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TREATING ALCOHOL AND DRUG PROBLEMS
IN PSYCHOTHERAPY PRACTICE
Treating
Alcohol and
Drug Problems in
Psychotherapy Practice
Doing What Works
SEC OND E DI T ION
Arnold M. Washton
Joan E. Zweben
The Guilford Press

New York London
Copyright © 2023 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
All rights reserved
Except as indicated, no part of this book may be reproduced, translated,

stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or
otherwise, without written permission from the publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED DUPLICATION LICENSE
These materials are intended for use only by qualified mental health professionals.
The publisher grants to individual purchasers of this book nonassignable permission

to reproduce all materials for which photocopying permission is specifically granted
in a footnote. This license is limited to you, the individual purchaser, for personal use
or use with patients. This license does not grant the right to reproduce these materials
for resale, redistribution, electronic display, or any other purposes (including but not
limited to books, pamphlets, articles, video or audio recordings, blogs, file-sharing
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for these and any other purposes must be obtained in writing from the Permissions
Department of Guilford Publications.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice
that are accepted at the time of publication. However, in view of the possibility of
human error or changes in behavioral, mental health, or medical sciences, neither the
authors, nor the editor and publisher, nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein
is in every respect accurate or complete, and they are not responsible for any errors
or omissions or the results obtained from the use of such information. Readers are
encouraged to confirm the information contained in this book with other sources.
Library of Congress Cataloging-in-Publication Data

Names: Washton, Arnold M., author. | Zweben, Joan E., author.
Title: Treating alcohol and drug problems in psychotherapy practice : doing
what works / Arnold M. Washton, Joan E. Zweben.
Description: Second edition. | New York : The Guilford Press, [2023] |
Includes bibliographical references and index.
Identifiers: LCCN 2022035472 | ISBN 9781462550869 (paperback) |
ISBN 9781462550920 (hardcover)
Subjects: LCSH: Substance abuse—Treatment. | Alcoholism—Treatment. |
Psychotherapy. | MESH: Substance-Related Disorders—therapy. |
Alcoholism—therapy. | Psychotherapy—methods. | BISAC: PSYCHOLOGY /
Psychopathology / Addiction | MEDICAL / Nursing / Psychiatric & Mental
Health
Classification: LCC RC564 .W37 2023 | DDC 362.292/86—dc23/eng/20220809
LC record available at https://lccn.loc.gov/2022035472
In memory of my late mother,
Mildred Rebecca Washton (1918–2018),
who lived through a century of remarkable change
—A. M. W.
In hopes that my family,

Avram, Joanne, Cameron, and Emily,
always enjoy the same fulfillment
in their work as I have
—J. E. Z.
About the Authors
Arnold M. Washton, PhD, is a psychologist in private practice in New York

and New Jersey, specializing in the treatment of substance use and other
behavioral health problems since 1975. Dr. Washton has served as Clini-
cal Professor of Psychiatry at New York University School of Medicine, as
director of several nationally recognized addiction treatment and research
programs, and as consultant to professional sports teams, government
agencies, media organizations, and major corporations. He has served
on the Substance Abuse Advisory Committee of the U.S. Food and Drug
Administration and has given expert testimony before special committees
of the U.S. Senate and House of Representatives on drug abuse trends in the
United States. The author of several books and numerous journal articles
on addiction and its treatment, Dr. Washton has devoted most of his career
to developing individualized approaches to treating addiction that incorpo-
rate the principles and practice of client-centered psychotherapy. His web-
site is www.thewashtongroup.com.
Joan E. Zweben, PhD, is an addiction psychologist who began treating co-

occurring psychiatric and addictive disorders, and training treatment prac-
titioners, in the 1970s. She has a broad-based background in mental health,
alcoholism, and drug dependence, and has experience with both residen-
tial and outpatient modalities. Dr. Zweben has a long-standing commit-
ment to building treatment resources through networking activities, and to
addressing stigma in its many forms. She is the founder and retired execu-
tive director of two treatment programs providing integrated services for
people with co-occurring disorders: The 14th Street Clinic (opioid treat-
ment) and East Bay Community Recovery Project (now part of Lifelong
Medical Care), both in Oakland, California. Active as a teacher and con-
sultant, Dr. Zweben is Clinical Professor of Psychiatry at the University of
California, San Francisco, based at the San Francisco VA Medical Center.
Her publications include four books, over 90 articles or book chapters, and
15 monographs on treating addiction.
vii
Preface
W e have written this book to provide practicing psychotherapists

with a “how-to” guide for helping people with substance use disorders
(SUDs). Because alcohol and drug problems are highly prevalent in the gen-
eral population, and especially among individuals with other behavioral
health problems, therapists of every kind (e.g., psychologists, psychiatrists,
clinical social workers, mental health counselors, marriage and family
therapists) are likely to encounter SUDs in their practices whether or not
substance use is a presenting or primary complaint. In fact, the need for
psychotherapists to address SUDs in their practices and opportunities for
them to do so have never been greater.
Our intended readers include therapists from a wide variety of profes-
sional disciplines, theoretical orientations, and varying levels of experience
in treating SUDs, ranging from general psychotherapists with little or no
experience in this area to dedicated specialists who, like us, have worked in
the addiction treatment field for several decades. Jointly, we have over 90
years of professional experience in the addiction field, working as psychol-
ogists, program directors, authors, lecturers, and clinical researchers. As in
the first edition of this book, published in 2006, our emphasis in this sec-
ond edition is on practical strategies and techniques. The integrated treat-
ment approach we describe here incorporates the types of clinical inter-
ventions (e.g., cognitive-behavioral, motivational, psychodynamic) that are
familiar to most psychotherapists. This approach is guided by two primary
goals: (1) to establish and maintain an empowering therapeutic relationship
with every individual we are trying to help—a bedrock principle of psy-
chotherapy for all types of behavioral health problems—and (2) to tailor
the treatment to the individual needs of each person and make appropriate
adjustments to the treatment as needs may change.
ix
x Preface
Whether you are a generalist or an addiction specialist, this book is

intended to enhance your knowledge, confidence, and ability to address
SUDs in people receiving your help with any type of behavioral health prob-
lem. A basic premise of this book is that well-trained psychotherapists, par-
ticularly those familiar with the principles and practices of client-centered
therapy, already possess many of the clinical sensibilities and skills needed
to address SUDs. Nonetheless, there are important facts and particular
skills that all therapists need to have to intervene effectively with these
disorders. Providing that information is one of the primary purposes of
this book.
This book is intended to serve as a practical guide, not as a compre-
hensive textbook or review of the scientific literature. The material covered
here extends from a description of the nature and course of SUDs to the
particular types of interventions that appear to work best with patients
in different stages of the recovery process. At various points in the book,
we illustrate specific treatment strategies and bring them to life with case
examples. In these vignettes, we have eliminated or disguised identifying
information. We discuss problems, pitfalls, and key issues encountered most
frequently in treating patients with SUDs: how to approach patients about
their alcohol and drug use in a nonthreatening way, how to enhance a cli-
ent’s motivation and readiness for change, how to sidestep early resistance
and avoid power struggles, when and how to involve family members and
significant others, how to assess and treat patients with coexisting psychi-
atric disorders, how to utilize in-office drug testing as a clinical tool, and
a wide variety of other nuts-and-bolts clinical techniques. We also discuss
relapse prevention strategies designed to enhance patients’ ability to main-
tain abstinence over the long term, the role of individual psychotherapy
in addressing a variety of ongoing and later-stage recovery issues, and the
special role of group therapy in treating SUDs.
In addition to private practitioners, this book is potentially useful to
clinicians working in all sectors of health care, where the likelihood of
encountering people with alcohol and drug problems has been on the rise
for many years. It is also useful to students and trainees in advanced courses
seeking to enter professional practice. In addition, counselors working in
addiction treatment programs may find this book informative because it
describes an individualized psychotherapeutic approach that differs signifi-
cantly from conventional “one-size-fits-all” addiction counseling.
Why publish this second edition? Our motivation for writing this sec-
ond edition stems from several developments in the landscape of addiction
treatment since the first edition was published—all of which highlight how
crucial it is for mental health practitioners to get more involved in address-
ing SUDs and that opportunities for them to do so are steadily increasing.
First, there is the ongoing opioid crisis of the past 15–20 years.
Increased supplies of prescription painkillers and more potent forms of
Preface xi
imported heroin and fentanyl have led to sustained increases in rates of opi-
oid use, addiction, and overdose deaths. Problems with methamphetamine
have reemerged, and widespread cannabis use has brought new problems to
the surface. As a direct result, the demand for medical and/or psychosocial
treatment for SUDs involving opioids and/or other substances has grown
to exceed what specialty addiction treatment programs and practitioners
alone can provide. Office-based practitioners are in an excellent position
to identify emerging alcohol and drug problems before they become more
severe and to offer a more acceptable treatment alternative for individuals
who do not want or need intensive treatment in a specialized program.
A second development that encourages greater therapist involvement
in treating SUDs has been a trend of increasing acceptance and prolifera-
tion of evidence-grounded behavioral or psychological approaches to treat-
ing SUDs that offer alternatives to traditional approaches based on the
12-step abstinence-only treatment model of Alcoholics Anonymous (AA).
The behavioral approaches with the strongest evidence of efficacy incor-
porate the types of interventions familiar to most mental health therapists,
including cognitive-behavioral, client-centered, motivational, psychody-
namic, mindfulness, and affect regulation techniques.
Many therapists work in outpatient or residential/hospital treatment
settings, instead of or in addition to private practice. The brief new chapter
(Chapter 6) on evidence-based treatment is intended to give a perspective
of the benefits and downsides of emphasis on these practices. It is certainly
useful to be familiar with research-based interventions in any practice set-
ting, but rigid application has led us to a new form of cookie-cutter treat-
ment. Respect, but not reverence, is in order. Individualizing treatment
remains the primary goal, using specific interventions as indicated by the
needs of the patient.
A third development has been the emergence of harm reduction
approaches to treating SUDs. Harm reduction is a paradigm-shifting alter-
native to traditional abstinence-only treatment that opens new vistas for
psychotherapists to play a more active role in treating SUDs. Rooted in the
principles of client-centered psychotherapy, harm reduction is a therapist-
friendly approach that makes use of the clinical sensibilities and skills that
well-trained therapists already possess. These include an ability to engage
clients in a therapeutic relationship that engenders positive change, a deep
respect for individual differences and the rights of clients to choose their
own treatment goals, and an ability to listen to, collaborate with, and meet
clients “where they are” rather than impose on them preformulated agen-
das. Alcohol moderation strategies, a particular application of the harm
reduction model, are discussed at length in Chapter 12, new to this edition.
Lastly, a fourth development that invites psychotherapists to get more
involved in treating SUDs is the growing importance of “medication-assisted
treatment” (MAT) based on research indicating that pharmacological
xii Preface
adjuncts for treating addiction are often more effective when combined
with psychosocial interventions than when given alone, as is often the
case with psychotropic medications used for treating psychiatric disorders.
Patients with SUDs who are engaged in an ongoing therapeutic relationship
with a mental health practitioner who collaborates with the medication
prescriber are generally more likely to give potentially helpful medication
a try, to adhere to prescribed medication regimens, to tolerate unpleasant
side effects, and to refrain from discontinuing the medication prematurely.
This second edition, like its predecessor, helps to fill a critical void
in the existing literature on treating SUDs. Much of what is written on
this topic is geared primarily toward the treatment of people with severe
SUDs in specialized addiction treatment programs. This book, by contrast,
focuses on patients presenting with a range of substance use problems from
mild to severe seen by mental health practitioners in office-based psycho-
therapy practice. These differences are significant in several respects. As
compared with the clinical staff of addiction treatment programs, private
therapists are able to offer more flexible, individualized care and to engage
people where they are when they first appear for treatment. They also are
more likely to see people in the earlier stages of developing or coming to
grips with an alcohol or drug problem, including those already in therapy
for other mental health problems. Office-based treatment offers an easier
entry point for many people who, for a variety of reasons, choose not to
seek help at addiction treatment programs. It also offers the option of indi-
vidual psychotherapy, which may not be available in addiction treatment
programs owing to a combination of limited resources and a common view
that group therapy is the most effective way to treat SUDs. Nonetheless,
many people grappling with alcohol or drug problems need and want both
the personalized attention and the stronger therapeutic relationship that
only individual therapy can offer. Many of them also want the help of a
mental health professional with the advanced training and skills to address
complex psychological issues that are frequently intertwined with alcohol
and drug problems. This includes people who realize that their personal
growth in later stages of recovery requires them to address certain issues
(e.g., intimacy, self-esteem, developmental traumas) in ways that peer-
led mutual-help programs (such as AA) or standard addiction treatment
programs cannot. The role of advanced mental health training in treating
SUDs has become increasingly clear in recent years with recognition of the
high rate of comorbidity between SUDs and a broad range of other mental
health problems and of the fact that positive treatment outcomes are more
likely when both sets of problems are properly addressed.
This book describes an integrated, multifaceted approach that is prag-
matic, flexible, nondogmatic, and empowering to clinicians from diverse
professional backgrounds and theoretical orientations. We describe how
to mix, match, and time the delivery of different types of interventions,
Preface xiii
including motivational, cognitive-behavioral, 12-step recovery, and psy-

chodynamic techniques. We utilize the stages-of-change model (Connors,
Donovan, & DiClemente, 2001; DiClemente, 2003; Miller & Rollnick,
2013; Prochaska, DiClemente, & Norcross, 1992) as a conceptual frame-
work and clinical guide for finding the “best fit” between where the patient
is on the continuum of motivation and readiness for change and what the
therapist should be doing at a particular point in time to help facilitate
change.
The population of people with SUDs is heterogeneous, contrary to pop-
ular stereotypes about them. People who develop substance use problems
differ from one another in many important ways, including the severity
of their alcohol and drug problems, their chosen goals regarding use (e.g.,
reduction vs. abstinence), their motivation and readiness to change, their
personal strengths and vulnerabilities, their psychological and emotional
states, their educational and socioeconomic levels, their personal beliefs
and value systems, and their cultural and family histories and frames of ref-
erence. Accordingly, different individuals must be approached in different
ways, and it is impossible to know in advance what will be acceptable to a
particular patient or work best for him or her. The clinician must have an
open mind, a flexible attitude, a willingness to go with the flow or change
direction when needed, and an adventurous spirit of trial and error.
Patients seek help from private therapists for a variety of reasons.
Some come from outpatient programs and want more individual time;
others are dissatisfied with the program’s approach. Regrettably, parts of
the addiction treatment field are still permeated with a great deal of ide-
ology, dogma, and rigidity that limits treatment options. Some clinicians
and programs continue to take an unwavering stance that there is only
one acceptable pathway to recovery for anyone with an alcohol or drug
problem. Specifically, they see abstinence as the only acceptable treatment
goal, and they see 12-step programs such as AA and Narcotics Anonymous
(NA) as the one tried-and-true method for attaining meaningful and last-
ing recovery. They also view confrontation of the patient’s denial and other
intractable defenses as required to motivate him or her to stop destruc-
tive behaviors, and they consider recovery to be impossible without the
patient’s fully accepting the identity of “addict” or “alcoholic.” Although
there is some value in each of these notions, we object to the absolutist
thinking that still dominates sectors of the addiction treatment field. The
one-size-fits-all approach is likely to be counterproductive with many
patients. Fortunately, there are a variety of outpatient programs in both
the public and private sectors that have incorporated other elements. Many
utilize evidence-based practices or trauma-informed care, have links to
medication-assisted treatment, or refer to psychotropic medication provid-
ers when indicated. Over time, these programs have developed much more
tolerance for ambivalence about recovery and drug use and use a variety of
xiv Preface
motivational and engagement strategies to attract and retain patients. It is

important for private practitioners to be familiar with what is available in
their communities. The broad diversity of people who seek help for alcohol
and drug problems points clearly to the need for a more flexible, inclusive,
comprehensive approach in order to increase the overall appeal, acceptabil-
ity, and clinical effectiveness of treatment for SUDs.
It is incorrect to assume that no method for treating SUDs really
works. Lots of different things work. The key is to figure out what works
best for whom at a particular point in time. The literature on SUDs is filled
with many excellent ideas, conceptualizations, and treatment techniques.
Some have strong empirical support, and others have never been adequately
studied. Clinicians need a menu of different options to choose from so they
can tailor the treatment to fit the individual needs of each patient. There
is no one best treatment method or approach for everyone with an alcohol
or drug problem. The only guide is to do what appears to work best with
the types of patients you treat. If you are looking for a cookbook method,
this book is not for you. What we offer here are some helpful suggestions,
guidelines, and techniques that you can use as you see fit. But they will need
to be adapted and modified to fit the patients you encounter. We hope what
you read in this book will empower you to more freely exercise your own
clinical judgment and unmoor your thinking from the confines of standard
approaches, each claiming to be the one and only effective way to deal with
people who develop problems with alcohol and other drugs.
Terminology
Throughout this book we use the terms “alcohol and drug problems”
and “substance use disorder” (SUD) somewhat interchangeably, although
technically they are not identical. The former is a generic term, not a for-
mal diagnostic category, that pertains to any form of substance use that
adversely affects a person’s health and/or psychosocial functioning and/or
adversely affects others—whether or not the problem is severe enough to
meet DSM-5 criteria (American Psychiatric Association, 2013) for a diag-
nosis of “substance use disorder.” The term “substance use disorder” is
the currently accepted diagnostic term used by health care professionals
to describe clinical conditions involving all types of substance use, as we
discuss in Chapter 2.
This book does not presume that all forms of substance use represent
pathological conditions that warrant a clinical diagnosis of SUD. Regard-
less of how substance use may be viewed by certain individuals or by soci-
ety as a whole, there are countless people whose substance use is not patho-
logical and therefore not deserving of formal diagnosis or clinical attention.
Although the legal system and government agencies seek to sanction any
Preface xv
use of illegal drugs whatsoever, in this book we adhere to the clinical (i.e.,
not the legal) definitions of these human health care problems. The terms
“client” and “patient” are used interchangeably throughout this book. In
addition, to maintain gender neutrality, we alternate between the pronouns
“he” and “she.” However, we urge clinicians to be attentive to or inquire
about the preferred pronouns of the patient and significant others and to
honor that in conversations.
Our readers will notice that the terms “addict” and “alcoholic” are
absent from this book. Despite widespread use in both the professional lit-
erature and popular press, in our view these terms have a distinctly pejora-
tive connotation that perpetuates negative stereotyping and discriminatory
attitudes toward people suffering with alcohol and drug problems. These
terms also foster the inaccurate impression that a greater degree of homoge-
neity exists among people who develop alcohol or drug problems than clini-
cal observation reveals. When it comes to SUDs, it is too easy to lose sight
of essential differences between individuals despite the fact that they may
all share the same diagnosis with regard to their substance use behavior.
Terminology continues to evolve and is now moving from “relapse pre-
vention” to “relapse reduction.” The latter is increasingly used in profes-
sional presentations and publications. There is recent advocacy to get rid of
the term “relapse” altogether to avoid the implication of failure, but much
valuable literature from the past uses that term. “Recurrence” is now the
term often used for a return of medical symptoms. We have taken a tran-
sitional posture and continue to use the term “relapse” as well as “relapse
reduction.”
The term “recovery” appears at various points in this book. Generally
speaking, recovery pertains to the process of personal growth, life enhance-
ment, and diminished vulnerability to relapse that accrues as a person not
only remains abstinent from all psychoactive substances but also works
actively to make the emotional and lifestyle changes necessary to achieve
a reasonable, satisfying life that does not include alcohol or drug use. An
important distinction is drawn between the terms “abstinence” and “recov-
ery.” Whereas abstinence is quite simply the absence of alcohol and drug
use, recovery refers to an ongoing process of personal transformation that
diminishes the likelihood that an individual will return to his or her former
pattern of substance use.
Scope of This Book
It is important for our readers to be aware of the scope of this book.

Although we strongly support the use of evidence-based treatments for
SUDs and incorporate many of these strategies into our work, much of the
material presented here is based on our own clinical experience and not
xvi Preface
necessarily on results of scientific research. We have not included compre-

hensive documentation on topics that do have a strong evidence base, but
we offer references in the spirit of providing additional reading. Although
recent studies support the efficacy of a wide variety of treatment approaches
and techniques for SUDs, no one approach has shown itself to be superior
to all others (Project MATCH Research Group, 1997). However, what does
appear to have an overriding influence on treatment outcome, regardless of
the chosen treatment approach or method, is the therapist’s attitude, inter-
action style, and clinical stance toward patients (Miller & Rollnick, 2013).
Therapists whose style is engaging, respectful, curious, empathetic, non-
judgmental, nonaggressive, optimistic, and encouraging tend to produce
better patient retention and outcomes. We emphasize throughout this book
the overriding importance of the therapeutic relationship as the primary
vehicle for facilitating positive change and the underpinning of all good
treatment. The importance of the therapist’s attitude and stance toward
patients with SUDs cannot be overemphasized, particularly in light of cer-
tain psychodynamic issues common to individuals with these problems.
Many patients carry a great deal of shame and guilt about their problems,
even if they are unaware of these feelings and vehemently deny that such
problems even exist. These feelings can be elicited and experienced quite
intensely if the clinician comes across in any way as nonaccepting or judg-
mental.
Using the therapeutic relationship to help patients acknowledge that a
problem exists and to develop the motivation for change is a challenging
but extraordinarily important task. In the integrative treatment model that
serves as the framework for what we do, the therapist adjusts and adapts
interventions to address the changing tasks that patients face at differ-
ent stages of treatment and recovery. Various types of clinical techniques
and interventions are utilized, as needed, to accomplish agreed-upon
treatment goals. Motivation enhancement techniques (an adaptation of
Rogerian client-centered therapy) are used to help patients to develop the
motivation and readiness to change. Cognitive-behavioral techniques are
used to help patients initiate behavior changes, avoid common setbacks,
and then maintain these changes. A psychodynamic understanding of the
patient and the patient–therapist relationship, coupled with attention to
both transference and countertransference phenomena, is helpful at all
stages of the treatment process.
Our readers should also know that this book addresses only addictive
disorders that involve the use of psychoactive substances. We do not deal
separately or specifically with addictive and compulsive behaviors such as
those involving food, gambling, work, exercise, spending, or sex. These
behaviors often are intertwined with SUDs (especially stimulant-related
sexual compulsivity) and are discussed here in that context, but not as sepa-
rate problems per se.
Preface xvii
Moreover, in our discussion of SUDs, we do not address nicotine

dependence and smoking cessation techniques. Although many, if not
most, of the treatment interventions discussed here (particularly cognitive-
behavioral techniques for establishing abstinence and preventing relapse)
can be adapted and applied to the treatment of nicotine dependence
(Ebbert, Hays, McFadden, Hurt, & Hurt, 2019) and increasing attention
is being focused on the linkage between tobacco smoking and other sub-
stance dependencies (Fertig & Allen, 1995), in our view nicotine depen-
dence differs importantly enough from other drug addictions to warrant
not addressing it here directly. Perhaps the most important difference is
that, although the long-term medical consequences of tobacco smoking are
quite ominous and potentially fatal, the psychological and behavioral con-
sequences are much less obvious and remain somewhat unclear. Whereas
alcohol and other drugs (e.g., cocaine, heroin) can and often do produce
striking changes in mood, affect, and behavior that often disrupt an indi-
vidual’s functioning and mimic a variety of psychiatric disorders, the
psychoactive effects and consequences of nicotine, in the overwhelming
majority of tobacco smokers, are pale by comparison. (A similar argument
can be made for the stimulant drug caffeine, except in individuals who are
exquisitely sensitive to this substance.) Few, if any, people seek help to alle-
viate tobacco-related mental health problems, with the possible exception
of those embroiled in serious conflicts with significant others who strongly
disapprove of the smoking behavior, which may also be a lightning rod for
other problems in the relationship.
It is also important for our readers to know that this book focuses
primarily on the treatment of functional adults (i.e., employed or otherwise
employable adults) seeking help from private office-based psychothera-
pists. We do not address issues specific to treating adolescents, individuals
with severe debilitating mental illness, or chronically unemployed persons.
Although the presumed treatment setting for this book is private psycho-
therapy practice, the clinical strategies and techniques we describe here,
especially an unfailing emphasis on meeting patients where they are, are
adaptable to all types of clinical settings and patient populations.
Acknowledgments
I (A. M. W.) am grateful to my wife and partner in professional practice,

Dr. Lori Washton, and my son, Jacob Ian Washton, for the inspiration and
joy they bring to my life.
I (J. E. Z.) am grateful to the substance abuse treatment community, col-

leagues, and patients who have made my life’s work meaningful.
We are indebted to Jim Nageotte and Jane Keislar of The Guilford Press
for their patience, encouragement, and unfailing confidence in this update.
Without their help, it could not have been finished. Colleagues and stu-
dents have contributed through their insightful questions and challenges to
our thinking. Above all, we are deeply grateful to the countless men and
women who have come to us over almost 50 years for help with alcohol and
other drug problems. They provided the raw material for this volume and
are the primary beneficiaries of our work.
xix
Contents
PART I. BASIC ISSUES AND PERSPECTIVES
CHAPTER 1 Why Treat Alcohol and Drug Problems 3

in Psychotherapy Practice?
CHAPTER 2 Clinical Course, Definition, and Diagnosis 12

of Substance Use Disorders
CHAPTER 3 Pharmacology of Psychoactive Substances 28
CHAPTER 4 Addressing Concurrent Psychiatric and Substance Use Disorders 58
CHAPTER 5 Ingredients of the Integrated Approach: Doing What Works 72
CHAPTER 6 The Place of Evidence-Based Principles and Interventions 91
CHAPTER 7 The Role of Medication 96
PART II. CLINICAL STRATEGIES AND TECHNIQUES
CHAPTER 8 Clinical Assessment 111
CHAPTER 9 Treatment Planning: Meeting Patients Where They Are 139
xxi
xxii Contents
CHAPTER 10 Abstinence Strategies 164
CHAPTER 11 Maintaining Positive Gains 181
CHAPTER 12 Moderation and Harm Reduction Strategies 206

for Alcohol Problems
CHAPTER 13 Psychotherapy in Ongoing and Later Stage Recovery 229
CHAPTER 14 Facilitating Participation in Mutual-Help Programs 239
APPENDIX 1 New Patient Questionnaire 251
APPENDIX 2 Inventory of “Triggers” for Alcohol and Drug Use 256
APPENDIX 3 Preparing to Go Off Antabuse 257
References 259
Index 277
Purchasers of this book can download

and print the reproducible appendices at
www.guilford.com/washton3-forms for
personal use or use with patients
(see copyright page for details).
PA R T I
Basic Issues and Perspectives
CHAPTER 1
Why Treat Alcohol and Drug Problems

in Psychotherapy Practice?
A basic premise of this book is that all mental health practitio-

ners, regardless of professional discipline or specialty area, should have the
knowledge and skills to competently address alcohol and drug problems in
office-based psychotherapy practice. This premise is based on many com-
pelling reasons, not the least of which is how common substance use disor-
ders (SUDs) are among people with other mental health problems and how
much preventable human suffering can be attributed to unrecognized and
untreated SUDs. Why, then, have so many psychotherapists overlooked or
deliberately chosen not to address these highly treatable problems in their
clinical practices? The answer lies in a myriad of obstacles, past and pres-
ent, that discourage mental health therapists from including SUDs among
the behavioral disorders they routinely treat in private practice.
One such obstacle stems from a lack of formal training in this area.
A majority of mental health professionals in practice today (ourselves
included) received little if any formal training in the diagnosis and treat-
ment of SUDs during graduate school, internship, or beyond. Despite the
widespread prevalence of SUDs in all clinical populations, graduate and
postgraduate training in the mental health professions (psychology, psy-
chiatry, social work, mental health counseling, etc.) have historically failed
to provide students with specific coursework, clinical supervision, research
opportunities, and specialization tracks in this area. These training defi-
cits perpetuate the mistaken belief that SUDs represent an entirely differ-
ent type of behavioral disorder from those that psychotherapists should be
prepared to treat and that the clinical skills needed to treat these disorders
lies outside the realm of what mental health clinicians should know how
to do. Accordingly, some therapists summarily decline to treat SUDs in
3
4 BASIC ISSUES AND PERSPEC TIVES
their practices based on the mistaken belief that they are best treated by
specialist programs. This is quite unfortunate, considering that clients with
SUDs are likely to respond well to intervention by therapists with whom
they have already established good rapport and at least the beginnings of
a good working alliance. The fact is, therapists are in an excellent position
to help clients come to grips with substance use problems and develop the
motivation to address it. Even in cases in which an individual’s substance
use problem is more severe than a therapist feels adequately prepared to
deal with, it is a critically important task to help that individual to develop
a more realistic view of the problem and possible goals and strategies for
change and, if needed, to accept referral for further assessment and/or spe-
cialty treatment.
Another obstacle is a stigmatized view held by many psychotherapists
(and other health care professionals) of individuals with serious alcohol or
drug problems. Historically, substance users have been stereotyped as resis-
tant, noncompliant, impulsive, unmotivated, and unresponsive to psycho-
therapy. In addition, they are presumed to be pathological liars and socio-
paths who are difficult and frustrating to treat. These negative stereotypes
generate self-fulfilling prophecies. Clinicians not having the confidence,
interest, or skills to properly address SUDs are not likely to do well with
these clients, and they may feel frustrated or “out of their league” when
attempting to help them. These experiences serve only to confirm nega-
tive stereotyping and reduce the therapist’s motivation to treat clients with
addiction or substance use problems. Regrettably, many practitioners have
not had a chance to see that many of the behavioral problems associated
with chronic substance use often subside or cease after a period of sustained
abstinence or markedly reduced use—suggesting that in many cases these
problems are secondary to substance use and not necessarily indicative of
a personality disorder. Antisocial, narcissistic, and other serious personal-
ity traits certainly do exist among people with SUDs, but only in a small
minority of the clinical population. There is little, if any, empirical support
for the notion that a predisposing “addictive personality” is common to
all or most people who develop SUDs. To the contrary, it appears more
likely that chronic use of psychoactive substances itself induces stereotypic
distortions in behavior and personality as a result of profound biochemi-
cal changes in the brain caused by substance use itself, combined with the
extraordinary behavioral demands of maintaining an active addiction—a
socially stigmatized problem—while concealing it from others.
Another reason why therapists avoid treating SUDs is concern about
the inherent risks of taking clinical responsibility for people engaged in dan-
gerous behaviors that may cause severe crises and ominous consequences.
There is no doubt that the risk of suicide, automobile injuries or fatali-
ties, serious medical conditions, and other adverse consequences is higher
among people with SUDs. It is understandable, therefore, that practitioners
Alcohol and Drug Problems in Psychotherapy Practice 5
unaccustomed to treating SUDs would avoid dealing with these patients—

yet another reason why improving the training and education of mental
health professionals in this area is so important.
Despite these obstacles, there are many compelling reasons why psy-
chotherapists should treat SUDs routinely in their practices.
• Unmet demand for treatment. The demand for treatment of SUDs is

greater than what specialty addiction treatment programs and practitioners
alone can provide. The negative impact of untreated SUDs has been made
glaringly obvious by the current opioid crisis. Although it is neither neces-
sary nor practical for all therapists to become addiction specialists, there
are certain facts and specific skills that mental health clinicians need to
know to attain the confidence and competence they need to address alcohol
and drug problems in their practices. Providing that information is one of
the primary purposes of this book.
• SUDs are highly prevalent and destructive. SUDs are among the
most prevalent, destructive, and costly health care problems in the United
States today. As highlighted by the recent opioid crisis (Wilkerson, Kim,
Windsor, & Mareiniss, 2016), SUDs are major contributors to a wide range
of adverse consequences, including overdose deaths, drownings, suicides,
domestic violence, automobile accidents, sexual abuse, HIV-risky sexual
behaviors, psychiatric disorders, adverse interactions with medications pre-
scribed for other medical conditions, and a wide variety of serious medi-
cal problems directly caused or exacerbated by substance use (Schulden,
Thomas, & Compton, 2009). The sheer prevalence of these problems and
the avoidable suffering they cause are reason enough why therapists should
attend to them.
• SUDs are frequently intertwined with other behavioral health prob-

lems. SUDs are especially common among people seeking help for mental
health problems whether or not substance use is a presenting complaint
or the primary reason for seeking professional help (Hasin & Kilcoyne,
2012; Substance Abuse and Mental Health Services Administration, 2019).
Whether they are aware of it or not, most therapists are already treating the
problems caused or exacerbated by alcohol and drug use without directly
addressing the source of these problems.
Undiagnosed and untreated SUDs frequently diminish or completely
nullify the effectiveness of both behavioral and pharmacological treat-
ments for other MH problems. The interaction between SUDs and other
MH problems is complex, multifaceted, and not adequately understood.
Chronic use of psychoactive substances can induce psychiatric symptoms
that mimic almost any type of mental health disorder, including anxiety,
depression, and bipolar disorders, personality disorders, and psychoses. It
is equally true that MH problems contribute to the misuse of psychoactive

substances. Many people with MH problems use psychoactive substances
to “self-medicate” negative moods and dysregulated emotions. In view of
the extraordinarily high rates of comorbidity between MH and substance
abuse problems, it is advantageous for SUDs to be treated by clinicians with
advanced mental health training who can provide integrated care for both
disorders.
• Increased need for medication-assisted treatments. The increased

availability of more effective medications for treating SUDs (e.g., buprenor-
phine, naltrexone) has been accompanied by increased recognition that
pharmacotherapy alone, no matter how effective, is often not sufficient
to produce positive treatment outcomes and lasting change. No medica-
tion can teach coping skills or address co-occurring psychological, social,
and behavioral problems associated with SUDs (Avery & Barnhill, 2018).
Studies indicate that the combination of psychosocial and pharmacologi-
cal interventions (known as medication-assisted treatment [MAT]) gener-
ally works better than either one alone (Dugosh et al., 2016). Working in
collaboration with prescribing physicians, psychotherapists can do a great
deal to increase the willingness of clients to try potentially helpful medica-
tions, adhere to prescribed medication regimens, and tolerate undesirable
side effects. Furthermore, because SUDs do not develop in a vacuum but
rather in the context of an individual’s life, treatment must address the
whole person, including complex psychological issues that go beyond the
addiction itself.
• Well-trained psychotherapists are well suited for treating SUDs.

It can be argued that well-trained mental health clinicians already pos-
sess many of the essential therapeutic skills needed to treat people with
alcohol or drug problems and that the challenge for nonspecialists is to
adapt, expand, and refine their clinical skills to work more effectively with
these patients. First and foremost is therapists’ well-honed ability to forge
a positive therapeutic relationship with every client, one of the most crucial
determinants of treatment effectiveness (Gerstley et al., 1989; McLellan,
Woody, Luborsky, & Goehl, 1988). Moreover, studies show that the thera-
pist’s attitude and clinical stance toward patients matter a great deal in
treating SUDs (Miller, 1983; Miller & Rollnick, 2013). In particular, Roge-
rian qualities of therapist warmth, friendliness, nonjudgmental acceptance,
and empathy are seen as more important predictors of treatment reten-
tion and favorable outcomes than the therapist’s theoretical orientation,
treatment philosophy, or personal addiction history. Psychotherapists are
trained to be highly sensitive and responsive to individual differences. The
diversity of people with SUDs necessitates flexibility and sophistication to
accommodate wide-ranging differences. Psychotherapists are generally well
prepared to make important diagnostic distinctions and to individualize

treatment according to differing patient needs—essential ingredients for
delivering effective treatment.
Harm reduction approaches to treating SUDs (Denning & Little,
2012; Tatarsky, 2002), rooted in the principles and practices of client-cen-
tered therapy, underscore the value of therapists’ clinical skills and sensibil-
ities in treating SUDs. These include good listening skills, nonjudgmental
acceptance, meeting patients “where they are,” and a keen appreciation
for the importance of tailoring treatment to individual needs. Emphasiz-
ing the centrality of the therapeutic relationship, harm reduction empowers
behavioral health clinicians from diverse theoretical backgrounds and pro-
fessional disciplines to treat SUDs routinely in clinical practice.
• Opportunities for early intervention. Another reason why psycho-

therapists should treat SUDs is that office practitioners are in an excel-
lent position to intervene with people in the early stages of developing an
alcohol or drug problem before it becomes more severe. Therapists have a
front-row seat for identifying emerging SUDs: Mental health practitioners
probably come in contact with more people with these problems than other
health care practitioners with the possible exception of primary care phy-
sicians. Typically, by the time people seek help at an addiction treatment
program, their alcohol or drug problems have already resulted in serious
consequences that earlier intervention may have helped to truncate or avoid
altogether. Many people with substance use problems seek professional
consultation and advice from psychotherapists as a first step in trying to
decide whether their alcohol or drug use is really a problem and what course
of action, if any, to take. Individuals who do not want or need an intensive
treatment program are often good candidates for office-based treatment,
including those already in recovery who want individual psychotherapy to
help them consolidate gains and work through unresolved issues. All in all,
office practitioners are well positioned to provide attractive low-threshold
treatment for individuals who are not attracted to traditional treatment
programs or have not done well in these programs.
Psychotherapists familiar with the dynamics of addiction, as com-
pared with those who lack this familiarity, are likely to view the behavior
of patients who use substances in ways that allow them to respond more
empathetically and effectively. The patient will likely be seen not as char-
acter disordered or resistant but rather as highly ambivalent about giving
up substance use and acting out this internal struggle by giving in to strong
urges and cravings to use. The experienced therapist will acknowledge that
cravings and urges are common features of the disorder, especially in the
early stages of abstinence, and offer helpful suggestions on how to deal
with these situations. For example, the therapist may offer suggestions
about how the patient can avoid “high-risk” situations that stimulate the
desire to use and will also teach the patient ways to “surf” or ride out the
cravings without resuming use. Lapses back to substance use are less likely
to be seen as evidence of resistance, willful noncompliance, or lack of moti-
vation but rather as emanating from ambivalence and lingering attachment
to substances that are emblematic of SUDs. The inherent difficulties in
counteracting what often are physiological and psychological compulsions
to use alcohol or drugs even in the face of serious negative consequences
will also be acknowledged. Thus therapists familiar with the phenomenol-
ogy and clinical course of SUDs are able to join patients in acknowledg-
ing the struggle involved in breaking free of habitual use and to utilize
behavioral and motivational techniques to facilitate change. This stance
fosters development of a strong working alliance that is more empathic and
supportive than standard confrontational approaches and more likely to
engage and retain patients in treatment, especially during the initial phase
when dropout rates are notoriously high.
• Availability of evidence-based approaches. Another reason why

therapists should address SUDs is the recognition that these disorders
respond to many of the same behavioral interventions that are effective in
addressing other mental health problems. Psychosocial treatments with the
strongest evidence of effectiveness are familiar to most therapists, includ-
ing client-centered motivational strategies (Miller & Rollnick, 2013) and
cognitive-behavioral interventions (Marlatt & Donovan, 2005; Washton
& Zweben, 2008).
• Private practice opportunities. Office practitioners well prepared to

treat SUDs are in an excellent position to expand the range of clients they
can service in an increasingly competitive marketplace. Many people seek-
ing help for an alcohol or drug problem reject the idea of going to an inpa-
tient rehab or intensive outpatient program but more readily accept indi-
vidualized treatment in a private office. The trend in recent years toward
treating SUDs in less restrictive environments (i.e., outpatient rather than
inpatient settings) has contributed to increased demand for office-based
treatment. Some managed care plans routinely refer patients with SUDs to
private therapists instead of routing these patients to specialized addiction
treatment programs. This reflects an increasing recognition that office-
based practitioners skilled in treating SUDs can provide clinically effec-
tive and cost-effective treatment alternatives for people who do not require
intensive inpatient or outpatient treatment. Similarly, there is a growing
demand for practitioners who can not only focus on the patient’s addiction
problem but also competently address co-occurring mental health prob-
lems. Many patients are inadequately treated by clinicians able to address
mental health problems but not SUDs and by addiction counselors who can
deal with SUDs but not mental health disorders. Relatively few therapists
have the professional competence to provide integrated treatment for both

types of disorders.
• Personal and professional gratification. Last, but certainly not

least, among the reasons why psychotherapists should address SUDs is that
working with these patients is extremely gratifying. It is very rewarding
to assist patients in liberating themselves from compulsive substance use
and its consequences. Contrary to popular stereotypes, people with alcohol
or drug problems often are not difficult to treat, and many show rapid,
observable, and rather dramatic improvement in a relatively short time.
There is no way of knowing just how profoundly substance use is affecting
a person’s functioning until the use is substantially reduced or completely
stopped. Positive changes often become evident almost immediately in the
days and weeks after the cycle of harmful alcohol or drug use is broken.
These changes include improvements in physical health and fitness, family
and other interpersonal relationships, work productivity and satisfaction,
self-esteem, and overall quality of life.
Both of us have chosen to work as specialists in this field, but it is prob-
ably more accurate to say that this field chose us. Like most other mental
health professionals, neither of us was formally trained in this area and
did not go into clinical practice with the intention of becoming addiction
specialists. It is the exhilarating experience of participating in the personal
transformation of our patients and the profound sense of both professional
and personal gratification we derive from doing so that originally moti-
vated us to enter in this field over four decades ago and continues to moti-
vate us today.
Unique Benefits of Office-Based Treatment
As compared with other modalities of treatment, such as inpatient rehab or

intensive outpatient programs, office-based treatment offers several unique
advantages.
• Lower entry threshold. Office-based treatment eliminates some of

the entry barriers that discourage many people from considering or accept-
ing treatment. It is up to the practitioner, of course, to skillfully seize the
moment by making maximum use of an opportunity to intervene proac-
tively. As stated earlier, as compared with outpatient treatment programs,
office-based treatment attracts many individuals who do not need or want
what conventional programs typically offer. This includes people in the
early stages of developing a problem, as well as those in the early stages
of acknowledging that the problem is serious enough to warrant clinical
attention. It stands to reason that people who do not acknowledge the true
nature or extent of a substance use problem are not likely to seek help for
it. Countless patients in therapy for other behavioral health problems could
be spared much pain and suffering by therapists who have the clinical skills
to intervene appropriately. Many people with alcohol or drug problems
seek professional evaluation and guidance from psychotherapists to find
out whether their alcohol or drug use is really a problem and what type of
treatment, if any, might be best.
• Access to flexible, individualized care. Office-based therapy adds

flexibility and choice to the menu of treatment options for people with
alcohol and drug problems. Accordingly, treatment can be more precisely
matched to address the specific needs of each individual. Private practitio-
ners are not constrained by agency policies and procedures or by institu-
tional control over treatment philosophy and approach. There are no rules
dictating which patients are admitted into treatment and how treatment
should be done. Practitioners have the freedom and flexibility to offer treat-
ment that meets patients where they are instead of requiring them to com-
ply with a preformulated treatment program.
• Provides an alternative, supplement, or sequel to addiction treat-

ment programs. Psychotherapists who treat SUDs are in a unique position to
offer effective alternatives to mainstream addiction treatment programs for
people who do not want or need what these programs typically offer. Some
traditional treatment programs based on the 12-step program of Alcohol-
ics Anonymous (AA) may alienate people in the early stages of addressing
an alcohol or drug problem with a dogmatic approach that advocates total
abstinence from all substances and frequent attendance at AA meetings.
Clients who do not accept this approach without challenge are often told
that they are “in denial.” Some patients readily accept the 12-step approach
and make good use of it (which we wholly support), but others are turned
off by the dogma and refuse to embrace the idea that there is only one effec-
tive path to recovery for everyone. One of the most important functions of
office-based treatment is to offer an alternative path. Office practitioners
have a unique opportunity and a clinical responsibility to offer flexible
individualized treatment that opens the doors for people who do not want
or need to be treated in traditional programs. The critical importance of
working through, joining, or temporarily sidestepping client resistance is
something that every psychotherapist appreciates.
Office-based therapy can serve not only as an alternative but also as a
supplement to other forms of treatment. For example, many people involved
in AA or other self-help programs seek help from psychotherapists when
they encounter psychological or emotional problems that these programs
cannot adequately address. Similarly, many involved in addiction treatment
programs may benefit from concurrent individual therapy that supports,
amplifies, and extends the therapeutic work being done in an outpatient

recovery group and increases treatment retention. Office-based therapy is
often an important component of aftercare treatment for patients who have
completed a structured inpatient or outpatient program and want the help
of a professional psychotherapist who knows how to deal with psychologi-
cal and emotional issues often intertwined with SUDs.
Final Comment
There are many compelling reasons why all psychotherapists should become
proficient in addressing SUDs, regardless of patients’ presenting com-
plaints. Considering the extraordinarily high rates of comorbidity between
SUDs and other mental health problems and the serious consequences that
can ensue if both problems are not adequately addressed, all practitioners
should know how to assess, treat, and properly refer patients with alcohol
and drug problems and should do so routinely in their practices. Office-
based treatment fills important gaps in the continuum of care for SUDs and
provides treatment options not currently available in the existing treatment
system. Treating patients with SUDs in office practice can be extremely
rewarding, both personally and professionally.
CHAPTER 2
Clinical Course, Definition, and Diagnosis

of Substance Use Disorders
A lthough there is a long tradition of thinking about alcohol and

drug problems in binary or “black-and-white” terms (i.e., addiction is seen
as either present or absent with no in-between), the current trend is to view
substance use problems on a continuum that varies along multiple dimen-
sions in a given individual, as reflected most notably in the revised diag-
nostic schema presented in DSM-5 (described later in this chapter). These
dimensions include, for example, the frequency, intensity, and pattern of
a person’s use, as well as the severity of substance-related medical, behav-
ioral, and psychosocial consequences.
There is also recognition that some patterns of substance use are not
pathological or problematic, defined mainly by the absence of apparent
harm or dysfunction associated with the use. For example, among the alco-
hol use categories defined by the National Institute on Alcohol Abuse and
Alcoholism (NIAAA, 2000), “low-risk drinking” connotes a level of alco-
hol consumption not likely to cause dysfunction or medical harm, based
on actuarial statistics regarding the likelihood of experiencing various
consequences at increasing levels of alcohol consumption. Keep in mind,
however, that no level of substance use is entirely harmless and safe. Unex-
pected adverse reactions and other consequences are always possible. And
the powerful reinforcing and other brain-modifying effects of psychoactive
substances can set in motion a gravitational pull toward more regular and
compulsive use, especially in vulnerable users.
Etiological and Risk Factors
SUDs are complex conditions with complex etiologies that must be under-
stood from a variety of perspectives. A nuanced understanding of the
12
Clinical Course, Definition, and Diagnosis of SUDs 13
nature and developmental course of these disorders can help to determine

whether clinical intervention may be indicated and, if so, what kind. It is
important for all therapists to be familiar with etiological factors that can
influence the clinical course of SUDs and with the diagnostic criteria that
define these disorders.
Addiction specialists view SUDs as conditions generated by complex
interactions between biological, psychological, and social factors present to
varying degrees in each person. Biological factors include the unique phar-
macological properties of the drugs themselves, as well as individual differ-
ences in how a person’s brain responds to various psychoactive substances
based on factors such as gender, age, and genetic heritage. Psychological
factors include the full spectrum of mental and emotional difficulties, as
well as cognitive and behavioral problems that elevate risk or provide resil-
iency. Social factors include variables such as socioeconomic status, the
prevalence of heavy drinking in certain peer groups and subcultures, and
religious/cultural prohibitions against using or overusing certain psychoac-
tive substances.
Many models and theories have been used to define and treat SUDs,
each shedding light on certain dimensions of the problem (Margolis & Zwe-
ben, 1998). Different factors come into play, for example, in the initiation of
substance use as compared with the progression to more serious problems.
Expectancies about the positive effects of substances develop through peer
influence, adult role models, and the mass media. These expectations can
shape the actual alcohol or drug experience during initial use when doses
are relatively modest. For example, research has demonstrated that study
participants given a placebo drink (not containing alcohol) and placed in a
party atmosphere report having just as pleasant a time as those who actu-
ally consumed alcohol (Marlatt, 1985; Yalisove, 2004). If influential peer
groups reinforce the desirability of drinking or taking drugs, then occa-
sional use may evolve into more regular or intensive use. Drinking alcohol
or using other drugs thus becomes part of an inclusion requirement—the
price of membership. Although adolescents are particularly susceptible to
these pressures, adults are by no means immune.
Once alcohol and drug use begins, other factors influence the transition
from occasional use to problematic use. A large body of literature documents
the influence of genetic predisposition to developing problems with alcohol
and other drugs, although genetics alone can never fully explain addiction
vulnerability (Bierut et al., 1998; Kendler & Prescott, 1998; Pickens, 1997;
Pickens et al., 2001; Saxon, Oreskovich, & Brkanac, 2005; Schuckit, 1989;
Schuckit & Smith, 1996; Tsuang et al., 1998; Vanyukov & Tarter, 2000).
Genetic and environmental factors have differing levels of influence for dif-
ferent types of drugs. For example, genetic factors that influence vulnerabil-
ity to alcohol dependence are thought to be somewhat different from those
influencing vulnerability to cocaine or opioid addiction. Genetic factors are
thought to increase individual vulnerability by shaping individual differences

in how psychoactive substances affect an individual’s brain and behavior.
Mediating factors may include aspects of an individual’s metabolism, sensi-
tivity to particular drug effects, level of tolerance to drug effects, and neuro-
logical differences. In some individuals, alcohol is an extremely potent rein-
forcer, capable of alleviating stress, depression, and anxiety. Progression to
serious problems is also influenced by biological factors. Women have higher
morbidity and mortality with lower levels of alcohol consumption than men,
owing to differences in absorption, distribution, and elimination. Although
women have been less likely than men to drink heavily or even moderately,
they are more vulnerable to alcohol-related liver damage, cardiovascular dis-
ease, and brain damage. Women may also be more susceptible to alcohol’s
negative effects on cognitive functions such as attention and memory (Zwe-
ben, 2019). Therapists should keep in mind that women who drink heavily
have a more rapid downhill course, pointing to the need for more vigorous
early intervention.
Late Onset of Detectable Signs and Symptoms
Patients who seek private office-based psychotherapy are often (but not
always) functional enough that symptoms of serious substance use prob-
lems are not readily apparent. Consider the following case:
James is an astute businessman whose vision and judgment allowed

him to build a highly successful company. Charming and gregarious,
he was sought after in many business-related social gatherings, where
alcohol was plentiful. He was a driven achiever and had great diffi-
culty unwinding after he finally left his office at the end of the day. His
alcohol consumption increased slowly over time until he was consum-
ing substantial amounts daily. He consumed a before-dinner drink, a
nightly bottle of wine with dinner, and an aperitif with dessert. High
levels of drinking were normal in his business subculture, and he never
appeared intoxicated, so his drinking behavior passed unnoticed.
His frequent brief affairs had disrupted his marriage, and he sought
therapy to clarify whether to seek a divorce. A medical checkup for
gastric distress revealed elevated liver enzymes and slight gastrointes-
tinal bleeding, both related to alcohol. Upon the advice of his physi-
cian, he decided to discontinue drinking and was astonished to find
himself struggling to accomplish this. His withdrawal symptoms were
sufficient to require medication, and he was chagrined that the type of
discipline he applied to his work life was not enough to keep him from
drinking. His therapist was able to offer behavioral strategies to estab-
lish and consolidate abstinence. This allowed James and his therapist
to work on other issues more productively.
Drinkers like James may appear to function well for a long time; then,
at some point, the cumulative effect of drinking results in what appears
to be a sudden onset of difficulties. At that point, other alcohol-related
manifestations, such as irritability, short-temperedness, silent withdrawal,
sexual indiscretions, or other interpersonal difficulties, can be examined
in a new light. You can reframe the patient’s unexpected struggle to stop
as a valuable learning experience about how easy it is to underestimate the
power of alcohol.
Unpredictable Course: Progression Is Not Inevitable
By the time an individual seeks specialized treatment for an alcohol or drug

problem, it is likely that the severity of the problem has progressed over
time. This can create a mistaken impression that progression from a less
severe to a more severe problem is inevitable, which is not the case. Special-
ist providers see a skewed sample of people that leans toward those with
more SUDs, but they do not draw sweeping conclusions about the nature
of SUDs as seen from this vantage point. Clinical experience, studies of
natural (untreated) recovery, and long-term prospective studies indicate
that there are subgroups of people who use alcohol and drugs to varying
degrees at different stages of their lives. Excessive or problematic use at one
point in an individual’s life is not necessarily predictive of progression to
a more serious problem at a later point in life. Researchers have long rec-
ognized that it is necessary to understand the natural history and course
of a disorder in order to determine to what extent clinical intervention is
indicated. Generalizations based only on clinical populations are inher-
ently skewed and not representative of the entire population of people in
society who have ever experienced significant substance use problems. A
50-year prospective study documented a subgroup that continued alcohol
abuse for decades without either remission or progression to more severe
symptoms (Vaillant, 1995). This study followed a college sample and a
working-class, core city sample from the Boston area. Findings supported
the view that social class is an important mitigating factor in developing
more serious problems. The working-class sample had significantly higher
rates of both death and complete abstinence from alcohol than the group
with greater social advantages. The middle-class college sample contained
more than twice as many who continued to abuse alcohol without signifi-
cant progression. Though your patient may never meet the criteria for a
full-blown SUD, this does not mean that the consequences are unimportant
for your therapeutic goals. Although the substance abuse pattern may be
stable, it may nonetheless undermine your patient’s quality of life and abil-
ity to make use of resources.
Recovery without Treatment
Although clinician intervention is a powerful catalyst for change, remem-

ber that recovery from serious alcohol and drug problems can occur with-
out formal treatment (Biernacki, 1986; Sobell, Ellingstad, & Sobell, 2000).
Studies of natural or untreated recovery, though relatively few and meth-
odologically limited, highlight some of the important factors that allow
people to overcome problems with alcohol and drugs. Both clinical and
nonclinical populations reported similar types of consequences that led
them to decide to change their substance use behaviors—increasing dys-
phoria, emotional distress, loss of important relationships, loss of jobs,
interference with performance, health problems, financial problems, and
legal problems. The most important factor cited as promoting success in
“natural recovery” is a supportive social environment that includes family
and significant others. Other influences include changes in work and gen-
eral lifestyle, changes in living arrangements, and involvement in religion.
Interestingly, many of the same factors have been identified as contribut-
ing to positive outcomes in addiction treatment programs. It has also been
observed that many individuals change their patterns of alcohol and drug
use as part of a more global “maturing out” process (Peele & Brodsky,
1991) that involves assuming new responsibilities, entering a new stage of
development in the life cycle, changing peer groups, and/or developing a
new set of values that excludes or competes with substance use.
Favorable Prognosis with Appropriate Treatment
Stigma and stereotypes have conveyed the mistaken assumption that people
with serious substance use problems are fundamentally untreatable. This
is far from the case. Those with mild to moderate problems often respond
well to brief interventions. Many have been contemplating the prospect
of change for a long while, and a brief conversation with recommenda-
tions from a therapist or physician is sometimes all it takes to initiate a
meaningful change process. Other patients may balk initially, then revise
their views and commitments as they continue to engage in a process of
self-examination.
A therapist working with visualizations noted that a patient had

unusual difficulty sustaining attention to the imagery and suggested
that marijuana use could be a contributing factor. The patient agreed
to experiment with discontinuing the marijuana, and after several
months he exhibited more normal powers of concentration. He was
surprised at the changes he noticed and decided to extend his commit-
ment to abstinence indefinitely.
Results with severely addicted populations also yield reasonably good

results if treatment is sufficiently comprehensive to address not only the
substance use itself but also the risk factors that undermine stable recovery.
Treatment of substance abuse has been compared with treatment for dia-
betes, asthma, and hypertension, three chronic relapsing medical disorders
that evoke very different attitudes from treatment providers but have com-
parable outcomes (McLellan, Lewis, O’Brien, & Kleber, 2000).
Improvement rates are similar across all four disorders and depend
heavily on patient adherence to specific treatment recommendations. Low
adherence results from a variety of factors: poor social support, psychi-
atric comorbidity, and poverty. If substance abuse is viewed as a chronic,
relapsing disorder, then it is unrealistic to expect a single treatment episode
to result in lifelong recovery or a cure for most people. It is possible that
individuals will require additional treatment, as in the case of those with
diabetes, who may repeatedly lapse in and out of managing their disease
properly. Treatment for an alcohol or drug problem can be intensive, such
as inpatient or residential treatment, or can consist of a continuum of out-
patient interventions fading in intensity as the patient progresses. Recovery
maintenance can occur in the mutual-help system (or self-help, discussed in
more detail in Chapter 14) without much costly treatment intervention. In
all four disorders, lifestyle changes are among the most important and the
key to achieving positive results over the long term.
Interaction with Other Mental Health Problems
Epidemiological studies have established that co-occurring disorders are

the norm, not the exception, among people with SUDs, and, accordingly,
treatment for SUDs must address these co-occurring problems. General
psychotherapists are usually well equipped to address the mental health dis-
orders but may need to enhance their knowledge base and clinical skills to
provide integrated treatment that addresses both substance use and mental
health problems. Substance use can exacerbate or obscure symptoms, lead
to earlier onset of serious disorders, and promote premature termination or
failure to progress in treatment. For these reasons, the office-based practi-
tioner is well advised to invest the time needed to become more proficient
in addressing SUDs.
Historically, substance abuse problems were viewed as manifestations
of an “underlying” disorder and were presumed to resolve once the “pri-
mary” disorder was addressed. This view produced a sizable cohort of treat-
ment failures and embittered many patients who lost decades of their lives
despite having sought help from professionals. The recovering community
developed an intense distrust of professionals. This distrust has dissipated
as mental health professionals have become more competent in addressing
SUDs and as people in recovery from addiction receive effective treatment

from mental health clinicians for co-occurring problems. However, one
legacy is the idea that the SUD must be treated first and other issues put on
hold until abstinence is firmly established. This was an appealing idea, but
it proved to be impractical. It became apparent that many people could not
make stable gains unless their other problems were effectively addressed,
and sequential treatment was ineffective for many. Clinicians have been
working on principles of integrated treatment, and the research literature
documents growing success with complicated populations, including those
with severe mental illness. In these models, issues of safety take priority,
no matter what the source of danger. Interventions to promote stabilization
address substance use issues, other psychiatric issues, medical problems,
domestic violence, and any other conditions that may interfere with initiat-
ing or sustaining recovery. The priorities for a patient are determined by an
individualized treatment plan.
SUDs Are Primary Disorders
A key to treating SUDs successfully is to approach them as independent

disorders with a life of their own, whether or not they are intertwined with
other mental health problems. Although many therapists can cite individual
examples of successfully addressing SUDs in psychodynamic therapy, there
are no systematic studies confirming the efficacy of nonspecific treatments
(e.g., psychodynamic psychotherapy) for SUDs. Patients present with mood
and anxiety disorders and relationship problems, believing their substance
use helps them cope with their difficulties. It is always possible to make
the case that the patient is engaged in some form of self-medication for
problems related to self-regulation deficits, overwhelming and disruptive
affects, the residue of previous traumas, and other unresolved emotional or
psychological issues (Khantzian, 1997; Khantzian, Halliday, & McAuliffe,
1990; Krystal, 1988). There is often some truth in such assertions. The
related assumption—that the substance use behavior would change once
the “underlying” issues were addressed—allowed patients to remain in
therapy for years, if not decades, without either the therapist or the patient
addressing their behavior. In retrospect, it is remarkable how long thera-
pists persisted in this approach despite its inadequacies. The absence of
systematic follow-up contributed to perpetuating this blind spot.
The view of SUDs as independent and often co-occurring conditions
has allowed for the development of specialized treatment approaches that
have, in turn, improved the effectiveness of psychotherapy. Substance use
functions as a “wild card” that promotes early dropout from psychotherapy
and undermines therapeutic progress if the patient does remain in treat-
ment. However, SUDs are often intertwined with predisposing, concurrent,
or resulting mental health problems. As such, they complicate the assess-

ment and treatment of other disorders. Designating SUDs as primary dis-
orders does not mean that you should postpone addressing other issues
until the substance use problem is resolved. In an integrative approach, you
must consider how various conditions interact and how to prioritize treat-
ment tasks appropriately. An extensive literature on co-occurring disorders
examines how best to address the challenges of specific combinations of
disorders (Miller, Fiellin, Rosenthal, & Saitz, 2019). In general, clinicians
need to focus first on safety, next on initial behavior change and stabiliza-
tion, and then on maintenance of gains and/or ways to make progress.
Addiction as a Biopsychosocial Disorder
A major challenge for the office-based practitioner is to appreciate the bio-

logical, psychological, and social factors involved in the initiation, progres-
sion, and maintenance of SUDs. Most specialists conceptualize problems
in terms of their own theoretical orientation and clinical experience, but an
integrated model requires the flexibility to shift perspectives.
A growing literature documents the many ways in which addiction
is a complex brain disease. Predisposing characteristics can set the stage
for future problems, as in the case of the individual who has endorphin
deficiency long before using any opioid substances. An individual with a
predisposition is more likely to develop problems because certain drugs are
dramatically more rewarding. Continuing drug use changes the brain in
ways that may not normalize immediately, if at all, upon cessation of drug
use. These changes are thought to contribute to persistent vulnerability to
relapse in all stages of recovery, even well after drug taking has ceased.
In current models, chronic drug use brings a cycle of spiraling dysregula-
tion of the brain’s reward systems, progressively increasing, and eventually
resulting in loss of control over drug taking and compulsive use. In time,
this process changes the reward set point in the brain, resulting in a con-
tinuous relapse vulnerability that remains high even though the patient is
abstinent (Koob, 2000; Koob & Le Moal, 2001). Research on the brain
supports the disease model first proposed by Jellinek (1960) more than 60
years ago.
The disease model is a component or centerpiece of many addiction
treatment programs in the United States, but, regrettably, this model has
been misinterpreted, misused, and misapplied. An essential tenet of the dis-
ease model, first developed in relation to a subtype of alcoholism and later
applied to drug abuse, is that individuals who have crossed the line from
controlled to uncontrolled use can never return to reliably controlled use.
In other words, it’s a one-way street. Thus the remedy (not the cure) for
alcoholism is abstinence. Jellinek (1960) and subsequent proponents of the
disease model of alcoholism noted that there is no cure for this condition;
however, it can be effectively held in remission by refraining from use. A
corollary is that abstinence from all intoxicants is required. There are two
main reasons for this. The first is the likelihood of drug substitution. For
example, it is common for cocaine or heroin users who have ceased using
opioids to escalate their alcohol consumption, often requiring treatment.
However, problems with alcohol may escalate slowly, leading the patient
to underestimate the connection. The second reason poses more complex
clinical challenges. It appears that the use of any intoxicant may stimulate
hunger for the primary drug of abuse. Use of the primary drug may occur
immediately, or even weeks or months later. For example, both clinical
experience and the empirical literature document the frequency of signifi-
cantly higher relapse rates to stimulant drugs (cocaine and methamphet-
amine) in individuals who continue to smoke marijuana or drink alcohol.
The fact that the return to using stimulant drugs may not occur immedi-
ately after using substances makes it more difficult for these individuals to
perceive the connection between these events.
A key principle in working with SUDs is that patients are likely to
connect immediate consequences with their substance use much more read-
ily than they do consequences that unfold over time. Thus cocaine users
will readily acknowledge that, if they are in a bar drinking and someone
offers them cocaine, their ability to resist temptation and decline the offer
is severely compromised. What appears harder to integrate is that the beer
today could be a harbinger of the cocaine relapse several weeks from now.
Even the patient who has repeated this cycle numerous times may continue
to defend drinking because “alcohol wasn’t a problem before I started using
cocaine.” Recent work on the neurobiology of craving offers one level of
explanation for such phenomena. Once the reward pathways are stimulated
by any psychoactive substance, the person is more likely to be drawn back
into using their primary drug of abuse.
In the biopsychosocial model, behavior is a major focus, especially in
early recovery. By avoiding the first drink or drug use, the patient avoids
setting in motion the cycle of events that lead to compulsive use. Behav-
ioral interventions assist the patient to change course while choice is still
possible and behavior is still voluntary. Various cognitive-behavioral mod-
els address motivation, commitment to abstinence, identifying necessary
psychological and lifestyle changes, and relapse prevention (Carroll, 1999;
Carroll, Libby, Sheehan, & Hyland, 2001; Kadden et al., 1995; Matrix
Center 1995, 1997, 1999a, 1999b). These are based in part on the premise
that feelings, thoughts, and behaviors interact with the effects of psychoac-
tive drugs on brain chemistry to initiate and maintain compulsive behav-
iors.
The development of the disease model was a landmark event in the his-
tory of treatment, because it provided the framework to move alcoholism
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succession is usually both short and simple, mesophytes giving place
to amphibious and ultimately to aquatic forms.
303. Successions in landslips. Landslips occur only in
montane and hilly regions, and here they are merely of local
importance. In many respects, they are not unlike talus; they show
essential differences, however, in that they are not sorted by gravity,
and in that they destroy vegetation almost instantly. The succession
arises as a rule, not upon the original soil, but upon that of the
landslip, and, as pointed out elsewhere, might well be regarded as
primary.
304. Succession in drained, or dried soils. In geological
times, the subsidence of barriers must often have produced drainage
and drying-out, just as elevation frequently resulted in flooding and
lake formation. At the present time, the drying-out of lakes and
ponds is the result of artificial drainage, or of climatic changes. The
former will be considered under successions brought about by the
agency of man. Climatic changes when general operate so slowly that
the stages of such successions are perceptible only when recorded in
strata. More locally, climate swings back and forth through a period
of years, with the result that in dry years the swamps and ponds of
wetter seasons are dried out, and the vegetation destroyed or
changed. If the process be gradual, the succession passes from
hydrophytic through amphibious to mesophytic, and, in dry regions,
xerophytic conditions. When the process of drying-out occurs
rapidly, as in a single summer, the original formation is destroyed,
and the new vegetation consists largely of ruderal plants. A peculiar
effect of climate occurs in regions with poor drainage, where the
result of intense evaporation is to produce alkaline basins and salt
lakes, in which the succession becomes more and more open, and is
finally represented by a few stabilized halophytes, or disappears
completely.
Fig. 63. A typical gravel slide (talus) of the Rocky mountains, before invasion.
305. Succession by animal agency. Successions of this class

are altogether of secondary importance, the instances in which
animals produce denudation being relatively few. Such are the heaps
of dirt thrown up by prairie dogs and other burrowing animals, upon
which ruderal plants are first established, to be finally crowded out
by the species of the original formation. Buffalo wallows furnish
examples of similar successions in which the initial stages are
subruderal, while overstocking and overgrazing frequently produce
the same result with ruderal plants.
306. Succession by human agency. The activities of man in
changing the surface of the earth are so diverse that it is impossible
to fit the resulting successions in a natural system. While man does
not exactly make new soils, he exposes soils in various operations:
mining, irrigation, railroad building, etc. He destroys vegetation by
fires, lumbering, cultivation, and drainage, and if he can not control
climate, he at least modifies its natural effects by irrigation and the
conservation of moisture. The operations of man extend from
seacoasts and swampy lowlands through mesophytic forests and
prairies to the driest uplands and inlands. Since the adjacent
formations determine in large degree the course and constitution of a
succession, it will be seen that the effects of any particular activity
upon vegetation will differ greatly in different regions. For
convenience, all classes of successions arising from the presence and
activity of man will be considered in this place, though, as indicated
above, some might well be regarded as producing primary
successions, while others produce anomalous ones.
307. Succession in burned areas. It will suffice merely to
point out that “burns” may arise naturally through lightning,
volcanic cinders, lava flows, etc., but the chances are so slight that
these causes may be ignored. The causes of fires are legion, and as
they have little or no effect upon results, they need not be
considered. From their nature, fires are of little significance in open
vegetation, deserts, polar barrens, alpine fields, etc., since the area of
the burn can never be large. In closed formations, the extent of fires
is limited only by the area of the vegetation, and the effect of wind,
rain, and other forces. Forest fires usually occur during the resting
period, except in the case of coniferous forests. In grassland, the
living parts are underground during autumn and winter, when
prairie fires commonly occur. As a consequence, the repeated annual
burning of meadow or prairie does not result in denudation and
subsequent succession. On the contrary, it acts in part as a stabilizing
agent, inasmuch as it injures the typical vegetation forms of
grassland much less than it does the woody invaders. All formations
with perennial parts above ground, viz., thicket, open woodland, and
forest, are seriously injured by fire. A severe general fire destroys the
vegetation completely; a local fire destroys the formation in
restricted areas; while a slight or superficial burn removes the
undergrowth and hastens the disappearance of the weaker trees. In
the latter case, while the primary layer of the forest remains the
same, succession takes place in the herbaceous and shrubby layers.
These successions are peculiar in that they are composed almost
wholly of the proper species of the forest, and that they are very
short, showing only a few poorly defined stages. A local fire initiates
a succession in which the pioneers are derived largely from the
original formation, particularly when the latter encloses the burned
area more or less completely. The constitution of the intermediate
and ultimate stages will depend in a larger degree still upon the size
and position of the burn. When a particular formation is destroyed
wholly or in large part, the first stages of the new vegetation are
made up by invaders from the adjacent formations. In the most
perfect types of succession, this dissimilarity between the new and
the old vegetation continues to the last stage, in which the
reappearance of the facies precedes that of the subordinate layers. In
many forest successions, however, the general physical similarity of
the ultimate stages permits the early reappearance of the herbaceous
and shrubby species, and the final stages affect the facies alone.
Successions in burned areas operate usually within the water-content
groups. The reconstruction of a mesophytic forest takes place by
means of mesophytes; of the rarer xerophytic and hydrophytic
forests, through xerophytes and hydrophytes respectively. This is due
to the fact that the alteration of the soil is slight, except where the
burning of the vegetation permits the entrance of erosion, as on
mountain slopes.
Fig. 64. Gravel slide formation (Pseudocymopterus-Mentzelia-chalicium), stage III
of the talus succession.
308. Succession in lumbered areas. Commercial lumbering,

especially where practiced for wood-pulp as well as for timber,
results in complete or nearly complete destruction of the vegetation
by removal and the change from diffuse light to sunlight, or by the
action of erosion upon the exposed surface. In the first place, short
mesophytic successions will result; in the second, the successions
will be long and complex, passing through decreasingly xerophytic
conditions to a stable mesophytic forest. Where a forest is cut over
for certain species alone, the undisturbed trees soon take full
possession, though the causes effective in the beginning will
ultimately restore the original facies in many instances. Such
successions are anomalous, and will be treated under that head.
309. Succession by cultivation. The clearing of forests and the
“breaking” of grassland for cultivation destroy the original
vegetation; the temporary or permanent abandonment of cultivated
fields then permits the entrance of ruderal species, which are the
pioneers of new successions. This phenomenon takes place annually
in fields after harvest, resulting in the secondary formations of
Warming, in which practically the same species reappear year after
year. In fields that lie fallow for several years, or are permanently
abandoned, the first ruderal plants are displaced by newcomers, or
certain of them become dominant at the expense of others. In a few
years, these are crowded out by invaders from the adjacent
formations, and the field is ultimately reclaimed by the original
vegetation, unless this has entirely disappeared from the region. The
number of stages depends chiefly upon whether the final formation
is to be grassland or woodland. Other activities of man, such as the
construction of buildings, roads, railways, canals, etc., remove the
native vegetation, and make room for the rapid development of
ruderal formations. In and about cities, where the original
formations have entirely disappeared, the chance for succession is
remote, and the initial ruderal stages become more or less stabilized.
Elsewhere the usual successions are established, and the ruderal
formation finally gives way to the dominant type. In mountain and
desert regions, where ruderal plants are rare or lacking, their place is
taken by subruderal forms, species of the native vegetation capable
of rapid movement in them. These, like ruderal plants, are gradually
replaced by other native species of less mobility, but of greater
persistence, resulting in a short succession operating often within a
single formation. From the nature of cultivated plants, succession
after cultivation generally operates within the mesophytic series.
310. Succession by drainage. Successions of this kind show
much the same stages as are found in those due to flooding. They
proceed from aquatic or swamp formations to mesophytic termini,
either grassland or woodland. When drainage takes place rapidly and
completely, the pioneer stages are usually xerophytic; cases of this
sort, however, are infrequent.
311. Succession by irrigation. Irrigation produces short
successions of peculiar stamp along the courses of irrigating canals
and ditches, and in the vicinity of reservoirs. These are recent, as a
rule, and are usually found in the midst of cultivated lands, so that
their complete history is still a matter of conjecture. The original
xerophytes are forced out not only by the disturbance of the soil, but
also by its increased water-content. A few of them often thrive under
the new conditions, and, together with the usual ruderal plants and a
large number of lowland mesophytes and amphibious forms derived
from the banks of the parent stream, constitute a heterogeneous
association. This is doubtless to be regarded as an initial stage of a
succession, but it is an open question whether the succession will
early be stabilized as a new formation, or whether the original
vegetation will sooner or later be reestablished under somewhat
mesophytic conditions. From the number of mesophytes and from
the behavior of valleys, it seems certain that the banks of such canals
will ultimately be occupied by a formation more mesophytic than
hydrophytic, into which some of the surrounding xerophytes of
plastic nature have been adopted.
312. Anomalous successions are those in which the physical
change in the habitat is relatively slight, resulting in a displacement
of the ultimate stage, or the disturbance of the usual sequence,
merely, instead of the destruction and reconstruction of a formation,
or the gradual development of a new series of stages on new soil. In
nature, the ultimate grass or forest stage of a normal succession is
often replaced by a similar formation, especially if the facies be few
or single. It is evident that certain trees naturally replace others in
the last stages of a forest succession, without making the latter
anomalous. The last occurs only when a normal stage is replaced by
one belonging properly to an entirely different succession, as when a
coniferous forest replaces a deciduous one in a hardwood region. The
presence and development of such successions can be determined
only after the normal types are known. The interpolation of a foreign
stage in a natural succession, or a change of direction, by which a
succession that is mesotropic again becomes hydrophytic, is easily
explained when it is the result of artificial agents, as is often the case.
In nature, anomalous successions are commonly the result of a slow
backward and forward swing of climatic conditions.
313. Perfect and imperfect successions. A normal succession
will regularly be perfect; it passes in the usual sequence from initial
to ultimate conditions without interruption or omission. Imperfect
succession results when one or more of the ordinary stages is
omitted anywhere in the course, and a later stage appears before its
turn. It will occur at any time when a new or denuded habitat
becomes so surrounded by other vegetation that the formations
which usually furnish the next invaders are unable to do so, or when
the abundance and mobility of certain species enable them to take
possession before their proper turn, and to the exclusion of the
regular stage. Incomplete successions are of great significance,
inasmuch as they indicate that the stages of a succession are often
due more to biological than to physical causes, the proximity and
mobility of the adjacent species being more determinative than the
physical factors. Subalpine gravel slides regularly pass through the
rosette, mat, turf, thicket, woodland, and forest stages; occasionally,
however, they pass immediately from the rosette, or mat condition,
to an aspen thicket which represents the next to the last stage. Such
successions are by no means infrequent in hilly and montane
regions; in regions physiographically more mature or stable, perfect
successions are almost invariably the rule.
Fig. 65. Half gravel slide formation (Elymus-Muhlenbergia-chalicium), stage IV of
the talus succession.
314. Stabilization. It may be stated as a general principle that

vegetation moves constantly and gradually toward stabilization. Each
successive stage modifies the physical factors, and dominates the
habitat more and more, in such a way that the latter seems to
respond to the formation rather than this to the habitat. The more
advanced the succession, i. e., the degree of stabilization, the greater
the climatic or physiographic change necessary to disturb it, with the
result that such disturbances are much more frequent in the earlier
stages than in the later development. Constant, gradual movement
toward a stable formation is characteristic of continuous succession.
Contrasted with this is intermittent succession, in which the
succession swings for a time in one direction, from xerophytic to
mesophytic for example, and then moves in the opposite direction,
often passing through the same stages. This phenomenon usually is
characteristic only of the less stable stages, and is generally produced
by a climatic swing, in which a series of hot or dry years is followed
by one of cold or wet years, or the reverse. The same effect upon a
vast scale is produced by alternate elevation and subsidence, but
these operate through such great periods of time that one can not
trace, but can only conjecture their effects. A normal continuous
succession frequently changes its direction of movement, or its type,
in transition regions or in areas where the outposts of a new flora are
rapidly advancing, as in wide mesophytic valleys that run down into
or traverse plains. Here the change is often sudden, and grass and
desert formations are replaced by thickets and forests, resulting in
abrupt succession. Species guilds are typical examples of this. More
rarely, a stage foreign to the succession will be interpolated,
replacing a normal stage, or slipping in between two such, though
finally disappearing before the next regular formation. This may be
distinguished as interpolated succession.
The apparent terminus of all stabilization is the forest, on account
of the thoroughness with which it controls the habitat. A close
examination of vegetation, however, will show that its stable terms
are dependent in the first degree upon the character of the region in
which the formation is indigenous. It is obviously impossible that
successions in desert lands, in polar barrens, or upon alpine
stretches should terminate in forest stages. In these, grassland must
be the ultimate condition, except in those extreme habitats, alpine
and polar, where mosses and lichens represent the highest type of
existing vegetation. Forests are ultimate for all successions in
habitats belonging to a region generally wooded, while grassland
represents the terminus of prairie and plains successions as well as
of many arctic-alpine ones.
CAUSES AND REACTIONS
315. The initial cause of a succession must be sought in a physical

change in the habitat; its continuance depends upon the reaction
which each stage of vegetation exerts upon the physical factors which
constitute the habitat. A single exception to this is found in
anomalous successions, where the change of formation often hinges
upon the appearance of remote or foreign disseminules. The causes
which initiate successions have already been considered; they may be
summarized as follows: (1) weathering, (2) erosion, (3) elevation, (4)
subsidence, (5) climatic changes, (6) artificial changes. The effect of
succeeding stages of vegetation upon a new or denuded habitat
usually finds expression in a change of the habitat with respect to a
particular factor, and in a definite direction. Often, there is a primary
reaction, and one or more secondary ones, which are corollaries of it.
Rarely, there are two or more coordinate reactions. The general ways
in which vegetation reacts upon the habitat are the following: (1) by
preventing weathering, (2) by binding aeolian soils, (3) by reducing
run-off and preventing erosion, (4) by filling with silt and plant
remains, (5) by enriching the soil, (6) by exhausting the soil, (7) by
accumulating humus, (8) by modifying atmospheric factors. The
direction of the movement of a succession is the immediate result of
its reaction. From the fundamental nature of vegetation, it must be
expressed in terms of water-content. The reaction is often so great
that the habitat undergoes a profound change in the course of the
succession, changing from hydrophytic to mesophytic or xerophytic,
or the reverse. This is characteristic of newly formed or exposed
soils. Such successions are xerotropic, mesotropic, or hydrotropic,
according to the ultimate condition of the habitat. When the reaction
is less marked, the type of habitat does not change materially, and
the successions are xerostatic, mesostatic, or hydrostatic, depending
upon the water-content. Such conditions obtain for the most part
only in denuded habitats.
316. Succession by preventing weathering. Reactions of this
nature occur especially in alpine and boreal regions, in the earlier
stages of lichen-moss successions. They are typical of igneous and
metamorphic rocks in which disintegration regularly precedes
decomposition. The influence of the vegetation is best seen in the
lichen stages, where the crustose forms make a compact layer, which
diminishes the effect of the atmospheric factors producing
disintegration. In alpine regions especially, this protection is so
perfect that the crustose lichens may almost be regarded as the last
stage of a succession. There are no recorded observations which bear
upon this point, but it seems certain that the pioneer rock lichens,
Lecanora, Lecidea, Biatora, Buellia, and Acarospora, cover alpine
rocks for decades, if not for centuries. Ultimately, however, the slow
decomposition of the rock surface beneath the thallus has its effect.
Tiny furrows and pockets are formed, in which water accumulates to
carry on its ceaseless work, and the compact crustose covering is
finally ruptured, permitting the entrance of foliose forms. The latter,
like the mosses, doubtless protect rock surfaces, especially those of
the softer rocks, in a slight degree against the influence of
weathering, but this is more than offset by their activity in hastening
decomposition, and thus preparing a field for invasion. Rocks and
boulders (petria, petrodia, phellia) furnish the best examples of this
reaction; cliffs (cremnia) usually have a lichen covering on their
faces, while the forces which produce disintegration operate from
above or below.
Fig. 66. Thicket formation (Quercus-Holodiscus-driodium), stage V of the talus

succession.
317. Succession by binding aeolian soils. Dunes (thinia) are
classic examples of the reaction of pioneer vegetation upon habitats
of wind-borne sand. The initial formations in such places consist
exclusively of sand-binders, plants with masses of fibrous roots, and
usually also with strong rootstalks, long, erect leaves, and a vigorous
apical growth. They are almost exclusively perennial grasses and
sedges, possessing the unique property of pushing up rapidly
through a covering of sand. They react by fixing the sand with their
roots, thus preventing its blowing about, and also by catching the
shifting particles among their culms and leaves, forming a tiny area
of stabilization, in which the next generation can establish a
foothold. The gradual accumulation of vegetable detritus serves also
to enrich the soil, and makes possible the advent of species requiring
better nourishment. Blowouts (anemia) are almost exact duplicates
of dunes in so far as the steps of revegetation are concerned; while
one is a hollow, and the other a hill, in both the reaction operates
upon a wind-swept slope. Sand-hills (amathia) and deserts (eremia)
show similar though less marked reactions, except where they
exhibit typical inland dunes. Sand-binders, while usually classed as
xerophytic or halophytic, are in reality dissophytes. Their roots grow
more or less superficially in moist sand, and are morphologically
mesophytic while their leaves bear the stamp of xerophytes. The
direction of movement in successions of this kind is normally from
xerophytes to mesophytes, i. e., it is mesotropic. In sand-hills and
deserts, the succession operates wholly within the xerophytic
(dissophytic) series. Along seacoasts, the mesophytic terminus is
regularly forest, except where forests are remote, when it is
grassland.
318. Succession by reducing run-off and erosion. All bare
or denuded habitats that have an appreciable slope are subject to
erosion by surface water. The rapidity and degree of erosion depend
upon the amount of rainfall, the inclination of the slope, and the
structure of the surface soil. Regions of excessive rainfall, even where
the slope is slight, show great, though somewhat uniform erosion;
hill and mountain are deeply eroded even when the rainfall is small.
Slopes consisting of compact eugeogenous soils, notwithstanding the
marked adhesion of the particles, are much eroded where the rainfall
is great, on account of the excessive run-off. Porous dysgeogenous
soils, on the contrary, absorb most of the rainfall; the run-off is small
and erosion slight, except where the slope is great, a rare condition
on account of the imperfect cohesion of the particles. In compact
soils, the plants of the initial formations not merely break the impact
of the raindrops, but, what is much more important, they delay the
downward movement of the water, and produce numberless tiny
streams. The delayed water is largely absorbed by the soil, and the
reduction of the run-off prevents the formation of rills of sufficient
size to cause erosion. As in dunes, such plants are usually perennial
grasses, though composites are frequent; the root system is, however,
more deeply seated, and a main or tap root is often present. On sand
and gravel slopes, the loose texture of the soil results generally in the
production of sand-binders with fibrous roots. Unlike dunes, such
slopes exhibit a large number of mats and rosettes with tap-roots,
which are effective in preventing the slipping or washing of the sand,
and run little danger of being covered, as is the case with
duneformers. In both instances, each pioneer plant serves as a center
of comparative stabilization for the establishment of its own
offspring, and of such invaders as find their way in. From the nature
of these, slopes almost invariably pass through grassland stages
before finding their termini in thickets or forests. Bad lands (tiria)
furnish the most striking examples of eroded habitats. The rainfall in
the bad lands of Nebraska and South Dakota is small (300 mm.); yet
the steepness of the slope and the compactness of the soil render
erosion so extreme that it is all but impossible for plants to obtain a
foothold. Their reaction is practically negligible, and the vegetation
passes the pioneer stages only in the relatively stable valleys.
Mountain slopes (ancia), and ridges and hills (lophia) are readily
eroded in new or denuded areas. This is especially true of hill and
mountain regions which have been stripped of their forest or thicket
cover by fires, lumbering, cultivation, or grazing. Where the erosion
is slight, the resulting succession may show initial xerophytic stages,
or it may be completely mesostatic. Excessively eroded habitats are
xerostatic, as in the case of bad lands, or, more frequently, they are
mesotropic, passing first through a long series of xerophytic
formations. Sandbars (cheradia, syrtidia) should be considered
here, though they are eroded by currents and waves, and not by run-
off. They are fixed and built up by sand-binding grasses and sedges,
usually of a hydrophytic nature, and pass ultimately into mesophytic
forest.
319. Succession by filling with silt and plant remains. All
aquatic habitats into which silt, wash, or other detritus is borne by
streams, currents, floods, waves, or tides are slowly shallowed by the
action of the water plants present. These not only check the
movement of the water, thus greatly decreasing its carrying power,
and causing the deposition of a part or all of its load, but they also
retain and fix the particles deposited. In accordance with the rule,
each plant becomes the center of a stabilizing area, which rises faster
than the rest of the floor, producing the well-known hummocks of
lagoons and swamps. All aquatics produce this reaction. It is more
pronounced in submerged and amphibious forms than in floating
ones, and it takes place more rapidly with greatly branched or
dissected plants than with others. In pools (tiphia) and lakes
(limnia), debouching streams and surface waters deposit their loads
in consequence of the check exerted by the still water and the
marginal vegetation, and delta-like marshes are quickly built up by
filling. Springs (crenia) likewise form marshes where they gush forth
in sands, the removal of which is impeded by vegetation. The flood
plains and deltas of rivers show a similar reaction. The heavily laden
flood waters are checked by the vegetation of meadows and marshes,
and deposit most of their load. The banks of streams (ochthia) and of
ditches (taphria) are often built up in the same fashion by the action
of the marginal vegetation upon the current. The presence of
marginal vegetation often determines the checking or deflecting of
the current in such a way as to initiate meanders, while natural
levees owe their origin to it, in part at least. Along low seacoasts,
waves and tides hasten the deposit of river-borne detritus, causing
the water to spread over the lowlands and form swamps. They often
throw back also the sediment that has been deposited in the sea, the
marsh vegetation acting as a filter in both cases. Successions of the
kind indicated above are regularly mesotropic. Where the soil is
sandy, and the filling-up process sufficiently great, or where salts or
humus occur in excess, xerophytic formations result. In certain
cases, these successions appear to be permanently hydrostatic,
changing merely from floating or submerged to amphibious
conditions, but this is probably due to the slowness of the reaction.
As a rule, the accumulation of plant remains is relatively slight, and
plays an unimportant part in the reaction. In peat bogs and other
extensive swamps, the amount of organic matter is excessive, and
plays an important role in the building up of the swamp bed.
Fig. 67. Pine forest formation (Pinus-xerohylium), stage VI of the talus succession.
320. Succession by enriching the soil. This reaction occurs to

some degree in the great majority of all successions. The relatively
insignificant lichens and mosses produce this result upon the most
barren rocks, while the higher forms of later stages, grasses, herbs,
shrubs, and trees, exhibit it in marked progression. The reaction
consists chiefly in the incorporation of the decomposed remains of
each generation and each stage in the soil. A very important part is
played by the mechanical and chemical action of the roots in
breaking up the soil particles, and in changing them into soluble
substances. Mycorrhizae, bacterial nodules, and especially soil
bacteria play a large part in increasing the nutrition-content of the
soil, but the extent to which they are effective in succession is
completely unknown. The changes in the color, texture, and food
value of the soil in passing from the initial to ultimate stages of a
normal succession are well known, and have led many to think them
the efficient reactions of such successions. It seems almost certain,
however, that this is merely a concomitant, and that, even in
anomalous successions where facies replace each other without
obvious reasons, the reactions are concerned more with water-
content, light, and humidity than with the food-content of the soil.
321. Succession by exhausting the soil. This is a reaction not
at all understood as yet in nature. A number of phenomena, such as
the “fairy rings” of mushrooms and other fungi, the peripheral
growth and central decay of lichens, Lecanora, Placodium,
Parmelia, and of matforming grasses, such as Muhlenbergia, and
the circular advance of the rootstalk plants, indicate that certain
plants at least withdraw much of the available supply of some
essential soil element, and are forced to move away from the
exhausted area. It is probable that the constant shifting of the
individuals of a formation year after year, a phenomenon to be
discussed under alternation, has some connection with this. It will be
impossible to establish such a relation, however, until the facts are
exactly determined by the method of quadrat statistics. So far as
native formations are concerned, there can not be the slightest
question that prairies and forests have existed over the same area for
centuries without impoverishing the soil in the least degree, a
conclusion which is even more certain for the open vegetation of
deserts and plains. With culture formations, the case is quite
different. The exhaustion of the soil by continuous or intensive
cultivation is a matter of common experience in all lands settled for a
long period. Calcium, phosphorus, and nitrogen compounds
especially are used up by crops, and must be supplied artificially. The
reason for this difference in reaction between native and culture
formations seems evident. In harvesting, not merely the grain, but
the stems and leaves, and in gardening often the root also, are
removed, so that the plant makes little or no return to the soil. In
nature, annual plants return to the ground every year all the solid
matter of roots, stems, leaves, and fruits, with the exception of the
relatively small number of seeds that germinate. Perennial herbs
return everything but the persistent underground parts. Shrubs and
trees replace annually an immense amount of material used in leaves
and fruits, and sooner or later, by the gradual decay of the
individuals or by the destruction of the whole formation, they restore
all that they have taken from the soil. This balance is further
maintained to an important degree by the activity of the roots, which
take from the deep-seated layers of the soil the crude materials
necessary for the formation of leaves and fruits. Upon the fall and
decay of these, their materials are incorporated with the upper layers
of the formation floor, from which they may be absorbed by the
undergrowth, or find their way again into the layers permeated by
the tree roots. From the universal occurrence of weeds in cultivated
regions, the pioneers in impoverished or exhausted fields are
uniformly ruderal plants. As is well known, the seed production and
ecesis of these forms are such that they take possession quickly and
completely, while their demands upon the soil are of such a nature
that the most sterile field can rapidly be covered by a vigorous
growth of weeds. As indicated elsewhere, ruderal formations
ultimately yield to the native vegetation, though in regions so
completely given over to culture that native formations are lacking or
remote, it is probable that successions reach their final stage within
the group of ruderal plants.
Fig. 68. Spruce forest formation (Picea-Pseudotsuga-hylium), stage VII, the
ultimate stage of the talus succession.
322. Succession by the accumulation of humus. This is the

characteristic reaction of peat bogs and cypress swamps (oxodia), in
which the accumulation of vegetable matter is enormous. The plant
remains decompose slowly and incompletely under the water, giving
rise to the various humic acids. These possess remarkable antiseptic
qualities, and have an injurious effect upon protoplasm. They affect
the absorption of water by the root-hairs, though this is also
influenced by poor aeration. The same acids are found in practically
all inland marshes and swamps, but the quantity of decomposing
vegetation in many is not great enough to produce an efficient
reaction. Formations of this type usually start as freshwater swamps.
The succession is apparently hydrostatic, but no thorough study of
its stages has as yet been made.
323. Succession by modifying atmospheric factors. All
layered formations, forests, thickets, many meadows and wastes,
etc., show reactions of this nature, and are in fact largely or
exclusively determined by them. The reaction is a complex one,
though it is clear that light is the most efficient of the modified
factors, and that humidity, temperature, and wind, while strongly
affected, play subordinate parts. In normal successions, the effect of
shade, i. e., diffuse light, enters with the appearance of bushes or
shrubs, and becomes more and more pronounced in the ultimate
forest stages. The reaction is exerted chiefly by the facies, but the
effect of this is to cause increasing diffuseness in each successively
lower layer, in direct ratio with the increased branching and leaf
expansion of the plants in the layer just above. In the ultimate stage
of many forests, especially where the facies are reduced to one, the
reaction of the primary layer is so intense as to preclude all
undergrowth. Anomalous successions often owe their origin to the
fact that certain trees react in such a way as to cause conditions in
which they produce seedlings with increasing difficulty, and thus
offer a field favorable to the ecesis of those species capable of
enduring the dense shade. Successions of this kind are almost
invariably mesostatic, as it is altogether exceptional that layered
formations are either xerophytic or hydrophytic.
LAWS OF SUCCESSION
324. The investigation of succession has so far been neither

sufficiently thorough nor systematic to permit the postulation of
definite laws. Enough has been done, however, to warrant the
formulation of a number of rules, which apply to the successions
studied, and afford a convenient method for the critical investigation
of all successions upon the basis of initial causes, and reactions.
Warming has already brought together a few such rules, and an
attempt is here made to reduce the phenomena of succession,
including its causes and effects, to a tentative system. At present it is
difficult to make a thoroughly satisfactory classification of such rules,

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Treating Alcohol and Drug Problems in

Psychotherapy Practice Doing What

Doing What Works Ten Common Sense Leadership Practices

Brown and Mulholland's Drug Calculations: Ratio and

What Psychology Majors Could (and Should) be Doing 2nd

Toward Solving Complex Human Problems Techniques for

DE IMPLEMENTATION CREATING THE SPACE TO FOCUS ON WHA

Precalculus: Practice Problems, Methods, and Solutions

How Linux Works 2nd Edition What Every Superuser Should

Dead Man in a Ditch 2nd Edition Luke Arnold

SEC OND E DI T ION

The Guilford Press

All rights reserved

Except as indicated, no part of this book may be reproduced, translated,

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

The publisher grants to individual purchasers of this book nonassignable permission

Library of Congress Cataloging-in-Publication Data

In hopes that my family,

Arnold M. Washton, PhD, is a psychologist in private practice in New York

Joan E. Zweben, PhD, is an addiction psychologist who began treating co-

W e have written this book to provide practicing psychotherapists

Whether you are a generalist or an addiction specialist, this book is

including motivational, cognitive-behavioral, 12-step recovery, and psy-

motivational and engagement strategies to attract and retain patients. It is

Scope of This Book

It is important for our readers to be aware of the scope of this book.

necessarily on results of scientific research. We have not included compre-

Moreover, in our discussion of SUDs, we do not address nicotine

I (A. M. W.) am grateful to my wife and partner in professional practice,

I (J. E. Z.) am grateful to the substance abuse treatment community, col-

PART I. BASIC ISSUES AND PERSPECTIVES

CHAPTER 1 Why Treat Alcohol and Drug Problems 3

CHAPTER 2 Clinical Course, Definition, and Diagnosis 12

CHAPTER 3 Pharmacology of Psychoactive Substances 28

CHAPTER 4 Addressing Concurrent Psychiatric and Substance Use Disorders 58

CHAPTER 5 Ingredients of the Integrated Approach: Doing What Works 72

CHAPTER 6 The Place of Evidence-Based Principles and Interventions 91

CHAPTER 7 The Role of Medication 96

PART II. CLINICAL STRATEGIES AND TECHNIQUES

CHAPTER 8 Clinical Assessment 111

CHAPTER 9 Treatment Planning: Meeting Patients Where They Are 139

CHAPTER 10 Abstinence Strategies 164

CHAPTER 11 Maintaining Positive Gains 181

CHAPTER 12 Moderation and Harm Reduction Strategies 206

CHAPTER 13 Psychotherapy in Ongoing and Later Stage Recovery 229

CHAPTER 14 Facilitating Participation in Mutual-Help Programs 239

APPENDIX 1 New Patient Questionnaire 251

APPENDIX 2 Inventory of “Triggers” for Alcohol and Drug Use 256

APPENDIX 3 Preparing to Go Off Antabuse 257

Purchasers of this book can download

Why Treat Alcohol and Drug Problems

A basic premise of this book is that all mental health practitio-

unaccustomed to treating SUDs would avoid dealing with these patients—

• Unmet demand for treatment. The demand for treatment of SUDs is

• SUDs are frequently intertwined with other behavioral health prob-