Ask an Expert: Should I Get Sober Before Going to Therapy?

By Dr. Richard Juman 06/21/16

The Fix's Professional Voices editor weighs in on a recommendation from a reader's therapist to leave and get sober before continuing therapy sessions.

Ask an Expert: Should I Get Sober Before Talking to a Therapist?
Come back when you're clean?

Dear Expert,

I'm in psychotherapy with a good therapist for a variety of issues, including mild depression and relationship difficulties. Over time, I've brought up the topic of my substance use—pot smoking most evenings and the occasional overuse of alcohol, usually at parties—with my therapist. She recently told me that she feels my substance use is interfering with therapy, and that she believes that in order for us to make progress on my issues, I would first need to be "clean and sober from all drugs and alcohol." She recommends that we stop seeing each other so that I can go for drug treatment, then return. What do you think?

Richard Juman, PsyD: Dear Reader,

The practice that your therapist is recommending has been prevailing in the mental health field for decades, but I do not agree with it in many cases on a number of levels.

First, I don't conceptualize your use of substances as a problem that should be construed as separate and apart from your other issues, operating to interfere with your ability to confront the depression and relationship problems. Your use of substances is one of several issues that you are dealing with, and my guess is that they are all related in certain ways. For example, your substance use may be perceived as, partly, an effort to self-medicate your depressive feelings, or as an escape from the pain of your relationship woes. The way that these issues interrelate should in itself be a focus of a treatment plan that seeks to understand the ways in which substance use, depression and relational issues all impact each other in reciprocal fashion. So isolating the substance use in a separate treatment can interfere with your ability to come to an understanding of these interrelationships and actually impede your ability to moderate or curtail your substance use. 

Second, I would be concerned about the impact that interrupting the therapy would have on the progress that you've hopefully been making in treatment and on the therapeutic alliance with your current therapist. I wonder if the latter has already occurred—if you are feeling a rift in the treatment alliance simply because your therapist has let you know that she would like you to go elsewhere for substance use treatment? Another aspect here would be that if you were to engage in good substance use treatment, you would undoubtedly work on the "other issues"—depression and relationship problems—as well. 

Finally, I think that these types of referrals can be perceived as stigmatizing by the client, even if that is not the therapist's intention. For many years, the health care system has ostracized substance users, in part because providers didn't believe that they had anything to offer. Hence the majority of people suffering from addictive disorders whose only source of help was in self-help programs. Even though the majority of good therapists are actually well-equipped to manage substance use issues among the other problems that clients present with, they often don't feel confident in this realm. I think that most clinicians, with some research (including the articles on The Fix's Professional Voices feature) and some good supervision, can ably work with substance use issues as part of the whole person therapy that is best provided in the context of a trusting therapeutic alliance. I encourage you to have this conversation with your current therapist.

Are there clients that should be referred out? Absolutely, especially those whose substance misuse is so dangerous or extreme that it is having a severely deleterious impact on the person's well-being, much less their ability to process issues in therapy. From what you have described, your situation doesn't fall into this category. Rather, it seems that your substance use, depression and relationship issues are complex, but by no means unusual. In fact, many clients in psychotherapy have some degree of potentially inappropriate substance use that a wise therapist will explore as part of their work. 

Best of luck in your recovery!

Richard Juman, PsyD—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is The Fix's Professional Voices Editor and former President of the New York State Psychological Association. [[email protected]] Find him on twitter—@richardjuman. Full Bio.

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