In my career, I have worked with individuals whose primary presenting issue is problematic substance use or addiction-like reliance on some activity (watching porn, etc.).

In the majority of cases (but not all), the individual beginning treatment has been more or less ultimatum into treatment by a relative. There is a continuum here, but it seems only a minority decide to seek treatment based on a purely internal self-evaluation process. Whatever the precise route to treatment, the reasons that the substance or the activity has the pull it has and is relied upon the way it is must be explicated and respectfully addressed if there is to be a realistic hope for permanent change in frequency of use. It would be unrealistic to underestimate the psychological potency of the reasons for use, and it would be unrealistic to underestimate the time and work necessary to bring about a permanent change in frequency of use. I say permanent deliberately because it is often fairly easy for people to desist temporarily in the wake of an interpersonal crisis. Naturally it is even easier if they are under 24 hour a day surveillance, they are housed in some kind of facility, their room is searched daily, etc. Obviously such a regimen cannot go on very long.

Strong self-motivation is of course optimal, but mixed feelings, ambivalence, and inner conflict are simply part of therapy and do not rule out an experience and an outcome that the client feels good about. The therapist must persist in being realistic and non-condemning of the client’s mixed feelings and ambitions. There are enough people in the client’s world that are angry, frustrated, uninterested in “excuses,” and so on; the therapist should not be one of those people. Therapy is not about providing strategies for non-use. If a person is internally dedicated to non-use he can and will devise his own strategies. Therapy is about providing a space for openly discussing the personal matters that determine how one thinks, feels, and ultimately acts. This must be a completely protected space, with no fear that what is discussed will leak out of the protected space. The therapist does not try to convince the client to embrace better habits. The therapist tries to foster discussion about the inner and outer influences, present and past, which are pertinent to drug use or a problematic activity. This may and probably will cover a lot of ground. The goal, reached via discussion over time, is to get into a better position to handle the various internal and outer influences relevant to the problematic drug use or activity. The goal is to use the break from the usual brought about by crisis and threat to over time lay down the capacity to live differently and better.