Mental health articles

denial is commonplace, it is best to fi nd ways to avoid head-on collisions with
the client. If, for example, the student starts out by saying, “I don’t drink half as
much as my friends do,” it may be useful to say, “I believe you, although it actually
doesn’t matter how much your friends drink. What matters is what happens
when you drink.” If when asked if he experiences negative consequences the student
responds, “Not really,” it may be useful to reply, “‘Not really’ suggests that
something happens on occasion, so tell me what has been happening.”
Oft en, a clinician is able to diagnose alcohol or drug dependence from the
start, but sharing this feedback may scare off the client and interfere with
treatment. It is important to remember that in the early phases of treatment,
the relationship with alcohol and drugs tends to be more important than the
relationship with the clinician, especially in cases of dependence. If use is
threatened, the student may choose the substance over the clinician.
In cases of substance abuse without dependence, moderation of use is a
reasonable goal. Standard psychotherapy practices are, of course, necessary:
inquiry, refl ection, reframing, off ering of a perspective, pointing out options,
and interpretations. Additionally, one needs to spotlight the connection
between substance use and other areas of the student’s life: mood, relationships,
sex, family life, academics, health, fi nances, and social life. Normally
the student has experienced adverse consequences, which have brought him
or her, whether voluntarily or involuntarily, into treatment. Reviewing these
consequences highlights the costs involved in misusing substances. Sometimes
adverse consequences that are obvious to the therapist are not seen by
the student. Pointing these out is essential, gently and nonjudgmentally if
possible—but when the consequences are severe, the therapist may wish to
be a bit more emphatic, particularly if the student’s denial is so blatant as to
distort reality. We remember saying to one student who had multiple adverse about the drinking, yet in every situation you’ve described, alcohol played a
prominent role.” We came back to this statement, session aft er session, each
time there was another adverse event.
When a student disagrees with the therapist’s view, then timing, dosage of
interpretation, and discretion are important. Sometimes harping on drinking
or drugging and their adverse eff ects only turns off the student. Instead
it may be useful to back off and focus on other topics, only briefl y discussing
substance abuse each visit. In time, the student may feel less defensive and
gingerly approach substance use and its consequences.

Th e harm reduction approach proposes that helping students reduce
consumption or problematic aspects of use is a positive step, and any such
movement should be reinforced. Setting limits on drinking is a good starting
point, no matter what number of drinks the student picks. What does matter
is to set a limit as a long-term experiment—6 months to a year, or more. If
the student can stick to a drinking limit while suff ering no further adverse
consequences, then there is evidence that moderation can work. If the student
cannot maintain the limit or experiences adverse consequences even
when drinking within the limit, then moderation is unlikely to be a viable
approach. A single lapse would not be defi nitive—lapses can be used for their
educational value and as an opportunity for resetting goals—but multiple
slips would be.
Some students try to set nonnumerical limits, saying that they want to “get
buzzed” but not be out of control. Our experience is that this approach invariably
fails, since “a buzz” impairs judgment, and impaired judgment prevents
an objective evaluation of harmful consequences or ability to control further drinking. If students propose such a vague goal, our response is that this isn’t
really a limit at all and it probably won’t work. Generally, a harm reduction
approach is reasonable and eff ective. It speaks to students where they are. However,
the promotion of abstinence may be the only reasonable and ethical stance
when there are severe or life-threatening consequences, even in the absence of
dependence. Consider a student who complains of anxiety, has recently been
consuming heavily, had an accident under the infl uence, gets into fi ghts when
drunk, has been subject to disciplinary action, and suff ers from an illness which
is exacerbated by drinking. In this admittedly extreme case, a harm reduction
approach may not work fast enough to spare the student more trauma. Abstinence
may be the only viable alternative.
But even though necessary, abstinence can be diffi cult, especially in the
earliest stages of treatment. And even if abstinence is easy at fi rst, students’
later urges to drink and diffi culties resisting temptation make it diffi cult to
sustain. It is not uncommon then for feelings to surface that substance abuse
previously anesthetized or swept away. Th ese feelings, notably depression
and anxiety, may be the source of students’ usage in the fi rst place, or may
represent shame or embarrassment over bad experiences while they were
under the infl uence. Such feelings can be so diffi cult to manage that people
in recovery oft en wind up using again to make them go away. Some have
said, “If this is what it is like to get sober, then I’d rather be drunk.” At this
point, the therapist needs to voice confi dence in the process and indicate
that such distress is a sign that the student is getting better, not worse. Th is
reassurance oft en enables the student to continue moving forward.
Another therapeutic issue is the “screw it” factor (to use the polite term).
Oft en a student has been working for weeks or months, trying so hard to be
“good,” until fi nally he or she runs out of patience, says “screw it,” and uses
again. Typically, immediately aft erward the student feels miserable about
the slip. Th e relapse shouldn’t be condemned, or else the student may fail to
report slips in the future. Rather, a slip should be used therapeutically and
explored for educational value. Th e slip, that precise moment when the usage
actually takes place, is typically the last step in a process that may have begun
weeks earlier, when frustration and other negative emotions started to build
up, leading to a preoccupation with using that now comes to the forefront.
Such craving, not unlike hunger for food or thirst for water (rather than the
clawing at walls sometimes portrayed in the media), grows over this time and
ultimately culminates in the slip.
Psychotherapy can help students make this journey toward abstinence.
In addition, AA, NA, inpatient treatment, an IOP, and group treatment may
be useful sequentially or in combination with individual psychotherapy to
arrive at this goal. Sometimes work done in the college counseling center is
preparatory to more intensive off -campus treatment, and sometimes it can
serve as follow-up care to such treatment.

It usually takes 6 months of sobriety—total abstinence from alcohol and
other drugs—for substance-dependent students to get back on their feet, and
a year to feel solidly in recovery. Th at is, assuming that they can make it. Some students (and many older adults) need to recycle many times through treatment before they fi nally succeed.

Tags: substance abuse