At the First Counseling Session for Substance Use Issues

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

Recommended reading

To understand the research on addiction:

To read a work of fiction in which the main character practices skills similar to the ones needed to recover from addiction:

For help with recovering from harm caused by misinformation and ill-treatment from societal norms and the addiction treatment industry:

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 3/31/19

Let’s Talk Openly About Substance Use

An elephant in the room when people talk about addiction is the subject of return to substance use after a period of abstinence. People with addiction who are maintaining abstinence may think, “Will I return to use?” or “Can I return to just a little use?” People who care for people with addiction may think, “Will you return to use?” and “How could you possibly return to use after all you’ve put me through?” People who have lost loved ones to addiction often think, “How could I have let them return to use?” and “How could I have been a better parent, partner, sibling, fill-in-the-blank so they wouldn’t have returned to use?”

So many conflicting, understandable thoughts in one room! Such fear with which to empathize!

Let's talk about the elephants in the room

The American Heritage Dictionary of the English Language defines “ambivalence” as “1. The coexistence of opposing attitudes or feelings, such as love and hate, toward a person, object, or idea,” and “2. Uncertainty or indecisiveness as to which course to follow.”

I posit that the majority of ambivalent feelings and thoughts about addiction are created by belief-based social norms rather than reason and research. This extends to return to use after a period of abstinence, commonly termed “relapse.”

The American Heritage Dictionary defines “relapse” as “1. To return to a former state. 2. a. To become sicker after partial recovery from an illness. b. To recur. Used of an illness. 3. To slip back into bad ways; backslide.”

The third dictionary definition is the one usually applied to people with addiction. When people were abstaining, they were observing “good ways.” When they returned to use, they were “slipping back into bad ways.” This implies that return to use is a matter of morality, a good-bad duality.

For addiction, however, it is the second definition that is confirmed by research. Addiction is defined as a medical illness, not a moral one. Therefore, for some people, return to use may well be “to become sicker after partial recovery from an illness.” Addiction has also been determined to be a brain disorder that causes substance seeking and use, despite negative consequences. Ergo, if a person is “not sicker,” no longer seeks substances, and no longer experiences negative consequences from using them, by research-backed definition, the person is in remission from this medical illness. When substance use is optional and without negative consequence, it is not indicative of medical illness.

Proponents of the moral model of addiction rage at these statements. However, the statements are supported by data. Humans have used substances for at least 12,000 years. The vast majority of people – 70 to 80% for substances in general, 92% for people who use opioids – do not develop addiction from substance use. Of those who do, research indicates that brains are made susceptible to developing addiction from trauma, particularly in early childhood – including the chronic trauma of poverty and economic hardshipchallenges with attention, autism spectrum disorder, and other factors.

[The primary argument against helping people with addiction – even after acknowledging the evidence from brain research that addiction is a medical illness – is that since people “chose” to use the substance in the first place, they deserve what they get.

Let’s check the facts.

  • Nearly 99% of Americans have “chosen” to use some combination of the legal, experience-altering substances alcohol, nicotine, and caffeine.
  • Two out of three Americans have “chosen” to use the substance of food in ways other than maintaining normal body weight, such that complications from obesity cost taxpayers an estimated $190 billion per year.
  • 70,000+ Americans died from “choosing” drug use that ended in overdose in 2017.
  • 300,000+ Americans die annually from “choosing” to use the substances of food and beverages that end in obesity-related complications.
  • 480,000 Americans die annually from “choosing” to smoke tobacco products containing the legal substance nicotine. (Without choice, 41,000 Americans die annually from secondhand smoke exposure.)

Using the logic of “choice” to exclude people from medical care, the debate over universal health care should be tabled since nearly no Americans deserve it due to their “choices.”]

If all elephants were led gently from the room, all debates silenced, and all criminal penalties for having a medical illness removed, a person who has been diagnosed with substance use disorder – the clinical term for what’s commonly called addiction – actually only has one concept to consider: harm. “Would my return to use cause harm to myself or others?” On the surface, that question seems simple. However, for many substances, there is no safe level of use. For example, ethyl alcohol is a neurotoxin, on the list with lead, nitric oxide, and Botox, served by the glass. The decision to return to use requires a complex cost-benefit analysis with rank ordering of risks and priorities.

Before that analysis can begin, the person with substance use disorder who is considering a return to use needs to achieve remission from the illness. Essentially, summarizing this definition and this one, the person needs to be able to live well enough without problematic substances. “Well enough” would be individually defined, not socially defined, or defined as a loved one might wish.

Based on the neuroscience of addiction, the brain without substances to which one has become addicted creates anguish akin to losing air, water, a limb, and one’s beloved, all at once. How to live with anguish is the first task in achieving remission.

This is why research has found that medical care, counseling, and support – in that priority order – are the foundations of achieving remission from substance use disorder. Through specific, comprehensive assessments, medical professionals can find physical and mental sources of anguish and ease them with medical treatment: medications, medical appliances, physical therapy – the list of medical help and support is nearly endless.

Developing addiction requires continued use over time. Addiction creates in the brain what’s termed “automaticity,” i.e. learned action such that conscious thought is not needed and does not occur, like brushing one’s teeth in the morning, or braking while driving. Prior to developing the automaticity of addiction, people first used substances for reasons. They continued to use substances for reasons. Once addiction occurs, addiction adds automaticity to continued use. But harkening back to the reasons for first use, then for continued use, offers clues to what needs and wants the substances met. Finding alternative ways to meet those needs and wants – beginning with medical care for this medical illness – is the second task in achieving remission.

(Automaticity explains why “Just say no” is cruel advice as a care strategy for the complex medical illness of addiction. “Just saying no” to automatically braking while I’m driving would take a lot of time and training on my part to recreate thought before action. And from you, I would need to see proof with my own eyes that your alternative strategy for saving myself from crashing works. Treatment outcome data for rehabs certainly does not support abstinence as a safe alternative to use.  If I go to rehab, I only have a 30% chance of not crashing?! If I have opioid use disorder and stop using opioids, I have only a 20% chance of not crashing?!)

Emotion regulation is the ability to become aware of the onset of strong feelings states that can become destabilizing, then to be able to simply adjust one’s inner “volume” to a more stable range. Lack of skill with emotion regulation – termed “emotion dysregulation” – is characterized by a sharp onset of strong feelings, a quick spike, continued intensity, and difficulty returning one’s inner state to a stable range. This is experienced as distress beyond bearing. Emotion dysregulation is a challenge common to people with substance use disorders and the conditions that can accompany them, such as trauma symptoms and mental illness. Substances can be used to effectively regulate emotions. Some substances are used as medications for this purpose. Illegal substances can do this work as well.

The more skill people have with regulation of emotions, the less likely they will be to seek and use substances to ease an emotionally dysregulated state. This is why cognitive behavior therapy, motivational interviewing, and contingency management are the top evidence-based methods for helping people with substance use disorders. Through various mechanisms, all of these assist with acquiring skillful emotion regulation, the third task of achieving remission from substance use disorders.

If I’m able to respond to medical care, can co-exist with what might remain an ever-present longing for the experience substances gave me, replace what substances did for me with alternatives, and learn skills to effectively regulate my emotions without illegal or non-prescribed substances, I might achieve remission from substance use disorder. Half of people achieve remission on their own, without treatment. Further, I may be able to return to use without experiencing negative consequences.

In consultation with medical and health care professionals, I might reconsider and expand the initial questions: “Would a return to use harm me or others? Use of what substances, in what amounts, with what regularity would reduce the risk of harm? What do I learn from doing a pros-cons, cost-benefit analysis with rank ordering?” Personally, I consider the possibility of return to use with simple I-statements: “If I want it or need it, I can’t have it.” A close second is, “If I think I deserve it or think I have earned it? I can’t have it.”

If I’m thinking something like, “I can’t take this anymore,” or “Only this substance will help,” or any version of “Blankety-blank this blank,” I reach out immediately for help. I’ve done my best to regulate my emotions but whatever I’m feeling and thinking as a result of what’s happening within or without has overwhelmed my skills. I can’t use substances in a state of stress or distress, not because using is morally wrong, but because the opposite of automaticity is consciousness. Brain science tells me that emotions can trump thoughts. As a person in remission from substance use disorder, I can’t risk automaticity kicking in again. It’s simply practical to require myself to be in a stable state to use substances, likewise to do almost anything that risks harm to me or others.

I reach out to others because social support is an evidence-based protocol for helping people with substance use disorders. The kind sound of others’ voices helps hum me and my brain back to a stable range.

If, after deep and probing conversations with myself and health care professionals, in my individual case, I/we determine that the potential benefits of returning to use outweigh the potential costs, I would create a safer use plan (again, for many substances, there is no level of use considered safe) and a post-use monitoring plan. I would also run these plans by health care professionals.

Tragically, medical illnesses cause misery to the people who have them and to those who love them. This is the human condition. Self-blame, other-blame, and second-guessing are no more merited for addiction than for any other medical illness.

Let’s free the elephants in the room. Let’s keep talking openly, directly, and factually about substance use.

. . . . .

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.

For further reading:

I Am a Person with the Health Condition of Addiction

I am a person with a health condition that’s commonly termed “addiction.” The primary symptom of addiction is continuing to use substances despite negative consequences. Why my behavior includes, or included, continued use is due to complex changes in my individual brain.

Anne GilesWhile some accuse me of making a “choice” to use, or selfishness for “liking to get high,” or of having moral or criminal problems, addiction research does not support these beliefs. My original use may have been of  my own volition, but with repeated, extensive use over time, my brain learned to use nearly automatically. Because alterations occurred in the organ of the brain, this condition is alternately termed a “disease,” a “medical illness,” a “brain disorder,” a “health problem,” and a “health condition.”

My brain may have been predisposed to developing addiction from trauma, mental illness, neurodevelopmental challenges – such as ADHD and autism – and/or conditions in my environment, such as abuse or poverty. Unfortunate brain changes resulting from addiction may have affected my judgment, decision-making, learning, memory, and self-control.

I have reasons for using alcohol and/or other drugs. You may or may not approve of my reasons, but they are meaningful to me, often because substances help me with emotional or physical distress.

Please don’t equate my use of alcohol and other drugs with “abuse,” nor with the term’s inferred – and stigmatizing – sexual and physical violation. Humans have used substances for 10,000+ years. If we count caffeine, nicotine, and alcohol, nearly all Americans are drug users. If we count being overweight or obese, more than two thirds of Americans have trouble limiting their intake of substances. Neither I, nor they, are substance “abusers.”

This is subtle but I need you to hear me: Substances are not the problem. Problems are the problem. Substances can solve problems – that’s why we use some substances as medicines. Substances can help people feel good, feel better, or do better.

My intention was to use alcohol and other drugs for my reasons and without harm to myself or to you. The majority of people who take or use substances do not become dependent upon them, i.e. experience physical symptoms without the substances, or become addicted to them, i.e. persist with using them despite adverse consequences. I expected to be like most people. I did not mean for this health condition to occur, nor do I choose or want it to continue. I deeply regret any hurt or hardship my having this condition has caused you.

Abstinence is not the solution to the problem of addiction. When I abstain, whether through my own attempt or mandated by authorities, I am under the neurobiological force of addiction, possibly under the physical force of dependence, and under the mental and physical forces of unmet purposes that substances served. These forces interact and magnify, causing anguish that’s nearly unbearable. This is why I continue to use, or return to use – what you call “relapse.” You perceive my return to use as evidence of self-indulgence, of lack of self-discipline. I experience my return to use as self-mercy.

If you want to help me recover from this health condition, we need to focus on what might be termed “the unbearability.” First, you can help me protect my health and safety if I’m still using by connecting me with harm reduction resources. Second, please get me medical care. Extensively-researched medications exist to ease the neurobiological, physical, and mental burdens of this illness. A physical exam and lab work can help detect other conditions that may be weighing down my system.

If I’m newly attempting to cut down or abstain, or am mandated to abstain, I don’t feel very good. Abstinence from some substances puts me in mortal danger. In an emergency, help me get to medical professionals. With urgency, help me make appointments and help me get to them. If I can trust you and you are a safe person for me, I might even ask you to go into appointments with me to help ask important questions and to take mental or written notes on the guidance I receive.

If there are policies or laws in the way of me getting medical care, I either can’t or dare not advocate for myself. I usually don’t have adequate resources to hire legal representation. And if I speak up, I risk punishment from authorities or shunning by society. Protest injustice on my behalf and on behalf of others denied health care for health conditions.

According to research, sometimes medications and medical care are all I need to achieve stability from this health condition. What was unbearable may now be bearable. If I’ve received medical care and am still suffering, I may benefit from counseling. Research suggests individual counseling if I can get it, and skills-focused (not general) group counseling if individual counseling isn’t available, I can’t afford it, or I find working together with others helpful to me.

Since addiction is a brain condition, counseling can’t specifically and directly treat areas of the brain affected by addiction. I need counseling that takes into account the workings of my brain, not my personal, moral, or spiritual selfhood. I may or may not choose to look at those subjects in the future. Right now, I need assistance with using my own mind as a tool to work with having this health condition.

Given what neuroscience research has revealed about addiction, the essence of effective counseling for addiction builds toward this: If I can become aware that I am feeling emotions, and name them, that simple act of consciousness activates both the “heart” and “mind” functions of my brain. I now have access to the innate essence of both – termed “Wise Mind” in dialectical behavior therapy, or, more generally, “inner wisdom.” From my inner wisdom’s state of attention, awareness, functionality, and self-kindness, I can learn and apply myriad skills that may help me consider what might be helpful for me to say or do next – or not say or not do.

If I’ve received medical care, then counseling, and I am still troubled, I may need what’s termed “support.” If you can help me figure out what’s working for me, and what’s not, and help me access resources to increase what’s working and decrease what’s not, that, too, lightens the load of what has been unbearable.

For some, addiction is a chronic condition. My condition is in remission now, but if a flare-up happens, I would welcome your help in getting evidence-based care.

You will have to fight for me. Even professionals who should know better – the science is right here for all to see – will call me an “alcoholic,” scorn my “choice” to drink again, and admonish me to “become a better person” to make my alcoholism go away. You will have to fight to keep misinformation and mistreatment from breaking my heart, my mind, my life.

I am a person. I am not an osteopororitic because I have been diagnosed with osteoporosis. I am a person in which a troubling health condition has occurred.

I am a person with addiction. Addiction is a health condition that responds to evidence-based treatment. I do not and cannot speak for all people with addiction, but my lived experience matters. In America today, evidence-based treatment for addiction is hard to get. When I am unwell, I am your sister citizen, at your mercy. I ask for your help in continuing to receive evidence-based treatment for addiction. I ask for your help in getting evidence-based treatment to persons who have what I have.

Maia Szalavitz and Keith Brown contributed to this article.

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.

The Case for Treating Addiction

An open letter to people with substance use issues in the New River Valley of Virginia

A guest post by Sanjay Kishore

If you’re reading this, you may question whether or not you have an issue with substance use, whether that’s alcohol, heroin, meth, or prescription drugs. If you do you have concerns, you may feel like you can overcome it on your own, or with the help of your friends or family. You may feel that you don’t need any outside help from folks like I am – medical providers – because you feel like you might be cheating on “real recovery.”

Sanjay KishoreI’m here to offer you another view. My name is Sanjay. I was born and raised in Southwest Virginia, and graduated from Radford High School. Right now, I’m a medical student at Harvard.

I am becoming a doctor to serve people. I want to share with you my understanding of effective treatment for addiction, straight from the halls of Harvard, so you can understand how to overcome substance use issues and addiction and get the help you both deserve and need.

Your path to success is much harder because of where we are from. That’s the honest truth. In our area, many people believe that all substance use issues are moral failings. We are taught that it is a person’s fault for even trying substances in the first place, and their own problem if they develop an addiction to them. Society tells us that the only way to fix the problem is to have enough willpower to simply “choose ” to stop being addicted. If you can’t do that, it’s believed you deserve to be punished – sent to jail, separated from your kids, fired from your job.

That narrative is not based in truth and science. More importantly, it has been responsible for the unnecessary deaths of thousands of individuals in our region alone. Addiction is a health issue. It can be treated quite effectively. And, most importantly, it’s not cheating to accept medical help for addiction. It simply makes sense to get health care for a health problem.

You may be resistant to going to a doctor. However, to get proper treatment, including medications and counseling, you have to be willing to see a medical provider to undergo a comprehensive evaluation of your physical and mental health. Medical providers like I am can AND want to be a part of your team. We are ready to help you through this process.

You can help us help you by separating the concepts of addiction and dependence in your mind. Addiction is a medical illness. Dependence is a physical response to the presence of a substance, such that a person feels physical withdrawal symptoms when that substance is absent. All people have dependence upon air and water and suffer without them. Taken over time, some medications, including antidepressants, blood pressure stabilizers, and opioids, result in drug dependence. Simply having withdrawal does not mean you are addicted. Infants may be born dependent upon substances, but they are not born with the medical illness of addiction. This is very important to understand when thinking about treatments that exist for addiction.

Scientific evidence has demonstrated that there are multiple treatments for addiction that can help save lives and transition people to recovery. These include a combination of medications, counseling, and other recovery support services. Importantly, withdrawal management alone is not proper treatment. Over 50% of patients with substance use disorders who enter short-term detox programs are not connected to proper follow-up treatment and return to use. Staying connected to medical professionals and other treatment providers will help you recover.

While medications are the first line of consideration for treatment of addiction, unfortunately, medical professionals in our area may not be willing to prescribe medications. There are some who do, however, and it is important for you to seek them out. It is important for you to try, and to ask directly for medications that may assist you. Medications for addiction can be very effective.

Medical professionals can help with other health problems. A significant proportion of people with substance use disorders have an underlying mental illness, such as anxiety, depression, or bipolar disorder, or a history of childhood trauma. Even if you have a specific substance use disorder that does not have a targeted treatment, medical experts have the ability to help manage other issues you may have that could help make your transition to recovery that much easier.

You may not even know you are suffering from a mental illness. For instance, many disorders can manifest themselves as physical symptoms, sometimes as pains and weaknesses, other times as nausea and diarrhea. It’s important to establish a relationship with a medical provider who can evaluate you through taking your history, performing a comprehensive physical exam, and ordering appropriate laboratory tests.

At the same time, many forms of drug use can place individuals at increased risk of other medical conditions. Sharing needles through injection drug use can transmit diseases like HIV and hepatitis C, which can cause devastating consequences, but can be treated by medical professionals if caught early. Some people re-using and sharing syringes can get bacterial infections of the valves of the heart, called endocarditis, which is a life-threatening condition.

Persistent alcohol use can cause liver failure, cancer, and pancreatitis, and requires monitoring of enzymes in your blood. Cocaine use can cause increased strain on your heart, and even lead to heart attacks.

I hope you are convinced by the case I, Sanjay, a fellow citizen from Southwest Virginia, have made: If you have the health condition of addiction, you need and deserve health care.

If you have substance use concerns, it can be extraordinarily helpful to establish a connection with a medical provider. This doctor, nurse practitioner, physician’s assistant, or other medical professional can help you connect with not only the right treatment for your addiction, but make sure you are safe, screen you for any other diseases that you may be at risk for, and link you to proper treatment for other conditions related to your mental and physical well-being.

I, and other members of the medical profession, are here to help you.

Sanjay Kishore is a fourth-year student at Harvard Medical School with hopes of becoming a primary care physician. He was born and raised in Radford, Virginia, where he first learned of substance use disorders and addiction. He then received his B.A. from Duke University, where he designed his own major entitled, “The Social Determinants of Health.” He worked with leading health policy experts as a Villers Fellow with progressive advocacy organization Families USA. As a community organizer, he founded Virginia’s first student-run health insurance enrollment campaign. He is a recipient of a 2017 Paul and Daisy Soros Fellowship for New Americans.

Sanjay advocates for the establishment of safe injection facilities in Southwest Virginia:

This guide to requesting medical care for addiction may be helpful to take to medical appointments.

The views expressed are the author’s alone and do not necessarily reflect the positions of any institutions or individuals associated with the author. 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.

My Approach to Treatment for Addiction

No one really knows what addiction is. Brain imaging studies help researchers get closer to understanding brain structures and functions involved with what is experienced on the individual level as wanting to slow down, switch, or stop, and not being able to. We may never know exactly what goes on in a brain’s 86 billion neurons and perhaps a similar number of glial cells. In this context, differentiating between cause and effect – this thing caused that thing – and correlation – these things happened at the same time but are unrelated – is difficult.

Illustration of DBT's States of Mind

Not knowing what causes problems makes them difficult to solve. With substance use problems, many beliefs, opinions, and theories underlie treatment protocols. What is meant by “treatment” and “cure”? Harm reductionists advocate for what’s termed “safer” use on the individual level, which may range from abstinence to supervised injection. The criminal justice system, child protective services, medication programs, insurers, and many employers and family members may mandate proof of abstinence via urine drug screen, whether or not that’s medically or therapeutically sound. Individuals may seek to abstain for their own reasons.

But estimates of rates of return to use with most methods range from 60% to 80%. Then there’s the confounding factor of what’s termed “spontaneous recovery.” A significant number of people “age out” of addiction without treatment. Why are some people able to moderate or eliminate use on their own, while some cannot? And why is “recovery” so variously defined and so variously achieved?

In such swirling uncertainty, I find Steven Covey’s guidance reassuring and clarifying: “Begin with the end in mind.”

What can we do together to increase the likelihood of achieving the end in mind?

If you are considering counseling, or have been mandated to counseling by authorities, we’ll assume that abstinence from banned, illegal, or non-prescribed substances is your objective, or that lessened use, within a range tolerated by authorities, is your end in mind.

The purpose of research is to use the wondrous logic and treasure of human minds to design and implement experiments whose results suggest what would be helpful to most people, most of the time, better than other things, and better than nothing.

Research is clear on what can help people limit substance use. However we define addiction, whatever mechanisms are at work in the human brain, whatever neurobiological, developmental, social, environmental, or historical forces are at play, people can learn and implement specific skills that may result in decreased substance use.

I am working on a book manuscript with a co-author to describe this process for those who prefer a self-help guide. In the meantime, I post resources and excerpts on this site, and offer individual and group counseling for those who prefer interactive learning and support.

Briefly, what research suggests helps people limit substance use begins with medical care. Specific medications are available to assist with some specific substance problems (alternately termed substance misuse, substance use disorder, and addiction). For example, the media is currently interested in opioid use disorder, for which the medications buprenorphine and methadone are the first-order standard of care. In some cases, medication is sufficient to help people meet their goals; counseling may not be necessary. Since stress is correlated with increased use, or recurrence of use, and untreated physical and mental conditions cause stress, individuals need medical care for whatever ails them, even if it’s an itchy rash or trouble sleeping. What medical care can ease needs to be eased.

In the context of receiving on-going medical care, individuals can then mobilize their strengths to help them do more of what they intend to do, or what they are required to do.

On their own, or with the aid of a counselor, individuals can begin to learn, and to implement, techniques that help them with what’s at the heart of many mental and emotional challenges: insufficient skill with emotion regulation. In a nutshell, this involves becoming aware of to what one is giving one’s attention and deliberately deciding whether or not to continue or discontinue that focus; identifying feelings and thoughts; adjusting the inner “volume” on one’s feelings; sorting one’s thoughts into “helpful” or “unhelpful” categories, then shifting attention to the “helpful” ones; and becoming aware of physical sensations and reducing discomfort.

Research suggests that these straightforward techniques – what I term “awareness skills” – acquired with deliberate practice and implemented consciously, offer remarkable strength in managing the emotional states and thinking patterns that, if left untended – while they may not cause recurrence of use – are correlated with a return to use.

Except with some medications for some substance use disorders, we don’t know how to directly treat the brain for addiction. While some methods are posited to directly ameliorate problems in the brain, the pace will be too slow for most people who want or need to reduce use now.

As they begin to use awareness skills, individuals can explore concerns related to substance use, including environmental cues and social capital. While people with addiction can often will themselves to choose to postpone use, compulsive use is the primary symptom of the illness. (This is another reason why medications for specific substance use disorders are invaluable. The lack of medication for methamphetamine use plagues many with amphetamine use disorder who attempt to cut back or abstain.) The brain alterations caused by addiction interfere with what we term “will” and “choice.” What strategies does one use in a double bind game of needing a function to address an illness that can compromise that very function?

Whether termed craving or longing, absence of the substance creates an intolerable state akin to pain for many people with addiction. Learning and using emotion regulation skills under such pressure, at the same time trying to discover and engage with replacements for the purposes served by substances, all the while continuing to interact effectively with one’s partner and children, and to hold down a job – well, it’s all very difficult.

And most people with substance use issues have experienced trauma, particularly in childhood. Over half have been diagnosed with mental health issues.  Many have physical pain. When substance use ameliorates these conditions, in the absence of substances, symptoms can escalate to unbearable levels.

Where can we turn for help with this Gordian knot? The research on addiction is actually quite clear on what is helpful. Comprehensive reports on addiction research were released in 2016, first by neuroscience journalist Maia Szalavitz, and then by the U.S. Surgeon General. Evidence-based treatment is at hand.

And no wonder research suggests that, coupled with medical care, skills-focused therapies – rather than personal analysis – can be helpful to people with substance issues who want to reduce or eliminate use. If I have substance use issues, personal insights might be helpful, but only if they free me to take action. I need something to do right now. Addiction is defined as a  brain disorder. Addiction is not a problem with the self.

Research reports that these therapeutic modalities can be helpful to people with trauma, mental health issues, and/or substance use issues: cognitive behavior therapy (CBT) and its varieties, including Cognitive Processing Therapy (CPT), dialectical behavior therapy (DBT), Motivational Interviewing (MI), contingency management (CM), and mindfulness-informed therapies, all offered in the context of, as Maia Szalavitz puts it, “Love, evidence & respect.”

Individuals can study these methods on their own, or work with a counselor, individually and in groups, to use these approaches to address their concerns. A primary skill to acquire is distress tolerance to endure the opposites that are true for many people with addiction: “I want to use AND I don’t want to use.”

Simply put, in tandem with medical care, if I have a substance use issue, if I’m aware of what’s going on in and around me, and have some skills to take action on what might be helpful to me, some supportive people in my life, and adequate resources, I may be able to gently – or muscularly if need be – help myself use substances with less risk, perhaps not at all.

Denigrating, devaluing, and dehumanizing through confrontation, humiliation, and incarceration do not reduce substance use, whether inflicted by others, or through one’s own thoughts. Some beliefs we hold about addiction are simply wrong.

Discussions about addiction treatment and policy seethe with controversy, debate, and acrimony – a lot of emotion dysregulation! I try to slide those aside like dusty curtains to see what’s possible out the window.

To achieve the end in mind – to reduce or end substance use, either by preference or mandate – in my work with myself and others, I have found kindness to be the most helpful modality. Self-kindness and other-kindness. Next would be acknowledging reality without shame or judgment.

If I am working with you, or will in the future, it is my honor, privilege, and delight.

. . . . .

Coloring page interpretation of DBT’ “States of Mind” by Christy Mackie. Downloadable .pdf coloring page opens in a new tab here.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, 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.