Good Psychotherapy Requires Clear Understanding of Addiction

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Skilled psychotherapists use a combination of theoretical approaches, including cognitive behavioral and psychodynamic methods, tailored to each patient’s needs and availability for in-depth work. Even moderate substance use interferes with psychodynamic work because alcohol and other drugs artificially quell anxiety stirred up by introspective examination of unconscious material.

Therefore, due to a high prevalence[i] of substance use and abuse, it behooves all therapists to be skilled in using cognitive behavioral and motivational interviewing approaches; this can clear away the underbrush, preventing deeper work. Just as trauma needs to be attended to before deeper work is possible, substance use must also be cleared before deeper work can be successful.

When overt addiction to alcohol and other drugs is present, referral to a mutual aid group, such as for alcohol, narcotics, cocaine, or marijuana, can greatly help therapeutic efforts. Just as medication-assisted therapy (MAT) is helpful for opiate addiction, 12-step assisted therapy is an important combination.

Intimate partners of people with substance use disorders also benefit from Al-Anon-assisted therapy. To maximize the impact of 12-step work, therapists must understand the psychological depth embedded in each step. This enables therapists to translate, interpret, and reframe A.A.’s sometimes archaic language, facilitating patients’ acceptance of chemical and emotional sobriety outlined by the Twelve Steps.

Whether your patients actively work the steps or not, they all need to make the same psychological changes promoted by the 12 steps to clear away the distraction of substance use. Understanding the character traits fostered by the 12 sequential steps provides therapists with a blueprint for the cognitive behavioral work they can initiate in therapy.

For example, the first step requires a humble acknowledgment of one’s powerlessness over one's drug of choice. For some, this means an inability to maintain sobriety despite heroic efforts. For others who are not addicted but use it often enough to interfere with deeper therapeutic work, a similar degree of humility and honesty is required to acknowledge that chemically managing their feelings prevents them from sustaining attention on unconscious forces requiring resolution.

For people with substance use disorder and the more moderate users, developing the necessary humility to admit they cannot reach their therapeutic goals while still using chemical substances is a significant narcissistic blow to their pride. The grief and despair caused by facing such impotence are softened by the hope offered in step 2—hope that new varieties of help become available after surrendering substance use.

Therapists’ appreciation of the subtle impact of even moderate use of substances (including cannabis), especially when it is habitual or regularly relied on to soothe tension and emotional discomforts, is a function of each therapist’s relationship to substances and their family history. It is easy to minimize the effect of whatever level of psychoactive substance use you and your social network are comfortable with.

It is just as easy to be overly reactive to occasional use, especially if you are affected by familial addiction, as one in four people are. The goal must be nonjudgmental awareness of chemicals' role in each person’s psychology. The question is always whether substances are used in place of psychological skills that remain undeveloped, underused, or atrophied.

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This requires hard introspection for many of us. I am reminded of a TV reporter who tried to make me look ridiculous by asking sarcastically if I think getting buzzed on alcohol once a month is a problem. I answered, most certainly, that it could be problematic if a man has sex with his wife only once a month and must get buzzed to risk approaching her. The core issue is substances' role in sidestepping issues that should ideally be handled with psychological resources.

Working the 12 steps develops character traits of humility, faith in the availability of support, honesty with self and others, awareness of character flaws and their impact on oneself and others, transparency, connection, willingness to change, spiritual awakening, and integrity. These will all prepare people for a much deeper dive into therapy and the search for a meaningful life.

The fact that millions of people worldwide have developed many of these positive character traits without therapy through 12-step recovery alone proves that the psychological tasks presented by the sequence of steps are a powerful recipe for growth. Skilled therapists know how to initiate and augment the developmental path outlined by the steps, whether patients participate in mutual aid groups or not.

Here is a recipe for improving your therapeutic skills, especially with patients with substance use disorder.

1. Prepare yourself for this work by analyzing your relationship to substances.
2. Always inquire in detail about any chemical substance use during the initial evaluation.
3. Use a patient’s substance use as an opportunity for initiating motivational interviewing.
4. Study each of the 12 steps, searching for personal meaning in each.
5. Understand the sequence of positive character traits developed from step to step.
6. A short course in the psychological depth embedded in the Twelve Steps can be found in my series of posts, beginning with A Meaningful Definition of Addiction Recovery. I hope you find the whole series enjoyable.