American counselors' acceptance of non-abstinence outcome goals for clients diagnosed with co-occurring substance use and other psychiatric disorders

Abstract Previous research has examined clinicians' acceptance of non-abstinence for clients who have a substance use disorder (SUD), but many SUD clients also present with a psychiatric disorder. To evaluate the acceptability of non-abstinence as a final outcome goal for clients with co-occurring diagnoses, we recruited a nationwide sample of 751 American substance abuse counselors to complete a web-based questionnaire. Respondents rated the acceptability of limited/moderate consumption by clients diagnosed with each of 18 co-occurring disorders: three psychiatric disorders (Major Depressive Disorder, Post-Traumatic Stress Disorder, Social Phobia) x three substances (alcohol, cannabis, opioids) x two levels of severity (DSM-5 Moderate SUD, DSM-5 Severe SUD). On average, non-abstinence was rated as unacceptable for clients with any of the 18 diagnostic pairs, although one-fourth to almost one-third rated limited/moderate use of cannabis somewhat or completely acceptable for clients diagnosed with a Moderate Cannabis Use Disorder when paired with any of the three psychiatric disorders. Furthermore, small proportions of respondents (13% to 20%) rated non-abstinence at least somewhat acceptable even when clients were diagnosed with a Severe SUD for any of the three substances and any co-occurring psychiatric disorder. Based on our findings, clients with co-occurring disorders who want to moderate their substance use will typically find their counselor does not accept that outcome goal. Because supporting non-abstinence respects client autonomy, could attract and retain clients in counseling, and is consistent with a recovery-oriented treatment model, we encourage continuing education about the benefits of non-abstinence as a treatment goal for clients with co-occurring disorders.