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Understanding Addiction/Treatment Knowledge CAP. Back to Course Index



A beginning user of mind-altering substances does not intend to become an abuser or an addict.  They intend to use on social occasions, with certain friends or for specific purposes. Few, if any, set out to cause harm to themselves or others; however, the history of problematic or excessive use and abuse of alcohol and other drugs indicates that many do get trapped and experience severe life-altering problems as they increase their use and continue to make high-risk decisions. Ultimately, if the using process continues it may result in addiction. Interestingly, once an individual reaches the addiction stage there is little chance of him or her returning to a non-drug lifestyle without professional help.

From a broader perspective, everyone that drinks or uses other drugs will not become a problem user or addict. Tempered use is typical for many people most of the time, but addiction is a widespread problem for many.

The occasional use of psychoactive substances may begin because of curiosity or influence of family or friends. The early experimental stage of use of a mood-altering substance usually occurs during the adolescent years, generally between 10 and 17 years of age. The typical progression is from tobacco and/or alcohol followed by marijuana. As use continues, other illicit drugs that are inhaled, injected, or ingested are added to the menu. Generally, the use of more potent drugs, particularly those requiring hypodermic administration, begins somewhat later.



There are multiple factors that have been identified that contribute to the development of a substance use disorder. However, no one factor, or no one set of factors, will affect all individuals similarly or explain drug use completely.

There are risk factors that increase the likelihood of the development of a substance use disorder. They are factors that increase the probability of an individual developing a disease or vulnerability, which is a predisposition to a specific disease process.  There are also protective factors that decrease the likelihood of the development of a substance use disorder.  Inside both of these are biological factors, psychosocial factors, contextual factors, such as familial and peer issues.  

A family history of drug abuse is one of the most important risk factors for the development of drug or alcohol abuse. However, the extent to which the increased risk is attributable to genetic factors involved in the metabolic, physiological, or subjective effects of drugs and/or alcohol or to shared environmental factors such as impaired family relationships, negative role modeling, or, indirectly, the transmission of psychopathology, is still unclear. There is a need for more studies that can discriminate the roles of genetics and social environment, and their interaction in the development of drug abuse. Genetic epidemiological paradigms such as adoption studies, twin studies, migrant studies, multigenerational family studies, and high-risk studies are particularly important methods for identifying the specific sources of familial influences on drug abuse. 



The commonly accepted stages of alcohol and other drug use along with some of the characteristics associated with each stage are as follows:

Experimental/Recreational Use Stage: An individual may drink or use a few times per month, typically on weekends when at a party or other social event.  Use is generally with friends; however, individuals may drink/use alone.  This may result in minor health problems and/or misdemeanor legal problems. The more common reasons people choose to use:

  • Experiment with alcohol and other drugs to satisfy curiosity
  • To acquiesce to peer pressure
  • To obtain social acceptance
  • To defy parental and other authority
  • To take risks or seek a thrill
  • To relieve boredom; appear grown-up
  • To produce pleasurable feelings and to diminish inhibitions in social/personal settings
  • Alter mood in social settings
  • To mask social ineptness
  • Because they like how it tastes and how it makes them feel (less inhibited/increased risk-taking)
  • Feeling that it is their right due to passage to adulthood
  • Influence of co-workers


Regular Use Stage: An individual typically uses alcohol and/or other drugs on a regular basis; generally several times per week.  Individuals typically drink/use to intoxication/impairment.  Use is situational and an individual may commence binge drinking; may use alone rather than with friends.  Binge drinking is especially risky as people generally drink to excess and lose their ability to think rationally and to control their actions; also, their emotions are seriously flawed. Individuals begin to encounter the consequences of their use.  For example, financial problems are generally more pronounced and they begin to experience increased social, work, and family problems. Use during this phase is driven by or result in:

  • Experience the pleasure the drugs produces; alter emotions/moods
  • Cope with stress and uncomfortable feeling such as pain, guilt, anxiety, and sadness
  • Overcome feelings of inadequacy
  • Avoid depression or other uncomfortable feelings when not using; substances are used to stay high or to mask uncomfortable feelings
  • Increased legal problems (public intoxication; driving under the influence; spouse/child abuse)
  • Increased financial problems
  • Increased social, work and family problems. Family involvement is disrupted due to use; poor performance at work/loss of employment.


Compulsive/Dependent Use Stage: An individual typically uses on a daily basis or almost daily; the individual is consumed with an uncontrollable and compulsive urge to seek and use, even in the face of negative health and social consequences.  Characteristics of this phase are:

  • Use is out-of-control
  • Time, energy, and money are focused on seeking and using drugs
  • Total preoccupation with drugs and drug-related activities
  • Most family, social and work functions are impaired
  • Tolerance is noted (more of a drug is needed to reach the desired effect)
  • Relationships with others may become strained and stressful
  • Responsibilities such as family and job are neglected
  • Continue using to avoid withdrawal symptoms
  • A major focus in life is when and where will I get my next fix
  • Alcohol and other drugs are needed to avoid pain and depression
  • Individuals use to escape the realities of daily living
  • An individual may experience severe health, social and financial problems
  • Legal problems are a way of life

Stage/phase progression (time-wise)

When describing the stages of substance use a factor that is often overlooked is the timeline for each stage and the cumulative time it takes for an individual to progress through the stages and to become addicted to his or her drug of choice. The timeline depicted below is for alcohol.  The stages and times for other types of drugs would vary considerably but the overall concept is valid for most psychoactive drugs. It should be noted that the stages are not absolute and may vary significantly from person-to-person. Also, the dependency stage is best characterized as three sub-stages: early dependency stage where individuals may very well have the ability to control their use if they are sufficiently motivated to do so (spouse may require them to choose between alcohol and his or her family); however, in the middle and later stages, there is little chance of the individual being able to control their use without professional help.

The figure below depicts the approximate time frames. As can be seen, an individual may remain in the experimental/recreational use stage for 10 to 15 years prior to progressing to the regular use/abuse stage. Typically, the regular use/abuse stage is shorter than either of the other stages.


ADDprocess fig1

Figure 1

Increased situational use (seeking out drinking functions), as well as psychological factors (need the drug to feel normal) helps to accelerate individuals through the Use/Abuse stage rather quickly. Also, during this stage, alcohol is often used as a crutch to help cope with stressful situations and to enhance joy associated with celebratory occasions.  Alcohol becomes the primary self-administered medication for all ills. It can become progressively more important to the individual and can become a dominant factor in all decisions and actions. As can be seen in Figure 1, the time frame for stage 2 is from three to five years.

The final stage is the Compulsive/Dependency stage. It is helpful to divide this stage into three sub-stages and look at the characteristics of each sub-stage independently. In each case, the point of focus is that alcohol and other drugs are becoming more important to the individual and he/she is making more concessions to it in terms of withdrawing from family, work and community responsibilities. Typically, early in the compulsive/dependency stage, an individual can stop drinking and/or using. It typically takes a catastrophic life incident (serious illness, accident, loss of family/family member) for the individual to revert to abstinence on his/her own. Through my years of counseling, I have seen approximately 5 to 10% of early compulsive/dependency alcoholics undergo a successful recovery program motivated internally (self-initiated). The middle and late sub-stages are a different story. The most significant characteristic of an individual in this stage is that the most important thing on their mind is when I will get my next fix. I have met individuals in the compulsive/dependency stage that would lie, steal, cheat or do almost anything to obtain alcohol or other drugs. They demonstrate the uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences lifestyle every day of their life.   Unfortunately, few stage 2/3 abusers have the physiological and psychological underpinning to get into recovery themselves.

The Compulsive/Dependency stage typically extends for several years. The early sub-stage typically does not extend beyond 5 years. The middle sub-stage is characterized by a worsening of the early sub-stage and can last up to five additional years. The final stage is characterized by total immersion into a drug-related lifestyle and will generally last until either recovery or death.



Twenty years of scientific research, coupled with even longer clinical experience, has taught us that primary focus on the physical withdrawal issues leaves the addict short of the necessary work that needs to be done from a psychological standpoint. From both clinical and policy perspectives, it does not matter what physical withdrawal symptoms occur beyond the medical issues. Other aspects of addiction are far more important. Physical dependence is not that important to the long term success of recovery because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications. Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances. Second (and more important), many of the most addicting and dangerous drugs do not even produce very severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples. Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly nothing liked the physical symptoms of alcohol or heroin withdrawal.

What does matter is whether or not a drug causes what we now know to be the essence of addiction which is the uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences? This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addiction uncontrollable, compulsive craving, seeking and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

The Essence of Addiction Drug craving and the other compulsive behaviors are the essence of addiction. They are extremely difficult to control, much more difficult than any physical dependence. They are principal target symptoms for most drug treatment programs. For an addict, there is no motivation more powerful than a drug craving.

Rethinking Addiction focusing on addiction as compulsive, uncontrollable drug use should help clarify everyone’s perception of the nature of addiction and of potentially addicting drugs. For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful and powerful concept of uncontrollable drug seeking and use. The task of treatment is to regain control over drug craving, seeking and use.

Rethinking addiction also affects which drugs we worry about and the nature of our concerns. The message from modern science is that in deciding which drugs are addicting and require what kind of societal attention, we should focus primarily on whether taking those causes uncontrollable drug seeking and use. One important example is the use of opiates, like morphine to treat cancer pain. In most circumstances, opiates are addicting. However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here. This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

Treating Addiction: Follow the science.  It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple. We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough. This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.  We will explore treatment further later in the course.

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction. We certainly will do a better job of serving everyone affected by addiction – addicts, their families, and their communities if we focus on what really matters to them. As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.



The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs.  Our hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life.  It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use.  The objectives are for the clinician involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs.  For example, as it is beneficial for an insulin-dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic drug user to be educated in all aspects of his or her drug of choice including impulse control, distorted cognitive ability and the consequences of poor decision-making.

Figure 2 depicts a typical addiction process and identifies the major functional blocks of the process.  The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings and influences of his family, friends, peers and other during his or her early life) it leads to that individual having a distorted cognitive ability.  That, in turn, enables an individual to continue to use and will ultimately result in the inability to manage his or her life (if the cycle is not disrupted).  The following paragraphs describe each block and how it impacts the user’s life.


Figure 2



An individual’s value/belief system reflects his/her perception of self and represents values, judgments, and myths that he/she believes to be true. A person’s value/belief system is fairly well established during the pre-teen years and is refined and honed by our experiences to make us into the person we are at any given time in our life.   It is the major control and decision-making guide and helps us to choose between right and wrong and things we do versus things we don’t do. Our value/belief system influences our thinking and decision making throughout our life. Most individuals have a value/belief system about:               

  • Religion
  • Alcohol and other drugs use
  • Sexuality
  • Race
  • Careers
  • Age
  • Peer pressure/fitting in
  • Time management
  • Social involvement
  • Community involvement
  • Family role
  • Social norms


A clinician should explore a client’s value/belief system to better understand what they believe about various topics including topics related to drug use.  An area I like to explore with clients is the environment they were exposed to during their early life.  For example, one area to explore is if their parents or caregivers had a permissive attitude toward drugs.  What type of friends did they have was their neighborhood safe and what was the norm regarding the use of alcohol and other drugs?  Other questions might include:

Were you exposed to limits or restrictions as a youth?

Did your parents use alcohol or other drugs?

Were you allowed to drink or use other drugs with your parents?

At what age did you start to drink or smoke?

Was there a permissive attitude toward alcohol and other drugs in your home/neighborhood?

Did you have a detailed schedule as a youth?

Did your parents involve themselves with your friends?

Did your parents monitor your activities?


Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of a specific activity (such as the use of alcohol and/or other drugs). To give an example of how our belief/values work in the life of a drug user, let’s suppose a person forms a concept of a problem user as one who dropped out of school and is unemployed.  Now, let’s suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act. In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem. The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use. It should also be noted that an individual’s belief system about drug use might change in response to his or her own experiences and influences from clinicians and other treatment modalities.  The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.



A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions. With respect to the use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use. It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities.

When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial.  The most common forms of denial are:

Rationalizing: Making excuses for drug use. 
Example, I’m restless and it helps me sleep; all of my friends use more than me.

Minimizing: Indicating his/her use is less serious than it really is.
Example: Sure I drink occasionally, but not that much; I only drink on weekends, real alcoholics drink every day.

Blaming: I drink because; everyone else does. The user admits involvement but the responsibility for it lies with some else.

An important challenge facing most compulsive users is to break through denial and accept the reality of their situation; consequently, the greatest challenge in counseling situations is to help the individual through this process. This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adopt new coping strategies and new ways to channel himself or herself away from his or her former lifestyle. Learning new concepts is usually met with resistance, as most individuals don’t want to change and will only change in response to pain or other strong motivator. Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist. A drug user in a quagmire may gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

Most frequently used form of denial (with respect to drug use) is: __________ (rationalizing, minimizing, blaming or others.)

Most frequently processed impaired thought:_____________________________.

I’m not a problem user because: ______________________________________.

If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with drugs and they are in need of professional help. The key to any cognitive change is that the individual is open and honest and willing to accept that change is needed. If they have a good attitude, it is easier for them to accept the perils associated with compulsive use. The net is that people can change but in most cases, the change must be initiated at the cognitive level. If one is in denial regarding a problem there is very little that anyone else can do to help that individual.



The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This on-going activity results in addiction (again, compulsive, uncontrolled drug craving, seeking and use). This lifestyle is problematic and typically follows a well-established pattern.  At this stage of use, his or her drug-related choices begin to disrupt normal activities with family, work, school, social, and community.  Also, it may cause personal health problems as well as financial problems that are difficult to deal with. His or her use is increasing in importance to where it is masking most other activity/relationships. It generally results in behavioral problems or the inability to manage one’s life.

As use continues, the individual begins to encounter the negative consequences of his/her behavior. In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help. The hypothesis is that deeply embedded in human nature is the tendency to resist all change until we finally experience pain and then we may stop to look at the cause of the pain. This process may manifest itself in any of the following:

  • Physical (health problems, increased risk-taking)
  • Social problems (family, work, school, community)
  • Emotional (feelings of guilt, shame or depression)
  • Spiritual (low self-esteem, feeling empty, isolated)
  • Financial (heavy debt load; inability to manage)

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her drug use. This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decision



Figure 3 depicts an individual addiction cycle for a drug user and identifies the major blocks associated with the cycle. Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).


Preoccupy is defined as to absorb wholly the mind or attention of or occupy beforehand or before another. It can be viewed as a locked-in mind state, where the main focus is on obtaining his or her drug of choice. Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration, and frequency. The initial onset may be mild but generally, get more intense as time passes without satisfying the impulse. The intensity of the state also varies depending on how long the individual has been a drug user as all individuals are creatures of habit and we program ourselves to expect resolution within a predetermined time frame or the mind will increase the desire to satisfy the impulse.  An approach to understanding this phase of use is to ask the user a series of questions such as:

  • What thoughts did you focus on when you initially began to use drugs?
  • Was your intent (to be accepted by your peers)?
  • Was your objective to prove your manhood or womanhood?
  • Did you use it as an act of rebellion?
  • What role did peers play in your decision to use?
  • How did the focus items change as the compulsion to use increased?
  • What are your thoughts like at present?
  • What do you think about using it again?
  • How often do you think about using it?

Remember that it takes time to break old habits and to re-program our minds to desire different things.  Also, remember the urge to continue to use will be very strong when an individual initially stops.  Its also safe to say that everyone thinks about resuming use, and individuals must be resilient in their efforts to break the cycle. This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.  Again, the mind wants to continue to do those things that bring pleasure.  A big shopping spree or hanging out with former using buddies are positive events in our minds and we want to repeat them.  Therefore there is a strong drive to set aside or dismiss concepts that would limit us doing what we want to do.  I have often stated in-group sessions that using is an extremely selfish action.  It basically says I will do what I want to do without any consideration for my health, family or other considerations.  Unfortunately, we all know there is the negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other (positive) thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds.  I often use the phrase, when one makes the decision (for example, to get high on drugs) they also accept the consequences.  Sometimes good happens, but most of the time bad and sometimes catastrophic event occurs.

The second part of the individualized addiction cycle is a set of habits that typically lead to use.  Some counselors may refer to this as ritualistic or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking. The preceding cycle discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (ritual) that are typically completed without thought.

A using ritual is a behavior that leads to use.  For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously included drug use (concert).  It may also be triggered by an argument with a spouse; loss of a job or other catastrophic events or it could be as insignificant as driving through a neighborhood where his or her former supplier lived. In any event, it is something that triggers a thought in our minds that initiates a chain of events that leads to using. This is another view of compulsivity.  It’s also important to note that when a ritual is initiated, it is very difficult to stop the process. For a compulsive user, it is virtually impossible without professional help.

Another assignment for the addicted individual is to describe what triggers their use. List and analyze the activities and behaviors leading to use. The objective is that the better we understand what motivates an individual; the easier it is to interrupt the cycle. The second part of the exercise is to identify what could be done to disrupt the process. This may be as simple as planning an evening of entertainment at home with the family. Whatever the case may be, the better one understands themselves, the easier it is to manage their lives and to make better decisions.

Compulsive actions are related to an irresistible impulse to perform an irrational act. In essence, the user has an impulse control problem and/or is susceptible to relapse. Compulsivity is characterized as continued use of the substance despite significant substance-related problems. Some clinicians refer to this phase as when the user begins to experience the consequences of his use.  Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop. This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future.  The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria.  Unfortunately, the opposite emotions, of fear, hopelessness, and helplessness, shame, guilt, depression, and despair are often encountered. One must remember that our minds retain positive memories and have a tendency to set aside the negative ones.  Consequently, the individual thinks he/she will experience a high, when, in fact, he/she has been deceived by his/her own mind.  I think one of the root causes of severe depression is when the individual is expecting an unrealistic outcome and finally realizes he/she has to deal with a set of negative consequences.

Despair is the end result of addiction and is where feelings of hopelessness abound. This block represents the consequences of compulsive use (negative impact on family, work, society, health) and the user generally has feelings of shame and guilt following episodes of use. However, the addicted individuals’ mind attempts to soften his/her despair by processing thoughts such as I will never use again; things will be different in the future. The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing neutralizing thoughts.  So, instead of facing the addiction, the individual’s mind has found another way to deny the addiction.  Consequently, the cycle continues.



People begin to use due to curiosity and a desire to fit into a social group (peer pressure).  Certainly, a youth who has already begun to smoke cigarettes and/or to use alcohol is at a higher risk to experiment with other drugs.  Research suggests that the use of alcohol and/or other drugs by other family members increases the risk of early experimentation as well as early problematic use.  Parents, grandparents, older siblings, other relatives, and caregivers are all role models for children to copy and follow.  At times, parents blindly trust teachers, youth camps, sports figures and others with their children without being aware of the negative influences that could surround these individuals. Studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol or tobacco. 



The following trends have been observed for heavy users versus their non-using counterparts:

Users as a whole have a lower educational achievement level.  This difference is more pronounced in math and science than in social studies and courses such as music and art and the finding is dependent on the age of first use. Some students lack the drive or desire to remain focused to solve difficult problems, whereas it may very well increase their interest in non-technical studies. It should be noted that this is a generalized trend and specific individuals may be able to excel in math and science and use drugs.

Many experience increased personality disorders such as depression, anxiety, fear, impaired judgment, distorted sensory perceptions, difficulty in carrying out complex mental processes, and impaired motor performance,  Some user experience unusual anti-social behaviors and a rebellious attitude.

Research has indicated an adverse impact on memory and retention that can last for days or weeks after the acute effects of the drug subside. For example, a study of over 100 college students found that among heavy users (of marijuana) their critical skills related to attention, memory, and learning were significantly impaired even after they had not used the drug for at least 24 hours. A follow-up to the initial study showed that a group of long-term heavy user’s ability to recall words from a list was impaired 1 week following cessation of use, but returned to normal by 4 weeks. The implication is that even after long-term heavy use if an individual quits, some if not most of his or her cognitive abilities may be recovered.



The American Society of Addictive Medicines (ASAM) has taken the lead in the standardization of concepts and approaches for alcohol and other drug treatment programs.

The levels of care established by ASAM are:

  • Level 0.5  Early Intervention
  • Level I  Outpatient services
  • Level II  Intensive Outpatient/Partial Hospitalization Services
  • Level III  Residential/Inpatient services
  • Level IV  Medically-Managed Intensive Inpatient services

A referral for a specific level of care must be based on a careful assessment of the patient with alcohol and/or other drug problem. The overall objective is to place the patient in the most appropriate level of care (described as the least intensive level that could accomplish the treatment objectives while providing safety and security for the patients). The levels of care represent a continuum of care that can be used in a variety of ways depending on the patient’s needs and responses.  For example, a patient could begin at a more intensive level and move to less intensive levels either in consecutive order or by skipping levels.  A patient could also move to more intensive levels depending on need.

A study of adult drug users found that 18-sessions of cognitive-behavioral-therapy (CBT) group counseling followed by 2-sessions of individual counseling (this amount of counseling is similar to the American Society of Addictive Medicine, Level 1) is effective for most patients who have not advanced to the addicted stage. This counseling includes motivational interviewing and advice on ways to reduce use. The study also indicated that focusing on what triggers their use and then help them to devise appropriate avoidance strategies could help patients. Outcome studies revealed the following results:

(1) use and related problems (school, work, family), as well as psychological problems, decreased for at least one year after treatment;

(2) approximately 30 percent of former users were drug-free after 3 months.



A significant challenge facing recovering addicts is to avoid relapse.  Treatment needs to find an approach where high-risk situations are assessed and then coping strategies are developed for each situation.

Consider the following:

Self-Efficacy:  The individual’s perception of his/her ability to cope with situations.

Expectations:  What is the consequence to the user of a specific behavior?

Attribute:  Why an individual exhibits a specific behavior.

Decision-Making:  Methodology used when the individual chooses a specific action.

Once this analysis is complete the following intervention strategies can be employed:

Self-monitoring:  Maintaining a log of urges/needs to use drugs. Additional information such as the intensity of urge and coping strategy employed may also be documented. 

Direct observation:  The individual rates the degree of temptation due to various situations. The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters. 

Coping Skills:  This analytical tool is used to document the client’s ability to cope once a high-risk behavior is encountered. This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement. 

Decision Matrix:  The matrix is used to document the consequences of a specific decision or action. It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.  Behavioral

Commitment: This tool is intended to establish limits on drug use (if any).It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using. 

Reminder Questions: They are used to key specific avoidance actions in the event of a strong urge.

It follows that a primary goal of any prevention program is to enable the individual to cope with the future, inevitable urges to use.  The initial step is to identify the coping strategies that can be used in high-risk situations.  It is also important to discuss an implementation plan for how these skills will be used.  Some have referred to this process as setting up a self-management program.  The goals of self-management programs are to teach the individual to anticipate and cope with the problem of relapse. This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

The most frequently applied prevention method is the cognitive-behavioral approach. The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming a compulsive user but has total responsibility for the management of his/her recovery.



This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, social and recovery-related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving one’s level of functioning while striving to remain drug-free.  A brief overview of a recovery process follows:

Pre-treatment phase:  The individual experiences or becomes aware of unpleasant consequences associated with drug use (family problems, loss of friends, loss of a job, loss of freedom); Loss of control of their life and emotional pain (may motivate an individual to enter treatment).

Initial stabilization:  Stop the use of all drugs; avoid former using buddies; professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);  Help with controlling impulsive behavior (counseling). The following phases are followed:

Phase 1:  Recovery (Getting Started): Helps individuals to accept and comprehend the addiction process: Identify use triggers: Develop a plan to avoid and control impulses. Learn problem-solving, stress management, and anger management skills. Accept personal responsibility for self (choices, decisions, behaviors, and consequences) Express feelings.

Phase 2:  Recovery (Early); Accepts need for recover; Accepts responsibility for management of drug use; Begins to develop a drug-free self-image; Acknowledges the need for lifestyle changes; new friends; Adjusts to non-use behavior applies new problem-solving skills as needed; May struggle with peer and family issues as drug-free lifestyle is demonstrated; Improved self-image.

Phase 3:  (Middle) Changed behavior and cognitive awareness aligned with new self-concept; Accepts responsibility for own recovery; Recognizes and embraces the success of recovery; Incorporates problem-solving skills into new lifestyle; Comfortable with lifestyle change; Continues to struggle with peer and family issues; Learns to balance and control life.

Phase 4: (Advanced) Focuses on learning coping skills to help deal with peers and family; Increases scope of life; starts to fulfill potential; Develops balance and takes control of life; Develops independence from the treatment program develops self-initiative; Accepts identity as a recovering individual.

After Care: Positive experiences fuel personal growth; Focus on total person (activities, spiritual growth and independence).

Keys To Avoid Relapse:

  • High Activity Level: An idle mind often wanders in the wrong direction;
  • Generate To-Do lists to guide daily activities;
  • Set goals to acknowledge and reward success;
  • Individual reward system: work toward a specific individualized reward. For example, a new car, trip, clothes;
  • Plan pleasurable activities; Hobbies, travel, reading, etc;
  • Plan self-improvement activities; Items that will help the individual feel good about themselves;
  • Exercise/active lifestyle;
  • Nutrition program;
  • Plan rest/relaxation time;
  • Eliminate or minimize stress where possible;
  • Think positive; Avoid high-risk situations here possible;
  • Avoid events that previously led to relapse;
  • Avoid people/functions whose focus is on drug use;
  • Avoid events and peoples that have triggered previous relapses;
  • Develop mind-management techniques: Block negative thought processes. The mind always leads the physical act (i.e., an individual thinks positive regarding an activity before they do the activity). Consequently, if we could train our minds to detect wrong thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using;
  • Avoid overconfident feelings, such as, I am in control and I have this problem licked. Generally, overconfidence leads to high-risk behavior and poor decision-making;
  • Avoid out-of-balance emotional states. Either feeling too good (overconfident) or too bad (depression) can lead to the resumption of use.

Forgetting or rationalizing away the pain and anguish of the former lifestyle. Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences. At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.)  Also, when they actually return to that lifestyle, they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.



The behavior usually doesn’t change until the individual decides that the consequence of continuing the behavior is too high. A person can do anything they want for a period of time, but after a while, they gravitate back to their state of most pleasure/least pain, whatever state that may be. So how as a field, do we help psychologically dependent individuals change their uncontrollable, compulsive behavior?            

Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, provided the following insight into drug addiction.   He stated, “The word addiction calls up many different images and strong emotions. But what are we reacting to? Too often we focus on the wrong aspects of addiction so our efforts to deal with this difficult issue can be badly misguided. Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to the question is it really addicting?   The conversation then shifts to the so-called types of addiction whether the drug is physically or psychologically addicting. The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field call physical dependence. The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be. Indeed, people always seem relieved to hear that a substance just produces psychological addiction, or has only minimal physical withdrawal symptoms. Then they discount the dangers and they are wrong.”

Drug craving, which can be defined as an intense, urgent, or abnormal desire or longing and the other compulsive behaviors is extremely difficult to control, much more difficult than any physical dependence. We may be missing the mark on long term success by our focus. For an addict, there is no motivation more powerful than drug craving.

Focusing on addiction as a compulsive, uncontrollable drug use disorder should help clarify  the perception of the nature of addiction and of potentially addicting drugs.  For the addict, the clinician, and the substance abuse counselor this more accurate definition forces the focus of treatment to a broader picture.  Understanding that in some cases managing withdrawal symptoms is a medical necessity and this view of focusing on the essence of addiction is not to lessen the purpose and intent of managing specific withdrawal symptoms but rather to expand the focus to the more meaningful and powerful concept of uncontrollable drug seeking and use.  The task of treatment is to regain control over drug craving. 



Understanding the addiction process, as it applies to a specific client, will help the substance counselor, as well as the drug abuser, to better understand the why behind their involvement with drugs.  It is important that counselors, as well as substance abusers, understand the cognitive, behavioral and physical aspects of drug use.  This enables the counselor to recognize the special needs of this sub-population and to be able to advocate counseling approaches and other treatment modalities aimed at their specific needs.  The counselor should be able to address topics such as impulse control, distorted cognitive ability and the consequences of poor decision-making.

If an individual has a flawed value/belief system, based upon his or her perceptions of events, teachings and influences of his or her family, friends, peers and others, it may lead to that individual having a distorted cognitive ability. That, in turn, enables an individual to continue to use and will ultimately result in the inability to manage the use.  

A counselor should explore a client’s value/belief system early in the treatment process to better understand what they believe about various topics and why they hold the views they hold.  The topics generally addressed with an addiction client include:

  • Determine if their parents or caregivers had a permissive attitude toward tobacco, alcohol and other drug use.
  • Determine was the social norm with friends and family regarding use of substances.
  • Determine if client was exposed to limits or restrictions as a youth.
  • Determine if tobacco, alcohol and other drugs were used in the home.
  • Determine if they drink, smoke or used other drugs with your parents/relatives/caregiver?
  • Determine at what age they began to smoke or drink alcoholic beverages.
  • Determine if there was a permissive attitude toward social activities in your home/neighborhood?
  • Did parents involve themselves with the client’s friends?
  • Did parents monitor activities?



It is important to emphasize that addiction can be treated, both behaviorally and, in some cases, with medications, but it is not simple.  There is a range of effective treatments and the industry continues to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.  Research has demonstrated that treatment can help addicted patients to stop using drugs, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment program.  It cannot be overemphasized that drug addiction is a complex illness characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. While the path to drug addiction begins with the voluntary act of taking drugs, over time a person’s ability to choose not to do so becomes compromised, and seeking and consuming the drug becomes compulsive. This behavior results largely from the effects of prolonged drug exposure on brain functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

Too often, addiction goes untreated: According to SAMHSA’s National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4 percent of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem. Of these individuals, 2.4 million (10.4 percent of those who needed treatment) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation or mental health center). Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it. 


Principals of Effective Treatment

  • Addiction is a multifaceted disease and demands a triad of treatment modalities. 
  • It affects the brain function and alters various behaviors. 
  • Addiction is a treatable disease; however, no single treatment program is effective for all individuals.
  • Effective treatment addresses the needs of the whole person (includes treatment for psychological and behavioral disorders).
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
  • Remaining in treatment for an adequate period of time is critical.
  • Counseling individual and/or group and other behavioral therapies are the most commonly used forms of drug abuse treatment.
  • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
  • An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
  • Many drug addicted individuals also have other mental disorders.
  • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long term drug abuse.
  • Treatment does not need to be voluntary to be effective
  • Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
  • Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. 



Medications can be used to help with different aspects of the treatment process. For example, medications are used during withdrawal to help suppress symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment”it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

Medications can also be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, there are medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse. The following medications are currently used frequently:

Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as other medications. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments.

Tobacco: A variety of formulations of nicotine replacement therapies now exist including the patch, spray, gum, and lozenges that are available over the counter. In addition, two prescription medications have been FDA approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.

Alcohol: Three medications have been FDA approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.


Behavioral Treatments

Behavioral treatments help patients engage in the treatment process, modify their attitudes and involvements related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches. Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling and 12-step support programs. Some programs also offer other forms of behavioral treatment such as:

Cognitive-behavioral therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.

Multidimensional family therapy, which was developed for adolescents with drug abuse problems as well as their families addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.

Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.

Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

Contingency management uses positive reinforcement to change behaviors. It is founded on the principle that if positive behavior is rewarded, it is more likely to be repeated in the future. Examples of rewards for positive behaviors in drug and alcohol rehab include day passes with family members or extra recreational activities.

Rational Emotive Behavioral Therapy is used to help clients identify self-defeating, unhealthy thoughts, consider the validity of those thoughts, and then learn to replace them with healthier ones. As a result, clients learn how to manage negative emotions, modify their thought processes, and develop healthier relationships with others.

Individual and Group counseling help clients through talk therapy and support groups.

There are also many treatment environments such as residential treatment programs that can be very effective, especially for those with more severe problems. Therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community treatment staff and those in recovery as a key agent of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the re-socialization of the patient to a drug-free, crime-free lifestyle. Treatment in a criminal justice setting can succeed in preventing an offender’s return to criminal behavior, particularly when treatment continues as the person transitions back into the community. Studies show that treatment does not need to be voluntary to be effective.

Benefits of Behavioral Therapy in Addiction Treatment

  • Provides incentives for maintaining abstinence
  • Modifies negative behaviors and attitudes
  • Improves life skills
  • Enhances the ability to handle stressful situations and triggers

A truly holistic approach to treatment will include a variety of complementary therapies that are used in conjunction with traditional behavioral therapies. Complementary therapies may include:

  • Art therapy, pet therapy, or music therapy – Helps synthesize experiences in different ways as well as reduce stress and bolster coping skills
  • Biofeedback – Trains the client to reduce the body’s response to stress on command, such as lowering the heart rate and blood pressure, by engaging in activities like progressive relaxation or deep breathing
  • Neurofeedback – Trains the client to interact with the brain waves and alter their frequencies to help reduce triggers like insomnia, anger, and stress
  • Meditation and other mindfulness practices – Help the client become more keenly aware of thoughts and emotions to help  better regulate mood, cope with triggers like cravings and stress, and improve the functioning of the immune system

Let’s explore a few of the mentioned behavioral therapies.

Individual counseling focuses on the symptoms of drug addiction and related areas of impaired functioning and the content and structure of the patient’s ongoing recovery program. Most importantly, helping the client decide what they want and why.Once they make this decision then helping them follow through with how. This model of counseling is time-limited and emphasizes behavioral change. It gives the patient coping strategies and tools for recovery and promotes 12-step ideology and participation. The primary goal of addiction counseling is to assist the addict in achieving and maintaining abstinence from addictive chemicals and behaviors. The secondary goal is to help the addict recover from the damage the addiction has caused in his or her life.

Addiction counseling works by first helping the patient recognize the existence of a problem and the associated irrational thinking. Next, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills and spiritual development to continue in recovery as a lifelong process.

Within this counseling model, the patient is an effective agent of change. It is the patient who must take responsibility for working on and succeeding with a program of recovery. Although recovery is ultimately the patient’s responsibility, the patient is encouraged to get a great deal of support from others, including counselors and other treatment staff, one’s sponsor, and drug-free or recovering peers and family members.

Overall, drug use is a maladaptive way of coping with life’s problems. It sometimes becomes compulsive and leads to a progressive deterioration in one’s life circumstances. Compulsive drug abuse is an addiction, which is defined as a disease. It damages the addict physically, mentally, and spiritually.

The goals and objectives of individual counseling generally center around the symptoms of the drug addiction and areas of impaired functioning that are related to it and the content and structure of the patient’s ongoing recovery program. Throughout the course of counseling, the addiction counselor should:

  • Help the patient to accept that he or she suffers from the disease of chemical addiction.
  • Point out the signs and symptoms of addiction that are relevant to the patient’s experience.
  • Teach the addict to recognize and re-channel urges to use drugs.
  • Encourage and motivate the patient to achieve and sustain abstinence.
  • Monitor and encourage abstinence by using objective measures, such as urinalysis and Breathalyzer tests.
  • Hold the chemically addicted person accountable for and discuss any episodes of use and strongly discourage further use.
  • Assist the patient in identifying situations where drugs were used to cope with life’s problems and in understanding that using drugs to cope with or solve problems does not work.
  • Help the addict to develop new, more effective problem-solving strategies.
  • Introduce the patient to the 12-step philosophy and strongly encourage participation in NA, AA, and/or CA.
  • Encourage the chemically addicted person to develop and continue with a recovery plan as a lifelong process.
  • Help the addict to recognize and change problematic attitudes and behaviors that may stimulate a relapse.
  • Encourage the patient to improve self-esteem by practicing newly acquired coping skills and problem-solving strategies at home and in the community.

Drug counseling sessions have a clear structure. However, within the framework of that structure, the content of the discussion is largely up to the patient. We make an effort to address effectively the patient’s individual needs at any point in treatment while also recognizing the commonality of many issues in addiction and recovery. People are indeed unique; however, the facets of a human problem like cocaine addiction usually follow familiar patterns. The validity of both realities should be respected.


Group Counseling is a special form of therapy in which people meet together under the guidance of a substance abuse counselor to help themselves and one another. Group counseling helps people learn about themselves

and improve their interpersonal relationships. It addresses feelings of isolation, depression or anxiety and it helps people make significant changes so they feel better about the quality of their lives.

Fundamental to group counseling is the idea that the group therapy experience can be a carrier of change for individuals and be an effective influence over precipitating that change. In a group, the counselor actually observes the interactions rather than hearing about the interactions from the individual.  In a group therapy situation, the client learns that she or he is not alone in his or her feelings.


Cognitive Behavioral Therapy is the therapy of choice for many clinicians who work with addiction clients. It is collaborative therapy that focuses on the strong interaction between the patient and therapist. They jointly consider and decide on the appropriate treatment goals, the types of skills and coping training needed, and when and if others should be brought into the sessions, and so on. Not only does this foster the development of a good working relationship it also assures a buy-in by the client to the treatment modalities. CBT is based on social learning theory. It is assumed that an important factor in how individuals begin to use and abuse substances is that they learn to do so. The several ways individuals may learn to use drugs include modeling, operant conditioning, and classical conditioning.

Modeling: With modeling, individuals learn skills/behaviors by watching others and then trying it themselves. For example, children learn a language by listening to and copying their parents. The same may be true for many substance abusers. By seeing their parents use alcohol, individuals may learn to cope with problems by drinking. Teenagers often begin smoking after watching their friends use cigarettes. So, too, may some cocaine abusers begin to use after watching their friends or family members use cocaine or other drugs.

Operant Conditioning:  Laboratory animals will work to obtain the same substances that many humans abuse (cocaine, opiates, and alcohol) because they find exposure to the substance pleasurable, that is, reinforcing. Drug use can also be seen as behavior that is reinforced by its consequences. Cocaine may be used because it changes the way a person feels (e.g., powerful, energetic, euphoric, stimulated, less depressed), thinks (I can do anything, I can only get through this if I am high), or behaves (less inhibited, more confident).

The perceived positive (and negative) consequences of cocaine use vary widely from individual to individual. People with family histories of substance abuse, a high need for sensation seeking, or those with a concurrent psychiatric disorder may find cocaine particularly reinforcing. It is important that clinicians understand that any given individual uses cocaine for important and particular reasons.

Classical Conditioning:  Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating). Over time, cocaine abuse may become paired with money or cocaine paraphernalia, particular places (bars, places to buy drugs), particular people (drug-using associates, dealers), times of day or week (after work, weekends), feeling states (lonely, bored), and so on. Eventually, exposure to those cues alone is sufficient to elicit very intense cravings or urges that are often followed by cocaine abuse.

Functional Analysis: The first step in CBT is helping patients recognize why they are using cocaine and determining what they need to do to either avoid or cope with whatever triggers their use. This requires a careful analysis of the circumstances of each episode and the skills and resources available to patients. These issues can often be assessed in the first few sessions through an open-ended exploration of the patients’ substance abuse history, their view of what brought them to treatment and their goals for treatment. Therapists should try to learn the answers to the following questions.

Deficiencies and Obstacles:

  • Have the patients been able to recognize the need to reduce the availability of cocaine?
  • Have they been able to recognize important cocaine cues?
  • Have they been able to achieve even brief periods of abstinence?
  • Have they recognized events that have led to relapse?
  • Have the patients been able to tolerate periods of cocaine craving or emotional distress without resorting to drug use?
  • Do they recognize the relationship of their other substance abuse (especially alcohol) in maintaining cocaine dependence?
  • Do the patients have concurrent psychiatric disorders or other problems that might confound efforts to change behavior?

Skills and Strengths:

  • What skills or strengths have they demonstrated during any previous periods of abstinence?
  • Have they been able to maintain a job or positive relationships while abusing drugs? 
  • Are there people in the patients’ social network who do not use or supply drugs?
  • Are there social supports and resources to bolster the patients’ efforts to become abstinent?
  • How do the patients spend time when not using drugs or recovering from their effects?
  • What was their highest level of functioning before using drugs?
  • What brought them to treatment now?
  • How motivated are the patients?

 Determinants of Cocaine Use

  • What is their individual pattern of use (weekends only, every day, binge use)?
  • What triggers their cocaine use?
  • Do they use cocaine alone or with other people?
  • Where do they buy and use cocaine?
  • Where and how do they acquire the money to buy drugs?
  • What has happened to (or within) the patients before the most recent episodes of abuse?
  • What circumstances were at play when cocaine abuse began or became problematic?
  • How do they describe cocaine and its effects on them?
  • What are the roles, both positive and negative, that cocaine plays in their lives?

Relevant Domains: In identifying patients’ determinants of drug abuse, it may be helpful for clinicians to focus their inquiries to cover at least five general domains:

Social: With whom do they spend most of their time? With whom do they use drugs? Do they have relationships with those individuals that do not involve substance abuse? Do they live with someone who is a substance abuser? How has their social network changed since drug abuse began or escalated?

Environmental: What are the particular environmental cues for their drug abuse (e.g., money, alcohol use, particular times of the day, certain neighborhoods)? What is the level of their day-to-day exposure to these cues? Can some of these cues be easily avoided?

Emotional: Research has shown that feeling states commonly precede substance abuse or craving. These include both negative (depression, anxiety, boredom, anger) and positive (excitement, joy) affect states. Because many patients initially have difficulty linking particular emotional states to their substance abuse (or do so, but only at a surface level), affective antecedents of substance abuse typically are more difficult to identify in the initial stages of treatment.

Cognitive: Particular sets of thought or cognition frequently precede cocaine use (I need to escape, I can’t deal with this unless I’m high, with what I am going through I deserve to get high). These thoughts are often charged and have a sense of urgency.

Physical: Desire for relief from uncomfortable physical states such as withdrawal has been implicated as a frequent antecedent of drug abuse. While the controversy surrounding the nature of physical withdrawal symptoms from cocaine dependence continues, anecdotally, cocaine abusers frequently report particular physical sensations as precursors to substance abuse (e.g., tingling in their stomachs, fatigue or difficulty concentrating, thinking they smell cocaine).

Assessment Tools: Standardized instruments may also be useful in rounding out the therapist’s understanding of the patient and identifying treatment goals. The following assessment tools are two examples, of many that can be used:

  • The Addiction Severity Index assesses the frequency and severity of substance abuse as well as the type and severity of psychosocial problems that typically accompany substance abuse (e.g., medical, legal, family/ social, employment, psychiatric).
  • The Change Assessment Scale assesses the patient’s current position on readiness for change (e.g., pre-contemplation, contemplation, commitment), which may be an important predictor of response to substance abuse treatment).

Learning serves as an important metaphor for the treatment process throughout CBT. Therapists tell patients that the goal of the treatment is to help them “unlearn” old, ineffective behaviors and “learn” new ones. Patients, particularly those who are demoralized by their failure to cease their substance abuse, or for whom the consequences of the use and abuse have been highly negative, are frequently surprised to consider using alcohol or drugs as a type of skill, as something they have learned to do overtime. After all, they are surprised when they think of themselves as having learned a complex set of skills that enabled them to acquire the money needed to buy the substance (which often led to another set of licit or illicit skills), acquired it without being arrested, use and avoid detection, and so on. Patients who can reframe their self-appraisals in terms of being skilled in this way often see that they also have the capacity to learn a new set of skills that will help them remain abstinent. In CBT, it is assumed that individuals essentially learn to become substance abusers through complex interplays of modeling, classical conditioning, or operant conditioning. Each of these principles is used to help the patient stop abusing cocaine.

Modeling is used to help the patient learn new behaviors by having the patient participate in role-plays with the therapist during treatment. The patient learns to respond in new, unfamiliar ways by first watching the therapist model those new strategies and then practicing those strategies within the supportive context of the therapy hour. New behaviors may include how to refuse an offer of drugs or how to break off or limit a relationship with a drug-using associate.

Operant conditioning concepts specific to substance abuse are evaluated through a detailed examination of the antecedents and consequences of this abuse, therapists attempt to understand why patients may be more likely to use in a given situation and to understand the role that cocaine plays in their lives. This functional analysis of substance abuse is used to identify the high-risk situations in which they are likely to abuse drugs and, thus, to provide the basis for learning more effective coping behaviors in those situations.

Therapists attempt to help patients develop meaningful alternative reinforces to drug abuse, that is, other activities and involvements (relationships, work, hobbies) that serve as viable alternatives to cocaine abuse and help them remain abstinent.

A detailed examination of the consequences, both long- and short-term, of substance abuse, is employed as a strategy to build or reinforce the patient’s resolve to reduce or cease use.

Classical conditioning concepts also play an important role in CBT, particularly in interventions directed at reducing some forms of craving for alcohol and other drugs. Just as Pavlov demonstrated that repeated pairings of a conditioned stimulus with an unconditioned stimulus could elicit a conditioned response, he also demonstrated that repeated exposure to the conditioned stimulus without the unconditioned stimulus would, over time, extinguish the conditioned response. Thus, the therapist attempts to help patients understand and recognize conditioned craving, identify their own idiosyncratic array of conditioned cues for craving, avoid exposure to those cues, and cope effectively with craving when it does occur so that conditioned craving is reduced.

 Since CBT treatment is brief, only a few specific skills can be introduced to most patients. Typically, these are skills designed to help the patient gain initial control over cocaine and other substance abuse, such as coping with craving and managing thoughts about drug abuse. However, the therapist should make it clear to the patient that any of these skills can be applied to a variety of problems, not just substance abuse.

The therapist should explain that CBT is an approach that seeks to teach skills and strategies that the patient can use long after treatment. For example, the skills involved in coping with craving (recognizing and avoiding cues, modifying behavior through urge-control techniques, and so on) can be used to deal with a variety of strong emotional states that may also be related to abuse. Similarly, the session on problem-solving skills can be applied to nearly any problem the patient faces, whether drug abuse-related or not.

Basic Skills First: This course describes a sequence of sessions to be delivered to clients; each focuses on a single or related set of skills (e.g., craving, coping with emergencies). The order of presentation of these skills has evolved with experience with the types of problems most often presented by substance abusing clients coming into treatment.

Early sessions focus on the fundamental skills of addressing ambivalence and fostering motivation to stop substance abuse, helping the patient deal with issues of alcohol and other drug availability and craving, and other skills intended to help the patient achieve initial abstinence or control overuse. Later sessions build on these basic skills to help the patient achieve stronger control over abuse by working on more complex topics and skills (problem-solving, addressing subtle emotional or cognitive states). For example, the skills patients learn in achieving control over craving (urge control) serve as a model for helping them manage and tolerate other emotional states that may lead to abuse.


Match Material to Patient Needs: CBT is highly individualized. Rather than viewing treatment as cookbook psycho-education, the therapist should carefully match the content, timing, and nature of the presentation of the material to the patient. The therapist attempts to provide skills training at the moment the patient is most in need of the skill. The therapist does not belabor topics, such as breaking ties with cocaine suppliers, with a patient who is highly motivated and has been abstinent for several weeks. Similarly, the therapist does not rush through the material in an attempt to cover all of it in a few weeks; for some patients, it may take several weeks to truly master a basic skill. It is more effective to slow down and work at a pace that is comfortable and productive for a particular individual than to risk the therapeutic alliance by using a pace that is too aggressive.

Similarly, therapists should be careful to use language that is compatible with the patient’s level of understanding and sophistication. For example, while some patients can readily understand concepts of conditioned craving in terms of Pavlov’s experiments on classical conditioning, others require simpler, more concrete examples, using familiar language and terms.

Therapists should frequently check with patients to be sure they understand a concept and that the material feels relevant to them. The therapist should also be alert to signals from patients who think the material is not well suited to them. These signals include loss of eye contact and other forms of drifting away, overly brief responses, failure to come up with examples, failure to do homework, and so on.

An important strategy in matching the material to patient needs (and providing treatment that is patient-driven rather than manual driven) is to use, whenever possible, specific examples provided by the patients, either through their history or relating events of the week. For example, rather than focusing on an abstract recitation of “Seemingly Irrelevant Decisions,” the therapist should emphasize a recent, specific example of a decision made by the patient that ended in an episode of use or craving. Similarly, to make sure the patient understands a concept, the therapist should ask the patient to think of a specific experience or example that occurred in the past week that illustrates the concept or idea.

“It sounds like you had a lot of difficulties this week and wound up in some risky situations without quite knowing how you got there. That’s exactly what I’d like to talk about this week, how by not paying attention to the little decisions we make all the time, we can land in some rough spots. Now, you started out talking about how you had nothing to do on Saturday and decided to hang out in the park, and 2 hours later you were driving into the city to score with Teddy. If we look carefully at what happened Saturday, I bet we can come up with a whole chain of decisions you made that seemed pretty innocent at the time, but eventually led to you being in the city. For example, how did it happen that you felt you had nothing to do on Saturday?”


Use Repetition: Learning new skills and effective skill-building requires time and repetition. By the time they seek treatment, cocaine users’ habits related to their drug abuse tend to be deeply ingrained. Any given patient’s routine around acquiring, using, and recovering from cocaine use is well established and tends to feel comfortable to the patient, despite the negative consequences of cocaine abuse. It is important that therapists recognize how difficult, uncomfortable, and even threatening it is to change these established habits and try new behaviors. For most patients, mastering a new approach to old situations takes several attempts.

Moreover, many patients come to treatment only after long periods of chronic use, which may affect their attention, concentration, and memory and thus their ability to comprehend new material. Others seek treatment at a point of extreme crisis (e.g., learning they are HIV positive, after losing a job); these patients may be so preoccupied with their current problems that they find it difficult to focus on the therapist’s thoughts and suggestions. Thus, in the early weeks of treatment, repetition is often necessary if a patient is to be able to understand or retain a concept or idea.

In fact, the basic concepts of this treatment are repeated throughout the CBT process. For example, the idea of a functional analysis of cocaine abuse occurs formally in the first session as part of the rationale for treatment, when the therapist describes understanding cocaine abuse in terms of antecedents and consequences. Next, patients are asked to practice conducting a functional analysis as part of the homework assignment for the first session. The concept of a functional analysis then recurs in each session; the therapist starts out by asking about any episodes of cocaine use or craving, what preceded the episodes, and how the patient coped.

The idea of substance use in the context of its antecedents and consequences is inherent in most treatment sessions. For example, craving and thoughts about alcohol and other drugs are common antecedents of abuse and are the focus of two early sessions. These sessions encourage patients to identify their own obvious and more subtle determinants of cocaine abuse, with a slightly different focus each time. Similarly, each session ends with a review of the possible pitfalls and high-risk situations that may occur before the next session, to again stimulate patients to become aware of and change their habits related to use and abuse.

While key concepts are repeated throughout the manual, therapists should recognize that repetition of whole sessions, or parts of sessions, may be necessary for patients who do not readily grasp these concepts because of cognitive impairment or other problems. Therapists should feel free to repeat session material as many times and in as many different ways as needed with particular patients.


Practice Mastering Skills: We do not master complex new skills by merely reading about them or watching others do them. We learn by trying out new skills ourselves, making mistakes, identifying those mistakes, and trying again. In CBT, the practice of new skills is a central, essential component of treatment. The degree to which the treatment is skills training over merely skills exposure has to do with the amount of practice. It is critical that patients have the opportunity to try out new skills within the supportive context of treatment. Through firsthand experience, patients can learn what new approaches work or do not work for them, where they have difficulty or problems, and so on.

CBT offers many opportunities for practice, both within sessions and outside of them. Each session includes opportunities for patients to rehearse and review ideas, raise concerns, and get feedback from the therapist. Practice exercises are suggested for each session; these are basically homework assignments that provide a structured way of helping patients test unfamiliar behaviors or try familiar behaviors in new situations.

However, practice is only useful if the patient sees its value and actually tries the exercise. Compliance with extra-session assignments is a problem for many patients. Several strategies are helpful in encouraging patients to do homework.


Give a Clear Rationale: Therapists should not expect a patient to practice a skill or do a homework assignment without understanding why it might be helpful. Thus, as part of the first session, therapists should stress the importance of extra-session practice.

“It will be important for us to talk about and work on new coping skills in our sessions, but it is even more important to put these skills into use in your daily life. You are really the expert on what works and doesn’t work for you, and the best way to find out what works for you is to try it out. It’s very important that you give yourself a chance to try out new skills outside our sessions so we can identify and discuss any problems you might have put them into practice. We’ve found, too, that people who try to practice these things tend to do better in treatment. The practice exercises I’ll be giving you at the end of each session will help you try out these skills. We’ll go over how well they worked for you, what you thought of the exercises, and what you learned about yourself and your coping style at the beginning of each session.”


Get a Commitment: We are all much more likely to do things we have told other people we would do. Rather than assume that patients will follow through on a task, CBT therapists should be direct and ask patients whether they are willing to practice skills outside of sessions and whether they think it will be helpful to do so. A clear “yes” conveys the message that the patient understands the importance of the task and its usefulness. Moreover, it sets up a discussion of discrepancies if the patient fails to follow through.

On the other hand, hesitation or refusal may be a critical signal of clinical issues that are important to explore with the patient. Patients may refuse to do homework because they do not see the value of the task, because they are ambivalent about treatment or renouncing cocaine abuse, because they do not understand the task, or for various other reasons.


Anticipate Obstacles: It is essential to leave enough time at the end of each session to develop or go over the upcoming week’s practice exercise in detail. Patients should be given ample opportunity to ask questions and raise concerns about the task. Therapists should ask patients to anticipate any difficulties they might have in carrying out the assignment and apply a problem-solving strategy to help work through these obstacles. Patients should be active participants in this process and have the opportunity to change or develop the task with the therapist, to plan how the skill will be put into practice, and so on. Working through obstacles may include a different approach to the task (e.g., using a tape recorder for self-monitoring instead of writing), thinking through when the task will be done, whether someone else will be asked to help, and so on. The goal of this discussion should be the patient’s expressed commitment to do the exercise.


Monitor Closely: Following up on assignments is critical to improving compliance and enhancing the effectiveness of these tasks. Checking on task completion underscores the importance of practicing coping skills outside of sessions. It also provides an opportunity to discuss the patient’s experience with the tasks so that any problems can be addressed in treatment.

In general, patients who do homework tend to have therapists who value homework, spend a lot of time talking about homework, and

expect their patients to actually do the homework. The early part of each session must include at least 5 minutes for reviewing the practice exercise in detail; it should not be limited to asking patients whether they did it. If patients expect the therapist to ask about the practice exercise, they are more likely to attempt it than are patients whose therapist does not follow through.

Similarly, if any other task is discussed during a session (e.g., implementation of a specific plan to avoid a potential high-risk situation), be sure to bring it up in the following session. For example, “Were you able to talk to your brother about not coming over after he gets high?”


Use the Data: The work patients do in implementing a practice exercise and their thoughts about the task convey a wealth of important information about the patients, their coping style and resources, and their strengths and weaknesses. It should be valued by the therapist and put to use during the sessions.

A simple self-monitoring assignment, for example, can quickly reveal patients’ understanding of the task or basic concepts of CBT, level of cognitive flexibility, insight into their own behavior, level of motivation, coping style, level of impulsivity, verbal skills, usual emotional state, and much more. Rather than simply checking homework, the CBT therapist should explore with the patients what they learned about themselves in carrying out the task. This, along with the therapist’s own observations, will help guide the topic selection and pacing of future sessions.


Explore Resistance: Some patients literally do the practice exercise in the waiting room before a session, while others do not even think about their practice exercises. Failure to implement coping skills outside of sessions may have a variety of meanings: patients feel hopeless and do not think it is worth trying to change behavior; they expect change to occur through willpower alone, without making specific changes in particular problem areas; the patients’ life is chaotic and crisis-ridden, and they are too disorganized to carry out the tasks; and so on. By exploring the specific nature of patients’ difficulty, therapists can help them work through it.


Praise Approximations: Just as most patients do not immediately become fully abstinent on treatment entry, many are not fully compliant with practice exercises. Therapists should try to shape the patients’ behavior by praising even small attempts at working on assignments, highlighting anything they reveal was helpful or interesting in carrying out the assignment, reiterating the importance of practice, and developing a plan for completion of the next session’s homework assignment.


Stages of Addiction

The stages of addiction treatment described here are:

          Treatment Initiation

          Early Abstinence

          Maintenance of Abstinence

          Advanced Recovery

As with other stage theories of development, the stage theory of addiction recovery is only a model. Individuals pass through the stages at their own pace, the stages are overlapping rather than discreet, and individuals may slip back at points and need to rework issues from previous stages. This theory does not, however, discount the considerable usefulness of having a model of the typical process in mind so that the patient’s place in his or her own recovery than can be compared with the model for better understanding the patient’s process and the steps needed to be taken to proceed.

Appropriate treatment for chemical addiction varies and is sensitive and responsive to the changing needs of the patient throughout his or her recovery. The addiction counselor should understand that addiction treatment must be progressive, just as the patient’s recovery process is progressive. To provide optimal counseling, the counselor must be sensitive to the patient’s evolving needs in treatment. To ensure a progressive approach to addiction treatment, the counselor must be prepared to address different topics in recovery, use different kinds of interventions, and hold the patient to a different level of responsibility as he or she works toward recovery.

The counselor should prepare for each session by checking the patient’s recent urine results and recalling the major themes or issues from the previous session. The counselor must understand the progressive nature of treatment and be familiar with the topics that are appropriate to the patient’s current phase in recovery. In summary:

  • Check urine test results.
  • Recall history from previous sessions.
  • Discuss topics appropriate to the patient’s phase of treatment.

During each session, the counselor should inquire how things have been going since the last session and whether the patient has used any drugs. Reported drug use should be noted. If the patient relapses, the patient and counselor should analyze the relapse, determine what precipitated it, and develop alternatives that can be used to avoid relapsing again. This process will probably require the full session.

If the patient presents with an urgent, addiction-related problem like family arguments or financial problems as a result of the addiction, the counselor should address these problems in the session. Emphasis should be on how these problems are related to addictive behavior. The counselor’s goal is to help the patient develop strategies for dealing with the problems without turning to drugs. For example, the loss of one’s job, the serious illness of a loved one, or severe relationship problems will require acknowledgment and some attention in the counseling session. However, the main purpose of the session is the promotion of recovery from addiction, not the resolution of the patient’s other life problems.

The counselor should always give the patient feedback regarding the most recent drug screen results. If the urine test was positive for cocaine, the counselor should confront the patient with this information. Even if the patient was admitted to recent use, the counselor should discuss the urinalysis result, so the patient is reassured that the counselor is monitoring his or her efforts to abstain. If, however, the patient denies any use even though the urine sample is positive for cocaine (which is not uncommon), the counselor should view this behavior as most likely indicative of denial, underlying which might be feelings of shame. The counselor will probably want to use themes of shame or denial in addressing this disparity.

A useful approach is discussing how the patient would feel and what it would mean if he or she were using drugs. If the patient continues to insist that there has been no cocaine use, the counselor probably should just drop the matter and agree to disagree for the present. Continuing to confront without moving the counseling anywhere probably is unwise because the counselor risks severing the therapeutic connection. If the patient insists that there is some type of laboratory error, the counselor may be able to split the urine and have half analyzed with a different test, or use a different screening procedure, such as a saliva test.

If nothing urgent must be addressed in the session, the counselor and patient should discuss the addiction-related topic(s) most relevant to the patient’s current needs in recovery. The topics central to recovery from cocaine addiction, and the stage of recovery they are particularly associated with are described in the next section. No more than two new topics should be introduced to the patient in a session. However, any topics that have already been introduced to the patient can be reviewed, if appropriate.




All people are different when it comes to their experience with addiction and mental illness. Some begin to experience mental health issues during childhood or adolescence and experiment with drugs and alcohol soon after, developing both an addiction problem and a serious mental illness at the same time.

Others may seek out drugs and alcohol in an attempt to “self-medicate” a mental health issue that develops in early adulthood or that develops out of an injury or trauma later in life.

Still, others may first develop an addiction problem that grows so severe that it causes mental health issues or triggers the onset of symptoms that may otherwise have remained dormant.

Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of both mental health and a substance-use disorder.

People with mental health disorders are more likely than people without mental health disorders to experience alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed untreated, or under-treated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Increasing awareness and building capacity in service systems are important in helping identify and treat co-occurring disorders. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services.

The term co-occurring disorder replaces the terms dual disorder and dual diagnosis when referring to an individual who has a co-existing mental illness and a substance-use disorder. While commonly used to refer to the combination of substance use and mental disorders, the term also refers to other combinations of disorders (such as mental disorders and intellectual disability).

Clients with co-occurring disorders (COD) typically have one or more disorders relating to the use of alcohol and/or other drugs as well as one or more mental disorders. A client can be described as having co-occurring disorders when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from another disorder.

Common examples of co-occurring disorders include the combination of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and poly-drug addiction with schizophrenia, and borderline personality disorder with episodic poly-drug abuse. Thus, there is no single combination of co-occurring disorders; in fact, there is great variability among them.

The combination of a substance use disorder and a psychiatric disorder varies along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Additionally, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

People with co-occurring disorders often experience more severe and chronic medical, social, and emotional problems than people experiencing a mental health condition or substance-use disorder alone. Because they have two disorders, they are vulnerable to both relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric distress, and the worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specifically designed for the unique needs of people with co-occurring disorders. Compared to patients who have a single disorder, patients with co-existing conditions often require longer treatment, have more crises, and progress more gradually in treatment.



Over time, numerous terms have been used to describe co-occurring disorders and their treatment.

Substance Abuse, Substance Dependence, and Substance-Induced Disorders

Substance use disorder in DSM5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience.

The DSM 5 recognizes substance-related disorders resulting from the use of 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances. Therefore, while some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.

There are two groups of substance-related disorders: substance-use disorders and substance-induced disorders.

Substance-use disorders are patterns of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result.

Substance-induced disorders, including intoxication, withdrawal, and other substance/medication-induced mental disorders, are detailed alongside substance use disorders.

Substance use disorders span 11 different criteria:

  1. Taking the substance in larger amounts or for longer than you’re meant to.

  2. Wanting to cut down or stop using the substance but not managing to.

  3. Spending a lot of time getting, using, or recovering from use of the substance.

  4. Cravings and urges to use the substance.

  5. Not managing to do what you should at work, home, or school because of substance use.

  6. Continuing to use, even when it causes problems in relationships.

  7. Giving up important social, occupational, or recreational activities because of substance use.

  8. Using substances again and again, even when it puts you in danger.

  9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.

  10. Needing more of the substance to get the effect you want (tolerance).

  11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.


The DSM 5 allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder1; four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” for certain substances and “in a controlled environment.”

Mental Disorders

The standard use of terms for non–substance-related mental disorders also derives from the DSM 5. These terms are used throughout the medical, social service, and behavioral health fields.

The major relevant disorders for co-occurring disorders include schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, and personality disorders.

The major relevant categories of mental disorders that frequently occur with substance abuse issues include:

  • Schizophrenia and other psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Factitious disorders
  • Dissociative disorders
  • Sexual and gender identity disorders
  • Eating disorders
  • Sleep disorders
  • Impulse-control disorders
  • Adjustment disorders
  • Personality disorders
  • Disorders usually first diagnosed in infancy, childhood, or adolescence


5 Most Common Mental Disorders Associated with Specific Addictions

Some conditions seem destined to come in pairs. Heart disease often follows a diagnosis of diabetes, for example, and allergies often come hand in hand with asthma. The same sort of joining effect sometimes takes hold when an addiction is in play. In fact, it’s quite common for certain drugs of abuse to be entangled with specific mental health disorders.  

These are five of the most common mental health/addiction combinations in play today.


Alcoholism and Anti-Social Personality Disorder

Alcohol abuse is associated with a number of mental health concerns, including:

  • Mania
  • Dementia
  • Schizophrenia
  • Drug addiction

According to the National Institute on Alcoholism (NIAAA), antisocial personality disorder (ASPD) has the closest link with alcoholism, as people who drink to excess on a regular basis are 21 times more likely to deal with ASPD when compared to people who don’t have alcoholism. Often, the two disorders develop early in life, the NIAAA says, but alcoholism can make the underlying mental illness worse, as people who are intoxicated might have lowered inhibitions, which makes their antisocial behaviors more prevalent.  


Marijuana Addiction and Schizophrenia

It’s not unusual for people who have schizophrenia to develop addictions. In fact, a study in the American Journal of Psychiatry suggests that about half of all people with schizophrenia also have a substance abuse disorder. However, there’s a particularly striking association between marijuana abuse and schizophrenia. It’s unclear why people with schizophrenia would abuse this drug, as it seems to produce many of the same symptoms these people experience when in the midst of a schizophrenic episode, but it is clear that marijuana abuse is at least somewhat common in those who have schizophrenia.


Cocaine Addiction and Anxiety Disorders

People who abuse cocaine often take the drug because it makes them feel euphoric and powerful. However, continued use seems to lead to symptoms that are more indicative of an anxiety disorder, including:

  • Paranoia
  • Hallucinations
  • Suspiciousness
  • Insomnia
  • Violence

These symptoms may fade away in people, who achieve long-lasting sobriety, but sometimes the damage lingers and the unusual thoughts and behaviors stick around even when sobriety has taken hold.


Opioid Addiction and PTSD

Post-traumatic stress disorder (PTSD) is a mental illness that takes hold in the aftermath of a very serious episode in which the person was either facing death or watching someone else die. Often, people who survive these episodes emerge with very serious physical injuries, and often, those injuries are treated with prescription painkillers. These drugs can also boost feelings of pleasure and calm inside the brain, and sometimes people who have PTSD are moved to abuse their drugs in order to experience euphoria. While people in physical pain do need help to overcome that pain, blending PTSD with painkillers can lead to tragic outcomes that no one wants.


Heroin Addiction and Depression

While heroin can make users feel remarkably pleasant in the short term, long-time users can burn out the portions of the brain responsible for producing signals of pleasure. In time, they may have a form of brain damage that leads to depression. They’re physically incapable of feeling happiness unless the drug is present. This drug/mental illness partnership is remarkably common, but thankfully, it can be amended with treatment and sobriety.



The symptoms of co-occurring disorders include those associated with the particular substance abuse and mental health conditions a person has. Co-occurring disorders can be difficult to diagnose because the symptoms of substance abuse or dependence can mask the symptoms of mental illness, and vice versa.

As stated, substance abuse is a maladaptive pattern of substance use that occurs despite the individual’s experiencing significant substance-related problems. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, substance use at lower levels might be more harmful (and therefore defined as abuse) than for individuals without such disorders.

People with co-occurring disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses such as HIV and hepatitis B and C, and early death. Anyone of these problems complicates the treatment of co-occurring disorders.



Mental health and substance abuse disorders often occur as a result of biological and environmental factors. Mental disorders and addiction are each a dynamic process, with varying degrees of severity, rate of progression, and symptom manifestation. Both types of disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk), and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

People with mental health disorders are more likely than people without mental health disorders to experience alcohol or substance-use disorder. Mental illness can lead people to use alcohol or drugs to make themselves feel better temporarily. In other cases, a substance-abuse disorder triggers or in some other way leads to severe emotional and mental distress.



To provide appropriate treatment for co-occurring disorders, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services recommends an integrated treatment approach. Integrated treatment is a means of coordinating substance abuse and mental health interventions, rather than treating each disorder separately and without consideration for the other.

Integrated treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Integrated treatment may include the following:

  • Help patients think about the role that alcohol and other drugs play in their life. People feel freer to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
  • Offer patients a chance to learn more about alcohol and drugs—how they interact with mental illnesses and with other medications—and to discuss their own use of alcohol and drugs.
  • Help patients become involved with supportive employment and other services that may help the process of recovery.
  • Help patients identify and develop recovery goals. If a person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated treatment can help that person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
  • Provide counseling specifically designed for people with co-occurring disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

All substance-abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with CODs. It is the responsibility of each provider to identify clients with both mental and substance use disorders and to assure them that they have access to the care needed for each disorder.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD’s. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location where clients are based on the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), client fears of being seen as mentally ill (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not the diagnosis. The four quadrants are

I.  low addiction/low mental illness severity
II.  low addiction/high mental illness
III. high addiction/low mental illness
IV.  high addiction/high mental illness

The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers in order to deliver appropriate care to every client with co-occurring disorders.



Many clients with COD require medication to control their psychiatric symptoms. Pharmacological advances over the past decade have produced antipsychotics, antidepressants, anticonvulsants, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.


Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance-abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse-prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use drugs or drink.


Group Therapy

Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.


Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings. Some offer several hours of weekly treatment, which can include mental health and other support services as well as individual and group counseling for substance abuse. Others provide minimal services, such as one or two brief sessions to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Individuals with COD often need a range of services besides substance-abuse treatment and mental health services. Generally, important needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse-prevention interventions after outpatient treatment need to be modified so that clients can recognize symptoms of psychiatric or substance abuse relapse on their own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly, since the return of psychiatric symptoms can often trigger a substance-abuse relapse.


The Medical System

Although not substance-abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health interventions do occur in medical units. Acute care refers to short-term care provided by intensive-care units, brief hospital stays, and emergency rooms (ERs). Providers in acute-care settings are not usually concerned with treating substance-use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance-abuse treatment but may be able to provide brief interventions and treatment referrals.

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with co-occurring disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. Because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with co-occurring disorders. At that point, the person with COD can be referred for appropriate services in the proper setting.



Some people look forward to the day they leave home so as to leave their family and childhood problems behind. However, many find that they experience similar problems, as well as similar feelings and relationship patterns, long after they have left the family environment. We learn so much from our family of origin, both positive and negative patterns frequently get repeated.

A healthy family system functions out of love, care and concern for its members in a manner, which creates and maintains order through consistent behavior. This system furthermore, seeks balance when that order is upset by the crisis by means of flexible problem solving and decision-making skills. Roles in a healthy family are determined by natural birth-order with clearly noticeable boundaries set-up through behavior from parent to child and sibling-to-sibling. Rules that affect the functioning are set for as long as they are deemed appropriate and developmentally necessary and are changed as needed in ways that offer all members clearer choices about their behavior. A healthy family, therefore, functions in loving, life-affirming, educative, disciplined, creative, and responsible ways that offer growth opportunities through agreement/disagreement and/or individual choice.

When chemical substances or obsessive/compulsive behaviors are introduced into, maintained or used by members to delay, cope with or kill the pain of crises, adequate problem-solving skills begin to breakdown because there is no longer a baseline of consistent behavior or a rational thinking process that can support those skills or the skills needed for flexible decision-making.

Various theories relating to family therapy have been developed over the past 50 years to assist the counselor when working with a dysfunctional family. Some of the more prominent theories are introduced in the following paragraphs.  

Behavioral Family Therapy

Behavioral family therapy suggests that all behavior is learned and thus can be unlearned. Leading experts in the field of behavioral family therapy include Gerald Patterson, Richard Stuart, Robert Liberman, Neil Jacobsen, and Gayola Margolin.

Although the goal of this therapy would be to modify behavior, i.e., change or control the triggers of substance use; change the family’s codependent reactions to the substance abuser, etc., using behavioral techniques to modify behavior without looking into the underlying dysfunction in family relations is can be of limited effectiveness. For example, family members may be trained to eliminate substance use and codependency to substance use. Such techniques will not be successful, however, if the family patterns of communication continue to be dysfunctional.


Structural Family Therapy

This model suggests that chemically dependent families respond best to interventions that use a “here and now”, “directive” and “concrete” approach. Structural family therapy offers a clear, precise framework for understanding and treating family dysfunction. A core belief is that improvement in the family will result in improvements in individuals in the family. Salvador Minuchin developed structural family therapy.

Proponents of this model suggest that dysfunctional behaviors, including substance abuse, occur when there are unclear levels of power and authority within the family, when mutual expectations are misunderstood and when rigid or diffuse boundaries exist within the family.


Strategic Family Therapy

Strategic family therapy emerged in the 1970s as an offshoot of the communication model of family therapy. Strategic family therapy focuses on the interaction patterns that maintain problematic behavior and uses problem-oriented strategies to disrupt those patterns. The focus is on establishing specific goals to address identified symptoms. There are three primary “schools” of strategic family therapy: Jay Haley and Cloe Madenes’ problem-solving approach combines structural theory and communication theory. The focus is on the presenting problems and the sequence of family events that maintain them. The Milan group (Selvini Palazzoli) subscribes to indirectly approaching chemical dependence in the family unit by using “positive connotation”, (a form of paradoxical relabeling), giving the family an injunction not to change, which soon leads them to changes. Mental Research Institute’s “brief family therapy” is associated with the work of Bateson and Erickson. This approach is primarily communicational and often lasts only ten sessions or fewer.

The therapeutic goal of strategic family therapy is not to change the family but to resolve the family’s current problem as efficiently and quickly as possible. They believe that resolution of the current problem will naturally lead to positive change in the family structure. Don’t we all wish this approach was always successful?


Communications Family Therapy

The communication model proposes that substance abuse, as family dysfunction, results from faulty communication patterns. Such communication problems might result from “double bind”, (contradictory messages with primary and secondary injunctions), or might result from a lack of problem solving or interpersonal skills. The belief is that family interactions are governed by family “rules” (often covert and that the purpose of the rules is to maintain family homeostasis). Contributors to this theory are Bateson, Satir, and Haley. The goal of communication therapists is to alter the interactional patterns that maintain the presenting symptom. Satir identified five styles dysfunctional families adopt when communicating with one another: placating, blaming, computing, distracting and leveling. Satir describes games that families play as being either for survival: rescue games, coalition games, lethal games; or for growth.

Communication therapy is active and directive, following a fixed treatment sequence and involving a great deal of teaching.


Family System Model

This model prescribed to the belief that each family member is directly interrelated to the others and change in the family member necessitates a change in other family members. The research and development of family systems therapy are attributed to Murray Bowen. Because the family is viewed as a system, the etiology of chemical dependence is viewed primarily in terms of the interrelationships among family members. Within this perspective, substance abuse is seen as a homeostatic mechanism that serves to maintain the family’s sense of balance. The idea of homeostasis suggests that other family members will attempt in covert ways to maintain the chemical dependent’s behavior to maintain a comfortable and familiar balance in the family. In essence, the chemical-dependent system is a system in which alcohol or other drug consumption is a major organizing principle for the patterns of interaction in the family. In a family system with a chemical-dependent member, the substance use often occupies a key position as a core identity issue for the family.


Theoretical Summary/System Theory Detailed

The aforementioned theories all have value and each may be beneficial in a specific situation and with certain family situations. However, individuals and families are unique and frequently if a therapist gets “locked in” to one technique it can lead to detrimental outcomes in counseling sessions. Said slightly different, we have proven that the concept of “one size fits all” does not work and this also holds true in family counseling. The therapist must be knowledgable and flexible so that they may match the appropriate counseling concept to the specific need of the family they are working with.

It is recommended that therapists working with families be knowledgeable in system theory.   This approach has proven effective and is generally favored by most family therapists. Initially, it must be recognized that families are multifaceted and are typically very complex with numerous interactions between individuals and others. Some interactions are direct and easily understood while others may have hidden agendas and are generally difficult to comprehend and understand. With this degree of complexity, and organizational orientation is effective when attempting to understand relationships within the family and interactions with others outside the family. Consequently, the orientation of the system is frequently the universally accepted framework by which to view the family. An overview of selected system concepts follows.

A system is a group of elements, which interact to form an organic whole. For example, a tree, an automobile, a nation, a family may all be viewed as systems. In each of these, the parts interact in ways, which maintain integrity and balance with the whole entity. Consequently, the actions of one part affect the actions of the other parts, which, in turn, change the first part; the components of a system are interdependent. In families, one can observe members reacting to each other in this circular, interdependent fashion, as in the following examples:

  • The more parents question a teenager about his or her whereabouts and activities, the briefer and less informative the teenager becomes, which prompts more questions, etc.

  • To the degree the father is strict with the daughter, the mother becomes more protective.

  • To the extent the grandmother spoils the grandchildren, the mother becomes more accommodating with them to win back their affections. The father reacts with more authority toward the children, displacing onto them his anger at the permissiveness of his wife and mother-in-law.

  • The process continues along the lines of ‘equal and opposite’ reactions to many of the issues that arise in the family.

A family has a “set” of ingrained characteristics and the better a counselor gets to know and understand them the easier and more productive working with a family can be. For example, a family has:

  • A structure and hierarchy: Different roles are defined for different members and power is not distributed evenly.

  • Powerful rules of conduct: Most of which are unspoken and unacknowledged.

  • A set of politics: Particular members are closer to some members than to others; two members will support each other against a third; one member may temporarily defer to another out of self-interest. The politics may change depending on the situation.

  • Habitual patterns: The content of the interaction between member’s changes, but how they deal with the content tends to be repetitive.

  • A history: Anyone who becomes involved in a family, step into their history.

  • Influencers from the outside: From the extended family, from the neighborhood, from the work and school community, form the environment.

  • A tendency to resist change: A family, like an individual, has a sense of self, and it will resist a challenge to its self-definition.

The systems-oriented counselor will focus on the following:

  • Treat the family, rather than individuals, as the primary unit of change. Individual change is assumed to be created within relationships in the family. Mapping is a technique, which brings family relationships into focus.

  • Use a broad definition of “family” to include anyone who may be enabling the problem to continue or who may be a resource for solving it.

  • Be aware that a change in one relationship may produce a change in another. When the mother and stepfather begin to work more effectively together, the siblings may get along better.

  • Take a wide-angle view of the physical and social context of the problem—the home, extended family, neighborhood, community, and culture. A systems orientation urges the practitioner toward a broad network focus.



The counselor works more with the reciprocal relationships between the family members than with the individual dynamics of each member. Even while talking to individual members, the systems counselor is exploring family patterns and repetitive sequences or actions and reactions between members. The family functioning is the target for change.

The systems-oriented counselor is the manager and director of the session—sometimes focusing on individuals, sometimes spotlighting the interaction between two or more members, and sometimes stepping back to see the family as a whole. To keep a balanced view and to understand the family balance, the counselor is working with sets of relationships, not individuals acting independently.


Examples of systemic questions and comments by the counselor:

  • To father, while mother and son are talking: “Where are you in this conversation?”

  • (To son): “I noticed that when you are silent, you may be sending a message to your parents. Could you find out what message they are getting?”

  • (To daughter): How does your mother react when your father and brother have a disagreement?”

  • (To mother and father): “Each time the two of you disagree, your daughter interrupts your conversation. Could you find out from her what this is about?”

  • “Who outside the home is aware of and concerned about the problem?”

Learning to work interactionally and systemically takes some adjustment, since most counselor education and training is individually oriented. Be patient and it will become easier over time.


The Family’s Response

The stages that a family goes through to come to grips with alcoholism (and/or other addictions) was first described by Joan Jackson in her classic monograph “Alcoholism and the family” in 1954. Her research was developed through meetings and interactions with members who were known as AA Auxiliary. Later the auxiliary became what we now know as Al-Anon. Her research was based upon a family in which the husband and father was the alcoholic. However, later finding have concluded that the stages may be viewed as describing any family with an alcoholic (and/or other addictive) members. The following six stages are identified and discussed in the sequence they normally occur in a substance-related dysfunctional family.



  • Denial is when family members initially explain excessive use of alcohol and/or other drugs away. For example, early in the emergence of alcoholism, drinking is explained away because it is due to tiredness, worry, nervousness or a bad day at work or some other similar reason. The assumption is that the episode is an isolated case and therefore is not problematic. Most time the excessive drinking may be in conjunction with a social event where it is customary for persons to over drink.

Early Problem Solving

  • The addicted spouse’s partner recognizes that use is not normal and attempts to pressure him or her into either reducing the amount consumed or to stop altogether. Typically, neither of these suggestions are followed long term. The next attempt is to use psychology and to pressure him or her to quit by using phrases such as “pull yourself together and use some will power” or, “if you really love me you will stop”. Again, this approach is seldom successful and it generally results in the alcoholic beginning to mask how much and how often he or she drinks and also to drink outside the home. At about this stage, the children began to exhibit problems in response to the family stress.

  • Some psychologists indicate the early attempts to eliminate or reduce alcoholism in the family have been successful and in such cases, neither formal substance abuse treatment nor support groups such as Alcoholics Anonymous (AA) are needed. However, the consensus is that professional help is warranted in most cases to protect against denial and the progression of alcoholism from social drinking to dependence. If it is not addressed and treated as a primary disease the family outcome is generally catastrophic. Historically, the danger for families at this point is that they might enter into a general counseling program with clergy, a family friend or a social worker that fails to address the problem head-on. This “general counseling approach” could be a way for the alcoholic to continue drinking and for both partners to pretend to be doing something about it. Substance abuse professionals are generally more knowledgeable about the symptoms of excessive use and how the disease of alcoholism progresses; consequently, the chances of alcohol problems going undetected are less likely.


Disorganization and chaos

  • The family system becomes disorganized and chaotic. The spouse can no longer keep everything under control and pretend everything is okay and he or she spends most of their time going from crises to crises. Typically families began to encounter physical, psychological and financial problems. Spouses may seek help from friends who know less than they about alcoholism or they may turn to the family clergy. Often they seek help from the family physician who might treat the symptom by prescribing a tranquilizer when confronted by the distraught condition. If at this stage the nonalcoholic partner seeks professional assistance and/or becomes involved with support groups the process may take a different course altogether.


  • Coping strategies have been developed and strengthened and the enabling partner gradually assumes the larger share of responsibilities for the family. This often means seeking employment outside the home and assuming complete financial control of the family. The major focus is directed toward family survival as opposed to “getting” their partner to change his or her behavior. In essence, the nonalcoholic spouse takes charge and develops a functioning family system even though the alcoholic partner may still be in the home. This concept can have important implications for the welfare of children in the family. Children fare better in families in which the family rituals are maintained, whether these are celebrations such as holidays, birthdays or other things “we always do together”.



  • Families with alcoholism have a high rate of separation and/or divorce. In many cases, the nonalcoholic spouse may not have any other viable option other than to separate. This is especially true if spousal abuse or domestic violence is present. If the family unit remains intact, the family continues living around the alcoholic member.


Family Reactions To Chemical Addiction

Denial, as noted previously, is the first stage that a family goes through when they are faced with a family member that abuses alcohol and/or other drugs. It is also considered the most prevalent and measurable reaction to chemical addiction in the family. For example, with most co-dependents, denial arises from the need to not have happen what is indeed happening. This is not happening; he cannot be an alcoholic because… the only reason his drinking has increased is because his boss stays on his back all the time; I promised myself that I would never marry anyone like my father and I didn’t, he is not nearly as bad; it’s those people that he hangs around with…The list goes on to infinity but the bottom line is that they refuse to accept that a problem exists in their family. Also, most families are in denial regarding denial and choose to blame others and situations outside the home for their problems. Unfortunately, denial is a major obstacle to effective treatment, as it is difficult to help someone who does not recognize they have a problem. Consequently, the first major challenge of family counseling is to help the family recognize the problem and to be willing to work together to make the necessary changes to fix the problem.

Bargaining begins when family members begin to recognize the problem and attempt to eliminate it. Example of typical bargaining sessions go something like this: I will stop complaining if you will stop drinking or using whichever the case may be; if you don’t stop I will file for divorce; beg; coerce; threaten; plead; cry; agree to comprise (you don’t have to go to treatment, just don’t drink at home- Just cut down; just switch from hard liquor to beer); or a million other things to attempt to get the alcoholic to recognize the pain that he or she is putting the family through. Excessive use of alcohol and/or other drugs is selfish. It’s doing exactly what the individual wants to do without regard to how it might affect others—generally the ones the alcoholic claims to love the most.

Disorganization and dysfunction begin to occur in the family structure. The family system begins to break down. Crises occur almost continuously and the family spends most of their time “putting out fires”. Crises may include financial problems, trouble with the authorities, loss of employment, stress-related illnesses and disintegration of family values.

Reorganization is marked by frantic attempts to restore sanity and balance to the family. The family system generally reorganizes with new roles to adjust to the chaos and pain.

Adjusting Mechanisms

Both the chemically dependent and the family members use adjusting mechanisms as a coping technique for surviving in a chemical-dependent system. The mechanisms may be either conscious or subconscious. The most frequent defense mechanism used by dependent individuals is denial. This denial, in essence, ignores the problem. The average length of time between the first accusation of being an alcoholic and recovery of the family system is 13 years. Using denial for that length of time creates an ingrained attitude. The stages of braking denial are admission, acceptance, and action. Other adjustment mechanisms include:

  • PROJECTION: Blaming others for our actions, reactions, and feelings. By putting the blame outside of him/herself, doesn’t have to change.

  • RATIONALIZATION: Making logical but unrealistic excuses for behavior.

  • WITHDRAWAL: Figurative, sometimes literal removal from the source of hurt. Usually accompanied by feelings of inadequacy and inferiority.

  • AGGRESSION: Designed to protect vulnerability and at times to manipulate others. Most often verbal but can be physical. Also can be implied (i.e., ignoring someone, walking away, etc.).

  • CONVERSION REACTION: Converting emotional problems into physical problems.

  • DISPLACEMENT: scapegoat someone or something else for the problem.



  • Always do the right thing (except that no one has told you what the right thing is).

  • If it doesn’t go as planned blame someone or something.

  • Always be in control; use whatever works: seduction, abuse, or martyrdom.

  • Never talk about “it”.

  • Don’t expect accountability or consistency.

  • Stay out of touch with your feelings

  • Above all: deny, deny, deny


Rules In The Chemically Dependent Family

Rule 1:  The dependent’s use of a chemical substance is the most important thing in the family’s life. For example, he or she is obsessed with maintaining his or her supply, and the rest of the family is just as obsessed with cutting it off. While he or she hides bottles, they search for them. While he or she stockpiles, they pour liquor down the drain. Like two football teams, their goals lie in opposite directions, but they are all playing the same game. They will plan their days around the dependent’s drinking hours—to be sure that nothing interferes to frustrate his or her plans, or to arrange to be home in order to meet his or her demands, or to arrange not to be home in order to avoid his or her fury or possible embarrassment in front of their friends. The dependent’s use of alcohol is the overriding family concern around which everything else revolves.


Rule 2:   Alcohol and/or other drug use are not the cause of family problems. At first, the user and his family deny that he or she is abusing any substances. When the dependency is glaringly evident, they insist that it is only a complicating factor or the result of the problems, not the root of whatever difficulties have led them to seek help.


Rule 3:  Someone or something else caused the dependency: He or she is not responsible. Here the dependent’s increasing tendency to project his or her guilt and to blame someone else for his or her situation gets crystallized into a rule and imposed on the rest of the family. The scapegoat may be his or her spouse or a child in trouble or a job he or she does not like—anything. Curiously, the scapegoat often goes along with the allusion and is overwhelmed with guilt and feelings of worthlessness.


Rule 4:  The status quo must be maintained at all times and costs. It is easier to understand the extremely rigid ways an alcoholic family responds to change by looking at a mobile of a group of butterflies. If a butterfly were to become snagged on some outside object, the string with which it is attached would pull taut and the supporting sticks would become rigid. Something similar happens when one family member gets snagged on a chemical. What’s more, he or she is afraid to get unsnagged, for he or she feels that without it they could not survive. So as rule-maker, he or she makes sure that the sticks and stings of the family system stay rigid enough to protect him or her from change.


Rule 5: Everyone in the family must be an enabler. When members of an alcoholic family are asked how they feel about the dependent’s drinking, they are quick to say that they would do anything to get him or her to stop. But all the while, they are unconsciously helping him or her to continue— “enabling” him or her to continue to use. One person in the family plays the role of the chief enabler, but according to this unwritten rule, everyone else must do their part also to protect the dependent and his dependency. They alibi for him, cover-up, take over his responsibilities and accept his rules and quirks docilely rather than rock the boat. These actions may be defended on grounds of love or loyalty or family honor, but their effect is to preserve the status quo.


Rule 6:  No one may discuss what is really going on in the family, either with one another or with outsiders. This is exactly the sort of rule we would expect in a system as unhealthy and closed as a dependent family.   Feeling threatened, the rule-maker tries to avoid letting people outside know about family affairs—specifically the degree of his or her dependency and the magnitude of its impact on his spouse and children— and, letting family members have access to new information and advice from outside that might undermine their willingness to enable.


Rule 7:  No one says what he or she is really feeling. This is a standard rule in severely dysfunctional families. The rule-maker is in so much emotional pain themselves that he or she simply cannot handle the painful feelings of his or her family, which makes his or her own feelings even sharper. As a result, communication among family members is severely hampered. What there is tends to be rigid, distorted, and incomplete, the messages bearing little resemblance to the real facts and feelings that exist.

Eventually, as his or her disease advances, the alcoholic completely represses his own feelings and unconsciously puts in their place false emotions that are less painful. These are the feelings that seem on the surface to prompt his or her actions. But to those of us who know him or her well, their performance is not quite convincing. They may respond as though they took his or her behavior at face value, but at some level, they sense a second, subliminal message coming from the real self that he or she has repressed.

They are thus confronted with contradictory messages coming from different parts of the dependent. One they hear with their rational minds, the other with intuition. They feel confused because the two messages are saying such totally different things:

 “If these kids would show a little responsibility for money, I wouldn’t have to be so hard on them.”   I’m so worried I’m going to lose my job because I’ve called in sick so many Monday mornings.


“If you were more affectionate, I wouldn’t stay out late at night” (I know I’m not satisfying to you—I don’t know what has happened to me lately).


“Why should I go to church? That new minister is only interested in money.” (I’m no good. I can’t face the minister, or the congregation either.)

Most often, the false emotion expressed in his or her behavior is the opposite of the true emotion that lies underneath. Aggressiveness masks fear; blaming masks guilt; controlling masks helplessness. But, ironically, his or her behavior evokes the same painful feelings in family members that the dependent is feeling underneath. In the table below we can see the dynamics of contagion by which the family members gradually come to manifest the psychological symptoms of alcoholism.



TRUE FEELINGS          BEHAVIOR                   FEELINGS


Guilt, self-hatred              Self-righteousness,          Guilt, Self-hatred



Fear                                Aggressiveness, anger     Fear


Helplessness                   Controlling (of others)     Helplessness


Hurt                                Abusiveness                    Hurt


Loneliness,                      Rejecting                        Loneliness,

Rejection                                                               rejection


Low self-worth                Grandiosity,                    Low self-worth





Family Mapping

A technique of using symbols to depict family relationships is referred to as mapping. The map indicates who is aligned with whom, who has close relationships, who has distant relationships and who is in conflict with whom. The map also shows who is the authority figure and has the most influence in the family. A map may be multi-generational, is subjective rather than factual and gives little social history. In general, a map is informational about the current relationships and situations between members.

The purpose of the map is to help the counselor to organize and display his or her impressions of the family, help to maintain a systems focus for the counseling sessions and to indicate a broad goal for counseling with the family.   The symbols used and what they mean are as follows:


Ö                          Female


ڤ                          Male


Ö m                      Mother


ڤ f                        Father


Ö f/age                  Female child/age


ڤ m/age                Male child/age


Map characteristics:

  • Relative size of the figures indicates apparent power in the family.

  • Identified Patient (IP)—The IP is identified by placing IP below his or her symbol.

  • Boundary line is shown to separate between parents and children

  • Relationships are indicated by different lines between members:


Dashed line: Less than normal connection

Single solid line: Normal connection

Double solid line: More than normal connection

Triple solid lines: Enmeshed

Diagonal slashed line: stressful relationship

Diagonal line: Argumentative/no physical conflict

Double diagonal lines: Infers verbal conflict, mild physical conflict

Triple diagonal lines: Heavy conflict

No symbol: Unknown relationship

Mapping an ideal family reveals the counselor’s assumptions about how the family relationships function best. For example:

  • Mother and father are of equal size (equal power in the family)

  • Children are below the parent-child boundary (clear line of authority)

  • Children are smaller than parents (parents are in control of family)

  • The older child is slightly larger than the younger (natural birth order)

  • The map has no conflict lines.

It is left as an exercise for the reader to develop the pictorial representation of this ideal family. Obviously, not may families look like that, certainly not all the time. It’s a model, an ideal; it gives a standard to aim for in counseling.

A typical family with a chemically dependent member could have the following characteristics:

  • Sever conflict between parents and a difference in size (apparent power) between them.

  • The older child is larger than mother (too much power and influence)

  • The older child is above the parent/child boundary (again, indicating too much power and influence)

  • The father and daughter are over-involved (enmeshed)

  • The daughter is in conflict with her mother and brother

  • The father-son bond is weak

  • Siblings are in conflict

Assuming the daughter is the Identified Patient (IP), the following are examples of systemic goals for counseling (while of course, the focus is on solving the presenting problem).

  • Help the parents reach an agreement regarding their limits on the daughter’s behavior. If they are more in agreement, the father –daughter closeness will decrease. This will place the daughter in a less powerful position in the family, especially in relation to the mother.

  • Explore the father-son relationship, creating conversations (enactments) between them during the sessions. If father-son become more communicative, it will also decrease the father-daughter closeness.

  • Likewise, explore the mother-daughter relationship. If they become better able to communicate, the daughter-father closeness will be diminished.

A map helps to clarify what we currently believe about the family organization and what may be contributing to the presenting problem. However. It’s a current working hypothesis about relationships and is subject to change as we learn more about the family. Again, it is left to the reader to construct the map.

There is a great deal of variability in how often dysfunctional interactions and behaviors occur in families, and in the kinds and the severity of their dysfunction. This is why it is crucial for counselors to know several techniques and recognize the most appropriate times to use each.

With new awareness and knowledge, new choices about how to live life, by discovering and changing conscious and unconscious behavioral patterns that presently cause difficulty, can be made. The family system can be taught new ways, effective ways to create change.




Founded in 1935 by Bill Wilson and Dr. Bob Smith in Akron, Ohio, Alcoholics Anonymous (AA), was founded to help alcoholics abstain from the consumption of alcohol and to “stay sober” through the sharing of their experiences with others who have had similar experiences in a protected environment.

The 12 Steps were developed later to help govern the fellowship and to establish a consistent approach to spiritual and character-building endeavors. The Twelve Traditions were introduced in 1946 to help stabilize the fellowship and to establish a consistent approach to helping all members.

AA consists of a group of men and women who have abused alcohol to the point their drinking was out of control at some time during their life. It is a self-supporting, multi-racial, multi-gender, nonpolitical, organization. The AA groups are available in most metropolitan areas in the United States, as well as in most foreign countries. There are no age or education requirements for membership. It is open to anyone who wants to do something about his or her drinking problem. AA membership has spread to diverse cultures holding different beliefs and values. The worldwide membership is currently over two million. AA sprang from the Oxford Group that was a non-denominational Christian outreach where some members found the group to help them maintain sobriety. One member was Wilson’s former drinking buddy who “got religion” and maintained his sobriety. Wilson was encouraged and decided to follow the same path which led him to a brief abstinence from alcohol and a commitment to a higher power. Wilson soon after attended his first group gathering and within days, he admitted himself to a hospital for detoxification. While under the care of a doctor, he experienced severe withdrawal symptoms that included seeing a bright flash of light, which he felt to be God revealing Himself to him. Following his hospital discharge, Wilson joined the Oxford Group and recruited other alcoholics to the group. Wilson’s early efforts were ineffective; consequently, he changed his focus to a more scientific approach with less dependence on the spiritual.

Wilson’s first success came during a business trip to Akron, Ohio, images-11where he was introduced to Dr. Robert Smith, a surgeon and Oxford Group member who was unable to stay sober. After thirty days of working with Wilson, Smith drank his last drink on June 10, 1935, the date marked by AA for its anniversaries. Bill discovered that new adherents could get sober by believing in each other and in the strength of this group. Men (no women were members yet) who had proven over and over again, by extremely painful experiences, that they could not get sober on their own had somehow become more powerful when two or three of them worked on their common problem. This, then—whatever it was that occurred among them—was what they could accept as a power greater than themselves. The initial reaction was that they did not need the Oxford Group; however, in 1955, Wilson acknowledged AA’s debt, saying “The Oxford Group had clearly shown us what to do. And just as importantly, we learned from them what “not to do”. Among the Oxford Group practices that AA retained were informal gatherings, a “changed-life” developed through “stages”, and working with others for no material gain, AA’s analogs for these are meetings, “the steps”, and sponsorship. AA’s tradition of anonymity was a reaction to the publicity-seeking practices of the Oxford Group, as well as AA’s wish to not promote itself.

The Basics of AA are:

  • The program is free
  • The program is structured around a set of “12- Steps and 12 images-6Traditions”
    to help the individual achieve and maintain abstinence from alcohol and or other drugs.
  • The program has a spiritual content that includes acknowledgment of a higher power. Each individual defines that higher power in their own way.
  • Meetings are often held in public places and are open to alcoholics and prospective AA members. Other AA meetings are “open” to anyone who wants to attend.
  • The only requirement for membership is a desire to abstain from alcohol and or other drugs.
  • You must have a severe drinking problem to join AA; however, anyone can attend open meetings.

The AA/12 step program is over seventy years old, a testament to its value in the addiction recovery process. It was visualized during the time co-founder Bill Wilson was writing the Big Book in 1938. As he was writing he became aware that a book was not sufficient within its self to enable people to overcome alcoholism; consequently, he and a host of others (including Dr. Bob) began to develop a more comprehensive program for recovery. The focus was for people to share their experiences with the use and abuse of alcohol and their attempts to overcome their alcoholism.   It utilized an individual’s belief/value system and guidelines (Traditions) to establish governess and to standardize the process of sharing their experiences. A number of steps already existed based on their personal experiences with the group and mostly by word-of-mouth; Wilsons’ intent was to put what existed under a single format and expand the program as needed. Wilson stated that writing the steps required, “no more than a few minutes”. He said that it was only when I came to the end of the writing that I re-read and counted them. Curiously enough, they numbered twelve and required almost no editing.” Those original 12 steps featured the use of God on several occasions, which Wilson reduced down to the minimum. The famous qualifier “as we understood Him” was not added until later. Beyond that, according to Wilson, the 12 steps “stand today almost exactly as they were first written.”

Alcoholics Anonymous is an international organization of individuals who have struggled with drinking at some point in their lives. It is supported by its members, and it operates independently of any outside funding. It is not affiliated with any religious or political group. The goal is to promote sobriety by “carrying its message” to suffering alcoholics. All AA members remain anonymous. The anonymity removes the stigma of identification and recognition and allows participants a more comfortable experience in recovery. Alcoholics Anonymous is open to all persons regardless of age, gender or ethnicity. A question that often comes up is whether AA is a religious organization or not? The answer is somewhat vague in that it originally focused on religion as a means to sobriety. But the program has since adopted a more spiritual focus rather than a God-centric one.



In the “Big Book”—the central text of AA that outlines the program—the twelve steps are defined as a “set of principles, spiritual in nature, when practiced as a way of life, can help expel the obsession to drink and enable the sufferer to become happily and usefully whole.” The 12 steps of AA along with a brief explanation of each are as follows:

  1. We admitted we were powerless over alcohol – that our lives had become unmanageable.

Many alcoholics have a hard time admitting that they can’t control their alcohol use. Most truly believe they can stop any time they want to; however, history and experience has proven that this is seldom the case. Once they acknowledge that they are unable to stop on their own, the recovery process can begin.

  1. Came to believe that a power greater than ourselves could restore us to sanity.

AA believes that people who are addicted to alcohol need to look to something or someone greater than themselves to recover. Sometimes a friend or a sponsor can fill this role. Oftentimes it takes a power greater than themselves. Those working the steps are free to choose whatever higher power works for them.

  1. Made a decision to turn our will and our lives over to the care of God as we understood Him.

This is the stage where the individual admits that he or she is unable to control their drinking. Typically, for this step, the alcoholic consciously decides to turn themselves over to whatever or whomever they believe their higher power to be. With this release often comes recovery.

  1. 4. Made a searching and fearless moral inventory of ourselves.

This step requires self-examination that can be uncomfortable, but honesty is essential in this process. The key is to identify any areas of past regret, embarrassment, guilt or anger.

  1. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

The key to this step is one getting honest with himself or herself and involves admitting to past poor decisions and questionable behaviors. Often, members will share this information with others and their sponsor.

  1. We’re entirely ready to have God remove all these defects of character.

This is a surrender of self and an admission that they are ready to accept help from any source.

  1. Humbly asked Him to remove our shortcomings.

This is a continuation of the surrender process that began in Step 6. It also infers that the recovering alcoholic is not strong enough to overcome his or her weaknesses on their own.

  1. Made a list of all persons we had harmed and became willing to make amends to them all.

The identification of individuals they have wronged through their alcoholism. The wrongs are left to the discretion of the individual and generally covers a range of inappropriate behaviors.

  1. Made direct amends to such people wherever possible, except when to do so would injure them or others.

This is a difficult step for many alcoholics; consequently, support from other members and their sponsor may be required to guide the individual through this process.

  1. Continued to take personal inventory and when we were wrong promptly admitted it.

Self-monitoring is essential for this step along with a willingness to change behavioral patterns that have led to inappropriate actions.

  1. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

This encourages a relationship and commitment to a higher power.

  1. Having had a spiritual awakening as a result of these Steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

This step encourages members to help others in their recovery. Many members become sponsors once they have completed the 12 steps. Since AA appeared in 1939, the program has helped millions of men and women recover from alcoholism.




images-5The Traditions govern the organization and provide the structure by which it maintains its unity and relates itself to the world about it, the way it lives and grows. The Traditions recommend that members remain anonymous in public media, altruistically helping other alcoholics and avoiding official affiliations with other organizations. The Traditions also recommend that those representing AA avoid dogma and coercive hierarchies. Subsequent fellowships such as Narcotics Anonymous have adopted and adapted the Twelve Steps and the Twelve Traditions to their respective primary purposes. The Traditions are also used to help resolve conflicts within the organization as well as with outside organizations. Most twelve-step programs have adopted these or similar traditions. The Twelve Traditions of Alcoholics Anonymous are as follows:

  1. Our common welfare should come first; personal recovery depends upon AA unity.
  2. For our group purpose, there is but one ultimate authority—a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
  3. The only requirement for AA membership is a desire to stop drinking.
  4. Each group should be autonomous except in matters affecting other groups or AA as a whole.
  5. Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.
  6. An AA group ought never to endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
  7. Every AA group ought to be fully self-supporting, declining outside contributions.
  8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.
  9. AA, as such, ought never to be organized; but we may create service boards or committees directly responsible to those they serve.
  10. Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy.
  11. Our public relations policy is based on attraction rather than promotion; we need always to maintain personal anonymity at the level of press, radio, and films.
  12. .Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

The Traditions recommend that members remain anonymous in public media and in their efforts to help other addicts. The Traditions also recommend that those representing AA avoid public attention whenever possible.   The unique characteristics associated with an addicts’ drug of choice have led to the formation of over 200 different and unique self-help organizations. For example, it is common to find Cocaine Anonymous, Crystal Meth Anonymous, Marijuana Anonymous, Nicotine Anonymous and a host of others in most metropolitan areas of the USA.   It is also common to find self-help organizations related to behavioral issues such as compulsion for, and/or addiction to, gambling, food, sex, and work and others.


          The Serenity Prayer

God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.

Living one day at a time;
enjoying one moment at a time;
accepting hardships as the pathway to peace;
taking, as He did, this sinful world
as it is, not as I would have it;
trusting that He will make all things right
if I surrender to His Will;
that I may be reasonably happy in this life
and supremely happy with Him
forever in the next.

The prayer is primarily commonly attributed to Protestant theologian Renhold Niebuhr, who composed it in the 1940’s. According to its website, Alcoholics Anonymous adopted it and began including it in AA materials in 1942, which may have done more to canonize it than any other cultural use of the prayer.

Early in 1942, writes Bill W., in A.A. Comes of Age, a New York member, Jack, brought to everyone’s attention a caption in a routine New York Herald Tribune obituary that read:

“God grant us the serenity to accept the things we cannot change, courage to change the things we can, and wisdom to know the difference.”“Never had we seen so much A.A. in so few words,” Bill writes. Someone suggested that the prayer be printed on a small, wallet-sized card, to be included in every piece of outgoing mail.

Ruth Hock, the Fellowship’s first (and nonalcoholic) secretary, contacted Henry S., a Washington D.C. member, and a professional printer, asking him what it would cost to order a bulk printing.

Early in World War II, with Dr. Niebuhr’s permission, the prayer was printed on cards and distributed to the troops by the U.S.O. By then it had also been reprinted by the National Council of Churches, as well as Alcoholics Anonymous.



imgres-5While not officially a part of Alcoholics Anonymous, the chip system is used throughout the country, and throughout the world for that matter, to mark special milestones in recovery. Various medallions are used to signify and mark varying lengths of abstinence from alcohol. These special tokens, usually about the size of a poker chip, are often given to those in recovery by their home group, sponsors (spiritual mentors), or even special friends or family members. Their intent is both to celebrate the accomplishment and to remind the recipient of their daily commitment to their personal recovery.
Needless to say, it’s not the medallions themselves that keep recovering The History of The AA Medallionindividuals sober. The importance is in the meaning behind the tokens. As those in recovery receive special tokens for one month, then two, then three months, and so on – the medallions generate a sense of pride for fulfilling their commitment to their recovery. Often a simple glance at a special token can provide motivation to continue to remain abstinent even when the thought of drinking arises. Jokingly, many “old-timers” have said to those new in recovery, “should the thought or desire to drink occur, place the medallion in your mouth. Once it dissolves, it’s then safe to take the drink.” 


images-2Keep Coming Back, It Works If You Work It, a popular slogan used to close A.A. meetings suggests that when an individual puts the work in the outcome will be positive. With 81 years behind it, two million members and 115,000 groups worldwide it would be hard to not say it has something of offer.

 The efficacy of AA/12 Step programs in treating addiction to alcohol and other drugs (AOD) is a complex subject with much debate as to its accuracy, effectiveness and repeatability. While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes other studies have failed to verify or confirm a positive contribution due to AA/12 Step participation. Most of the studies have used data gathered from individuals attending meetings run under the auspices of the AA organization. Many investigators consider this a possible bias toward a favorable outcome. 

A famous Saturday Evening Post article cited AA co-founder Bill Wilson as claiming its program enjoyed a 50% success rate immediately, and another 25% success rate after a relapse or two. The figures were repeated three years later in an article published in The American Journal of Psychiatry. These articles – and the success rates – have been cited repeatedly over the years by both supporters of 12 step programs as indicative of their success – and critics of the program, as indicative of their deliberate misinformation. Regardless of how one views the original assessment, it is very difficult to accurately pinpoint the efficacy of the 12 step programs due in part to their anonymous nature and an absolute refusal to release treatment data that could be used to identify a member; consequently, we will have to live with the information that is available until additional data is collected and analyzed.

Among the most recent assessments of the rates of success or failure comes from AA, entitled, “Alcoholics Anonymous Recovery Outcome Rates: Contemporary Myth and Misinterpretation” released on 1 January 2008. Its introduction states, “This paper is written for AA members and is intended for internal and public circulation as an item of AA historical and archival research. It is offered to help inform the AA membership and academic researchers of a widely circulated misinterpretation and mischaracterization of AA recovery outcomes” and it offers the following statistics for AA:

  • Of those in their first month of AA meetings, 26% will still be attending at the end of that year.
  • Of those in their fourth month of AA meetings attendance (i.e. have stayed beyond 90-days) 56% will still be attending AA at the end of that year.
  • The 2004 Survey showed an increase in the length of sobriety over the 2001 Survey (as has every triennial survey since 1983).
  • As of the 2004 Survey, long-term AA sobriety was so prevalent that the “Greater Than Five Years” range of previous surveys was subdivided into: 5-10 Years (14%) , >10 Years (36%), > 5 Years (50%).
  • For growth of AA sobriety ranges, the 1983 Survey showed 25% of AA members sober over 5 years and the 2004 Survey showed 50% of AA members sober over 5 years.
  • For growth of AA sobriety averages, the 1983 Survey found the average AA member sober for 4 years and the 2004 Survey found the average AA member sober for more than 8 years.

According to AA’s recent membership survey, 27% of members have been sober less than one year, 24% have 1–5 years sober, 13% have 5–10 years, 14% have 10–20 years, and 22% have more than 20 years sober. A review measuring the effectiveness of AA did not find any significant difference between the results of AA and twelve-step participation compared to other treatments. This appears to indicate that it is difficult (or nearly impossible) to value or separate out the contribution of one element of the treatment regimen. The conclusion is that the studies have failed to demonstrate that AA/12 step is a strong factor in preventing use and abuse of alcohol and other drugs when compared with other interventions.  The uncertainty could be overcome with large samples with and without specific treatment modalities. I personally think there is a residual or latent “good” that may manifest its self in many participants sometime in the future. Again, this would be difficult to measure and probably more difficult to get the recovery industry to accept without a lot of research. The bottom line is that AA/12 step is effective and needs to be constantly improved and enhanced to increase its effectiveness.

As noted previously, nailing down precise numbers on the success rates of 12 step programs is almost impossible, and generally a very biased business.

Even so, the grassroots 12-step program remains the preferred prescription for achieving long-term sobriety.

Since the inception of Alcoholics Anonymous, the progenitor of 12-step programs, science has sometimes been at odds with the notion that laypeople can cure themselves.

Yet the success of the 12-step approach may ultimately be explained through medical science and psychology. Both offer substantive reasons for why it works.

The twelve-step approach is an established program with a set of guiding principles to direct a course of action for tackling problems whether it be related to alcoholism, drug addiction and/or other compulsions.  Some meetings are known as dual-identity groups which encourage attendance from certain demographics. Some areas also have beginner’s groups as well as “old-timer” groups that limit who can share, or speak during the meeting, by the length of time the members have been in the fellowship.

In accordance with the First Step, twelve-step groups emphasize self-admission by members of the problem they are recovering from. It is in this spirit that members often identify themselves along with an admission of their problem, often as “Hi, I’m Roger, and I’m a problem drinker”. The statement also generally includes an admission that the individual is “powerless within himself or herself” over the substance-abuse related behavior at issue. The strong inferences is that there is lack of control over this compulsion, which persists despite any negative consequences that the person may endure as a result. The First Step also infers that the individual is “powerless” over the substance-abuse related behavior at issue and lacks the ability to control his or her compulsion, which persists despite any negative consequences that the person may endure as a result.

As noted previously, the principles of AA have been used to form of other fellowships specifically designed for those recovering from various pathologies; each emphasizes recovery from the specific malady which brought the sufferer into the fellowship. Demographic preferences related to the addicts’ drug of choice has led to the creation of Cocaine Anonymous, Crystal Meth Anonymous, Pills Anonymous, Marijuana Anonymous and Nicotine Anonymous. Behavioral issues such as compulsion for, and/or addiction to, gambling, crime, food, sex, hoarding, and work are addressed in fellowships such as Gamblers Anonymous, Overeaters Anonymous, Food Addicts in Recovery Anonymous, Sexual Compulsives Anonymous, Sex and Love Addicts Anonymous, Sex Addicts Anonymous, Emotions Anonymous, and Workaholics Anonymous. Also, Auxiliary groups such as Al-Anon and Nar-Anon, for friends and family members of alcoholics and addicts, respectively, are part of a response to treating addiction as a disease that is enabled by family systems. In some cases, where other twelve-step groups have adapted the guiding principles, these have been altered to emphasize principles important to those particular fellowships, and to remove gender-biased language.

The emotional obsession is described as the cognitive processes that cause the individual to repeat the compulsive behavior after some period of abstinence, either knowing that the result will be an inability to stop or operating under the delusion that the result will be different. The description in the First Step of the life of the alcoholic or addict as “unmanageable” refers to the lack of choice that the mind of the addict or alcoholic affords concerning whether to drink or use again.


FREQUENTLY ASKED QUESTION (from internet website)

  • Is personal information protected?

Anonymity is the foundation of all AA traditions. Any information that is shared in AA is treated in a confidential and protected manner.

  • Is it religious?

Alcoholics Anonymous has only one requirement for membership and that is the desire to stop drinking. There is room in AA for people of all shades of belief and non-belief. We have seen many people come to AA and refuse to accept our help because they become angry or upset when others talk of their beliefs. If you are unable to accept that others have a belief that you don’t, you will find it very difficult to come to terms with. If on the other hand you can be tolerant of other peoples’ right to believe in whatever they want to, you will find others tolerant of your rights to believe whatever you choose. Let’s make no bones about it; the 12 step regime that members follow has its origins in a Christian group. As a consequence you will see God mentioned quite often. Many members believe in God, and we have other members that come from and practice all sorts of religions; but also many are atheist or agnostic, so don’t be put off. Because it is a spiritual program (not religious) those who believe in some form of divinity often find it useful to incorporate the AA into their religious practices and vice versa. This is their choice, there is absolutely no requirement. What we all have in common is that the program helps us find an inner strength that we were previously unaware of, where we differ is attributing the source.

Whatever you do, please don’t let someone else’s religious beliefs prevent you from finding the solution that is available to you through Alcoholics Anonymous.

  • Is it a cult?

Its members are not forced to attend meetings, they are free to leave at any time and the recovery program is simply a list of suggestions which while many do chose to follow, also many chose to go their own way about it. The majority of members quite happily fit the culture of AA into their normal life and belief systems.

  • Must you be able to talk in groups and confess that you are an alcoholic?

Nobody is forced or pressured to speak at an AA meeting or to declare themselves to be alcoholic. Newcomers benefit most from listening to the experience of speakers and will have the opportunity to speak to members on a one to one basis if they choose.

  • What is the 12 Step Program?

It is a series of steps taken by the alcoholic which assist them to achieve and maintain sobriety. They include acceptance of the fact that they are alcoholic, learning to trust and rely on something outside of themselves for help, acknowledgement of and making amends for past behavior, changing present behavior and passing the help received on to other alcoholics.

  • Can people attend another center while attending AA?

Yes, members can and do attend other  treatment centers. Many people have come to AA through other centers. This continuity is useful in the recovery process.

  • Does the AA program include a Philosophy of Recovery?

AA is based around the concept of recovery from a persisting, chronic illness prescriptive. It includes the philosophy elements of belief that everyone has the potential to recover and the inherent ability to lead a satisfying, useful life.



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