By Maggie Hooker, LICSW, LADC
Why changing our relationship with substances involves more than simply deciding to stop.
“Why can’t you just stop?”
In my work with substance use and mental health concerns, I see how much shame surrounds this question. People recognize the effects of their substance use on their relationships, work, and well-being. They want things to change. But understanding that a pattern is causing harm is not the same as knowing how to change it.
When someone struggles to make that change, they can begin to see it as a personal failure. Questions about why they continue become questions about their character, their determination, or how much they care about the people around them.
I want to make room for a different conversation.
That starts with understanding what role substances play in each person’s life. What relief are they looking for? What difficulties has substance use created? What do they want to be different?
For me, an important part of this work is allowing hope to re-enter the conversation—not by overlooking the difficulties, but by helping someone understand that their struggle does not have to define their future.
Understanding substance misuse and substance use disorder
Using the term substance misuse offers an approachable starting point. Here, I am talking about a relationship with alcohol or other substances that is causing difficulties and that someone wants help understanding or changing.
It is not a diagnosis I am asking readers to give themselves.
Clinical terminology has also changed. The older categories of substance abuse and substance dependence were combined into substance use disorder, with severity assessed along a spectrum rather than as a single, uniform experience. Alcohol use disorder, for example, is diagnosed as mild, moderate, or severe according to the symptoms someone experiences. (American Psychiatric Association)
I appreciate that recognition of a spectrum. People’s experiences do not always fit the image they associate with addiction.
Someone might think, “I’m not drinking first thing in the morning, so this isn’t something I need help with.” Others compare themselves with someone whose difficulties appear more severe and question whether their own concerns deserve attention.
I do not want uncertainty about a label to prevent a useful conversation. We can begin by looking at how substances are impacting daily life, what feels difficult to change, and what each person wants to understand.
The language should help us have that conversation, not become another barrier to it.
Why is it difficult to stop using alcohol or other substances?
Knowing the consequences does not automatically provide another way to respond to distress.
Someone who drinks to quiet anxiety, for example, can recognize that alcohol is contributing to their difficulties while still experiencing it as a source of immediate relief. In that moment, another reminder of what drinking is costing them does not necessarily help them respond differently.
Research helps explain this conflict. The National Institute on Alcohol Abuse and Alcoholism describes how alcohol can temporarily reduce uncomfortable feelings, while repeated drinking to cope with stress contributes to more negative feelings between drinking episodes. Those feelings can then encourage further drinking. This is one way short-term relief becomes part of a longer-term difficulty. (NIAAA)
That does not explain every person’s substance use. It does help us move beyond the assumption that continuing to drink simply means someone does not understand or care about the consequences.
In my work, I want to understand what a substance is doing for someone, as well as what it is doing to their life. Is it a way to quiet painful thoughts, manage overwhelming feelings, or get through situations they do not yet know how to handle differently?
Understanding that role is not the same as excusing harm. It helps us identify what else needs attention.
The work involves developing other ways to respond, not simply asking someone to give up a practiced response and manage without it.
Compassion and nonjudgment are essential to that conversation. We can take consequences seriously while also helping someone develop self-compassion. I do not see self-criticism as a substitute for understanding, skills, or support.
Can substance use and trauma be addressed together?
Substance-related concerns and mental health difficulties sometimes become closely connected. In my work, that includes anxiety, depression, and trauma-related distress. Trauma is not part of everyone’s experience, and I do not assume that it explains each person’s substance use.
Where these concerns overlap, though, treating them as separate conversations misses something important.
Someone who drinks to quiet nightmares or painful memories still needs help with those experiences. Asking them to resolve their substance use before discussing any of that distress leaves part of the difficulty unaddressed.
Research supports considering care for both conditions. A 2026 randomized trial by Lortye and colleagues involved 209 adults receiving care for both a substance use disorder and posttraumatic stress disorder, or PTSD, at two treatment centers in the Netherlands. It compared starting PTSD therapy alongside substance-use care with starting it after an initial period of substance-use care.
Participants receiving both together had better PTSD outcomes at three months. However, the researchers did not find statistically significant differences between the timing groups at six or nine months, or differences in substance-use outcomes. The finding supports avoiding unnecessary delays in PTSD care; it does not establish that simultaneous care is always better or that it produces greater reductions in substance use.
The VA’s National Center for PTSD likewise advises that having PTSD or a substance use disorder should not automatically prevent someone from receiving evidence-based care for the other condition. (VA PTSD)
This is not an instruction to begin intensive trauma work immediately. These findings concern people with diagnosed PTSD and substance use disorders receiving structured professional care. The study also excluded some high-risk situations, including acute suicidality and ongoing physical or sexual abuse. Individual assessment and safety remain essential.
In my work, considering both concerns does not mean discussing the most painful experiences on day one. We can begin by understanding patterns, developing strategies to feel more grounded, and building skills for managing distress.
The aim is to make room for the whole experience without trying to address everything at once.
What do you want your life to look like instead?
When people describe their goals, they often begin with what they no longer want.
They want to stop drinking. They want to stop repeating patterns that damage relationships. They want to stop feeling that substances are making decisions for them.
Those goals matter. But I also ask people to imagine what would be different if our work together were helping.
What would their life look like? What would they hear more of? How would they feel in themselves? What would they be able to do?
Someone wants to make room for depression and anger without turning to alcohol, and to respond to these feelings in ways that move them toward connection rather than away from it. Someone else wants to feel grounded and strong in themselves. Another person imagines hearing more laughter in their home.
Those details give us a direction. They turn “I don’t want this anymore” into a conversation about how each person wants to move forward.
Research is also examining outcomes beyond substance use and diagnostic symptoms. A second paper from the same trial, published in the July 2026 issue of Behaviour Research and Therapy, examined emotional distress, difficulties managing emotions, relationships, and trauma-related guilt and shame.
Adding two of the trauma-focused approaches—eye movement desensitization and reprocessing, or EMDR, and imagery rescripting—to substance-use care improved psychosocial outcomes, such as social dysfunction, at three months compared with substance-use care alone. Findings varied across measures and approaches, and direct comparisons did not establish consistent superiority of one trauma therapy over another. This was an additional analysis of the same participants, not a separate trial.
The relevance here is that research can ask not only whether symptoms change, but also how someone feels and functions. These findings do not test every approach to care or prove that values-based goals cause those improvements.
In my own work, I ask each person to make their goals practical. What would greater connection look like this week? What would they notice if they were responding differently to anger? What skills or support would help?
I am not choosing those goals for someone. Each person takes an active role in identifying what matters and what useful progress would look like in their life.
How therapy supports changes in substance use
I have worked with people whose starting goal is to reduce harm and people who want to stop using a substance altogether. Some arrive with a clear sense of what needs to change. Others want help understanding their patterns and considering their options.
That starting point gives us information. It does not replace careful clinical judgment about what is safe and appropriate.
A 12-step program is part of the path for some people, but it is not the only possible source of support. I want to help each person identify a way forward that fits their circumstances rather than assume everyone needs the same model.
Psychological care is also not the whole answer for every situation. Evidence-based options for alcohol use disorder include behavioral therapies and medications together, with mutual-support groups providing another source of help. The appropriate combination depends on each person’s clinical needs. (NIAAA)
A note on safety: Alcohol withdrawal can be life-threatening. People who drink heavily over time, or experience withdrawal symptoms when they cut back, should seek medical advice before stopping or substantially reducing alcohol. Some people need medically supervised withdrawal care; a self-directed change plan is not an appropriate substitute. (NIAAA)
Within therapy, my work includes understanding behavior patterns, exploring beliefs and experiences that shape those patterns, and developing different ways to respond to distress. When substance use overlaps with other mental health concerns, those connections belong in the conversation too.
The focus is collaborative and individualized. We pay attention to what each person needs, what is helping, and what we want to change as the work develops.
Building more than one source of support
I also want to understand what supports someone beyond the therapy room.
When substances have become a primary way of managing distress, it is important to explore what else is available. Otherwise, we remain focused on taking something away without enough attention to what someone needs in its place.
In my work, these conversations include sleep, eating regularly, physical activity, friendships, and community. For people who find meaning in a spiritual practice, that belongs in the conversation too.
This is not a checklist everyone must complete. I want to understand what is already helping, what has become difficult to maintain, and where a realistic change could offer additional support.
I think of these resources as different parts of a foundation. When someone relies on just one support, a difficult event puts a great deal of pressure on it. Developing several sources of support gives us more to draw on when life becomes demanding.
These resources do not replace clinical care, and they do not remove grief, conflict, or unexpected stress. They are part of building a life in which someone has more than one response available.
We start with what is useful and realistic, not an expectation that every part of life must change at once.
Working with me at Hanover CBT
At Hanover CBT in Hanover, New Hampshire, I work with substance-related concerns, trauma, and overlapping mental health difficulties. My approach is collaborative, with attention to each person’s experiences, needs, and goals.
You can read more about my clinical background and approach, or contact Hanover CBT to discuss the support you are looking for. (Hanover CBT)
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You do not need to arrive with a label, a complete explanation, or a finished plan.
You can start with the recognition that something about your relationship with substances is affecting your life. You can want change and still have questions about what change would involve.
In my work, I want to understand each person’s story without reducing them to a diagnosis or a behavior. That includes listening to what has been difficult, recognizing the impact of substance use, and exploring what they want to be different.
Central to this is the therapeutic relationship. Building trust, feeling understood, and developing a shared understanding of what we are working toward creates a foundation for meaningful change. I see therapy as a collaborative process, where each person feels supported, respected, and actively involved in their care.
Compassion does not mean avoiding difficult questions. It means approaching those questions without treating someone’s struggles as a verdict on who they are.
For me, allowing hope to re-enter the conversation means helping someone begin to imagine—and work toward—something different. The path is not the same for everyone, but a strong therapeutic relationship gives us a foundation from which to explore what comes next.
Seoka’s closing comment
What I appreciate about Maggie’s approach is that she asks what each person would like their life to look like, not only what they want to stop doing. That matters.
At Hanover CBT, we work primarily from the ACT model. We want to understand what matters to each person, what is getting in the way, and what kind of care is a good fit. Compassion and nonjudgment come with honest conversations and careful clinical decision making.
We take substance-related difficulties seriously without reducing someone to those difficulties. Each person brings their own experience, strengths, and goals, and should be an active participant in deciding how we move forward together.
About the author
Margaret “Maggie” Hooker, LICSW, LADC, is a licensed clinical social worker and alcohol and drug counselor at Hanover CBT. She has more than 20 years of experience, including work in community mental health, substance-use services, and outpatient and residential care at the VA Medical Center in White River Junction, Vermont. (Hanover CBT)
This article provides general educational information and is not a substitute for individualized clinical assessment or medical advice.
Research and clinical resources
Lortye and colleagues, 2026. Trial comparing the timing and type of PTSD treatment for people with co-occurring substance use disorders. Journal of Substance Use and Addiction Treatment, 183, 209878. Read the paper.
Faber and colleagues, 2026. Analysis of psychosocial outcomes from the same trial. Behaviour Research and Therapy, 202, 105053. Read the paper.
American Psychiatric Association. Explanation of changes to substance-related diagnoses in DSM-5. Read the diagnostic overview.
National Institute on Alcohol Abuse and Alcoholism. The Cycle of Alcohol Addiction and Alcohol Use Disorder: From Risk to Diagnosis to Recovery.
VA National Center for PTSD. Treatment of Co-Occurring PTSD and Substance Use Disorder.
