Client Experiences of Abstinence-Only Substance Abuse Treatment: Are You Not Working the Program or Is the Program Not Working for You?

Background and Purpose:Substance abuse treatment is characterized by high drop out rates and lower access to treatment among certain racial and ethnic minority groups. The dominant model of service delivery in the United States is abstinence-only, a high-threshold model requiring abstinence for participation. Attunement to what “doesn’t work” for clients – from the client point-of-view – is often dismissed which may further distance clients from needed services. This paper explores client reports of disengagement from abstinence-based social services to explore the way in which the paradigm of mandatory abstinence may act as a barrier to access. Understanding why clients elect to disengage from services has implications for our efforts to increase access and enhance engagement in substance abuse treatment. 

Methods:Data for this paper is derived from a larger descriptive study of the impact of participation in two harm reduction (i.e., non abstinence-based) programs -- one an urban drop-in center for homeless active users and the other a private practice center for clients with the ability to pay for services. Interviews were digitally recorded, transcribed, and analyzed using a grounded theory approach. This paper reports on 32 participant responses to qualitative questions about past treatment experience. Program participants at the drop-in center were mostly male (60%), African American (60%), and White (40%).  In contrast, clients interviewed at the private practice center were predominately White (94%) and mostly male (65%). 

Findings:Thematic analysis indicated negative experiences in past treatment by almost all respondents. These findings are not surprising given that clients interviewed were participants in harm reduction programs, an alternative to abstinence-only programs. Feelings of being judged, stigmatized, labeled, and dismissed were a few of the experiences reported. One female respondent from the private practice center reported: “I spent seven months in a residential place that basically said you’re pretty much a junkie, you’re always gonna be a junkie and your best thinking got you where you are today.” 

Conclusion and Implications: Understanding the experience that prompts clients to disengage in one program (to later meaningfully engage in another) can help to explain low engagement and treatment completion from the client point-of-view. These narratives of stigmatization can assist us as providers to design substance abuse treatment to yield higher levels of engagement, challenging reductionist stereotypes of substance users as unmotivated and lacking readiness for change. Research such as this can inform client-centered approaches to care.