What the Substance Is Doing

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This is the second post in the Addiction and Recovery in Primary Care series. The first post, Most People Get Better Without Us, established the conceptual framework—the models we inherit about addiction, the natural recovery literature, and the functional contextualist foundation that orients the clinical work that follows. This post builds on that foundation.

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The wisest strategy for a therapist is to assume that there is no organic basis for mad behavior and to proceed as if the problem is a social one. …it should be assumed that mad young people are sacrificing themselves to stabilize their families. …A therapist facing a mad young person should first assume that he or she is responding adaptively to a mad social situation. …people communicate in deviant ways in response to an organizational structure of a deviant type.

—Jay Haley, Leaving Home: The Therapy of Disturbed Young People

Jay Haley was writing about psychosis, not substance use disorders. The “mad young person” of his title is the acutely disturbed patient cycling through psychiatric hospitalizations, the one the mental health system has given up on or never quite known what to do with. But the frame generalizes without distortion: the person whose substance use is visible in the chart, whose behavior appears self-destructive, whose pattern of return visits without apparent change has exhausted the care team’s patience—that person is, in most cases, responding adaptively to a social situation that is itself disordered. The substance is not the problem. The substance is the solution to a problem that preceded it, often by decades.

Understanding what the substance is doing—what it provides, what it regulates, what it makes tolerable—is the first clinical task. Everything else follows from that.

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From Framework to Room

The previous post in this series established the theoretical ground: functional contextualism as the philosophical framework, contextual trauma therapy (CTT) and Acceptance and Commitment Therapy (ACT) as implementations, and the natural recovery literature as the empirical corrective to specialty addiction training’s assumptions about the primary care population. That post ended with an invitation to show up differently.

This post accepts that invitation. It develops the trauma-substance relationship that Post 1 named but did not fully examine, translates the functional framework into clinical moves, and makes the case that primary care is not a lesser setting for this work—that for the population most primary care BHCs actually encounter, it is in many respects a better one.

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Adversity, Adaptation, and Affect

The Adverse Childhood Experiences (ACE) study established something that continues to be underappreciated in clinical training: there is a graded dose-response relationship between the breadth of childhood exposure to abuse and household dysfunction and nearly every category of adult health risk behavior . The relationship is not incidental or statistical noise. It is robust across multiple replications and multiple substance categories. Persons who experienced four or more categories of adverse childhood experiences showed four- to twelve-fold increased risk for alcoholism and drug abuse compared to those who experienced none.

This is a mechanistic claim, not merely an epidemiological one. It is saying something about why people use substances. The mechanism is affect regulation—the management of internal states that, in the context of developmental adversity, were never adequately learned because the environment never provided the conditions for learning them. The patient who drinks to sleep is not failing to make healthy choices. She is solving a problem she has been solving since childhood, with the most reliable tool available to her. The patient who uses opioids to manage pain that has no clear physical substrate is not drug-seeking. He is regulating an affective and somatic experience that became organized around pain long before the opioids arrived. The patient who smokes when the anxiety becomes unbearable is not weak-willed. She is managing something that would otherwise be unmanageable, in the moment, with the resources she has.

Haley’s insight—that the presenting problem is a response to the organizational structure of the social situation—adds a dimension that the ACEs data alone does not supply. The adversity is not only historical. The social field in which many FQHC patients live is itself disordered: poverty, structural racism, housing instability, chronic community-level stress, intimate partner violence, and the ongoing demands of survival in conditions that routinely exceed available resources. The substance is doing something in that current context, not only in relation to what happened in childhood. Both levels of analysis are necessary. The developmental history explains the affect regulation deficit; the current social context explains why the deficit continues to be activated and why it has not resolved.

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Complex Traumatization and Why It Changes the Clinical Calculus

The Trauma in Primary Care series on this blog introduced the distinction between PTSD and complex traumatization, drawing on Steven Gold’s CTT framework. That distinction is worth restating here because it is directly relevant to the substance use presentation.

PTSD, as conventionally understood, involves a discrete traumatic event or series of events that produce a diagnosable symptom cluster: intrusion, avoidance, negative cognitions and mood, hyperarousal. The clinical protocols developed for PTSD—prolonged exposure, EMDR, cognitive processing therapy—are organized around the assumption that there is a specific traumatic memory that can be identified, processed, and integrated.

Complex traumatization is different in kind, not just in degree. It emerges from developmental and relational experiences—neglect, chronic emotional abuse, chaotic attachment, exposure to ongoing violence—that shaped affect regulation, self-concept, and interpersonal functioning at a foundational level, before any discrete event could be retrospectively identified as the trauma. Most primary care patients with significant substance use histories fit this profile rather than the PTSD profile. They did not have one terrible thing happen to them. They grew up in a world that was, in Haley’s term, organized in a disordered way—and they adapted accordingly.

This distinction changes the clinical calculus significantly. The treatment protocols developed for PTSD—which require the patient to make contact with distressing material in a controlled way—presuppose a level of affect tolerance and stabilization that the complex traumatization patient has not yet developed. Standard addiction treatment, which frequently involves group modalities, confrontational therapeutic styles, and an implicit demand for abstinence as a precondition for engagement, is poorly suited to this population for the same reason: the treatment itself can be activating in ways the patient cannot yet manage. This is not treatment failure. It is a mismatch between the clinical intervention and the patient’s actual functional profile.

CTT’s response is to place stabilization before everything else—not as a preliminary stage to be completed quickly before “real” treatment begins, but as the primary clinical task for as long as it takes. Stabilization means building the internal and relational resources that would make it possible to tolerate the cost of change. In practice, this means that the BHC in primary care is frequently not in the business of treating the substance use directly. She is in the business of building the conditions under which the patient’s own change process—which, as Post 1 established, is already underway for most people—can continue to unfold (GATHER: Generalist—the BHC working with substance use presentations is working with the whole person and the full context, not managing a discrete disorder .).

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What the Functional Question Produces in the Room

Functional contextualism, as a clinical orientation, begins with a question the disease model and the moral model rarely ask: what is this behavior doing? Not what is causing it, not what category does it belong to, but what function does it serve in this person’s life, in this context, at this moment?

Applied to substance use, the functional question produces a different encounter from the outset. Before asking how much, how often, and with what consequences, the BHC asks what the substance provides. The answers are usually not complicated. Sleep. Calm. Relief from physical pain. Social ease—the ability to be in a room with other people without the level of hypervigilance that is otherwise constant. A few hours of not caring about what is otherwise unrelenting. The answer to that question is not a diagnostic datum. It is the clinical target.

William Miller’s foundational motivational interviewing paper grounded MI explicitly in self-efficacy and attribution theory—which is to say it was a functional contextualist intervention from the beginning, even when it was not described that way. The ambivalence that MI is designed to explore is itself a functional phenomenon: the patient is ambivalent because she accurately perceives that the substance is currently doing something she does not know how to do without it. Treating ambivalence as resistance, as the moral model tends to, is a clinical error. Ambivalence is information. It is the patient accurately reporting the functional situation.

Albert Bandura’s self-efficacy framework adds the other essential piece: the patient who cannot imagine managing without the substance is not in denial. She has low self-efficacy for a specific set of behavioral alternatives—alternatives she may never have had access to, never been taught, or may have had available and lost. Building self-efficacy in the encounter is not cheerleading. It is the clinical work. The BHC who can identify one moment in which the patient managed something difficult without the substance, and who can reflect that moment back with genuine curiosity about how it happened, is doing something that has a direct pathway to the change process.

What this produces, practically, is a different opening to the encounter. Not “I see in your chart that you’ve been using alcohol—can you tell me about that?” but something closer to “Tell me about what your days are like. When do things get hard?” The substance use will appear in that conversation, because it appears in the patient’s days. But it appears in context—in relation to what it is managing—rather than as a problem the BHC has come to address.

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Primary Care as Therapeutic Affordance

The four Cs of primary care—first contact, continuity, comprehensiveness, and coordination —describe a model of care that is, for the complex traumatization population with substance use concerns, better suited to the clinical task than specialty addiction treatment in several important respects.

First contact means the BHC encounters patients before they have decided there is a problem, before they have decided they want help, and before the shame and institutional wariness that accumulate through repeated specialty treatment contacts have had time to build. The primary care encounter is often the first clinical contact in which a patient has been asked about her substance use by someone who is not there specifically to evaluate it. That changes the encounter.

Continuity is the structural advantage that is most difficult to replicate in episodic specialty care. The complex traumatization patient does not build trust quickly, and she should not be expected to. The relational foundation that CTT identifies as the prerequisite for any subsequent clinical work is built over time, across encounters, through the experience of being met consistently and without judgment. The primary care BHC who has seen a patient four times over two years for different presenting concerns is in a different relational position than the addiction counselor meeting her for an intake.

Comprehensiveness means the BHC can see the substance use in the context of everything else—the chronic pain, the insomnia, the relationship that ended, the housing situation that became unstable, the child who is struggling in school. This is the clinical picture that Haley’s framework requires: the substance use cannot be understood in isolation from the organizational structure of the patient’s social situation. Primary care, because it sees the whole person over time, has access to that structure in a way that specialty care, seeing the substance use problem, does not.

Coordination means the BHC is positioned to influence not only the patient but the team—to help the PCP understand why the patient who “keeps coming back” is not failing treatment but inhabiting a predictable stage of a change process, to translate the functional framework into language that the care team can use in their own encounters, to prevent the moral model from crystallizing in the chart language before it follows the patient permanently.

None of this is an argument that primary care is sufficient for every presentation, or that it is superior to specialty addiction care. The argument is that they are different—offering different things to different populations at different moments in the change process—and that the difference is worth understanding clearly rather than flattening into a simple hierarchy.

Medication for opioid use disorder (MOUD) is itself now a primary care tool. Buprenorphine prescribing by PCPs and advanced practice providers has expanded substantially, and integrated PCBH and MOUD programs represent one of the clearest demonstrations of primary care meeting the full complexity of severe OUD . Low-threshold buprenorphine models—prioritizing same-day entry, flexible procedures, harm reduction, and availability in non-traditional settings—extend this logic further, reaching patients who would not engage with conventional specialty addiction services . MOUD in primary care is not a lesser version of specialty addiction treatment; for many patients with opioid use disorder, it is the appropriate treatment delivered in the appropriate setting.

What specialty addiction care offers that primary care cannot is something distinct from medication: medically supervised withdrawal for patients whose physiological dependence makes unmanaged cessation dangerous, inpatient structure for patients whose social environment is so saturated with cues and access that outpatient work cannot gain traction, the intensity of residential treatment for patients whose functioning has deteriorated beyond what brief contact can address. Some patients need those things, and a primary care BHC who cannot recognize when a presentation exceeds the scope of primary care is not serving her patients well. The same stepped-care logic that governs the trauma series applies here: primary care is the appropriate first setting for the majority of presentations; specialty referral is reserved for the presentations that genuinely require what only specialty care can offer.

What primary care offers in return—continuity, first contact, the absence of stigmatizing referral, the ability to encounter patients longitudinally across presenting concerns that have nothing to do with substance use—is not a consolation prize for patients who cannot access specialty care. It is a genuinely distinct therapeutic affordance, best suited to the population that is actually walking through the primary care door: the ambivalent, the early-stage, the complex traumatization patients who have never sought specialty care and are unlikely to, and the many people whose change process is already underway and who need presence more than they need treatment.

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The Job

Haley’s “mad young person” is responding adaptively. The adaptation costs something—it costs the patient, and eventually the people around her, more than the original problem did. But understanding it as adaptation rather than as failure changes what the clinician does next. It produces curiosity rather than frustration, and curiosity is the only clinical instrument that is consistently useful in this work.

The BHC’s job, in these encounters, is not to fix the substance use. The substance use is, in most cases, fixing something else—imperfectly, at increasing cost, in a way that will eventually become unsustainable. The BHC’s job is to understand what it is fixing well enough to be genuinely useful: to offer something that does the job better, to build the self-efficacy that makes alternatives imaginable, to reduce the shame that keeps the clinical door closed, and to stay present while the patient’s own change process—which was already underway—continues to unfold.

That is not a small job. For a population that has been told, explicitly and implicitly, that their problem is a moral failure or a brain disease or a treatment-resistant chronic condition, being met by someone who asks what the substance is doing—and who waits, with genuine curiosity, for the answer—is an experience that may not produce immediate change but that becomes part of the context in which change eventually becomes possible.

Most people get better without us. The ones who do it in part because of us usually do not remember the specific intervention. They remember being met.

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