Therapy serves as an integral component in addressing a variety of mental health-related concerns. For some conditions, such as those involving substance use, ongoing therapy is even more important. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recognizes substance-related disorders across ten classes of drugs, including alcohol, cannabis, phencyclidine, other hallucinogen, inhalants, opioid, sedative/hypnotic/anxiolytic, stimulant, tobacco, other (i.e., unknown). It defines a substance use disorder as a “problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.”
Further classification delineates the illness according to severity levels, (i.e., mild, moderate, or severe), with severe presentations including six or more diagnostic criteria and also recognizes changes in severity over time (i.e., “in early remission”, “in sustained remission”, “on maintenance therapy” or “in a controlled environment”). Specific criteria aside, substance use disorders create a cascade of pain and suffering.
Today, however, addiction is becoming more appropriately viewed, not as an indicator for potential criminality, but as a mental health condition, no less deserving of compassion and empathy than any other illness.
When I began my journey to become a Clinical Psychologist, I sought specific experience treating adults and adolescents with concerns related to substance use. I entered my training with a preconceived notion about the appearance of substance use, subscribing to the stereotypical image of what it looks like to be addicted to drugs and alcohol. For some of my clients and patients, substance use resulted in a complete loss of baseline functioning. Many individuals lost their jobs as a result of drug use, several becoming homeless and others barely holding on to even the most basic of resources. Other individuals, however, maintained competitive salaries, returning home each day to a seemingly picturesque life, yet silently shouldering immense pain and suffering.
Now, as a practicing clinician, I am humbled by the various faces of addiction and the fact that one individual’s journey may look entirely different from another, but measure equally in terms of overall suffering.
Early schools of thought vilified drugs and alcohol and the individuals that used these substances. Addiction was perceived as a sign of weakness, a lack of control, and those suffering were institutionalized and seen as a societal nuisance.
Today, however, addiction is becoming more appropriately viewed, not as an indicator of potential criminality, but as a mental health condition, no less deserving of compassion and empathy than any other illness. Substance use results in neurological changes, stimulating the reward circuitry in the brain that releases dopamine and strengthens the association between a particular behavior and a desirable emotional state. Ongoing and excessive use weakens structures in the brain that are associated with executive functioning, such as impulse regulation, which further increases an individual’s relapse potential.
These sustained brain changes explain why addiction is so difficult to kick.
What factors contribute to addiction?
Whether a person succumbs to addiction depends on the intersection of psychological, biological, social, and physiological etiological factors. Genetic and environmental variables not only inform the initiation of drug and alcohol use but also contribute to the subtle transition from recreational use to overuse. Heritability studies show that, given specific scenarios, genotype plays a significant role in vulnerability to addiction, helping to explain why some individuals are more likely than others to use substances in excess.
This means that, to a certain extent, when an individual is born into a family with a history of addiction, they are already fighting against the odds.
So why does this matter?
Knowing that a person may be genetically predisposed to substance use can help prevent the issue from manifesting altogether by increasing self-awareness during the formative years when recreational experimentation is most pronounced. As a provider, it is important to acknowledge the role of genetics because doing so can also inform the treatment approach from a harm-reduction model to an abstinence-based model of intervention.
For instance, if I am working with a client who has a deeply entrenched family history of substance use, I might be less inclined to advocate for a treatment model that emphasizes moderation versus complete sobriety.
At Two Chairs, we match you to one of our 50+ expert therapists according to these types of unique considerations; things like your family history, your social circumstances, your preferences for a therapist, and what modalities they utilize in treatment. We put an incredible amount of thought into the way we match our clients when they start therapy with us, because clinical research shows that client-therapist compatibility is the biggest predictor of successful outcomes in care.
Why is therapy important when dealing with addiction?
Clinical presentations are complex: Rarely does addiction exist in isolation. Many individuals who struggle with substance use also suffer from other mental health disorders, which may appear comorbidly or predate the onset of addiction. For instance, there is a high rate of comorbidity among substance use, anxiety, depression, and eating disorders and there is even greater overlap amongst people with severe forms of mental illness, as drugs and alcohol are used to self-soothe and self-regulate in the midst of these disorders.
It is rare for a person in therapy to present with solely substance-related concerns and, more often than not, these individuals are also suffering from layers of other psychological issues.
Therapy is an opportunity to not only address the behavioral manifestations of emotional suffering but also to explore factors that led to the development of addiction as well as those that maintain the cycle of use and abuse.
Therapy gives you tools: Most people who become addicted to drugs or alcohol never intended to develop a substance use disorder. Rather, substances were used as a coping mechanism to deal with life stressors. The problem is, however, that once you use an effective coping strategy, your brain draws an association between that particular stressor and your response.
Eventually, you begin to rely on that coping strategy, regardless of whether doing so is beneficial in the long run. For many, drugs and alcohol offer a reprieve that becomes anticipated and expected.
Therapy can help people develop an individualized recovery toolkit, replacing maladaptive coping skills, such as drugs and alcohol use, with alternative options, such as behavior activation (i.e. physical activity), mindfulness practice, social support, journaling, etc.
Increased self-awareness: Drawing attention to one’s thoughts, feelings, needs, and motivations for change, allows one to establish personalized goals. Therapy encourages honest introspection and provides a safe environment for this exploratory process. Therapy is also a place for one to explore their strengths and weaknesses, and to understand how certain traits that may have contributed to addiction can be rechanneled to promote the desired changes. Looking at oneself with radical honesty can be intimidating and, at times, painful. Thankfully, therapy offers a supportive and safe environment for doing so.
Therapy keeps you accountable: The power of accountability should not be underestimated. Seven months ago I began working with a client who was not only apprehensive about weekly therapy but very much uncertain about getting sober. Sobriety carried a persona that the client did not subscribe to and, as a result, they refused all adjunctive support services with an all or nothing model or recovery.
We spent many months together exploring reasons for drinking, ways to cope without alcohol, etc., and except for the occasional ebb of drinking, their behaviors remained mostly unchanged.
My background treating eating disorders and also being on the receiving end of care taught me that ongoing, intensive therapy helps promote change. As a result, we increased session frequency to twice weekly and supplemented it with daily text check-ins to maintain communication between sessions.
The expectation that they were accountable to someone during and outside of session helped the client move towards sobriety. Ultimately, when we name something as a problem and commit to making changes, we take away part of its power and take on a responsibility to do differently.
Addiction thrives in secrecy: Despite ongoing efforts to increase consciousness around addiction and to normalize those it impacts, the term “addiction” still carries a negative connotation. As a result, people suffering from drug and alcohol use often do so in secrecy, which consequently adds fuel to their illness. For a former client, disclosing their struggle was the first step towards reclaiming their life. Naming their struggle outwardly allowed them to recruit the support of their significant other during moments of distress and fight against addiction as a united front.
How to Access Care
Entering the mental healthcare system is daunting. If you have never been to therapy before, or even if you have, the process of finding a therapist who not only meets your needs but also your schedule availability can feel like an expensive game of trial and error. Many of my current clients considered abandoning their pursuit of therapy altogether because of this overwhelming and arduous process. But this does not have to be the case. Although finding a provider can be a multi-step process, breaking it down into more manageable action items can make it less intimidating.
Step 1: Contact your insurance company. Most insurance companies offer a list of providers who are considered “in-network”. From there, prospective clients can initiate contact with these practitioners to determine appointment availability and therapy cadence.
Step 2: Ask your community. Some of my current clients, current and former, found their way to my panel via word of mouth. For some, the suggestion came from a close friend who had a positive experience finding a therapist through Two Chairs while other referrals were offered by a Primary Care Provider or another community referral source.
Step 3. Search online. Online databases such as Psych Central or Psychology Today provide information on practicing clinicians of all backgrounds. Clients can often refine their search to focus on particular specialities, such as addiction, as well as other preferred variables including gender and location, amongst others. You can also check out the National Queer and Trans Therapists of Color Network, which aims to advance healing justice by transforming the mental health of queer and trans people of color.
In addition to searching for an individual therapist, the internet is a bountiful resource for all things therapy-related. Many of my clients have reported success in finding other therapeutic resources such as support groups, online forums, and other affordable services to supplement individual therapy. One of the silver linings associated with COVID-19 is the fact that most services are now offered virtually, thus eliminating additional barriers related to transportation and making it easier for clients to access support services from the comfort of their own home.
Step 4. Contact treatment centers in your area. If a client is interested in receiving care to address a particular presentation, such as substance use, it can be helpful to connect with treatment centers in one’s primary geographic area. Many rehabilitation centers maintain a referral list of providers and might also be able to provide additional community resources that are more cost-effective than traditional treatment approaches.
At Two Chairs, we aim to streamline the process of helping to connect clients with providers. We recognize that cold-calling from a list of providers in your area can feel enormous and overwhelming and emphasize the connection and rapport between parties, while also helping clients navigate the process of receiving insurance coverage for an out of network provider.
If you or someone you know is seeking mental health care, you can reach out to our Care Coordination team at [email protected] or by phone at 415.202.5159. If you or someone you know is experiencing a crisis or emergency and needs immediate help, call 911 or go to the nearest emergency room.