An Uncontrollable Use
Substance use disorder (SUD) is a mental disorder affecting one’s brain and behavior, leading to an uncontrollable use of substances such as drugs, alcohol or medications. Symptoms can range from moderate to severe, with the most severe form of SUD referred to as an addiction.[1]
The National Institutes of Health (NIH) note the prevalence of SUD among adults in the U.S.:[2]
Nearly one-third of adults have alcohol use disorder at some time in their lives, but only about 20 percent receive treatment.
10 percent of adults have drug use disorder at some point in their lives, but only 25% receive treatment.
Further, nearly 6% of those aged 12+ experienced prescription psychotherapeutic drug misuse in 2020.[3]
Comorbid conditions tend to present more in those with SUD, although research has not yet found concrete causal relationships among them. Co-occurring disorders may include: anxiety disorders, depression, attention-deficit hyperactivity disorder (ADHD), bipolar disorder, personality disorders, and schizophrenia. In the event of comorbid conditions, treatment for one disorder may be compounded and more difficult, though is still achievable.[4]
Compared to those without drug use disorder, individuals experiencing drug use disorder are:[5]
1.3 times as likely to experience clinical depression
1.6 times as likely to have post-traumatic stress disorder (PTSD)
1.8 times as likely to have borderline personality disorder (BPD).
Generally, it is better to treat the SUD and co-occurring mental disorder together, not separately. Thus, health care providers need to conduct full evaluations and provide a treatment plan based on one’s specific situation, in regards to their: age, misused substance and comorbid mental health disorder(s). Both Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) have been found to be effective in treating substance use disorder.[6]
Q&A
SAS THERAPISTS DISCUSS SUBSTANCE USE DISORDER AND EFFECTIVE TREATMENT MODALITIES
1. How does someone even become aware that they have a problematic substance/alcohol use disorder/addictive disorder versus simply enjoying ____ to relax/unwind on a frequent basis? How does someone know when it’s time to seek assistance?
“Awareness of alcohol or substance use disorder or an addictive disorder (e.g. gambling, shopping, etc.) often comes as a result of some unwanted consequence related to the behavior - for many people this looks like a DUI, concern expressed from a loved one, physician, employer, etc., a negative test result from the doctor, or just feeling so crappy the next day that you start to wonder if the substance is worth the pain. It could be an incredible amount of debt, being kicked out of a casino, or having your credit cards maxed out and shut off/things going to collection. People also become more aware of the behavior as problematic when they try to stop and can't seem to stick to that goal. It freaks them out. Generally speaking, if you're worried you might have a problem, there's a good chance you do!
It's also important to note that using a substance to ‘unwind on a frequent basis’ in and of itself is problematic - what happens if you don't use this substance? What do you feel? If you can't tolerate your thoughts or emotions or physical sensations without using a substance to ‘unwind,’ it might be a good time to check in with a therapist.” (Jennie Ketcham Crooks, LICSW, MSW)
“This is a question frequently asked, both by those who use substances themselves and concerned loved ones. There are some aphorisms from the recovery world I often quote when helping to answer the question, including: ‘If you have to control it, it is already out of control.’ While of course this isn’t absolute, it can be a helpful realization that even minor things like counting drinks or scheduling use (‘I only use on weekends’, etc.) are not common in actual recreational users. It can be a cue for us and friends/family that the ‘control’ is gone if we are talking about controlling, so that cue can lead to seeking assistance. It is a helpful reminder that merely seeking assistance is not admitting addiction or signing-on for lifetime abstinence. Many folks today are trying on a trend – with regard to alcohol – called ‘sober curious’ for instance, which highlights a period of sober time with an attention to what is lost and gained without the presence of a drug (including alcohol) in their lives. In all, seeking assistance or merely asking questions (Google can be our friend!) is unlikely to be harmful. The more you know, right?!” (Kate Willman, MA, LMHCA, HCA)
2. In your experience, what are the biggest obstacles that someone has to overcoming a substance/alcohol use disorder/addictive disorder? How can they best overcome those obstacles?
“A major obstacle is the way in which society normalizes the use of alcohol and marijuana in particular - we think as if we ‘should’ be able to ‘drink normally,’ and when we fail to do so, it is pretty crushing. So we try and try again, and fail and fail again. Yet, the biggest obstacle to overcome is the tolerance of uncertainty; we don't know if you'll ever use again (That is, not until you use! Then we know!). Intolerance of uncertainty may be one contributing factor to why the relapse rates are so high. If one cannot tolerate the uncertainty about when they will use again, the only way to gain certainty is to use.” (Jennie Ketcham Crooks, LICSW, MSW)
“The first ‘big obstacle’ that comes to mind is that drugs work. That may sound a bit odd, but: it’s true! The substances themselves will always be potent, will always have a desired effect on neurotransmitters at various levels, and are likely to always be made available in one way or another. In fact, some addictive substances are even legal to obtain. Therefore – in part to account for the assurance that drugs work – the next biggest obstacle most folks must overcome is their own desires to keep using. Again, this might sound odd to an outsider, but many addicts even in long-term recovery readily admit that if they could still use successfully, they would! So a person might have every desire in the world to stop using, and they can still retain some desire to keep using. Behavioral addictions like gambling or pornography use are similar in that the process or ‘chase’ of the behavior stimulates neurotransmitters in much the same way as a substance would.
One of the best ways I’ve seen others face and overcome this obstacle is through mutual support. Whether friends, family, professionals (like a therapist), or simply peer support from other people who have struggled with substance use or behavioral addictions… most people simply cannot do it alone. Many people today have also been able to find help online, through anonymous forums, meetings and/or social media. In the end, however, only the individual will be able to decide for themselves when ‘enough is enough’.” (Kate Willman, MA, LMHCA, HCA)
3. In what ways has the pandemic affected substance/alcohol use disorder/addictive disorder (rates, types, recovery) that you personally have witnessed in practice?
“Many people use substances or alcohol to ‘feel better’ - socially, it's been a way to connect (‘let’s grab a beer!’), physiologically it depresses your system (Anxious AF? Let’s grab a beer!), and the pandemic has been a context in which many people have needed social connection and experienced increases in anxiety (germs everywhere folks).” (Jennie Ketcham Crooks, LICSW, MSW)
“The pandemic seemed to exacerbate existing problems and / or introduce new anxieties for people. Many of our best, most natural coping mechanisms were unavailable to us, including – for instance – the live support of family and friends, the release, productivity + enjoyment of the workplace, and various hobbies enjoyed both socially or alone. And all of this at a time when we needed to cope more than ever. The already easy access to legalized substances like alcohol and cannabis became even easier via delivery programs in many areas, and so some people came to rely on use as a coping mechanism in the absence of others.
The two-or-so years of pandemic saw a decrease in coping outlets coupled with an overall increase in anxiety and depression (amidst other social, economic and political stressors). To boot, many people found themselves isolated. In other words, a prime opportunity for addiction issues to flourish, and since addiction already breeds isolation, a lack of social accountability encouraged isolation in the pandemic even further.” (Kate Willman, MA, LMHCA, HCA)
4. Would any specific psychotherapeutic modality be better-suited for someone battling these disorders than others? If yes, which would you recommend and why?
“I think that any therapy that supports a client to identify their values and take committed action in alignment with those values will help them tolerate the distress of overcoming an substance or addictive disorder. I often talk about substances/alcohol or addictive behaviors as a solution to some problem, so knowing what's important to you in this life can help increase your motivation and your distress tolerance; chances are if you've quit a substance or alcohol (or gambling or shopping), whatever problem substances or alcohol solved will still be there. Ultimately, behavioral therapy will be an important component of treating substance and addictive disorders because your behavior will be required to change.” (Jennie Ketcham Crooks, LICSW, MSW)
“There is clinical research to support all types of different modalities for treating addiction.
The first that comes to mind specifically is Dialectical Behavioral Therapy (DBT) for its focus on skills to promote and practice emotional regulation, mindfulness, and tolerance for distress.
Acceptance and Commitment Therapy (ACT) combined with harm-reduction practices also comes to mind as a frequently used treatment as it does not focus on symptom reduction as an outcome. This can aid in recovery from or re-evaluation of a person’s relationship with drugs in that it removes focus on the substances and/or behaviors themselves and instead brings focus back to the person themselves.
Several variations on psychodynamic therapy have also been seen in addiction treatment, including existential and narrative therapeutic approaches.
Finally, people struggling with addiction – both behavioral and with substances – are still people, right? And their use is just a symptom of what are much larger problems. The person-centered approach can assist in a practitioner’s ability to use the best modality when treating those with use issues while also taking into account the presence of comorbid conditions.” (Kate Willman, MA, LMHCA, HCA)
5. Do certain comorbid mental health conditions appear more prevalent than others in those with these substance/alcohol use disorders? Do some conditions make treatment more difficult?
“We see a high comorbidity between social anxiety and alcohol use disorder, largely related to what I noted in question 3 - when we feel nervous about social engagement, it can be easy to ‘grab a beer.’ While beer makes that anxiety go away temporarily, it ends up reinforcing an unhelpful learning pattern wherein the person ‘learns’ that beer is what kept them safe in the social engagement (versus learning that social engagement - and the experience of anxiety! - is a safe activity). That learning then says, ‘I must drink beer EVERY time I engage socially.’” (Jennie Ketcham Crooks, LICSW, MSW)
“The observable correlations between mental health issues and substance abuse are many.
First, the most common mental health issues such as depression, anxiety, etc. can lead to use or abuse of substances as a form of neutralizing discomfort (sometimes colloquially known as ‘self-medicating’). We see similar patterns in those experiencing behavioral addictions. Second, substance use itself can contribute to the experience of one or more symptoms of mental health issues – including depression, anxiety, suicidal ideation, psychosis, obsessive thoughts, etc.
Even further, there is substantial evidence that neurological changes can occur as a result of substance use, depending on frequency, duration + severity of use, as well as what substances are used and at what age(s) use begins. There are often correlations between substance use and mental health symptomology that are etiologically indistinguishable, i.e.: there is often a reciprocity between mental health issues and substance use issues that can make it difficult to discern the specific dynamics between them, let alone causation or source of either or both.
This is all to say that there are many possible comorbid conditions – especially those in the mental health realm – that make treating addiction more difficult. Additionally, a holistic perspective shows us that this generally means the life of the client is more difficult, and we should do our best to help mitigate confusion or shame in these cases. There are certainly some conditions we see more often than others – anxiety, depression, chronic pain, and various forms of trauma – however, this might be less correlated to addiction and more because these are prevalent conditions anyway.” (Kate Willman, MA, LMHCA, HCA)
6. Can you give an example of how you may guide someone in therapy who wants to overcome a substance/alcohol use disorder/addictive disorder?
“If someone is seeing me specifically for addiction, we will begin with a practice of noting - with gentle curiosity - the behaviors they'd like to question. We gather data, do some values mining, and a functional assessment: Is this behavior moving you closer to or further away from a meaningful life. Then, depending on that result, we make some changes and commit to action. After a period of treatment, and after you see the changes happening in your life, we will do a course of mindfulness-based relapse prevention.” (Jennie Ketcham Crooks, LICSW, MSW)
“I would start by assessing for co-occurring disorders and then – if they are present – do my best assess which has a higher acuity and therefore probably requires attention first (this may or may not be the use itself). I’d also assess a client via the Stages of Change model to attempt to decipher ‘how ready’ they are to stop using. For instance, if a person is in ‘precontemplation’, we wouldn’t want to start jumping into recovery strategies. Once I’ve assessed where someone is in the process, we can collaborate on options to move forward. Sometimes a client needs support, needs to experience trust and empathy before they are willing to face the big world ahead of them without their drug or behavior of choice. Therapy, thankfully, is a great place to receive these, and even if a strong desire to change isn’t first apparent, it can develop over time through an informed and cooperative relationship.” (Kate Willman, MA, LMHCA, HCA)
7. Is there anything else you’d like to share with those interested in learning more about treatment and/or may be battling substance/alcohol use disorder/addictive disorder, themselves?
“Now, more than ever, there is more information about [and less stigma surrounding] the prevalence of substance use issues and the insidious nature of the disease of addiction. For those readers who don’t, themselves, identify as struggling with either of these issues, I urge you to become informed anyway, because the likelihood that you or someone you know will at some point face one or more of these issues is essentially guaranteed.
Support, accountability, empathy, and inclusion are paramount in treating the very real (and, too often, fatal) diseases of substance abuse + mental illness. We can all help by informing ourselves and others about the perils of addiction, the resources available for recovery, the universality of mental health issues, and the reality that love and understanding are key in facing these successfully.” (Kate Willman, MA, LMHCA, HCA)
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
Jennie Ketcham Crooks, LICSW, MSW & Kate Willman, MA, LMHCA, HCA
Editor: Jennifer (Ghahari) Smith, Ph.D.
For more information, click here to access an interview with Psychiatrist Lantie Jorandby on Addiction Recovery.
Additionally, you may click here to access an interview with Psychologist Robyn Walser on Trauma & Addiction.
REFERENCES
1 National Institutes of Mental Health (NIH). (n.d.) Substance use and co-occurring mental disorders. (accessed 9-20-2022) https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health#:~:text=A%20substance%20use%20disorder%20(SUD,most%20severe%20form%20of%20SUDs
2 National Institutes of Mental Health (NIH). (n.d.) 10 percent of US adults have drug use disorder at some point in their lives. (accessed 9-21-2022) https://www.nih.gov/news-events/news-releases/10-percent-us-adults-have-drug-use-disorder-some-point-their-lives
3 NIH: National Institute on Drug Abuse. (n.d.) What is the scope of prescription drug misuse in the United States? (accessed 9-21-2022) https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse
4 NIH. Substance use and co-occurring mental disorders.
5 NIH. 10 percent of US adults have drug use disorder at some point in their lives.
6 NIH. Substance use and co-occurring mental disorders.