You are struggling with something you cannot quit. More than that, you know it has crossed that line into harmful. It is taking over more of your life than you want it to. Part of you wants to stop. You know that therapy will help. But do you need to be sober before you start?
It is the question I am asked most often by clients with addictions.
The answer? That depends on the therapist you choose. And you can, and should, ask them where they stand.
Some therapists will ask you to be sober
Many therapists will insist on sobriety before you start. There are a lot of good reasons for that.
Firstly, the work is likely to deepen, faster. If you have already started quitting, you are likely to be in the absolute thick of it. You are likely to be experiencing all the resistances that are going to keep you in addiction. Seeing a therapist at this stage can be enormously helpful. It can help you face the maelstrom of feelings that accompany giving up a substance or behaviour.
Being sober is also a powerful intention-setting before you start what therapists like to call “the work”. Quitting before you start, and telling your therapist that you have quit, signals to both of you that you are serious, and that you are ready to stick to the process.
The process will not be easy. I suspect you know that. What you might not know is that, as part of the work, you may act out against the process and against your therapist. Doing that from a place of sobriety lets both you and the therapist face what is happening. You will not have being high or drunk, or being hungover or on a comedown, to hide behind.
The process of recovery from addiction is, in my view, a process of radical honesty with yourself. Being sober before you start can help with that process. There is not the familiar crutch to hide behind.
I will not ask you to be sober
I, and some other therapists, will not insist on sobriety before you start. I take a harm reduction approach.
For some people, taking that first step, of going one, two, three days without, feels impossible. You might be experiencing this. You start brimming with good intentions, but then the feelings start. Perhaps it is the tension in your body, perhaps it is the thoughts racing around your mind, but those feelings and thoughts become louder, and more intense, and you cannot bear it any more.
Relapses happen. They will happen. And I will work with you to make sure that when they happen next, you can pick yourself up and try again. The relapse is part of the work, and I want to be there for you when it happens. This will be vulnerable. But it will deepen the work.
There may be a great many relapses before your last one. There might never even be a last one. But that is OK. That is all part of it. I want to be next to you for the ups and downs. I do not want to be presented with a finished product.
I also want to name that sobriety may not be possible, in the short term at least, or ever. You might be addicted to chemsex, and going sober would mean months without intimacy that are just too much to bear, maybe now, maybe ever. You might be in a circle of friends who aid and abet your addiction, and right now, for all kinds of reasons, it might be impossible to leave. That is not ideal, for sure. But life is messy.
What happens if I relapse?
Relapsing is part of this process. It is not a failure, it is a bump in the road. You will relapse, probably many times. Our job is to make sure you get back up. Because the opposite of recovery is shame. It is shame that keeps you where you are. My job, and the aim of our work together, is to face that shame head-on.
And in how you feel about the relapse, there might be a clue as to what therapist you should go for. For many, a contract around sobriety will be the thing that keeps them from relapsing. Or when they do, a commitment not to do so again can be powerful. But for others, when they relapse, the shame of having done so, of having let someone down, can be what ends the work.
What happens if I drink or use before the session?
Again, that depends on the therapist. Many will say that you should not come to the session. You are unlikely to be able to process your feelings, or even to connect to them. You might be belligerent or threatening.
I will insist that you come to therapy. We might not do our best work, we probably will not. But I want to see you at your worst. Recovery is a process of radical honesty. Showing up in your addicted state is honest. It shows me who you are when you are not trying to be good. I suspect that you do a good job of keeping your addiction at bay for others. You probably do not go to work drunk, or show up high to look after your kids.
If it is when you are alone that the demons come, what might it be like to bring the demons with you to therapy?
But that does not mean that showing up drunk or high will be without consequence. We will talk about it and explore what is going on. If it happens week after week, we will explore that too. I might have a reaction and it might feel helpful to name that. Your impact on me, and holding that, is part of the work.
There are limits too. I need to feel safe. And if you have overdosed, you should call 999 instead of coming to see me. Withdrawing too fast from heavy use of alcohol and benzodiazepines can kill you, so please speak to a GP to make sure you can cut your usage safely.
What questions should I ask a prospective therapist?
I would ask your therapist if you need to be sober before you start, and if so, for how long. Many will ask that it has been 30 or 60 days since your last relapse.
Ask too what happens when you relapse, how they will handle it and what you should do. And finally, if it feels right, ask them what happens if you relapse before a therapy session.
These conversations can be vulnerable and more than a little scary. The question you should ask yourself at the end of it is simply: could I talk to this person every week? Could I talk to this person after my worst week?
If the answer to that question is yes, the rest will follow.
You can search verified, independent UK therapists by location, specialism and approach on The Therapist Finder, including therapists who work with addiction.
By Andrew Tobert. View profile.
