I first heard the term “dialectical abstinence” in the summer of 2019, several weeks into an intensive outpatient program (IoP) for opioid use disorder offered in South Florida by Memorial Outpatient Behavioral Health. The concept was presented as a combination of abstinence and harm reduction: maintaining total abstinence from all non-prescribed opioids as the ultimate goal, but viewing any failures to meet that goal through a harm reduction lens.
It sounds okay—great, even, for patients who genuinely want to pursue abstinence. The problem was the application.
The program was designed to help patients achieve abstinence through the use of a slow buprenorphine taper, expected to be completed over the course of about a year. This was coupled with individual and group therapy that also decreased in frequency—from five hours, six days a week to an eventual one hour a week.
A recurrence of use should be viewed, we were told, as a source of learning and growth. Then staff would read off the list of patients who had to pee in a cup.
The group styles varied. Some were led by peer support counselors and typically explored the 12 Steps. Others were led by a pharmacist and taught us about medication and biology. Most were taught by a rotation of licensed clinical social workers who brought their own personal slants to emotional regulation, relapse prevention and other related issues.
Counselors stressed that we had a medical condition, that our use was not the result of a moral failing, and that we should work through feelings of shame rather than obsessing over our past actions. A recurrence of use—virtually always discussed as a hypothetical event—should not, we were told, be viewed as a life-shattering failure, but as a source of learning and growth. Then, at the end of group, staff would read off the list of patients who had to pee in a cup that day.
Given how unfamiliar I previously was with “dialectical abstinence,” I reached out to several experts to ask whether they’d heard of it. No one I spoke with—including several doctors and counselors with decades of experience in both clinical work and research—had heard the specific term. But when I described it as a combination of abstinence goals and harm reduction in a treatment setting, most recognized the general concept.
Brooke Feldman, MSW, who has over a decade of experience of social work within Philadelphia’s behavioral health system, wondered whether it could be related to the similarly titled “dialectical behavior therapy” (DBT). DBT was originally designed as a treatment for borderline personality disorder but is now utilized for a variety of health concerns. Essentially, it teaches patients how to notice and observe harmful thoughts and feelings, and then choose how to engage with them instead of instantly reacting. It is intended to help patients better cope with change and stress while learning how to accept themselves, flaws and all.
Some available information support Feldman’s supposition. In a 2015 article by Jeremy Schwartz, LCSW about the use of DBT for managing drug addiction, the practice of dialectical abstinence is described as “[helping] the person in therapy to do everything possible to achieve abstinence, while also supporting a harm-reduction approach when relapse happens.” That article cites a 2008 paper published in the journal Addiction Science & Clinical Practice, according to which: “Several randomized clinical trials have found that DBT for Substance Abusers decreased substance abuse in patients with borderline personality disorder. The treatment also may be helpful for patients who have other severe disorders co-occurring with SUDs or who have not responded to other evidence-based SUD therapies.”
Memorial and Schwartz did not respond to Filter’s requests for further comment about this model by publication time.
Are “affirmations of absolute abstinence” compatible with “radical acceptance”?
A slideshow published online by Jeana Johnson, an Ohio-based recovery coach, describes dialectical abstinence as “an intervention program that teaches individuals how to synthesize the addict’s thoughts and behaviors with affirmations of absolute abstinence, radical acceptance, nonjudgmental problem solving, and perpetual plans for relapse prevention.”
Are “affirmations of absolute abstinence” compatible with “radical acceptance”—a term often used to describe the core philosophy of harm reduction?
Feldman said it could work in an addiction treatment setting, if “rather than forcing people to practice abstinence when they’re not at that place…[the program is] really supporting people to make choices for themselves about their [drug] use and deciding for themselves about whether abstinence or moderation is the path for them.”
“I don’t think it’s a good overall goal,” said Justine Waldman, MD, the medical director of REACH, a harm-reduction centered health hub in New York. She had also never heard of dialectical abstinence but was responding to my description of what I experienced. “But it could be a good option for the right patient. For someone who’s motivated by abstinence, that might be really helpful.” When I asked her to outline a hypothetical dialectical abstinence practice, she emphasized the necessity of it being one of many choices, and of utilizing an individualized treatment plan shaped by the patient.
Harm reduction has always included abstinence as one of the goals it seeks to support. The Harm Reduction Coalition states that “Harm reduction incorporates a spectrum of strategies from safer use, to managed use to abstinence to meet drug users ‘where they’re at,’ addressing conditions of use along with the use itself.” The key distinction, however, is that abstinence is one of the goals it seeks to support—not the only or ultimate goal.
The concept of dialectical abstinence enjoys some official support. A slideshow published by the Florida Department of Children and Families Office of Substance Abuse and Mental Health describes it as a theory that combines DBT and substance use disorder treatment, specifically aimed toward people with co-occurring borderline personality disorder and SUD.
Although that doesn’t perfectly match the program I attended, the goals and practices described in the slideshow are similar. The goals are centered around attaining a state of “clear mind”—a phrase frequently used at Memorial.
According to Johnson’s presentation, “the clear mind concept appreciates the importance of abstinence-maintenance skills, mindfulness of cravings, and acceptance of the anxiety that comes with committing to abstinence for success.” It is a state of social functionality and mental clarity; the “normative” equilibrium that allows patients to engage in healthy, everyday life processes without relying on a daily IoP practice to remain abstinent.
In practice, at Memorial, this looked like group sessions geared toward emotional regulation. We were taught anger management skills, ways to identify whether our emotional reactions were appropriate, and skills for dealing with grief and sadness. We were shown ways to experience enjoyment without the use of substances. In that way, we were taught emotional harm reduction.
Some of the skills we learned were genuinely helpful, particularly those centered around emotional regulation. But the skill-set was finite; eventually, attending groups daily meant repeating lessons. And the obsessions with abstinence felt dismissive in a group of people who had been using substances to cope for years, some for decades, and may not all have been fully committed to stopping, even if most of us wanted to decrease or discontinue our chaotic opioid use. Harm reduction as applied to future or current drug use was virtually taboo.
That day, it became clear that staff controlled the version of harm reduction doled out—and that anything that did not explicitly encourage abstinence was unwelcome.
One day at Memorial I mentioned to the pharmacist that I thought it was a good idea for staff to tell patients that if they use while maintained on buprenorphine, they don’t have to wait to go into withdrawal before taking their next buprenorphine dose. I thought this information could help prevent patients from going on long runs of illicit opioid use, and help patients avoid unnecessary discomfort or even overdose.
The next day, a group of staff—including my individual counselor and the rarely-seen program administrator—brought me into a room and accused me of trying to teach patients how to overdose. They threatened to block me from attending groups, and I had to convince them that I did not have nefarious intentions and was benefiting from the program before they would relent.
That day, it became clear that staff controlled the version of harm reduction that was doled out to patients—and that anything that did not explicitly encourage abstinence was unwelcome. Abstinence was clearly the most important outcome at this facility. Harm reduction was just an afterthought, a way of interacting with a relapse once it had occurred.
Patients who used—even just once or twice—were often threatened with inpatient referrals. Several people in the groups were returning from inpatient stints that had been the outcome of that very scenario.
For me, the end came when I missed a few days of treatment due to the flu. When I returned, I was denied a dose of buprenorphine due to my inability to pee while being watched. After that, I ended up copping a hit of dope to stave off the inevitable withdrawal. I informed my counselors about my lapse the next day, hoping that this would illustrate my need for treatment, which I wanted. Instead, I was discharged.
When it comes to addiction treatment in general, abstinence is often dangled as the One True Outcome, like some religious mandate. Jeff Deeney, a writer and social worker, recalls accepting a counseling position at a publicly funded buprenorphine rehab program in Philadelphia a few years back. He described the majority of clientele as people with long use histories, many of whom were living on the streets, and most of whom were mandated or pressured into the program through some authority—whether criminal justice, family court or relatives.
“The pressure for abstinence is total … so to sit inside that environment and say ‘I’m going to do harm reduction’ becomes the question of, ‘What does that mean? What can I do here?’”
The program required patients to seek total abstinence from all non-prescribed substances, but when Deeney asked them whether that was what they truly wanted, most patients said no.
With their goals in mind, he began teaching them the principles of harm reduction, shaping his group therapy sessions around different practical methods to keep them safe.
But, Deeney admitted, it sometimes felt like a futile charade. “The pressure for abstinence is total,” he said. “The state of Pennsylvania wants it, the court wants it, the site itself wanted it, the funding source wanted it, so to sit inside that environment and say ‘I’m going to do harm reduction’ becomes the question of, ‘What does that mean? What can I do here?’”
Deeny’s observation is true of facilities all over the United States. I can’t tell you how many times staff at Memorial reiterated that their funding relied upon abstinence being the goal. That didn’t mean they had to send patients away if their urine screen came back positive one time, but it did mean that they were required to show that all patients were making substantial progress toward total abstinence.
Where does harm reduction factor into that?
“The challenge is you have this treatment industry that has very much colluded with the criminal justice system and the child welfare system and are sometimes expected to carry out the goals of these systems instead of the goals of the person coming for treatment,” said Feldman. “Sometimes you just have to be creative.”
It’s possible that dialectical abstinence is exactly that: an attempt to creatively sneak harm reduction principles into abstinence-based treatment settings, so that the onus does not have to fall on individual counselors like Deeney, who risk their jobs and reputations by acting as lone-wolf radicals up against the Goliath treatment industry.
If so, it’s not the worst idea, but as Waldman emphasized, it only works if patients are given agency in their treatment goals and design—something I was not afforded at Memorial.
A more pessimistic reading would be that such programs merely pay lip-service to harm reduction, in order to portray themselves as forward-thinking while remaining committed to an abstinence-only mindset.
Unfortunately, if funding requires abstinence; if patients have to feign a desire for total abstinence in order to gain access to evidence-based medicines; if people have to discontinue drug use in order to stay out of jail or keep their children; if people are already stripped of agency before they get to treatment, then slipping whispers of harm reduction and self-love into these programs might be little more than a token gesture.