Approaching Substance Use Disorders with Compassion and Community

How can behavioral health professionals support clients who struggle with drugs, prescription medications, or alcohol? 

A substance use disorder (SUD), according to the National Institute of Mental Health, affects a person’s brain and behavior. They are often unable to control their use of alcohol, drugs (legal or illegal), or medications. At the far end of the range of symptoms is addiction.

Unfortunately, it’s quite common for a person diagnosed with a mental health condition to also experience substance use disorder — and vice versa. More than one in five adults with mental illness have a co‑occurring substance use disorder. 

Behavioral health professionals should be familiar with the ways trauma, mental health, and substance use issues overlap. Trauma‑informed treatment spaces can be places where people can talk openly about substance use without fear of judgment; by creating an open dialogue with clients, behavioral health professionals can help them get access to appropriate treatment.

How Common Are Substance Use Disorders?

If you’re a behavioral health professional, you will encounter people with substance use disorders.

The 2019 National Survey on Drug Abuse and Health found that 20.4 million people (7.4 % of the population over the age of 12) had a substance use disorder. Because of the stigma attached to substance use, many people with substance use disorders fear the condemnation of others in their families and communities. They may have trouble finding compassionate and effective treatment, especially if they live in rural areas or cannot obtain adequate insurance coverage.

Add the national trauma of a pandemic, and the problems only worsen.

The Connection Between Mental Illness and Substance Use Disorders

It’s difficult to separate out mental health issues from substance use disorders; they often exist together.

The National Institute on Drug Abuse reports that approximately half of people experiencing mental illness also will experience a substance use disorder. For youth, the number may be even higher. 

In particular, the data show high rates of substance use disorders among people with anxiety disorders and serious mental illness (SMI) such as major depression, schizophrenia, and bipolar disorder, according to data from the Substance Abuse and Mental Health Service Administration’s National Survey on Drug Use and Health.

Because the connection between the two is so strong, it’s useful to understand current definitions of addiction and approaches to treating substance use disorders.

What Is Addiction? 

The American Society of Addiction Medicine (ASAM) provides the following definition of addiction.

“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. 

Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.” 

What are those prevention efforts and treatment approaches? And how do behavioral health professionals approach the thorny subject of addiction with clients?

What Is Stigma?

Chris Dorval, LICSW, defines stigma as “the complex of attitudes, beliefs, behaviors, and structures that interact at different levels of society (i.e., individuals, groups, organizations, systems) and manifest in prejudicial attitudes about and discriminatory practices against people” in his course Breaking the Stigma of Substance Use Disorders.

Stigma is the result of making assumptions about people based on something that is usually beyond their control, like race, income, or substance use. And stigma gets in the way of recovery. 

Behavioral Health and Recovery

The Substance Abuse and Mental Health Administration (SAMHA) promotes a holistic approach to helping people with mental and substance use conditions. They emphasize that hope is the foundation of recovery. 

Recovery is different for everyone, and it is not a solo project. Community support and networks are key to developing the resilience to manage recovery. 

In addition to having the strong support of family, peers, and friends, SAMHSA lists the following 4 dimensions of life recovery:

1. Health. People need to be able to make informed choices about their physical and emotional well‑being to overcome or manage a disease or symptoms.

2. Home. People need safe and stable places to live.

3. Purpose. People should have the independence, resources, and income to be able to participate in society and conduct meaningful activities.

4. Community. We all need access to networks that provide support, friendship, and love.

When these elements are present, a person has a better chance of successful recovery.

Advice for Behavioral Health Professionals

For behavioral health practitioners who are addressing substance use disorders, flexibility is key. Young people and older people may have very different paths and needs for recovery.

SAMHSA recommends that behavioral health services be “responsive and respectful” of people’s beliefs, practices, and cultural and linguistic needs. Mental health and addiction services should always keep in mind the diversity that exists in languages, cultures, and needs. And practitioners should actively work to reduce disparities in mental health access and outcomes. 

Approaching all behavioral health clients with a sense of cultural humility and a strengths‑based perspective is a good start.

It’s also important to understand the ways that language matters for people with substance use disorders. Terms such as clean/dirty, addict, alcoholic, relapse prevention, abuse, and dependence can reinforce stigma. 

Instead, behavioral health professionals can use recovery‑oriented terms such as person in recovery, recovery maintenance, and substance use (instead of abuse).

Continuum of Care in Treatment

To standardize addiction treatment, the American Society of Addiction Medicine created a continuum of care from the least intensive to the most intensive level of treatment. 

The levels use the Roman numeral system.

Level 0.5: Early intervention services

Level I: Outpatient services

Level II: Intensive outpatient services/partial hospitalization

Level III: Residential/inpatient services

Level IV: Medically managed intensive inpatient services (this usually means a medically managed detox, such as for someone with an opioid use disorder)

To determine where people fall on this continuum and how to best support them, treatment centers and substance use counselors begin with a needs assessment. 

These assessments are used to determine how much people are using and how often, whether they have participated in treatment, whether they have a history of mental health conditions, and whether they have medical issues or are prescribed medication. 

Motivational Interviewing

Not everyone who has substance use disorders wants to stop using drugs or to get treatment. And until they do, it is difficult for them to make behavioral changes.

One technique that has shown promise in addressing substance use issues is Motivational Interviewing (MI), a technique first described in Behavioural Psychology by William Miller, PhD. 

Dr. Miller went on to coauthor a book titled Motivational Interviewing: Preparing People to Change Addictive Behavior. This model emphasizes listening to clients to figure out what they want and helping them discover their own motivation for changing behaviors. Miller went on to co‑develop something called the drinker’s check‑up (DCU), which appeared to show reductions in problem drinking. 

An article on the website of American Addiction Centers explains that the technique of Motivational Interviewing involves the following steps:

1. Engaging with the client about issues, concerns, and hopes

2. Focusing the conversation on the patterns and habits the client wants to change

3. Evoking motivation for change 

4. Planning practical steps a person can take to make the change they want to make

As always, developing a trusting relationship with the client is key to effective treatment. Using Motivational Interviewing is one way to help clients identify what their internal desires are. Instead of being told they have to quit using a substance, they are choosing to make a change.

Motivational Interviewing, however, is not the path to recovery for every person. People with significant mental illnesses and people who have trouble focusing on or sticking to a plan might benefit from more in‑depth types of counseling, medication, or digital therapeutics to overcome addiction.

Breaking the Stigma

Millions of people who are suffering from substance use disorders are hesitant to reveal their struggles with substances or to seek treatment because of the stigma associated with drug and alcohol abuse. 

Stigma leads to issues of trust in families or communities. It also leads to discrimination. The book Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change explores attitudes about people with mental and substance use disorders. People with substance use disorders experience a great deal of public stigma.

There are too many messages out there telling us that substance use disorders are a result of people’s own behavior — something that they can control. And studies show that people with substance use disorders are perceived to be especially dangerous and unpredictable.

Behavioral health professionals can start by helping clients understand how common it is to face challenges with substances. They can explore nonjudgmental, trauma‑informed, strengths‑based techniques for discussing substance use with clients. 

The Consortium offers several trainings related to addiction and recovery, including some that focus on harm reduction strategies, women and opioid use disorders, and Person‑Centered planning.

When behavioral health communities work together to provide compassionate, trauma‑informed support and equitable resources for people who struggle with substance use, we have a healthier society.