD) for decades, it felt like a ray of hope—a realistic path toward recovery.

Few SUD treatment programs are equipped to treat psychiatric conditions, and many mental health providers require abstinence as a condition of treatment. This program, on the other hand, was rooted in the principles of harm reduction—meeting people where they are to provide knowledge and resources that empower them to make safer choices that are good for their health, even if that means continuing to use drugs or alcohol. By the time Bond learned of this program, she had been participating in author Stacey McKenna’s then-ongoing study of methamphetamine use and survival for a couple of years.

During one of their regular check-in phone calls, she explained her enthusiasm: “Of course, they don’t want me to come to group spun out [because some people are sober]. But the fact that I still use meth on my own time, that’s not a problem. I can still come; I can still take care of my mental health.”

For people like Bond, whose drug use is deeply intertwined with emotional, psychological and material survival, abstinence is not only not the only answer, but it may not even be the best solution. Rather, a harm reduction-driven ethos that values and supports all positive shifts in behavior can drastically improve, and even save, people’s lives. For example, stand-alone harm reduction interventions such as syringe service programs have been around for decades and significantly reduce the incidence of infectious disease and overdose while also connecting clients to social and mental health programs, including drug treatment.

When this perspective replaces abstinence in SUD treatment—as with medications for opioid use disorder—health, recovery and employment opportunities improve, while run-ins with the law decline. Yet it remains difficult to find providers who take this kind of approach when mental health conditions are involved. It’s time for that to change.

A Tragic Combination of Disorders

Approximately 1 in 3 adults in the United States deals with mental health or substance abuse issues, and a sizable proportion of these people—between 25% and 50%—struggle with both. When these disorders occur together, there can be big consequences. For example, individuals with co-occurring disorders are significantly more likely to experience homelessness in their lifetime. Furthermore, adults with dual diagnoses are 12 times more likely to be arrested compared to those with neither a substance use nor a mental health disorder, and six times more likely to be arrested than people living with just a mental illness.

For most of her life, Bond struggled with the already complicated intersections of mental illness and poverty. She suffered severe insomnia, and when sleep did come, she often woke in a sweat due to night terrors that sprang from decades of trauma. When life’s stressors escalated—say, in the wake of a breakup—it triggered unmanageable impulsivity, which could take the form of one-night stands, excessive spending or shoplifting. Alternatively, she sometimes fell into a deep depression, turning inward, rebuffing friends, lacking the energy to engage in the hustle necessary to make ends meet. Every winter, she “lost” weeks of memories, often waking at truck stops or on buses with no recollection of how she arrived.

It wasn’t until her mid-30s that Bond began using methamphetamine. A single mother, she found that the drug helped her work long hours driving trucks to pay the bills and support her two young children, but she continued to struggle to maintain housing. Her meth use, it turned out, also provided authority figures with an explanation for her slips into homelessness and occasional shoplifting (the combination of which cost her custody of her children). With no perceived need to look deeper, Bond was not diagnosed with a mental illness until she arrived in Colorado in her early 50s, despite the fact she had been living with the above symptoms for years prior to trying methamphetamine.

This is likely due in part to the fact that diagnosing and treating co-occurring mental health and substance use disorders is incredibly challenging. With only limited research currently available, historical evidence suggests that only about 2 in 5 adults with dual diagnoses receive treatment that addresses either their mental health or substance use issues, and just 1 in 10 receive treatment for both.

Those with dual diagnoses who do receive substance use treatment are often dissatisfied with the quality of their care, are less likely to complete treatment, and tend to have worse recovery outcomes compared to their counterparts without co-occurring conditions. One reason for this may be that the current landscape is not designed for specialized care of co-occurring disorders, although truly integrated care has proven to be superior compared to separate treatment for each condition.

But it may also be about the rigid attachment to abstinence-based approaches among many SUD and mental health treatment providers. Surveys of substance use treatment providers show that few accept non-abstinence as an appropriate intermediate or final goal for people with substance use disorder or dependence, regardless of whether they have a dual diagnosis. Many providers’ preference for abstinence has been linked to a range of factors, including personal and family experience with substance use, past clients’ unsuccessful attempts to use harm reduction-based approaches to recovery, and stigmatization of addiction.

minority of residential SUD treatment facilities offer any medications for opioid use disorder. And of the nearly 15,000 U.S. centers that treat co-occurring mental health and SUD, roughly half do not even allow smoking or vaping anywhere on the facility campus.

On the other hand, people living with dual diagnoses often have management or reduction—not abstinence—as a primary treatment goal. One study conducted among people living with both a mental health condition and an opioid use disorder found that between 22% and 30% of those who desired substance use treatment were not ready to stop using or feared coercive treatment. Both factors, in turn, had served as major barriers to seeking care in the first place.

Good Intentions, Failed Treatment

Immediately after receiving her initial mental health diagnoses, Dorothy Bond worked with psychiatrists to find the right medications and optimize doses to manage symptoms and minimize side effects. During those first few years, therapists and doctors repeatedly told her that she needed to quit using methamphetamine if she wanted to continue treatment or to attend group therapy sessions.

In years of interviews, Bond repeatedly expressed a desire to have more control over her life and her drug use. But she was neither ready nor able to quit using methamphetamine entirely. It was too deeply embedded in her life and sometimes contributed to her well-being in meaningful ways. Meth often served as a way to cope with the growing pain she suffered as the result of decades of severe physical, emotional and psychological abuse. In addition, Bond’s status as a meth user sometimes facilitated her everyday survival, providing a doorway into social and emotional support networks that ensured everything from a shoulder to cry on to odd jobs and safe places to spend the night.

During the five-plus years that McKenna spent with Bond—conducting interviews and observing her daily life—it was clear that factors such as loss of housing triggered a return to chaotic drug use more often than drug use led to housing instability. Thus, when mental health providers required sobriety, it prompted Bond to lie or skip appointments altogether, both habits that hurt her mental health and substance use recovery efforts.

While the insistence on abstinence as a condition of treatment may stem from good intentions, it fails to acknowledge the complex realities in which problematic substance use and mental illness tend to coexist, thus creating a treatment environment that alienates many who desire and could use help. After all, despite popular assumptions that people primarily use drugs to get “high,” that’s frequently not true. Extensive research, memoirs and journalistic accounts highlight myriad ways that drugs are employed as tools in everyday life, from basic material survival to performance enhancement to the explicit and specific management of mental health symptoms prior to or during treatment.

The Benefits of Harm Reduction

Consequently, it is unsurprising that many people with dual diagnoses do not view abstinence as their goal. While some people may want to completely abstain from substance use as part of their treatment, many do not. As such, therapeutic efforts that require abstinence for those who are not ready for or interested in giving up all substance use end up holding psychiatric care (or other health-related services) hostage. Such an approach either excludes an entire subset of patients, drives poorer adherence and higher dropout rates, or amounts to coercive SUD treatment, which comes with plenty of its own harms.

Data indicates that compulsory treatment leads to mixed recovery outcomes—such as issues with treatment retention and post-treatment substance use—at best. Furthermore, involuntary SUD treatment has been shown to increase risk for overdose and suicide upon discharge. For mental health conditions, involuntary treatment also shows mixed outcomes, and medical ethicists generally advocate for its use only in a very narrow range of situations.

On the other hand, treatment that is rooted in a harm reduction ethos allows people to reduce the quantity or frequency of substance use with the goal of minimizing or even eliminating the negative outcomes associated with that use. For people living with co-occurring mental health and substance use disorders, such an approach can be life-changing, perhaps even lifesaving.

Shortly after Bond found a dual diagnosis therapy group that did not require her to give up methamphetamine use as a condition of treatment, her life began to look up. The consistent support she derived from the meetings, coupled with increased transparency and openness with psychiatric providers, improved her general well-being. In the months that followed, Bond’s methamphetamine use declined in both quantity and frequency, and she felt more controlled and less compulsive about her decisions whether and when to use. In addition, her mental health stabilized considerably.

Contrary to the standard orientation toward abstinence in SUD treatment, stabilization of symptoms is often the desired outcome for mental health conditions. Complete remission of symptoms may not be possible in every case, so people are often classified as being “in recovery” from a mental illness while still experiencing symptoms. This is essentially a harm reduction stance.

Another way in which mental health care incorporates harm reduction is by respecting patient autonomy and allowing for shared decision-making about treatment. For example, non-adherence to antipsychotic medication can be a challenge while treating psychosis. Patients may not take their prescribed medicine for a number of reasons, including undesirable side effects and perception of the medication’s efficacy. A clinician who takes a harm reduction approach to this challenge might respect a patient’s desire to stop taking their medication, discuss the risks associated with this decision, provide alternative treatment options, and help them reduce the negative side effects of abruptly stopping the medication by instead tapering the dose.

Both mental health conditions and substance use disorders are chronic health issues. Unlike with an infectious disease, there is no medication that wipes away the symptoms or causes. Thus, treatment is about managing symptoms, reducing risk and harm, and empowering people to appropriately deal with challenges via a range of tools and coping mechanisms. For individuals living with co-occurring disorders, integrated care and options rooted in harm reduction can change the course of their lives. Nonetheless, such programs remain relatively scarce, and many people living with dual diagnoses may find themselves constantly navigating not just their symptom management but their ability to access effective treatment.

As McKenna’s study wound down, Bond’s quality of life was improving: She had moved off the affordable housing waitlist into her own apartment, expanded her social network to include many people who did not use meth or other drugs, and was establishing a renewed relationship with her children. Harm reduction-based treatment provided her with new tools and unconditional support, allowing her to prioritize her mental well-being. But managing life with a dual diagnosis is an ongoing process, and although Bond’s circumstances and well-being had improved in many ways, that new apartment was in a different town more than 30 miles away, and she lacked a vehicle or money for gas. Thus, just as things were looking up for Bond, access to the very program that had been so beneficial declined, leaving her future uncertain, like that of so many people struggling with dual diagnoses.

Harm reduction is an approach that has been proven time and again to work for many people and is applicable across a range of health conditions and risky behaviors. But Bond’s story shines a light on the problems in our current system: We must recognize the limitations of abstinence-only recovery, and work to expand the availability and accessibility of harm reduction-based treatment for people living with co-occurring mental health and substance use disorders. Doing so would increase the ability of Bond and others like her to not just find but maintain an upward trajectory of more stable living and better mental and physical health.