The Space Between Stimulus and Response

Reflections on addictions counseling and creating change

How I can help Sahira now, how I’d like to help her in the future…


I am fortunate in that I have some work experience with people coping with addiction. I have been privileged to learn from more experienced clinicians, as a co-facilitator of an intensive outpatient treatment program (IOP). The IOP focuses on early recovery skills including identifying internal/external triggers for use, exercising environmental control to reduce contact/influence of triggers, dealing with cravings, the relapse process, post-acute withdrawal syndrome (what the brain and body go through as they recover), dealing with feelings, building new social networks, replacing using activities, and structuring time. Our approach draws heavily from CBT— replacing unhelpful behaviors with those that are more adaptive and identifying the belief systems that underlie these behaviors. One of my strengths for assisting Sahira is my knowledge of this evidenced-based practice for addressing substance use.

I also tend to be compassionate and empathic over judging. A non-judgmental stance would be important for developing a rapport with Sahira, and for helping her to overcome shame and guilt for the choices she has made during active addiction. Without trying to be too personal, I’ll disclose that I am adopted. I share this because I think this experience has helped me to realize that genetics are only a small part of the equation that determines who we are. Our environments and experiences are huge determinants of who we will become. I believe that different environment and different experiences could have made me someone else (anyone else). I do not judge individuals with addiction because I know that I could have found myself in the same place if circumstances had been different. There are always opportunities to recognize our humanness, and how our needs as people make us more alike than different.

As part of our program, we look at the losses and gains for use (decisional balance) and we discuss readiness to change (stages of change). These are Motivational Interviewing approaches, yet I am less familiar with practicing all the components of this technique: expressing empathy, rolling with resistance, developing discrepancies and supporting self-efficacy. I feel comfortable with my ability to empathize with clients and to affirm positive behaviors. However, I do want to build on skills for eliciting change talk and for reflecting on what I see and hear from clients. Specifically, I often find myself asking closed-ended questions, when I would generate more meaningful conversation with open-ended questions. I could also improve on skills relevant to self-efficacy— assisting clients with generating small, realistic goals that can be tackled between sessions, and on helping them to generate possible solutions to problems.

My clients often utilize 12-step programs, yet I have only been to several meetings. I do not know the ins and outs of stepwork or the culture well. I would like to become more familiar with AA, NA and other derivatives. The principles of 12-step programs sometimes differ from my training as a clinician, but there is no question that they are programs that my clients value. They assist individuals in building new sober support networks that help them to remain abstinent, reducing their exposure to triggers and reducing isolation. Clients undergo self-exploration through the 12 steps. They learn from the behaviors modeled by others who are more established in recovery. They feel empowered and comforted to when they learn that this illness affects many people. Further, it seems valuable that individuals enter the rooms of AA/NA as equals. Addiction does not discriminate on the basis of sex, race, religion, education or wealth.

In a nutshell, I feel comfortable with my skill in delivering Rogers’ Three Conditions for growth— genuineness, unconditional positive regard and empathy. However, I would be a better clinician if I developed more specific knowledge of interventions including Motivational Interviewing, support groups, and perhaps mindfulness-based cognitive therapies, like Dialectical Behavior Therapy and Acceptance and Commitment Therapy. I would like to develop greater skills in working with depression, anxiety and trauma too, as they are so often co-occuring in clients with substance use problems.

6 thoughts on “How I can help Sahira now, how I’d like to help her in the future…

  1. Meg,

    Great post. Thanks for sharing that you are adopted as you are correct in saying that “Our environments and experiences are huge determinants of who we will become” I absolutely agree with this statement. Some part of us is inherited but for the most part I think that our environment shapes who we will become and even the way our parents relate to us as kids and this has nothing to do with genetics. My clients would be referred to programs like your IOP along with some of the out-patient partial hospitalization programs offered by Sheppard Pratt. We primarily focus on the Mental illness part of it along with adding in the 12 step program. If someone uses then we usually find alternate treatment programs outside of our day program sobriety support groups. We went through a comprehensive 2 year training on DiClemente & Prochaska’s stages of change model, to include motivational interviewing, in becoming a person centered environment. I must say it really has made a tremendous difference at my organization. I’ve seen clients who were non-verbal begin to speak up and participate in these trainings (staff & clients) and actually contribute intelligent thoughts. The transformation at our organization is amazing and has come a long way from 20 years ago. We now have a welcoming environment where our clients feel more comfortable with sharing and collaborating with the team on their goals. I liked that you said addictions does not discriminate because it does not and neither does mental illness.


    • Hi Lisa, Thanks for your comments!

      You’re completely right, mental illness does not discriminate either. Dual-diagnosis is so complicated. It can be so hard to tease apart addiction and other illness like schizophrenia, depression trauma, other anxiety, etc.

      That comprehensive training on MI and stages of change sounds amazing! I love how you said your clients have been empowered by this change in thinking and approach. It sounds like you feel it is now a nicer place to work too, is that right?

      Take care, Meg

  2. hey meg, just thought I would tell you that you need to change your time zone to eastern because I just posed my comment on 6/16 at 8:43pm & it showed up as 6/17 12:42 am. Lisa

  3. Meg, I enjoy reading your blog. I think you make a very important point and that is, sometimes with clients that are going through very difficult experiences and could find themselves lost, it can be very helpful for the counselor to share some personal information. In your case you mention sometimes sharing that you are adopted. I think this could be very good in a number of levels. First you show the client that you trust them and care for them enough to share something so personal. Then I think it also is important for clients to see that counselors are human beings too, we have a past, problems and challenges in our lives as well. This can make the relationship client- counselor stronger and more genuine. Finally I think by sharing this part of your life with clients, you give them a very good example of how sometimes in life we have to face different situations and at the end come out stronger and more confident of who you are. I think sharing this type of personal information can be very powerful for your client, and make them feel like they can overcome their problems. However, I also think as counselors we need to first be careful what and how much information we disclose. There must be a reason and particularly I would be very careful in deciding which clients I would share certain personal information with. I think you bring up a very interesting point and that is how sometimes by showing a client that we also had rough moments in our lives, that can help them in their treatments.

    Thank you,

    • Hi Virginia,

      Thanks for your thoughtful comment. I completely agree that self-disclosure has to be used carefully to ensure that the therapy continues to remain about the client’s needs and that boundaries remain professional and not personal. For me, it helps to look at my own intentions. Why do I want to disclose? Is it to help the client? Is there a clear message that a client can take away from my story? Is it so that a client will like me? Or is it to improve rapport? And so on…

      I also agree that clients share so much of themselves with us, they want to see at least glimpses that we are also human beings who are vulnerable and working to become our best selves.

      Take care, Meg

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