Try to put aside everything you’ve learned or been told about addiction. Let’s just look at what the latest research has to say.

Whether the substance is legal, illegal, or prescribed, when substance use morphs into difficulty with stopping or inability to stop using, it’s become addiction and a medical condition. In recommended priority order, the treatment for this medical condition is medical care, counseling, and support.

I urge clients to first get addiction-savvy medical care. Then I provide the secondary tier of treatment: counseling. Traditionally, clients are invited to take their time in counseling because having insights and making changes takes time. However, because 1) substance use itself can be endangering, and 2) symptoms of substance use disorder are criminalized, we’re not allowed time.

Paradoxically, the desired treatment outcome for most people – abstinence – takes time to achieve. On day one, however, authorities can demand proof of abstinence by requiring negative urine drug screens. People can lose jobs, custody of their children, scholarships, prescriptions for medications, even their freedom if they don’t abstain. But if people could abstain, they wouldn’t have the defining symptom of this medical illness, i.e. inability to abstain.

Regardless of this injustice, how can a person attempt to achieve and sustain abstinence as quickly and effectively as possible?

According to research by NIDA, people use substances for these main reasons: to 1) feel good, 2) feel better, 3) do better, and 4) feel connected.

These are normal, reasonable, understandable needs and wants. But when substances meet these needs and wants, and the person abstains, then the needs and wants aren’t met. Add the brain automaticity that occurs through addiction and, logically, the person would return to use.

How can we help people get understandable, human needs and wants met by substances without substances? How can we help them 1) feel good, 2) feel better, 3) do better, and 4) feel connected?

Research suggests that there is a finite set of very specific skills – a protocol – people can learn to equip themselves to do for themselves what substances did. It is not necessary for people to “be ready to change,” or “want to feel better about themselves.” They simply need to learn the skills and apply them. In the contest between the power of these skills vs. substance use, the skills simply have to be mastered at a 51% level. A 51% skills level may overpower a 49% brain-based return to substance use.

I’ve been a counselor since 2014 and been able to offer research-informed counseling in private practice since October 1, 2018. My anecdotal data suggests, so far, with deliberate effort and practice, these skills can be learned in about 8 weeks, beginning with 1 week of daily appointments, followed by 3 individual sessions and 1 skills-focused group session (not general group counseling) per week, daily homework, and daily text contact. Less than that simply doesn’t achieve many clients’ ends in mind, i.e. abstinence and negative urine drug screens. It makes sense that the traditional one-hour session of counseling per week would be ineffectual given the condition is present 168 hours per week.

Some all-or-nothing statements are appropriate here: No one wants to have problems with substances. Everyone wishes they didn’t. Almost everyone minimizes the significance of substance use. Hardly anyone wants to quit using substances. Everyone dreads what comes up when they stop using substances. And yet. While some small groups and communities of people tolerate substance use, most laws, policies, and social norms do not. However much we might wish things were different, the reality is that, to protect their freedoms in the U.S. under current conditions, people may need to be free of substances. Health-wise, for many substances, there actually is no safe level of use. Further, the interaction of substances, including medications, unfortunately, can cause injury, even death.

Ideally, people would slowly taper in custom-selected methods that meet their needs and wants while tapering out substances that do the same. Unfortunately, the endangering nature of substances usually doesn’t allow for that time and criminalization doesn’t permit it.

The skills are selected and offered based on the weight of research in their favor, and in an order that respects and recognizes 1) the realities of the reasons a person uses substances, and 2) the realities of the challenges they will face when they stop. Instruction, coaching, and practice with the skills are all offered quickly and efficiently.

And the skills are offered in the context of kindness. At essence, what helps a person with substance use and other issues is an on-going, kind, thoughtful, informed, inner conversation. “Tough love” isn’t really love because it hurts. In our work with ourselves and each other, we do our best to practice love love.

Note that I make no moral commentary. Substance use isn’t good or bad. People who use substances aren’t good or bad. In today‘s America, substance use endangers one’s freedoms. The offering of skills is simply a practical approach to regaining one’s freedom from substances and their use.

. . . . .

“Sun of Self-Kindness” coloring page by Nichol Brown. Coloring page .pdf opens in another tab here.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. 

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

As the counselor at a person’s first appointment for substance use issues, I inhale a deep, athletic breath. An urgent, high stakes race has begun.

If substance use has evolved into “substance use disorder,” commonly termed “addiction,” the person’s use meets NIDA’s defining criterion of “persistence despite adverse consequences.” This disorder impedes the very brain functions needed to achieve remission from substance use disorder, starting with decision-making and rank ordering of priorities. Further, the brain has overlearned substance use to the point of what’s termed “automaticity.”

Against these odds, can evidence-based protocols for achieving remission be conveyed in a way the client can understand and apply fast enough, for long enough, to slow or eliminate the person’s substance use, all in hopes of decreasing the occurrences of “adverse consequences”? In other words, can we get what works together swiftly enough to outrun the workings of this medical illness, of which the symptoms aren’t a cough and sniffles, but ominous “adverse consequences,” even premature death?

For many people, myself included, substances offer a nearly otherworldly experience of comfort and relief that meaningfully and profoundly meets needs and wants. Who in the world would want to quit that? And adverse consequences don’t happen every time…

That’s the competition.

I have a nifty, bright office where we can spread our work out on a round, white table. I wear nice clothes with a little style – what my mother termed “oomph,” usually from Bonomo’s – that I think the clients might enjoy.

But the clients and I both know, even with my faux tree and fashionable boots, I can’t play. Not against the bliss and oblivion offered by substances. We both go into the session knowing counseling vs. substances is laughable. Sometimes we do laugh, albeit ruefully. Then we give this counseling thing a go.

I urge clients to get medical care, the first line of treatment for substance use disorder. Medical care can directly treat some substance use disorders and provide relief for other accompanying physical and mental conditions that may be stressing the system and increasing the longing for relief through substances.

Then I offer evidence-based counseling protocols for assistance with substance use disorders, including cognitive behavior therapy (CBT), motivational interviewing, and contingency management. For fundamentals of these approaches, I use the umbrella term, “awareness skills.” We train with these skills in the most straightforward, interesting, engaging, and diverse ways I can think of.

We acknowledge the limits of skills. Science is getting closer, but so far can’t pinpoint exactly where and what is happening in the brain, so there are no direct ways to treat addiction. (The exception is opioid-based medications for opioid use disorder, which directly ameliorate the corresponding brain issues.) Counseling cannot accurately, efficiently, and directly treat the brain for addiction.

Risks lurk like beasts by my phony ficus tree: scientific uncertainty, the illness itself, co-occurring trauma and mental illnesses, return to active use, and those salivating “adverse consequences.” For many substances, there is no safe level of use, including the legal substances nicotine and alcohol. If the client is continuing to use substances, even minimally, a steel-toed boot hovers above the whole shebang, ready to drop. Given this scenario, a client simply showing up for an appointment is an act of heroism.

Although I have never had Army Special Forces training, I liken recovery from addiction to what I read and hear about the final survival test. Candidates are dropped into unknown territory, disoriented, with no weapons and no tools. Amidst conflict and instability, they are subjected to deprivations, dangers, and opponents’ unconventional tactics. Only their personal resources and their skills save them.

In a territory made unknown by the limits of science, with the potential for “adverse consequences” around every corner, people with substance use disorders don’t have the luxury of trial-and-error learning. We wrangle up strengths. We learn and immediately execute knife-sharp skills that research reports are effective, including silent, motionless observation. We race to save our lives.

Further reading

• Insider’s Guide to Early Abstinence
• Let’s Talk Openly About Substance Use
• How to Help a Loved One with Addiction: An Evidence-Informed Approach

Recommended reading

To understand the research on addiction:

• Unbroken Brain: A Revolutionary New Way of Understanding Addiction, by Maia Szalavitz. If you only have time to read two chapters, read Chapter 11 and Chapter 12.
• Resources listed in For Clients

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. 

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Last updated 11/26/19