Outplaying the Game of Abstinence Solitaire

It would be easier to not use substances if wishing to use them would go away.

I think I’ve been on a personal, anti-wishing campaign since I began to abstain from alcohol nearly seven years ago. The neuroscience of addiction explains, however, that shutting down the brain structures and functions that long for alcohol would shut down the same networks that bond and attach to the ghost child I could never conceive and to my mother, gone seven years now. It is my humanity, not a pathology, that wishes for the substance that lifted me up and relieved me of my anguish, as if I were held in my mother’s arms.

Outplaying abstinence solitaireUsing the proverbial metaphor of life as a card game, wishing to return to use is a card I’ve been dealt. It’s a fact. What other cards are on the table? Medical care and medications are the first line of treatment for substance use issues. Let’s say I’ve got that. Given that each week holds 168 hours, even if I could schedule 40 hours of medical appointments, counseling sessions, and supportive meetings, that leaves 128 hours. We’re told we can’t recover alone, yet’s who’s going to staff my alone time? How can I help myself play what’s essentially a game of abstinence solitaire during all those hours I’m solo?

Based on my personal and professional experience, knowledge of counseling protocols, syntheses of literature reviews of research, and my desire to help people who want to or are mandated to abstain from substances, I’ve devised two “card decks.”

The first deck, entitled “Why Some People Return to Substance* Use After Abstinence: The Cards on the Table,” lists forces at play for many people with substance use concerns. For short, I call this the “fact deck.”

  1. Many memories of positive experiences of substance use: experience of substance ≠ experience of consequences of substance use
  2. Few memories of experiences of negative consequences of substance use: experience of substance ≠ experience of consequences of substance use
  3. Abstinence anhedonia: Inability to feel pleasure during abstinence comparable to pleasure experienced using substances
  4. Automaticity overpowers autonomy: Unskillful attention management; unskillful emotion regulation; unskillful thought-sorting; environmental cues
  5. Experience of substances and substance use outcompetes experience of available life offerings (“Is this all there is?!”)
  6. Experience of substances relieves inner experience better than other available options
  7. Deprivation effect, up arrow: Abstinence may be experienced as deprivation, result in unremitting feelings of panic or rage, and cause bingeing to compensate.
  8. Deprivation effect, down arrow: Abstinence may be experienced as deprivation, result in unremitting feelings of hopeless despair, and cause a sense of helpless return to use.
  9. Mysterious brain changes inexactly defined despite the best efforts of the best minds and hearts among researchers, treatment providers, journalists, and those in remission.

The second deck is entitled, “How I Can Help Myself Abstain from Substances*: Outplaying the Hand I Have Been Dealt.” I call it the “action deck.” It provides corresponding counter-plays.

  1. Many memories of the positive experience of substance use: Fact. Nothing to do but accept.
  2. Few memories of the experience of negative consequences of substance use: Fact. Nothing to do but accept.
  3. Abstinence anhedonia: Fact. BUT research suggests I can have a direct impact on anhedonia and apathy by deliberating discovering and “dosing” myself with multiple, small, anticipation-reward experiences.
  4. Autonomy vs. automaticity: Use of awareness skills can effectively overpower automaticity: attention management; emotion regulation; thought-sorting; outmaneuvering or avoiding environmental cues
  5. Experience of substances and substance use outcompetes life: I must honor my preferences and collect an adequate number of ways which, enough of the time, together, have more value than the value offered by substances. (synergy = whole greater than sum of parts)
  6. Experience of substances outcompetes relief of inner experience: I must keep experimenting with other ways to experience relief and increase my ability to tolerate distress.
  7. Deprivation effect, up arrow: Feelings of panic or rage: I must find what I can, and add what I can, to have enough experiences enough of the time to help my life feel enriched enough, not impoverished by scarcity.
  8. Deprivation effect, down arrow: Feelings of hopeless despair: I have to find what I can, and add what I can, to have enough experiences enough of the time which help me feel reassured and encouraged enough.
  9. Mysterious brain changes: Fact. Nothing to do but accept.

*”Substance” is defined as any substance with which use or overuse can cause negative health consequences. Problematic substances may include nicotine, caffeine, alcohol, marijuana, methamphetamine, opioids, other drugs, and food. One would not abstain from food, however.

I can envision these cards as screens in a mobile application.

(In another life, I was part of technology startups and this is what’s left of our attempts to create software applications for people in recovery. Potential referrers wanted clinical trials to prove efficacy and our attempts to gain funding failed. I cringe at the stigmatizing language I used in 2013 and am part of an initiative to change that.)

Because the magnitude of each factor might vary for each individual, the size of each card could be customized. Individuals could add or delete cards as well. The point is that I’ve created a simple, static version of a complex, dynamic system.

If you would like to try your hand at playing abstinence solitaire, here are .pdfs of the “fact deck” and the “action deck.” Once I printed the pages, I used scissors to snip the cards apart. I played the fact deck first, arranging the cards in the order of their impact on me.

Seven years ago, the deprivation effect cards would have been in the upper row. Today, an hour with a glass of wine might outcompete the many lonely, child-absent, partner-absent, elderly-parent-caregiving hours I’ve currently got going.

I have to outplay the hours that drain and demoralize me. Using the “action deck,” I play the synergy card. I work on creating enough small, meaningful experiences, enough of the time, to keep myself on the ground above a chasm of longing.

From using the fact and action decks, I’ve realized that many of my efforts to help myself with abstinence have been attempts to move cards glued to the table by reality. I’ve wasted time and energy on what I can’t do. I can shift my efforts to what I might be able to influence.

Some of the fact cards seem like wild cards, ones that might play me rather than me playing them. I have done everything that research and logic suggest to do, yet there they are.

Here’s how I see to play this. First, I acknowledge non-judgmentally and kindly that I really wish I didn’t have to play this game at all. However, given the current state of beliefs, policies, and laws about substance use, I simply may be required to abstain or risk losing what’s precious to me. So. Let me really look at the cards on the table. What’s really on the table? And the game is abstinence solitaire? Let me strategically and skillfully play the cards I’ve been dealt.

Fact Deck (.pdf)

Action Deck (.pdf)

Insider’s Guide to Early Abstinence may be helpful as well.

The abstinence solitaire card decks are supplements to the guide Sanjay Kishore, M.D. and I have co-authored, Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns. A .pdf of 107 pages, Help that Helps is a self-guided program – tested and refined by real people with real substance use issues – for people with substance use challenges who need or want to abstain.  Caveat: Any self-help guide is to be used in tandem with medical care.

Last updated 10/25/19

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. 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.

Chanel Miller Is With Us

I am recommending Chanel Miller’s Know My Name: A Memoir to my clients who have experienced trauma, to their partners, parents, and family members, and to anyone who wants to better understand trauma and how to begin to heal from it.

I concur with Laura Norkin, Deputy Editor of InStyle, who posted on Twitter, “Very few stories, in this seemingly endless trauma vortex, are actually worth dipping back into your own PTSD spiral in order to read. This is one – because she talks about climbing back out.”

Know My Name by Chanel MillerAlthough I learned in 2016 that “Emily Doe’s” victim impact statement had been published on BuzzFeed, I was not one of the 15 million+ who read it.  While clinicians term the primary symptom of post-traumatic stress disorder (PTSD) “avoidance,” having experienced trauma myself, I was simply being merciful, willing to do anything to protect my broken heart and wild mind from further tragedy.

When I learned through The New York Times that “Emily Doe” had identified herself as Chanel Miller and written a memoir, again I hesitated.

I am so very sorry for what has happened to the narrators of trauma survivor stories. Many survivors can only record that miserably electrified, detailed memory set that comes with trauma. The narrator and the listener or reader re-experience the trauma in excruciating detail, became overwhelmed with horror, and stay stuck in anguish. “This shouldn’t have happened,” If only I had or hadn’t…,” and “I don’t know what to do except endure” are beliefs often underpinning many experiences of trauma.

They were part of mine as well. But these beliefs are so much less a part of how I think about the traumas I experienced. I was taken through Cognitive Processing Therapy (CPT) by a local psychologist about two years ago. Based on the findings of neuroscience about the traumatized brain, paired with cognitive theory, CPT helps people use their own tender hearts and wise minds to directly help themselves. Even today, I tear up with compassion for myself when I remember the dawning realization that how I was thinking about myself as a result of what happened was causing my suffering. My poor self! I was writhing and whimpering from my own mean thoughts! I had no idea I was doing to myself what I would never even consider doing to anyone else.

I rarely think in self-cruel ways now and can catch myself pretty quickly when I do. PTSD can be a tough disorder, but I have few symptoms because I treat myself kindly. As a counselor, I was eligible to train in CPT and became a rostered provider of CPT. I attempt to pass the kindness forward.

Still, I protect myself as much as I can from situations in which I feel helpless and sad. In sum, PTSD results from feeling unrelentingly overpowered and helpless. To quote CPT founder Dr. Patricia Resick at a seminar I attended, “At essence, PTSD is unfelt sadness.”

Wondering if her memoir might be helpful to clients, however, I listened to Chanel Miller tell her own story.

Chanel Miller states openly that she engaged in therapy and thanks her therapist in the acknowledgements. I don’t know if she engaged in CPT, but she takes herself through a similar restorative process.

Yes, as she recalls and recounts the details, downward trajectories threaten downward spirals. But she challenges what she’s telling herself about herself throughout her story.

As I listened to her memoir, I heard her record realities, feel feelings as a result, becomes aware of associated thoughts, and differentiate between thoughts that are about facts and thoughts that state beliefs. She then challenges those beliefs with the facts as she sees them and as those who love her see them. She comforts herself as she can, but even when she simply has to get back in bed, she continues to seek to affirm the reality of her own self.

Again, as I see it, it seems that the inner narrative she discovers, composed of facts and realities, revives and restores her to stability, even through the punishing experience of the trial and sentencing. It’s harrowing! But she uses the very skills that brain researchers – as currently formulated by CPT – reveal are helpful: have an on-going, compassionate, interested, inner conversation, feel and name feelings, become aware of thoughts associated with the feelings, identify the thoughts that are misbegotten beliefs, meticulously dismantle those beliefs with facts, and free yourself.

I felt and thought infinitudes while I listened to Chanel Miller’s story, but I only cried three times, once when she recounted something loving her mother said, once when she recounted something bold her father said, and finally when she was thanking the Swedes in her acknowledgements. I am so very sorry for her pain, but I am uplifted and strengthened by her compassion and bravery.

BuzzFeed published all 7,000 words of Emily Doe’s/Chanel Miller’s impact statement and, I too, cannot make a selection from her memoir to quote. William Zinsser asked writers to ask, “Is every word doing new work?” For those of us with trauma stories, perhaps as yet unspoken or unwritten, Chanel Miller’s words help do the work with us and for us.

CPT is the counseling protocol recently featured on This American LIfe. It is a recommended treatment for PTSD by the Veterans Administration and the American Psychological Association (APA).

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. 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.

Solutions to Problems with Problematic Beliefs

The problems with problematic beliefs – termed “cognitive distortions” in cognitive behavior therapy and “Stuck Points” in cognitive processing therapy – are:

  • The reality I experience is filtered through my beliefs. What I experience can be partial and distorted.
  • What I believe influences what I feel and how intensely I feel it.
  • When a belief comes to mind, the next thought is more influenced by my belief than by reality.
  • When a belief comes to mind, the sentence I say next to myself is more likely to be born of that belief rather than from the facts of the situation.
  • When I am holding a belief in my mind, the sentence I say next to someone else may be more influenced by my belief than by facts.

New pathsHolding problematic beliefs can result in these problematic actions and states:

  • Self-criticism: Low self-esteem and self-devaluation as expressed in the tendency to criticize or devalue myself.
  • Self-blame: Extent to which I blame myself for negative, unwanted events in my life, including events outside my control.
  • Helplessness: Perception of being unable to control important aspects of my life.
  • Hopelessness: Extent to which I believe that the future is bleak and that I am destined to fail.
  • Preoccupation with danger: Tendency to view the world, especially the interpersonal domain, as a dangerous place.

(Adapted from Cognitive Distortion Scales by John Briere, Ph.D.)

Therefore, problematic beliefs cause problems with:

  • how I feel right now
  • what I’m able to think about right now
  • what I choose to say or do next
  • how I interact with others

Obviously, the solution to having problematic beliefs is simply taking a look at my beliefs and pulling the problematic ones like so many weeds. However, problems arise when I begin to examine my beliefs.

I use beliefs to try to keep order in my world. Beliefs are how I’ve organized what’s happened to me and what I’ve learned so I know where to go and what to do. I’ve used beliefs like rock-solid facts to line the paths in my garden. If I bend down to take a closer look and see weeds rather than rocks, I feel wild. I fear tumbling end over end into unlined chaos. And I feel ashamed. I think, “I believed I was right about that! But I’ve discovered I’m wrong!” Fear and shame are terribly distressing feelings. No wonder I stand back up and avoid looking at the edges of the path again.

But holding problematic beliefs causes me suffering and causes suffering to those I love. But looking for problematic beliefs causes me suffering. What a double bind! Suffering everywhere I turn! I feel trapped by suffering!

I believe I must do something, anything, to end this suffering right now! I believe I cannot take this!

Oh, my. Those are statements of problematic beliefs. The reality is that I actually can set myself up to do this task of weeding in kind, skillful, efficient ways so I suffer as little as possible as briefly as possible. It won’t be pain-free, granted, but I can learn skills, I can surround myself with support, and I can get this done.

And good enough will do. I just need to clear some of the biggest problematic beliefs (“I am to blame for what happened because I am bad and wrong” is a common problematic belief ready for the mulch pile).

Newly aware of what’s really going on with me, I can then shape new paths based on my values and priorities. I have the freedom that awareness gives me.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia. She is a rostered provider of Cognitive Processing Therapy for PTSD.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. 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.

Derivation of a Counseling Protocol for Problematic Substance Use

In my counseling practice, I assist people with substance use concerns to meet their harm reduction goals until the nearly inevitable moment when authorities in the criminal justice system, or child custody agencies, employers, and medication providers require them to abstain.

I am attempting to derive a research-informed, brief counseling protocol to assist individuals who want or need to abstain from substances.

Bob Giles
Abstinence from substances is a social construct. As NIDA’s research has revealed, people use substances for very human reasons: to feel good, to feel better, to do better, out of curiosity, and to feel a sense connection with others. As use of substances achieves these ends, abstaining from them would be illogical. Humans have used substances for reasons meaningful to them for over 12,000 years.

I want to share my thinking and progress as I derive the protocol. I welcome feedback.

Nota bene

  1. Mandated abstinence has no science or humanity to back it.
  2. Attempting to treat opioid use disorder with abstinence endangers the individual. The only treatments known to cut death rates by half or more are the medications methadone and buprenorphine.
  3. Medical care – not counseling – is the first line of treatment for problematic substance use.  Medical care may be sufficient.

(About the opioid poisoning crisis, please consult this guide from Northeastern University’s Changing the Narrative. For a consideration of harm reduction and alcohol, please read this editorial by April Smith.)

Given that, for eons, humans have found substances helpful and meaningful, why then does society require some of its people to abstain from them?

Although society intentionally or arbitrarily legalizes and criminalizes the use of some substances and not others, “problematic use” can be a useful term. If behaviors resulting from substance use result in harm to others or to property, society may require individuals to “cut down” or abstain from those substances.

“May require” is a key concept. Public over-consumption of ethyl alcohol, a known neurotoxin, is celebrated in America’s tailgating culture. The frequency of physical assaults, sexual assaults, arrests, and hospitalizations associated with tailgating does not diminish their popularity or legality.

In sum, a protocol to help people abstain from substances after use becomes problematic has to counter these forces:

  • People using substances is not an anomaly or aberration but part of a 12,000-year history. Source
  • People use substances for reasons that are meaningful to them. Source
  • Substance use may be a cultural norm.
  • Substance use concerns are rare.  90% percent of people who use substances of any kind do so without issue. Source
  • Individuals’ seeking treatment, believing treatment can help, and progressing in treatment are undermined by negative beliefs (cognitve distortions) and internalized stigma born of society’s moralization and criminalization of the use of some substances and not others, and the systematic stigmatization of addiction.

A powerful, rarely-reported counter force exists. The majority of people who might meet criteria for a diagnosable substance use disorder achieve remission on their own without treatment. Indeed, according to this 2010 study, “Life‐time cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively.”

Remission does not need to require abstinence, however, and the number of years required to achieve remission on one’s own puts many people with problematic use in jail. Efficiency is an imperative.

A counseling protocol to address problematic substance use, then, would specify, sequence, and foster the human brain’s natural tendency to return overuse to moderate or absent use.

Definitions provided by researchers

The primary terms used to describe problematic substance use in the research literature are “addiction,” “substance use disorder,” and “substance abuse.” “Substance abuse” is a stigmatizing phrase and is not further used in this article.

(Although gambling disorder is termed an addiction, as is Internet gaming, my focus is on substance-related concerns.)

“Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs.”
National Institute of Drug Abuse (NIDA), July 2019

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

My working definitions

Based on the definitions provided by researchers, and for the purposes of deriving a counseling protocol to address substance use concerns, I find using the term “substance use disorder” most helpful.

My working definition of substance use disorder is:

Substance use disorder is a health condition involving modifications to brain structures and functions that result in persistence in use despite negative consequences.

My working definition of remission from substance use disorder and, therefore, the intended outcome of the protocol is:

Remission from substance use disorder is characterized by living a healthy, functional life, in connection with others, such that substance use does not result in adverse consequences for the individual, others, or society.

To derive a counseling protocol for substance use disorder, I am currently modeling the approach taken by Dr. Patricia Resick, founder of Cognitive Processing Therapy (CPT) for PTSD. She described her research methods in a seminar I attended April 4-5, 2019 (recording of her presentation as continuing ed is here), as well as in the Cognitive Processing Therapy manual. She began with therapeutic hypotheses based on need, knowledge, experience, and literature reviews, derived a protocol based on these hypotheses, tested the protocol, modified it, then developed research experiments to test for the protocol’s ability to produce outcomes better than other methods and better than no method.

I am in the phase of seeing the need and using the synergy of my knowledge, experience, and literature reviews to begin to derive the protocol. I have field tested the components with individuals and small groups.

My progress so far

  1. Here is a summary of my literature reviews and how the research informs my approach to counseling. The page includes links to pivotal studies and/or systematic reviews.
  2. Here is a plain language summary of the protocol.
  3. Here is the first articulation of the protocol as a research-informed, plain language, self-guided program co-authored with Sanjay Kishore, M.D.: Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns.
  4. I term the components of the protocol “awareness skills.” Here is a delineation of those skills in the form of an awareness skills self-assessment.
  5. Here is a 3-page document that summarizes and diagrams my early thinking on stability. In this document, I call the protocol “Cognitive Processing of Substance Use” but I am uncertain what would be the most helpful title.

My working hypotheses

  1. Substance use is a human practice that meets human needs.
  2. Persistence despite negative consequences is a necessary, often admirable, human trait.
  3. Persistence in substance use despite negative consequences – not use itself – is the problem.
  4. Persistence in using substances despite negative consequences is a result of over-functioning of normal brain functions. This process is understood somewhat, but not comprehensively, by brain researchers. “Overlearning” and brain automaticity are presumed to be central factors.
  5. Neither an individual nor a counselor can expertly, directly, accurately, or efficiently pinpoint, nor administer to, brain structures in need of assistance.
  6. Since many who meet the criteria for substance use disorder achieve remission on their own, substance use disorder may be chronic for some but not all. (The exception is opioid use disorder which may produce brain changes that require  life-long treatment with medication.)
  7. If “remission” is defined, not as abstinence from substances, but as absence of the hallmark symptom of substance use disorder, i.e. persistent use despite negative consequences, then remission can be achieved.
  8. Trauma is nearly 100% present because a) inability to use one’s own mind to stop a behavior is traumatizing; b) society’s misbegotten beliefs expressed by partners, family members, treatment providers, and medical professionals are covertly and covertly assaultive; c) two-thirds of people with substance use concerns have experienced trauma, particularly in early childhood.
  9. Individuals, on their own or with the assistance of counselors, can learn to co-travel with and/or manage altered brain functioning.
  10. Emotion dysregulation is a defining symptom common to substance use disorder and disorders that co-occur, including trauma, mental disorders, and physical conditions.
  11. Cognitive skills assist with emotion regulation.
  12. Attention is the initial mechanism by which management of emotions and/or cognitions occurs.
  13. Inner and outer conditions, broadly termed “stability,” contribute to emotion regulation.
  14. “Autonomy over automaticity” is a reasonable summary of what individuals need to achieve in order to abstain.
  15. Medical care is essential for providing a) medications that directly ameliorate problems in the brain, and b) stability through testing, treatment, and/or medications for mental and physical conditions that may drain a person’s energy and endurance to learn and implement skills.
  16. Research on the “shared neurochemistry between love and bonding and attachment and addiction” offers a promising opportunity for counseling to be of assistance to people with substance use concerns.

While I understand the need for individualized care and the cautions about “one-size-fits-all” thinking, the very purpose of research is to offer us what’s helpful to most people, most of the time, better than other treatments, and better than no treatment. When people are suffering, I see an emergency need to use research to increase the probabilities that what we are offering might be helpful.

At times, I do question my efforts because I challenge the premise of mandated abstinence. Am I contributing to the harm done? I protest as I can. But I work relentlessly on this protocol for the people who are suffering now.

Again, I welcome feedback. Please contact me.

. . . . .

The photograph is of my father, Robert H. Giles, Jr., Ph.D, on September 27, 2019. He is helping me conceptualize sequencing the components of the protocol. The question – literally on the table with sugar packets and a salt shaker representing components – was in what order they needed to be offered to achieve the end in mind, symbolized by syrup.

A Virginia Tech Professor Emeritus, my father has urged me to share anything about his developing neurocognitive disorder – popularly termed “dementia” – that might be helpful to others. I estimate he has lost 80% of his cognitive functioning, including his ability to construct meaningful sentences and sequence them meaningfully. I sometimes think I’m listening to a collage.

However, with regard to the skills used to perform his life’s work, he retains extraordinary facility. I pick him up from his assisted living facility every two to three mornings to consult with him when he can think, and to just be with him when he can’t. He is able to assist most when I offer diagrams or manipulables. Although he and his graduate students pioneered computer-aided natural resource management in the 1970s, he brings systems thinking, decades of primary research knowledge and experience, and novel approaches to my work. His department head said at his retirement party, “Giles has more ideas in one hour than most people have in a lifetime.” Other than Maia Szalavitz and Sanjay Kishore, M.D., no other individual has contributed more to the existence of this protocol than my father. I dedicate its derivation to him and consider him a co-founder.

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. 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.

Insider’s Guide to Early Abstinence

If you want – or are required – to abstain from substances or behaviors, research and its logical implications offer clear guidance on what is helpful. The statements below are written in straightforward language and imperative mood, but honoring each individual is intended. In parentheses is an explanation or explanatory clinical term.

Important: Medical care is assumed and may be sufficient.

Research is clear on what can be helpful

Reassuringly, doggedly, determinedly – relentlessly, when necessary – do these things:

  1. Educate yourself. Don’t believe anybody or any source that doesn’t cite research. (“Personal experience” is anecdotal data, not research data.)
  2. Become the leading expert on yourself. Learn yourself fully, inside and out, so you can know exactly with what you need help. (ancient wisdom: “Know thyself”; logic)
  3. Turn the volume on the intensity of your inner state up or down towards stability. When you sense signs of “flooding,” intervene on your own behalf. (emotion regulation)
  4. Command your attention. (autonomy over automaticity)
  5. Identify thoughts as helpful and unhelpful. Shift your attention to helpful thoughts. (cognitive theory)
  6. Revise false beliefs with facts. (cognitive theory)
  7. Train. Learn skills, then drill and test. (autonomy over automaticity)
  8. Give yourself the mercy that substances or behaviors gave you using your own mind and your own heart. Use your self as the tool. (logic)
  9. Create a life that outcompetes a life with substances or problematic behaviors. People use substances for reasons. The reasons reemerge during abstinence. Life without substances needs to be better than life with them. (logic; NIDA)
  10. However, for now, “good enough” may have to do. Achieving and maintaining abstinence can be a painstaking process requiring attention and endurance. Awards may come later rather than sooner. (delay discounting)
  11. Co-travel with longing. (logic; research on bonding; acceptance of reality)
  12. Approach reality rather than avoid it so strategies are fact-based. (cognitive theory)
  13. Identify problems and solve them. While some are more difficult to put down or stop than others, substances and behaviors don’t make people use or do them. People use substances and engage in behaviors to solve problems, usually to relieve an inner experience of an inner state that feels unbearable. Get to the problem, solve it alternately, and the need for the substance or action may be eased or absent. (logic)
  14. Consult your inner wisdom before speaking or acting. (DBT “States of Mind”)
  15. Specifically, use your inner wisdom to do a cost-benefit analysis with rank ordering before choosing what to say or do – or not say or not do. (cognitive theory)
  16. Lead, follow, and choose based on your values and priorities. (DBT emotion regulation)
  17. Identify automatic patterns of feeling, thinking, behaving, and interacting and replace them with sequences of conscious choices. (autonomy over automaticity)
  18. Mind your energy. Say “yes” to activities, work, study, and relationships that may take short-term effort but provide long-term stability or growth. Say “no” to what includes a thought of “should” and depletes rather than restores. (logic)
  19. Strengthen the whole system through self-care. (backed by about a billion research studies)
  20. Get help with what you can’t do yourself. (belief-freed logic)
  21. Gently but firmly know that if you want to, you can’t. Only when using the substance or engaging in the behavior is no longer automatic or desired might an experiment be conducted. Indulgence may feel merciful in the short-term, but it usually weakens, not strengthens. (autonomy over automaticity)
  22. Surround all your efforts with self-kindness. (research on the interrelatedness of brain functions involving persistent behaviors and bonding, attachment, and love)

While some links are provided, a clinical summary of the research underpinning the statements above and the self-guided program Sanjay Kishore, M.D. and I have co-authored, free for all to use –  Help That Helps: A Kind, Research-Informed, Field-Tested Guide for People with Substance Use Concerns is here.

Self-help is not an evidence-based treatment for substance use disorders. Any self-help guide for substance use concerns is to be used in tandem with medical care.

Harm reduction is the standard of care for substance use concerns but is rarely permitted. This guide is intended to be of supportive, direct help to the many people who are mandated to abstain by the criminal justice system, child custody agencies, employers, and universities.

Last revised 9/25/19

Anne Giles, M.A., M.S., L.P.C., is a counselor in  private practice in Blacksburg, Virginia.

The views expressed are mine alone and do not necessarily reflect the positions of my colleagues, clients, family members, or friends. 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.