A 4-Step Framework for Substance Use Disorders

Substance use disorders are profound and complex problems that have a destructive impact on a person’s life. When a person is caught in the turmoil of addiction, they have crossed into a pathological pattern of use over time related to several different problems.

 

Substance Use Disorders Exist on a Spectrum

An employee who occasionally misses a deadline or day at work, or a student who binge drinks on the weekends and engages in some high-risk behaviour, may have a mild to moderate substance use problem. On the other hand, someone with a severe substance use disorder or chronic addiction may use substances nearly all day every day, need an increasingly larger amount of them to get the desired effect, and experience withdrawal symptoms if they do not use. In addition, they may struggle to maintain employment, have high absenteeism at work or school, and spend a great deal of their money on substances.

The greater the impact of the substance use problem, the more likely the person also has emotional difficulties and may experience feelings of shame, guilt, remorse, anger, sadness, or anxiety.

The greater the impact of the substance use problem, the more likely the person also has emotional difficulties and may experience feelings of shame, guilt, remorse, anger, sadness, or anxiety. The individual may demonstrate other concerning behaviours, such as no longer spending time with friends, changing the people they spend time with, or experiencing problems in their friendships. The person may spend increasing amounts of time using the substance or need more of the substance to reach the desired level of intoxication.

Substance use disorders arise from a mix of many interwoven risk factors, including:

• Having a family history of addiction or substance use problems
• Predisposed vulnerability to developmental, cognitive, social, emotional, or behavioural challenges
• Exposure to trauma, which could mean the direct witnessing of an event or learning about the traumatic experience of someone one is close to; multigenerational trauma or cultural trauma; childhood neglect, maltreatment, or abuse
• Living in a home with some kind of family relational problem, which could take the form of a chaotic and unpredictable environment, domestic violence, or chronic, hostile communication
• Other psychological problems, such as anxiety, depression, or post-traumatic stress
• Difficulty with regulating challenging emotions like anger, sadness, fear, shame, guilt, or remorse

Substance use disorders vary in nature and complexity. As such, counsellors will routinely meet people at different stages of the problem. Some people will be seeing the counsellor for unrelated issues and may be completely oblivious or in denial about their problematic use, whereas others will have a great deal of insight into their problem and a willingness to actively work on change.

Finding agreement on a goal is a grounding mechanism in which both the individual and the counsellor know what they are trying to achieve.

 

Start By Finding a Common Goal

Finding agreement on a goal is a grounding mechanism in which both the individual and the counsellor know what they are trying to achieve. To do this, it’s important to be clear on the goals of the client and the goals of the counsellor. Goals are often set after understanding the factors that keep the problem in place and the specifics of that individual’s substance use problem.

Once goals are established, a number of counselling interventions can be helpful. As people reduce their use or abstain from substances, they usually encounter challenging symptoms. Individuals often need counselling to work through intense urges to use substances, to help manage emotions, and to recognize triggering thoughts.

Working through these challenging related factors can have a powerful impact on recovery. Though setbacks in the counselling process and relapses into the substance use disorder are often part of treatment, creating a plan to overcome these obstacles facilitates forward momentum. In my experience, I have found the following framework helpful for guiding recovery:

1. Develop a trusting and respectful relationship.

This is the foundation for client comfort, active participation, and helpful connection.

2. Establish the goal.

Work to identify key issues that will need to be addressed in order to achieve the treatment goal. In addition, the choice between abstinence or harm reduction will need to be addressed.

3. Manage urges, cravings, thoughts, and emotions.

Identify the internal triggers that lead to the problematic use.

4. Manage relapses and re-evaluate goals.

A challenge in substance use treatment is the high likelihood of relapse. Recognition and management of obstacles allows for imperfect progress towards the goals.

Many people still hold onto their problematic use because of the social ease it creates.

The loss and harm caused by substance use disorders often generates a dark cloud of despair and desperation. Many people still hold onto their problematic use because of the social ease it creates, the softening of harsh feelings it offers, or the blissful oblivion it can offer them. Even though the person may know their problematic use harms them, it is crucial to remember the important purpose that substance use has served in their life and that it may be hard to give up.

As a counsellor, it can be hard to understand why someone holds onto their problematic use when it is so evident that it is causing incredible destruction. It is important to remember the life circumstances that keep the problematic use firmly in place.

Like any big storm, the clouds part from time to time, or the sun might shine down momentarily, and these are the moments that we as helpers look for, strive to hold onto, and remember for our clients and ourselves. For some people, the clouds may be all-encompassing, dark, and heavy, whereas for others, the sky may be slightly grey with a great deal of light peeking through. No matter where the person is at, celebrate the small changes and bits of light until the sun overtakes the sky.

It is important to remember the life circumstances that keep the problematic use firmly in place.

I have found that when I strive to meet the client exactly where they are, not where I would like them to be, this is when our most collaborative bond is formed. At that point, we can face the chaos of the problematic substance use together, using the strategies I have outlined above. We then move away from powerlessness and fear to power and freedom.

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