When the outside world looked at Julie Bates-Maves’ client “James,” it saw a 60-something “junkie” who had wasted 20 years of his life shooting up heroin. But in James’ community of people who used heroin, he was a respected man — an authority figure who could be trusted.

Throughout his two-decade addiction, James had established himself as a safety expert, recounts Bates-Maves, a member of the American Counseling Association. It might seem incongruous to use the word “safety” when speaking about heroin use, but safer injection practices can save lives. James derived great satisfaction from helping his peers reduce their risk of contracting HIV or hepatitis by teaching them never to share needles and demonstrating how to clean their own. He also taught others how to inject without missing the vein.

James’ process of giving up heroin took about a year, but he did well with overcoming the physical addiction, says Bates-Maves, a licensed professional counselor (LPC) whose master’s degree is in rehabilitation counseling with a concentration in alcohol and substance abuse counseling. The hard part was when James was alone and feeling lonely. He struggled with feelings of uselessness, and he knew where he could readily find validation. Among other users, all James had to do was offer to lend his expertise. There was always someone willing to take him up on his offer.

“He had not found respect in virtually any other area of his life,” Bates-Maves says. That meant that in trying to give up heroin, James would also have to leave behind the solitary piece of his world that made him feel worthwhile.

Once Bates-Maves understood that using heroin was tied to James’ sense of self, she realized they needed to examine what it was about the behavior and the attached relationships that provided him with a sense of meaning.

“It was a lot of picking each other’s brains and saying, ‘Let’s try to dissect this,’” she recalls. They set about trying to uncover the actual source of the sense of meaning that James derived from using heroin. “Is it truly tied to the syringe and the bleach and the cotton and the heroin?” she asked him. “Or is it that somebody is listening to you because they think you know something that they don’t?”

Ultimately, James realized that he didn’t actually need the heroin. “I just need someone to look at me and think I’m smart and that I have something to offer,” he told Bates-Maves. So, they worked together to identify another way for James to find a sense of meaning and feel as if he had something to offer others.

Earlier in his life, James had pursued a welding career. For various reasons, he had abandoned that path long ago. But now, he was ready to pick it up again.

With Bates-Maves’ help, James got re-enrolled in a tech program for welding. By going back to school, he acquired a skill set that not many people possess, built new relationships and experienced a sense of validation. He was able to say, “Hey, I’m 62, but I don’t have to check out of the game, and I don’t have to stay stagnant in everything I’ve done,” Bates-Maves explains. “I can add new things to my life, and by adding more to my life, I can add to other people’s lives.”

“So,” she adds, “it became sort of a sense of altruism for him of wanting to give to the world and then to feel good about doing that.”

James had been addicted to heroin for 20 years and recognized that over that time, he had hurt and taken a lot from others, particularly his family. “He had kind of felt like a leech for a long time, and now it was finally time to be able to give that back and repay,” Bates-Maves says.

James was a watershed client for Bates-Maves. His story was the one that changed how she viewed substance abuse counseling. James’ narrative hadn’t been just informational — it had been existential. It made her realize that counselors need to have those types of discussions — about the search for meaning, about the grief and loss that come with substance abuse — with all clients in recovery.

Bates-Maves and the other counseling professionals interviewed for this article say that when therapists center treatment solely on elimination of the substance and everything associated with it from the person’s life — without considering the myriad factors that contribute to use, abuse and the drive to reuse — they are actually hampering clients’ recovery.

The need for grief work in substance abuse therapy

“We oversimplify the picture of addiction,” Bates-Maves says. “We do that as a world broadly, and we definitely do that in the counseling profession sometimes. …We think of it as the erosion of a life — it’s only somebody moving backward, it’s only someone being stuck. And we get stuck in that narrative.”

Counselors often focus on getting clients “unstuck,” which is certainly not without worth, but it is limited, says Bates-Maves, an associate professor of clinical mental health at the University of Wisconsin-Stout. “I’ve worked with many clients who … loved being stuck [in addiction],” she says. They loved the feeling of being someone else, the ability to lose sight of negative things, the ability to create an optional numbness.

Addiction sets the stage for a lot of destruction in people’s lives, but it can also serve as a kind of desperate sustenance for users who see no other way to cope with life, Bates-Maves says. The bald truth is that substance abuse also adds things to life, and that’s something counselors don’t talk about enough, she asserts. Counseling is a profession that focuses on concepts such as identity and a person’s sense of meaning, yet counselors often neglect to explore how these concepts tie in to addiction — what clients are actually getting from their substance abuse, what makes it attractive or useful to them, she says.

When presenting on the role that grief and loss play in addiction, Bates-Maves has frequently heard from audience members that the clinics in which they work have told them not to talk about the “good stuff” that substance use brings. She says the usual company line is, “You can’t have them celebrate the high or tell those so-called glory war stories. That’s encouraging their desire to use.”

“We’re so blinded by this fear of people going back to use,” Bates-Maves says. “What if the glory days were the only time people felt powerful, or what if when they’re high, it’s the only time they don’t feel intense [emotional or physical] pain? What if it’s the only time they feel confident enough to engage with another human? … Those are central treatment issues, and they can come out of the quote-unquote ‘positive experiences’ in addiction. There’s a lot to let go of when you’re trying to get to recovery. There’s a tremendous amount of loss, and [we’ve] somehow largely missed that as a field.”

Bates-Maves feels so strongly about the necessity of counselors having these conversations with clients as part of the recovery process that she wrote a book, Grief and Addiction: Considering Loss in the Recovery Process, which was released at the end of September.

“Addiction … ravages your life,” Bates-Maves says. “Nobody likes that.” Even so, she continues, counselors need to encourage clients to think about the things they risk losing when they determine to confront their addiction.

“Even if they’re good losses — things you want to go away — it’s still a massive change that you’re undertaking,” she tells clients. “You deserve to feel sad and frustrated and sorrowful … and relieved.”

Even though the changes people go through in recovery need to happen, clients deserve to know that it’s OK for them to miss the things they leave behind. “You can miss it forever and still change,” Bates-Maves says emphatically.

“When we start to try and shove people forward to recovery without looking at the rearview mirror at all, we’re going to miss the things that will chase them down later,” she explains.

Bates-Maves believes Kenneth Doka’s model of disenfranchised grief perfectly explicates the losses sustained by people struggling with addiction. In the recovery process, these clients typically must abandon coping methods and even relationships that are unhealthy. As such, these things are often deemed “unworthy” of grieving over.

Similarly, many clients in recovery have lost friends to stigmatized deaths such as overdose, suicide, hepatitis and AIDS. Other clients may have chosen abortion or had a miscarriage because of their addiction. Once again, these individuals can be made to feel that they aren’t allowed to grieve those losses, Bates-Maves says. In particular, family members — and the courts — tend to convey the message, “You dug your own hole.”

But everyone has losses from predicaments that are primarily self-created, Bates-Maves argues. “I have this grief all the time where I’m the one who caused the problem, but I’m still really mad that I have it,” she says.

Emotions that are denied usually just fester and show up in other ways, Bates-Maves says. “Just let people” — including those struggling with addiction — “be angry. Let them be sad. Just because we’re the creators of our own misery does not mean we don’t deserve to be miserable about it,” she says.

Counselors can offer clients support as they learn to acknowledge that their current reality — whatever stage of addiction or recovery they’re in — is incredibly tricky and comes with myriad, and often confusing, emotions, Bates-Maves says. What counselors shouldn’t do is tell clients that what they’re feeling is wrong or try to “cheerlead” them into a different emotional state, she continues.

People sometimes picture coping as having overcome a difficulty so that it no longer has any emotional effect on them, Bates-Maves says. “I think it’s really important for all of us to remember that’s not what coping is. Coping isn’t getting over something. … It’s living with something. It’s getting through it as you’re in it.”

“My job as a counselor is not to make the pain go away, because I can’t,” Bates-Maves continues. “It’s not to force the transformation of pain. That’s a hope, but sometimes that can take longer than my relationship with [the client].”

So, what is the other side of grief? What is the goal of grief work? Bates-Maves describes it as learning to walk with and carry your pain in a way that doesn’t sink you. “You want the pain to be manageable so that you can live life with it there,” she says.

Bates-Maves recommends a variety of methods to help clients, including those walking through addiction and recovery, with their grief and pain. One method is containment — the idea of compartmentalizing the pain and building psychological space for it. She says this is particularly useful for pain attached to situations that are unlikely to be resolved anytime soon. Some clients make actual physical boxes, write down their thoughts, feelings or whatever it is that is causing them distress, and lock it up, but the container need not be literal, Bates-Maves explains.

The intent of the exercise is not to lock the person’s pain up forever, but rather to put it aside so that the person can carry on with the other parts of their life. This acknowledges the reality that even when people are hurting badly, the demands of living go on. When a client has the time or desire, they can open the container, sit with the pain and feel whatever they feel. Being able to set aside the pain temporarily allows clients to care for their children, drive to work or even just relax by watching TV or listening to music without being confronted by constant intrusive thoughts, Bates-Maves says. Journaling is another way that clients can create a space outside of their own heads for their emotions, she adds.

In contrast, radical acceptance, a method that is the polar opposite of locking one’s thoughts away, can be very effective for some clients. “It’s this idea that we cannot always change things and we need to accept and acknowledge it and keep moving,” Bates-Maves says. With radical acceptance, clients learn that their grief and pain are valid but that they can feel those emotions and still keep moving alongside them.

Bates-Maves has also had clients who experienced intense and disturbing dreams about their grief. She would teach them “directed dreaming.” Clients would take five to 15 minutes before going to bed to create detailed mental pictures in their minds of what they wanted to dream about. With practice, people can learn to direct their dreams, Bates-Maves says.

For clients who frequently feel overwhelmed, Bates-Maves recommends belly breathing. She explains that teaching people to breathe more efficiently can reduce panicked breathing, which helps take the body from a state of distress to one of relaxation, or at least closer to it.

She sometimes helps clients transform their pain by learning to reframe how they view their losses. Certain clients realize that they will never feel differently about parts of their past but that they are OK with that. Some clients work through their pain by seeking connection with others. And some clients decide that they need to spend more time with themselves rather than with others, hoping to learn who they are without addiction.

Attachment, trauma and addiction

Many people with addiction have been primed to seek solace in substances or processes because of a history of trauma and a lack of healthy attachments, says ACA member Oliver J. Morgan, who has written numerous books on substance abuse and addiction. Caring relationships can help mitigate the effect of trauma in a child’s life, whereas a lack of those connections is traumatic in itself. Feeling cared for helps build healthy neural connections such as a fully functional stress response and the reward, reinforcement and motivation systems that contribute to emotional coping skills, he explains.

When someone finds it difficult to cope with stressors such as the lasting pain of trauma, dysfunctional relationships, loneliness or the everyday disappointments and frustration of life, they may turn to addictive substances or behaviors, says Morgan, a licensed marriage and family therapist who has been clean and sober for over 30 years but once was addicted to alcohol.

Over time, chronic use and abuse of substances or processes oversensitize areas of the brain related to dopamine so that they are easily triggered, he says. The brain then connects those areas to memory and environmental cues that themselves create desire. In other words, addiction causes the brain to react to cues that a client may not even know exist, Morgan says, creating what neurobiologists call “pulses of craving.”

“The brain organizes reward around memories so that we remember to repeat [the action],” says Morgan, a master addiction counselor. “It’s how we learn and how we fall in love.” A particular song on the radio, specific places or people, or even certain scents can serve as triggers.

That’s why he views all addiction counseling as relapse prevention. “From the beginning, you need to prepare people for the possibility, if not probability, of relapse,” says Morgan, a professor of counseling and human services at the University of Scranton.

He uses psychoeducation to explain the neurobiology underlying addiction and relapse — not just to clients, but to their families if they are willing to listen. Morgan believes this is essential to preventing a common scenario: A client relapses and their family says, “He told me he was going to stop and he didn’t. He lied to me.”

It’s not quite that simple, Morgan says. He explains to families that their loved ones mean it when they say they’re going to stop using, but they’re not anticipating that their brains are going to react to these cues. So, a relapse doesn’t mean that the client isn’t committed to recovery, Morgan says. The support of loved ones helps clients remain dedicated to the recovery process and keep believing that they can achieve it — even if they are momentarily derailed by a relapse.

Morgan, a member of the International Association of Addictions and Offender Counselors, a division of ACA, believes that relationships are the ultimate buffer against addiction. From the start of the recovery process, he helps clients begin forging new relationships with people who are clean and sober. They might develop these connections by finding sponsors or reaching out to strangers at Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or other recovery group meetings and virtual gatherings.

Morgan also gives clients a laminated card with steps to take if they feel the urge to use. This can function as a kind of crisis plan or serve as a reminder to clients that they have tools to help prevent relapse. The first step is to acknowledge their urge but to remind themselves that it is just a feeling, not something that they have to act on.

Next, Morgan wants clients to reach out to someone whom they trust and can talk to. “The best way to deal with stress is to buffer with a relationship,” he says. The person or people clients reach out to could be a sponsor, recovery group members or Morgan himself. This gives clients a way to share the burden by verbalizing their feelings and getting some advice. If none of this works, he tells clients to call him (assuming he wasn’t the person they reached out to initially).

Because the urge to use is triggered by external and internal cues that clients may not even be aware of, Morgan urges counselors to walk these clients through their past. He asks clients to think about times when they were using or wanted to use. What was happening in their lives at the time? What were their favorite songs? The broader the exploration of everything in their lives, the more likely it is that potential relapse triggers can be identified.

“Sometimes,” Morgan says, “you have to wait for them to come into session and say, ‘I really wanted to use’ [to discover their triggers]. That’s why it’s important to let them have access [to you] when it happens [between sessions] so that you can walk them through it. ‘Where were you? What happened? Who was with you?’”

Once the client and counselor have identified triggering situations, they can work together to come up with better ways to handle them. In his own life as someone who was addicted to alcohol, Morgan uses humor. “I make a joke out of it and talk about it widely,” he says.

When Carol Sloan Goodall, a licensed clinical addictions specialist, led group work at a local recovery center, she frequently had clients form smaller circles to identify three external, three internal and three sensory triggers. Group members also had to come up with three ways to cope with each trigger.

“I was often pleasantly surprised to see how many different realistic coping skills they created and excited to see the clients impressed and motivated by these ideas,” says Goodall, a licensed clinical mental health counselor in private practice in Charlotte, North Carolina.

Common external triggers involved people, places and things. Internal triggers usually involved emotions but sometimes also included cravings, chronic pain or illness. Sensory triggers were just that — input from the five senses, such as smells, tastes and sounds.

The coping skills that clients came up with were varied. One client described avoiding temptation by changing their route upon realizing that their drug dealer lived on a particular street. Another client felt like their home was a trigger, so they rearranged the furniture and changed the color of the accessories to make it appear new and different.

“One client said he carried a dryer sheet in his pocket and sniffed it when triggered by scents reminding him of drug use,” Goodall recalls. “Another client stated that the perfume cards you spray in department stores served the same purpose.”

Goodall also suggested that when confronted by triggers, clients could distract themselves with sensations such as snapping a rubber band on their wrists or holding an ice cube.

Morgan is a believer that practicing mindfulness can help clients identify and even anticipate triggers. He teaches clients to sit down and find a place on which to focus — a spot on the wall, a beam of sunlight, a candle. Then he instructs them to just “be” in that moment and observe what is happening around them in the here and now, to cultivate awareness and to notice if the urge to use is creeping up. He also finds this mindfulness practice helpful for coping with anxiety and creating a sense of calm by just being in the moment, letting one’s thoughts and emotions float by, and then letting them go.

The necessity of reducing in-person meetings during the pandemic has in some ways made it easier for those in recovery to get support. Groups such as AA, NA and other recovery organizations swiftly moved their meetings to digital platforms. People can access virtual meetings or keep in touch with other group members through social media, email or phone. Counselor clinicians have also had to become more comfortable with virtual counseling. Morgan sees this as a positive because he thinks not having to show up in person to access resources is easier for many people who are seeking help with substance abuse. It’s less uncomfortable for these clients, Morgan says, because they don’t quite have to put themselves out there completely.

Going from prison to the outside world

Julia Thielen, an LPC located in South Dakota, works at an intensive outpatient facility with a particularly challenging substance abuse population: clients living in a post-prison transitional facility after being incarcerated for as long as 10 to 15 years.

These clients are not only working toward recovery, but also coping with trauma and trying to navigate a world that they don’t recognize or understand, Thielen notes. They have records, have spent years without employment, are often estranged from their families, have often lost friends to causes such as overdose, and struggle to form a sense of identity. Life has generally moved on without them. The things these clients may have once wanted — steady jobs, families, a house of their own — now feel largely out of reach to them, Thielen says.

Those around these clients often want to sugarcoat their circumstances and make them feel better, but what they really need, Thielen says, is someone to hear them out and help them set realistic goals. “Yes, you are past 30, so having a house before then is not going to happen. But is it possible to achieve that by 40?” she asks them.

For clients who have spent a particularly long time in prison, just getting a job is challenging, Thielen says. They lack a history of employment and have to disclose that they spent time in prison. They need help finding any form of employment just to reestablish a work history so that further down the line, future employers at potentially more attractive jobs might be able to see them as responsible and hard-working, she explains.

In addition to teaching these clients emotional self-regulation skills such as deep breathing, Thielen and her colleagues instruct them in basic life skills. Many of these individuals spent their adolescence and young adulthood in prison, so in essence, they have skipped a developmental stage, she says.

Thielen’s clients regularly talk about the challenges of finding healthy friends and activities. “One of the big things they are lacking is any kind of support or stability in their lives,” she says. Getting these clients involved with AA, NA or another recovery group is one way to help them establish friendships with people who don’t use or who are also in recovery.

Many of Thielen’s clients don’t know what healthy friendships look like, so she spends a significant amount of time helping them identify red flags from their past relationships, such as behaviors that led them toward addiction or contributed to them staying addicted. Often, Thielen says, these friends from clients’ former lives would call in sick for the client when they were hungover, pay their fines for misbehavior or help them come up with excuses for their probation officer.

Another piece of the puzzle is to help these clients articulate what values they would like potential friends to possess. Often, the easiest way to do this, Thielen says, is to ask them what values and beliefs they would like to instill in their own children and to look for those same characteristics and qualities in others when forming new friendships.

But most of Thielen’s clients still have strong ties to the people they previously used with. These aren’t “healthy” friendships, but many of these clients have no one else in their lives upon being released from prison. In many cases, their families and any friends they had who weren’t fellow users have given up on them long ago. From the perspective of some clients, the people who were their fellow users and have maintained contact have “been there” for them, and the clients want to reciprocate. But spending time with these friends — who may not be interested in stopping their own substance use — is the most common road back to addiction and, often, reincarceration.

Some clients can have the hard conversations and cut ties with the people who are linked to their past substance abuse and prison time, Thielen says. But that’s almost an impossible ask until they have formed new relationships. That is why getting them into some type of new community such as a self-help group, addiction recovery group or church group is critical, she says.

Another challenge is that although a transitional facility can offer support and shelter to those who have recently been released, the environment isn’t very conducive to learning responsibility, Thielen says. These clients learned to follow a particular set of rules in prison, and now they learn to follow another set of rules in the transitional facility, but they aren’t necessarily learning how to set a budget, how to cook a meal or even how to buy groceries for themselves.

Thielen and her colleagues attempt to set clients up with case managers and life skills coaches, but she acknowledges that some individuals are very resistant to this kind of instruction.

Prevention and intervention

Counselors do have opportunities to intervene — before addiction, before prison, before a life goes off the rails. Morgan notes that while the focus is typically on those who are physically addicted to substances, almost three times as many people are problem users. And it is these individuals whom counselors are most likely to see, he says.

Morgan asserts that addiction professionals don’t necessarily know how to deal with those individuals who are problematic users but have not reached the threshold for addiction. Recovery centers aren’t suitable for these individuals because they aren’t physically addicted, he says.

But professional counselors can help clients explore and recognize their problem use through exposure to motivational interviewing and the stages of change, Morgan says. Often, these clients have ended up in the counselor’s office because they’ve had trouble at work, at school, with their family or other relationships, or elsewhere. They may flatly deny any suggestion of “problem use,” but counselors can suggest exploring what is going on in these clients’ lives.

“If they’re willing, that already puts them into precontemplation,” Morgan says. Counselors can take that recognition that something’s not quite right and say, “Let’s look at what change looks like,” he suggests. “Let’s stop drinking, drink less or drink less harmfully.”

“We have to pay attention to moments of opportunity,” he stresses. “Someone gets pulled over for a DUI — that’s a moment of opportunity.” If someone is overdrinking and prone to accidents around the home, every visit to the emergency room is an opportunity, Morgan continues. Some hospitals are already using motivational interviewing for brief interventions in the ER, and the success rates have been impressive, he says.

The problem is that for too long, the message has been that when people with substance abuse problems are ready, they will seek help, Morgan says. But most of the time, they’re not going to come in on their own, he asserts.

“We have to raise the bar,” Morgan concludes.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

International Association of Addiction and Offender Counselors (iaaocounselors.org)

IAAOC, a division of ACA, is an organization of professional substance abuse/addictions counselors, corrections counselors, students and counselor educators concerned with improving the lives of individuals exhibiting addictive or criminal behaviors.

Counseling Today (ct.counseling.org)

• “Hidden in plain sight” by Laurie Meyers
• “Standing in the shadow of addiction” by Lindsey Phillips
• “Grief, loss and substance use” by Susan Furr and Derrick Johnson
• “Healing the healers: Counselors recovering from familial addiction” by Suzanne A. Whitehead
• “Group counseling with clients receiving medication-assisted treatment for substance use disorders,” by Stephanie Maccombs
• “Informed by trauma” by Laurie Meyers
• “Suicide, substance abuse and medical trauma” by Bethany Bray

Books (imis.counseling.org/store)

• A Concise Guide to Opioid Addiction for Counselors by Kelvin Alderson and Samuel T. Gladding
• A Contemporary Approach to Substance Use Disorders and Addiction Counseling, second edition, by Ford Brooks and Bill McHenry
• Addiction in the Family: What Every Counselor Needs to Know by Virginia A. Kelly
• Treatment Strategies for Substance and Process Addictions by Robert L. Smith
• Introduction to Crisis and Trauma Counseling edited by Thelma Duffey and Shane Haberstroh
• Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes

Webinars and article for continuing professional development (https://imis.counseling.org/store/catalog.aspx#)

• “Opiate Addiction and Chronic Pain: Overview of Counseling Approaches” with Geri Miller
• “Opiate Addiction and Chronic Pain: Ethical Practices for Counseling Clients Who Live With Chronic Pain” with Geri Miller
• “Opiate Addiction and Chronic Pain: Hope, Resilience and Self-Care Strategies for Counselors and Clients” with Geri Miller
• “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl
• “Developmental Approaches in Treating Addiction” by Ford Brooks and Bill McHenry
• “Complicated Grief: An Evolving Theoretical Landscape” by Laurie A. Burke, A. Elizabeth Crunk and E.H. Mike Robinson III
• “Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Misuse” with Amy E. Williams and Kristin Bruns

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

• Substance use disorders and addiction
• Grief and loss

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.