Helping Someone with a Substance Use Disorder—When They Don’t Think They Have One
By Dr. Scott Schinaman, Psy.D., MBA, CEDS-C
Working in the mental health field, we often encounter one of the most challenging clinical situations: supporting someone with a substance-use disorder (SUD) who doesn’t believe they have a problem. It’s a delicate balance—offering compassion without enabling, addressing concerns without pushing someone away. As mental health providers, it’s crucial that we navigate this space with empathy, patience, and evidence-based strategies.
Understanding Denial: It’s Not Just Stubbornness
Denial in substance use isn't always a conscious choice. Often, it's a psychological defense mechanism—protecting someone from the shame, guilt, or fear that might come with acknowledging a substance problem. The brain’s reward system also plays a crucial role. Substances hijack the dopamine system, leading individuals to prioritize the use of drugs or/and alcohol over negative consequences, relationships, or health.
Recognizing this helps shift our approach from confrontation to curiosity and compassion.
Lead with Empathy, Not Ultimatums
One of the most effective tools we have in the talk therapy world is the therapeutic alliance. When a client doesn't see their substance use as problematic, our first job isn’t to convince them otherwise—it’s to build trust.
Use motivational interviewing (MI) techniques to explore ambivalence. Ask open-ended questions like, “What do you like about using [substance]?” followed by, “Are there things you don’t like?”
Reflect back on their own words, helping them identify discrepancies between their values and their using behaviors.
Avoid labeling. Terms like “addict” or even “substance-use disorder” can trigger defensiveness, shame, and/or guilt, especially early in the process.
Focus on Function, Not Diagnosis
Sometimes it helps to shift the conversation from “Do you have a problem?” to “Is this working for you?” Frame substance use in terms of its impact on the person’s goals, relationships, and health. For example:
“How is your alcohol use affecting your energy or motivation lately?”
“Have you noticed any changes in your mood or anxiety since you started using “X” more frequently?”
This client-centered focus promotes self-reflection and increases the chances of genuine engagement and connection.
Involve Natural Support Systems—Carefully
Families and friends often notice the problem before the individual does. If they’re involved, we as clinicians can guide them in setting boundaries while maintaining a supportive stance. Community-based approaches like CRAFT (Community Reinforcement and Family Training) help loved ones learn how to reinforce sober behavior and avoid enabling, as does other community-based group support like Alanon.
It’s important to coach support systems to resist the urge to “fix” or force insight. Instead, encourage them to highlight natural consequences in a non-judgmental way…which is difficult.
Offer Harm Reduction and Entry Points
While abstinence may be the long-term goal, meeting someone where they are is often more effective. Harm reduction strategies—like discussing safer use practices or helping the person consider cutting back—can open the door to deeper change later.
Even if someone isn’t ready to engage in treatment for their SUD, they may be willing to work on related issues like anxiety, depression, or relationship conflicts. These entry points allow us to plant seeds and slowly build insight.
Know When to Wait—and When to Act
We must accept that some people won’t be ready to change right away. That’s not failure—it’s part of the process. Our role is to hold space, offer tools, and stay consistent. But if an individual is in immediate danger—such as experiencing suicidal thoughts, repeated overdoses, or severe withdrawal—we must act swiftly, involving crisis intervention, medical treatment or a higher level of care.
Final Thoughts
Helping someone who doesn’t see their substance use as a problem requires patience, clinical skill, and a deep well of compassion. It’s not about forcing change—it’s about planting the seeds, cultivating readiness, and being there when the soil is ready for growth…growing roots if you will.
The journey from denial to awareness to recovery is rarely linear. But with the right approach, we can walk alongside our clients, patients, and loved ones—without judgment—and help them take the first step toward healing and recovery.
References:
Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.
Meyers, R. J., & Wolfe, B. L. (2004). Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening. Hazelden.
SAMHSA (Substance Abuse and Mental Health Services Administration). (2023). TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change. Journal of Consulting and Clinical Psychology, 51(3), 390–395.
National Institute on Drug Abuse (NIDA). (2022). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
