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.
  6. Added 12/9/19. I use “awareness skills” to describe the protocol. Here’s a schematic indicating the context for the protocol: The Context for Learning and Implementing Awareness Skills.
  7. Added 12/9/19. Here is our outcome data from year one.

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.

Last updated 12/9/19

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.

A Kind, Research-Informed Guide for People Seeking Abstinence from Substances

As a novice group counselor at a social services agency, I earnestly explained curriculum materials from what became a discredited list for what was then termed “substance abuse.” A weary client, court-mandated to treatment, listened respectfully, head tilted towards his hands folded on the table. He would be returned to jail if he used substances again. When I finished talking, he paused, then looked up at me. With earnestness matching my own, he asked, “How do you abstain?”

If he could abstain, he would be free.

I was stunned and chilled by the chasms this realization revealed.  Counselors are advised to “meet clients where they are.” I remain ashamed I was miles away from meeting his true needs. And I didn’t know the answer to his question. That was five years ago. I have devoted myself to answering it since.

In an ideal world, the health condition of addiction/substance use disorder would be managed by health care professionals, not the court system. Rather than ordering up the distress and danger of abstinence, the treatment plan might taper down substance use while tapering in supportive replacements. The criminalization and stigmatization of substance use force health care professionals to try to help the people in their care maintain abstinence to prevent loss: of employment, of custody of their children, of university enrollment, financial aid or scholarships, and of freedom through incarceration for displaying symptoms of an illness. (What an ethical double bind! The primary symptom of addiction is return to use. If clients could abstain, they would be in remission and wouldn’t meet the criteria for the very disorder for which they are in treatment with us.)

For those attempting or mandated to achieve and maintain abstinence from problematic substances, estimates of rates of return to use in year one range from 60% to 80%.

What works to help people overcome the odds of returning to use?

Self-help is not an evidence-based treatment for substance use disorder. Yet, each week holds 168 hours. While people with substance use challenges who follow evidence-based treatment plans may benefit from medications and several hours of medical and voluntary counseling appointments per week, the rest of the time people are on their own.

How do you abstain? During the times when people must help themselves, research offers clear guidance.

With Sanjay Kishore, M.D. and the contributions of countless other individuals with substance use challenges, 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.  Again, the caveat: Any self-help guide is to be used in tandem with medical care. (For those who are allowed to practice harm reduction, this workbook may be helpful.)

My theory is that interspersing an hour per day of remission-focused work with research-informed materials during each of the 7 days of those 168 hours per week can increase the chances of remaining abstinent. Help That Helps offers those materials. To push past one-year return to use stats, I’ve devised a year-and-a-day notebook project to assist. For 52 + 1 = 53 weeks, individuals are invited to do engaging exercises with reference to Help That Helps. I add new ideas and materials on the For Clients page. On the For Clients page, I also offer suggestions for further reading.

My client was returned to jail for return to use soon after he asked, “How do you abstain?” I regret beyond words my inability to answer at the time.

Today, I know that, after medical care, the research suggests that self-care is the primary method people can use to help themselves abstain. A self-care checklist is on pages 28-29 in Help That Helps. An example of a day spent practicing self-care is here. Second, they can begin to identify the needs and wants met by substances and ponder alternatives. Assistance with that process is on pages 13-27 in Help That Helps.

I have been in remission from alcohol use disorder since the end of 2012. I had the luck of choosing to attempt abstinence from the substance that had become problematic for me rather than being mandated to it. Regardless, the first years were spent in anguish, easing up only once I was able to follow the guidance of research, primarily through reading Maia Szalavitz’s Unbroken Brain: A Revolutionary New Way of Understanding Addiction and  Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, both published in 2016.

As a person in remission who is also a counselor, I see my work as three-fold. One, I protest the war on people who use drugs. Two, I advocate for addiction policy reform to allow free access to evidence-based treatment. Three, I get evidence-based treatment to the people who have what I have.

I am only person and can only do so much. But in my sections of Help That Helps, I tried to write words that would have reassured, informed, and guided me. I hope they offer comfort and guidance – even freedom – to people who have what I have.

If I can be of any service in any way, please do not hesitate to contact me.

Image: iStock

Last updated 9/14/19

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

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.

Health Care Professionals Must Take Back What Happens to People with Addiction from the Criminal Justice System

The health care gold standard of achieving remission from addiction or substance use disorder is not the absence of substance use, but the absence or presence of substance use such that substance use does not result in notable harm to self, others, or society. Nine out of ten Americans use substances without noticeable harm.

In contrast, the gold standard of the criminal justice system is abstinence as evidenced by negative urine drug screen. As with most health conditions, during the time that treatment is attempting to help the person achieve remission, an individual is likely to display symptoms of the condition. With substance use disorder, that defining symptom is continuing to use substances despite adverse consequences.

Unite to help people with addiction

This disconnect harms our outcomes. For health care professionals who treat people with substance use disorders, time after time, we and our patients and clients see clinical stabilization, patients and clients display the symptom of the illness for which we are treating them – use – and they’re incarcerating again, re-traumatizing and destabilizing them.

The arguments for “sanctions,” i.e. re-incarcerating drug court participants and people on probation or parole who test positive for illegal or banned substances are: 1) Using illegal substances is breaking the law and they should go to jail for that. 2) They committed crimes while using substances and they should go to jail for that. 3) They should be grateful to be in drug court or on probation/parole rather than in jail.

We, health care professionals who treat people with addiction, need to continue to educate the criminal justice system that our patients and clients are not yet cleared for medical release. Addiction is a medical illness for which people may need emergency, then urgent, then long-term care. Even wounded armed robbery suspects are taken to the hospital first. Only when they are medically cleared for release are they taken to jail. Then due process begins. In contrast, people with substance use disorder are a uniquely persecuted population, particularly when they participate in drug court. They are presumed guilty of crimes and incarcerated over and over again – without due process – for having wounds.

Our current system overrules medical and public health best practices in favor of criminal justice mandates. In terms of dollars and cents, the criminal justice system is robbing health care professionals of our outcomes which are increasingly required by payers for reimbursement. If not for humanitarian reasons, then for economic reasons, health care professionals must take back what happens to people with substance use disorders from the criminal justice system.

If we must have drug courts – although the data overwhelmingly denies their effectiveness – they need to be transformed into aftercare treatment courts capable of receiving patients and clients who are still weakened and vulnerable as they attempt to recover from this potentially life-threatening medical illness.

For further reading

Image: iStockphoto

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.