Chapter 1
Substance Use Counseling: An Introduction

To the Fish and the Owl
The Alpha and the Omega
Synchronicity at the Time of Death
Brought Forth Life and Spirit

—Ford Brooks

A client presents during his intake evaluation that he is using 3 grams of cocaine four times a week and is about to lose his job, his marriage, and all his life’s savings because of his use. He is coming to you for help, yet he is resistant to inpatient substance use treatment.1

A 16-year-old female student is referred to you for “behavioral problems” in the classroom and was just suspended for smoking cigarettes in the bathroom. During the session, you suspect that she is under the influence of drugs.

A 60-year-old male comes in for issues of depression, yet during the session, you detect the faint smell of alcohol.

In each of these cases, what would you do and how might you proceed? Working with clients who struggle with substance use issues is very challenging and, at the same time, can be extremely rewarding. As clinicians who have worked with this client population and as counselor educators who teach this subject, we wish to convey information, suggestions, and strategies to best work with clients who use, misuse, or are addicted to alcohol or drugs.

Our Stories

When I (Ford) started as a counselor in the substance use field, I struggled because I was a novice with only a basic understanding of the requirements to work with clients with an alcohol or drug addiction. Despite being anointed a master’s-level alcohol and drug rehabilitation counselor, I toiled and labored to understand the use of self in effecting positive change, especially with clients experiencing significant emotional and physical pain. I could not fully envision the power of compassion, nor could I fully grasp the negative presence my frustration could have on clients. I struggled to grasp how spontaneity and hope could possibly be as important as confrontation, urine screens, and alcohol and drug education.

When I (Bill) started working with clients who had substance use issues, I struggled. My previous counseling experiences were with other types of clients exhibiting other types of problems. I labored to effectively connect and make meaning of the stories of clients with a substance use disorder (SUD).2 As I saw clients relapse, I saw failure; as I saw clients using again, I framed it as wrong. My dichotomous thinking regarding clients with an SUD retarded my general nature of believing in and valuing the journey.

The Counseling Relationship

One of the main reasons we wrote this text is to encourage readers to more fully engage in the helping process with clients with an SUD. In essence, we hope to help you avoid our mistakes and to provide you with informative and creative approaches to working with this unique population of clients. We consider genuine compassion and deep understanding to be the core values manifested by effective counselors. We cannot stress this enough. Although such values are appreciated by many types of clients, we suggest that they are crucial in counseling clients who use alcohol or drugs.

The amount of shame, guilt, embarrassment, and terror that clients with an SUD feel can be beyond description. Self-stigma may also affect individuals’ willingness to seek help for their substance use (Gutierrez et al., 2020). Therefore, clients need a sense of safety, understanding, and compassionate care in the counseling relationship to change and grow. My (Ford’s) first supervisor described it as “loving your clients to wellness.” I took her wisdom and found that clients responded and grew when I did just that—therapeutically loved them.

We want counselors reading this text to own this fact: Your way of being in the therapeutic relationship affects client growth. Counselors bring to the therapeutic relationship a self (e.g., compassion, genuineness, spontaneity, creativity), which is used as an instrument of change in the counseling relationship.

Carl Rogers (1957) suggested that certain counselor characteristics were necessary in the therapeutic relationship for clients to feel supported and begin the change process. He believed that the counselor’s ability to be genuine, express accurate empathy, and provide unconditional positive regard was significant in the foundation of counseling relationships. We agree with Rogers. Clients are well served when counselors are authentic, can accurately empathize and understand their clients’ worldviews, and have compassion for their clients.

We suggest that counselors can maintain this helping attitude by framing the client’s anger, blame, and dishonesty as a function of survival in a chaotic, chemically induced world. By doing so, counselors can understand their clients’ substance use as an important relationship they will protect with whatever means possible. A genuine, truthful, and in-the-moment relationship allows clients to know, without question, that they are understood and cared for during their emotional pain and time of crisis. The connection that is forged between counselors and clients following a substance use–related crisis can be profound. In an effort to help empathize with clients with an SUD, Gideon (1975) encouraged counselors to frame clients as disconnected, isolated (from self and others), and afraid. He emphasized the value of understanding clients’ experiences and creating an environment of trust and safety.

One way such a relationship can transcend technique is as follows: Clients, who for years have been isolated in addiction and reveal for the first time how sad and depressed they have felt, can immediately begin to experience a sense of relief and connection after sharing their torment with an understanding human being. Genuine and authentic counselors increase the likelihood of engaging with their clients in a trusting, therapeutic relationship, which can result in clients attempting change with new behaviors (W. R. Miller & Rollnick, 2013).

Counselors who are truly with clients during these low points (perhaps to depths that many people will never approach) are privileged to hear such astonishing stories. Therefore, we suggest that counselors need to both realize and appreciate the courage it takes to share such pain after so much isolation. Please pause for a moment and consider the previous message. We encourage you to reflect on the strength, bravery, and perhaps enormous pain clients go through as they share their stories. Recognize this: You are uniquely qualified to provide your distinct gifts, talents, and compassion for the human spirit.

Mistaken Images of People With Substance Use Issues

We suggest that counselors assess for and then address those biases they may have about individuals who use, misuse, or are addicted to alcohol or drugs. For some counselors, the words alcoholism, addiction, and drug use may conjure strong negative images of individuals nursing inexpensive bottles of liquor wrapped in a brown paper bag; gaunt, unkempt folks with needle marks wearing bloody clothing; or maybe young students struggling in school because of their marijuana use. However, most people with an SUD hide their use, are often indistinguishable from nonusers, and function in society, albeit at times under the influence.

For many counselors, the field of substance use counseling harbors a challenging and perplexing population (Chasek et al., 2012; Cornfield & Hubley, 2020). However, such a viewpoint on the part of a counselor can hinder the development of both a helping attitude and an open, compassionate heart. Remaining open and compassionate can be particularly difficult when clients become angry, minimize their substance use, or seemingly lack motivation in following through with their treatment goals. If counselors do not develop a well-thought-out helping attitude, clients are often blamed and labeled as “resistant.” Paradoxically, such reactions by counselors typically yield an increased defensiveness from the client, whereby the resistance is in response to both the counselor and the counseling approach (here we suggest to the reader that this is similar to a self-fulfilling prophecy by the counselor). Instead, what counselors should create is a helping attitude, which includes the following seemingly paradoxical attitudes: to be supportive yet questioning, to be unconditionally present yet at times direct, and to possess an overall attitude of realistic optimism.

Establishing a Genuine Helping Relationship

A starting point may be for counselors to foster a helping attitude when working with clients with substance use issues. This is evident when the counselor’s personal exploration of bias has entered the therapeutic process. One example is a counselor who is angry and disgusted by a client who uses heroin. This counselor, with all the desire to be helpful and effective, will have substantial difficulty in developing a helping attitude. However, if this same counselor comes to understand and respect the nature of heroin use and addiction and can empathize with the client’s emotional suffering, a helping attitude is possible. Counselors need to maintain this respectful and helpful attitude. One way to do this is to continue to develop knowledge and understanding in the area of substance use. For example, as counselors realize the powerful effects of narcotics coupled with an understanding of the client’s life in relation to heroin, empathy and ongoing support on behalf of the counselor...