Do’s and Don’ts in Psychotherapy for People Who Have Addictions

Rehab Helps Thousands of Addicts Quit. It Can Help You, Too.

All people are human beings. As obvious as this is, it is often forgotten in treatment of people suffering with addictions. Instead of seeing them as folks with a very common behavioral symptom arising from understandable human feelings and conflicts, in our society we have labeled them as though they are somehow different from everyone else, requiring a special label: “addicts,” or “substance abusers.”

It has even become routine to say these people have a distinct diagnosis: “Substance Abuse Disorder.”

Labeling Addiction

Sadly, many professionals believe that by calling a behavior a “disorder” they have done something useful, important or even scientific. The opposite is the case. Labeling behaviors as disorders or diseases tells us nothing about the cause of these problems, how they work, or how to treat them. Indeed, calling a behavior a “diagnosis” makes things worse, because it implies this is something wholly different from the all the other compulsive behaviors that we do understand quite well.

I know many very well-qualified therapists, people whom I would trust to treat my friends and family, who forget everything they know about human beings once a person with an addiction walks into their offices.-Lance DodesOnce professionals buy the idea that their patients have a disorder or a disease, they think of them differently. I know many very well-qualified therapists, people whom I would trust to treat my friends and family, who forget everything they know about human beings once a person with an addiction walks into their offices. They mistakenly think they have little to offer these people and send them off to addiction counselors who typically have far less education and training in human psychology or, just as bad, tell them that they should be in two treatments at the same time: meeting with the addiction counselor for their addictive behavior and meeting with themselves for everything else. This plan shows a gross misunderstanding of the fact that addictions are just one aspect of a person’s psychology, common emotional symptoms shared by much of humanity.

Trying to separate treatment of addiction from a good psychotherapy actually undermines the opportunity to focus on the emotional factors that create addictive thoughts, which is the most critical part of any treatment. How to do this, either for yourself or in a psychotherapy was, in fact, the subject of my book, Breaking Addiction.

All of the above suggests some guidelines for seeking psychotherapy, if you have an addiction:


  • Find a therapist who will treat you like a person. Anyone who diagnoses you with “substance abuse disorder” or a similar label is telling you he or she thinks of addiction in the most superficial way possible and is either not interested in exploring the issues behind the behavior or doesn’t understand the essentially psychological nature of addiction.
  • Find a therapist who will treat your addiction, not refer you to somebody else to deal with it. This means not sending you to an addiction counselor who almost always will be a person with little training or education in human psychology as I mentioned above, but it also means not sending you off to a self-help group. The success rate for AA is between 5% and 8%, a fact that most therapists don’t realize.

    Sending you to a non-professional support group also should raise strong suspicions that the therapist doesn’t know how to treat it as part of psychotherapy. And if you do try a 12-step approach, it’s key that you be prepared to leave quickly unless you are in that 5-8% group.

When the 12-step approach isn’t helping you, never believe that it’s because you haven’t “worked the program” hard enough. That’s a common message among 12-step members and it is both insulting and scientifically wrong.

My colleague and I reviewed all the scientific studies about this in our recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry and we found that only a small group benefits from staying longer; for the other 90%, there is no evidence that proves staying longer does any good at all).

  • In therapy, talk about the feelings and issues that preceded addictive thoughts or acts, not about the consequences of addiction, as I mentioned above (and described in Breaking Addiction). It’s understandable to spend time regretting the consequences of behavior, but it has no lasting therapeutic value. What you want to learn about is what leads to the behavior, not what follows from it.
  • Seek a therapist who understands that the occasions when you have addictive thoughts are golden opportunities to understand what made them arise, not occasions for self-criticism or a reason to try to suppress these thoughts.


  • Don’t expect a quick cure. Since addiction is not some unique diagnosis separate from the rest of human life, we should have the same expectations from its treatment as we do for any other human problem. We don’t expect a compulsion to clean your house, wash your hands, overeat, or work too much to disappear when you enter psychotherapy. Those behaviors may persist as you are working out the factors that lead to them. Even though this is self-evident, people still sometimes say they don’t have time to work out the factors behind addiction because it is so dangerous. But this reasoning is backwards.

    The fact that addictions are dangerous is all the more reason to pursue a treatment that roots out its cause. And it is important to keep in mind that the success rates of the alternative, superficial or support-based, interventions (like AA) are awful. It is one of the tragedies of modern life that so many people think they should stick with these support programs despite never getting better, losing years and decades of their lives rather than seeking a more knowledgeable treatment.
  • …the most meaningful and important changes are within a person’s inner world. Yes, those changes often show up in behavior, but not always, and not necessarily at the same time as progress is being made inside.-Lance Dodes

  • Don’t judge your progress on the basis of how much your behavior has changed. We have all been flooded with the idea that measurable behavioral results, preferably in numerical terms, are the only way to know the effectiveness of any treatment. But most of us realize that the most meaningful and important changes are within a person’s inner world. Yes, those changes often show up in behavior, but not always, and not necessarily at the same time as progress is being made inside.

    Think of a person’s self-esteem gradually improving, but there being no clear behavioral way to measure that. Or, think of a person feeling less alone in the world. He or she might make more friends, but also might just feel more at peace, and less lonely. There is simply not a good correlation between measurable behavioral change and therapeutic progress.

    Of course, everyone has the same goals with addictive behavior: having it end or, at the very least, having it cause less harm. But measuring your progress on the basis of the number of times per week you drink, eat, or clean the house should not be the basis for evaluating what’s happening in good psychotherapy.

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What Are Your Thoughts on this Topic?

  • AddictionMyth

    Many people will say, “Sure, but treatment is expensive. AA is free.” Well that’s a good point. I think attending free support groups is great. Though AA has cult-y aspects that can be dangerous for vulnerable people, so you should read up on that before attending. You don’t have to call yourself ‘alcoholic’. Instead you can say, “I drink too much.” If people try to get you to confess ‘disease’ or act inhospitable then it’s probably not the right group in the first place. (Also, it is not illegal to stand up for people who are bullied in this way under the current caliphate.)

  • Silver Damsen

    The more I read Lance Dode’s work, the more I like and respect it. He is a true voice of sanity in the wild, wild, wild world of “addiction” treatment today. I am former AA, and actually did stay sober my first year in AA and still even have this same untouched sobriety date of something over 3 and a half years, Jan 9, 2012 (but plan on eventually losing this date but that is another story).
    However, while I was sober in AA, the other aspects of its ideology demoralized me and lead me to breakdown. Believe it or not, AA tends to believe that the best treatment for those with PTSD is to intentionally trigger them even to the point of hysteria because this is believed to help the individual realize that PTSD doesn’t exist and they have control over their reactions. At least that was one reason I was given for why I would be triggered to the point of hysteria in meetings and then vilified for not having emotional control.
    Thus, I would urge even more strongly than Dodes for people not even to experiment with whether AA will work for them or not, but instead try one of the 9 or so other sobriety/moderation programs around today, and/or treat the abuse issue holistically as part of a broader psychotherapy approach. Studies indicate that AA is not working. More are dying from addiction than every before, and many of those that die have a failed experience with AA or NA.
    Yes, AA is well-known and has famous and spokespeople, especially actors. However, if you notice, most of these actors do not do all that well in AA, and in addition actors are probably not the best source of information on how to avoid a program associated with cult tactics. Indeed, while most people know that Scientology is a cult, still more than a few are happy to boast about that they are a proud part of Scientology.

    • AddictionMyth

      Your experience with PTSD is a perfect example of the crazy-making insults and bullying that people are subjected to at AA. You rile someone up and then say, “You sound angry and bitter. You know, resentments are a deathly business for the true alcoholic.” The only thing I disagree with you is that I think AA is fine as long as you don’t engage in the bullying or better yet call it out. You could be saving someone’s life.

  • Tom

    Great article. I see this as a direct attack on two-hatter therapists allied with the addiction treatment (AA) industry. I’ve written about my experience with this kind of bad therapy on

  • fattyz

    Yes, good. The “professional community” of shrinks, therapists psychologists and social workers is very difficult to navigate. Mostly they try to pawn you off on AA so someone else can worry about your “substance abuse”. I left a psychologist, a really intelligent guy with PHD’s plastered all over his office walls who was a closet stepper. He wouldn’t listen to my “anti – AA sentiments” because he had been using AA as a crutch for years in his practice. This is the kind of nonsense you’ll face as you start “therapy shopping.” Finding a good therapist is like finding a good anything, practically impossible. You have to keep trying though lol.

  • Deborah Starling

    Really interesting article! Something often overlooked by people is the scope that an addictive personality can encompass. Often people focus on certain things (drugs, alcohol) when in reality, people who suffer from addictive behaviors can often become addicted to anything. Once an addict completes a 12 step program (or anything similar) they often replace their current addiction with something new. A book I read recently entitled “Addiction is the Symptom” by Dr. Rosemary Brown (link to attempts to understand and help treat the root causes of the addictive behavior in general, instead of the specific addiction. An addict needs to move past the specifics of their addiction and figure out what they are suffering from on an emotional level that is fueling this behavior. This book provides some very poignant insight into how to heal emotionally, instead of just bandaging the symptoms.

  • bluedye33139

    A diagnosis of “substance use disorder” (there is no such thing as substance abuse disorder) means that a person has experienced distress and impairment from substance use. Most people entering treatment for addiction issues have experienced distress and impairment in role functioning because of their use pattern. If you believe that saying someone has experienced distress or impairment from substance use is a way of stigmatizing an individual, I suspect that you have misunderstood how language is being used.

    A person’s ego-dystonic substance use frequently causes unhappiness and real suffering. Few people go into treatment without having first experienced that suffering. Saying so does not mean that someone is flawed or evil or worthless as a person — it means that they have fallen into a pattern that they do not want to remain in.

    For people whose use pattern is ego-syntonic, therapy would explore a person’s beliefs and feelings regarding substance use and how it is impacting their life. Again, it would not be necessary to approach a person with a belief that they are flawed or evil or broken. Also, a substance-use counselor focuses on substance use because in most states, psychotherapists without substance-use disorder training are not licensed to do substance-use treatment. When someone has detoxed and either done inpatient or outpatient chemical dependency treatment, then they should be referred to a psychotherapist or analyst or counselor for work on the deeper issues, which SUD counselors are not licensed to do.

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