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.
  8. Added 12/16/19. Here is the first iteration of the brief protocol requiring 5 sessions.

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