Substance Abuse and Addiction

Treatment: Practical Application of

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 Preface vii

specific, thorough applications for those dealing with substance abuse issues. Second,
I use a “running case study” approach throughout the text. The case study, introduced
in Chapter 1, is incorporated throughout the book in each chapter. Thus, students can
follow how the client is conceptualized and counseled through the different theories.
This approach has been adopted in other theories texts (see Corey, 2009).

Organization of the Book

The organization of the book is divided into three major sections. The first section
includes Chapters 1 through 4, and consists of general information related specifi-
cally to substance abuse and substance abuse and addiction counseling. Chapter 1
provides a brief introduction to the text, highlighting the importance of theory, pro-
viding information on evidenced-based practices, and presenting the full case study
to be used throughout the text. In Chapter 2, I cover important terms and con-
cepts related to addiction, models of addiction, and key ethical issues that substance
abuse clinicians need to aware. In Chapter 3, classifications of substances, physiologi-
cal and psychological effects, and physiological aspects of addiction are provided.
Chapter 4 consists of information on screening, assessment, evaluation, and diagnosis
of ­substance-related problems.
The second section of the text consists of theoretically grounded approaches
that have empirical support in the substance abuse and counseling literature. These
approaches would be considered evidence-based in that, in general, they have greater
support from scientific outcome research as to their effectiveness in treating addictions
compared to approaches described in the third section of the text. This section may be
particularly important for students or professionals whose primary agency or place of
employment places a strong emphasis on evidence-based treatment approaches.
It is important to note that the counseling theories outlined in the second section
do not have the same degree of empirical evidence for their effectiveness. For exam-
ple, some approaches (i.e., Motivational Interviewing) have more scientific support
than others (group therapy). In writing this section, I attempted to present the theo-
retical applications in order from most empirical support to least. The section begins
with Chapter 5 and a thorough review of the principles and practices of Motivational
Interviewing, followed by cognitive behavioral therapy and its application to addic-
tions (Chapter 6), relapse prevention (Chapter 7), group therapy (Chapter 8), and fam-
ily therapy (Chapter 9).
The final section of the book includes theoretically grounded approaches that
are supported by an extensive conceptual literature base, although they do not have
the empirical research support as compared to the approaches in section two. Despite
the limited outcome research, the approaches in this section provide the clinician with
a comprehensive, theoretical road map for how to conceptualize addiction problems
as well as a complete system for intervention, including strategies and techniques
consistent with the theoretical model. These approaches should not be thought of
as “inferior” to the approaches in the first section: The lack of empirical outcome
research does not render any approach ineffective. Numerous authors have noted the
implementation of these approaches in their substance abuse and addiction agencies
or private practices around the world. Several also have commented how theoretically
based treatment has provided a “breath of fresh air” from more traditional approaches
viii Preface

that lack an organizing theoretical model. This section includes solution-focused ther-
apy (Chapter 10), Adlerian therapy (Chapter 11), Gestalt therapy (Chapter 12), and
existential therapy (Chapter 13).
Within each theoretical chapter, I begin with a brief introduction, followed by an
overview of the major tenets of the theoretical approach. Admittedly, I struggled with
finding a balance between covering the theory sufficiently to provide background,
and at the same time not turning the text into a book on theories! This was easier to
accomplish for some theories compared to others. For example, the Adlerian theoreti-
cal overview is quite extensive; however, this theory is multifaceted and complex and
I thus felt a bit more at liberty to expand this section of the chapter. Other theoretical
approaches are more straightforward and thus did not require an extensive explana-
tion. Following an overview of the major tenets, I discuss each theoretical approach
as applied to substance abuse and addiction counseling, followed by a survey of tech-
niques and strategies that one could employ consistent with each theory. Multicultural
considerations and the application of each theory to diverse clientele who may strug-
gle with addiction are given focus across all theoretical chapters. This is followed by
an example of how the theory might apply to the “running case study,” demonstrating
what the theoretical approach might “look like” with the same client. Where appropri-
ate, smaller, mini case studies that highlight specific points/techniques about a theory,
how to deal with different addiction issues, and strategies with clients from diverse
backgrounds are provided throughout the text. Each theoretical chapter concludes
with a summary of strengths, limitations, and potential ethical issues.

A Comment about Word Selection

In writing about substance abuse and substance abuse counseling, an author has
many choices of words to consider. For example, does he say substance abuse, chemi-
cal dependency, addiction, substance addiction, substance dependence, or some
­combination? I have been taught to avoid labels, for example, “alcoholic,” yet many of
my clients admit they are “alcoholics” and do not mind my use of the word (although
I use it sparingly, more in a sense of asking what the term means to the client). After
all, it is their language, and if this term fits for them and does not impede the change
process, what is the big deal?
Yet, language does matter: The way we communicate with our clients has a large
impact on whether or not they show up for the next session and plays a key role in
one of the most powerful common factors in therapy—the relationship. As such, I have
been intentional about avoiding more derogatory, labeling-based terms such as addict
and substance abuser and instead tried to use the more respectful “addicted individual”
or “client struggling with substance abuse [or addiction].” I may not have succeeded in
every instance, but the intention was there. This wording of client problems was sug-
gested by the American Psychiatric Association in the latest edition of the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR; APA, 2000).
The terms substance abuse, substance addiction, substance dependence, and
chemical dependency are used interchangeably throughout the text. When the reader
comes across these terms, he or she can assume I mean “heavy substance use and
associated problems.” Although “abuse” and “dependence” are not the same thing
from a strict clinical perspective, as explained in Chapter 4, these terms will most
 Preface ix

likely be dropped from the DSM-V, due out in 2013. I believe this is a good thing;
clients struggle with substance use problems, and these problems are often on a con-
tinuum rather than separated into two distinct categories.
A couple of other points on wording are worth mentioning. Throughout the
text I use the word clinician to refer to any mental health professional who works
with clients struggling with substance abuse. Therapy, psychotherapy, and counsel-
ing are used interchangeably. In most instances, I use the term client rather than
patient, a clear influence of my clinical training. However, it is important to note that
patient is typically used more often in medical settings, and so there might be occa-
sions when patient is used within a medical context or discussion in the text. The
book has many client examples, and I took strides to include both male and female
examples.
The reader should be aware that the substance abuse treatment field probably
has more acronyms than any other professional field! Sometimes the sheer number
can be overwhelming and difficult to keep straight. At the same time, they do serve
an important purpose: Acronyms provide an easy way to abbreviate the long name
of an organization or treatment approach and are especially helpful if these names
are used frequently throughout a chapter. In most cases, I spell out the organization
or treatment approach first, followed by the acronym. Subsequent mentioning of the
organization or approach is used with the acronym.

Did you know this book is also available as an Enhanced Pearson eText? The afford-
able, interactive version of this text includes 3-5 videos per chapter that exemplify,
model, or expand upon chapter concepts. Look for the play button in the margins to
see where video is available in the affordable enhanced eText version of this text.

To learn more about the enhanced Pearson eText, go to www.pearsonhighered.com/

etextbooks.

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x Preface

Acknowledgments
From the start, I envisioned being the sole author of the book and making this a
reality required many days and nights of solo writing. However, I would be remiss
not to mention those who have been a tremendous help in putting a project like this
together. I am grateful to my department chair, Dr. Scott Young, who believed in my
ideas and encouraged me to contact my publishing representative. It was his persis-
tence that allowed me to get connected with the right people and to see the project
through. I also would like to thank my colleagues at UNCG, many of whom continu-
ously inquired about the book, how it was coming along, and provided encourage-
ment along the way.
I am indebted to Rev. Jack Hileman at Presbyterian Counseling Center in
Greensboro, North Carolina, who brought me onboard and gave me the experiences
and supervision I needed to strengthen and develop my clinical approach to working
with clients struggling with addiction. His encouragement and positive attitude are
characteristics that I strive to emulate every day. I wish to thank my research apprentice
and doctoral student, Ed Wahesh, for his assistance in organizing the literature review
for each chapter. His work saved many hours on my end and for that I am grateful.
A special thanks to Meredith Fossel, my Senior Acquisitions Editor at Pearson.
Meredith was extremely supportive of my endeavor and provided the encouragement I
needed to push through. Her feedback was always on point, and she guided me in this
process. I also appreciated her patience with me as deadlines were moved or renegoti-
ated several times. Her commitment to the project strengthened my commitment to the
project. I also enjoyed our informal conversations about our beloved Buckeyes!
I also wish to express my appreciation for those individuals who reviewed
the manuscript throughout its development: Gonzalo Bacigalupe, University of
Massachusetts Boston; Shoshana Kerewsky, University of Oregon; Diane McDermott,
University of Kansas; Fidencio Mercado, The University of Texas-Pan American;
Victoria Osbourne, University of Missouri; Tresvil G. Pack, University of Arkansas at
Little Rock; Mark S. Parrish, University of West Georgia; Carol Rankin, California State
University, Fresno; Thomas Smith, Florida State University; Dallas M. Stout, California
State University, Fullerton; David Tews, Loyola University Chicago; and Metoka Welch,
South University-Richmond.
Finally, I would like to thank my beautiful wife, Denise, and two adorable chil-
dren, Evelyn and Alexander, who endured long hours of “Daddy is in the barn writing
again.” Their unending support, encouragement, and love I will always cherish. This
project is as much a part of them as it is of me.
Todd F. Lewis
Greensboro, NC, USA
July 25, 2012
 Brief Contents

Chapter 1 Introduction 1

Part I  asic Concepts of Substance Abuse and Addictions

B
Counseling 15
Chapter 2 Terms, Models, and Ethical Issues in Substance Abuse
and Addiction 16
Chapter 3 Substance Classifications, Effects, and Associated
Dangers 33
Chapter 4 Assessment, Diagnosis, and Treatment Planning 53

Part II Theoretical Approaches Supported by Empirical

Evidence 85
Chapter 5 Motivational Interviewing 86
Chapter 6 Cognitive Behavioral Therapy 116
Chapter 7 Relapse Prevention in the Treatment of Substance Abuse
and Addiction 148
Chapter 8 Applying Group Theory in the Treatment of Substance
Abuse and Addiction 180
Chapter 9 Applying Family Systems Approaches in the Treatment of
Substance Abuse and Addiction 216

Part III Theoretical Approaches with Less Empirical

Support 251
Chapter 10 Solution-Focused Therapy in the Treatment of Substance
Abuse and Addiction 252
Chapter 11 Adlerian Therapy in the Treatment of Substance Abuse
and Addiction 276
Chapter 12 Gestalt Therapy in the Treatment of Substance Abuse
and Addiction 312
Chapter 13 Existential Therapy in the Treatment of Substance Abuse
and Addiction 344

xi
 Contents

Chapter 1 Introduction 1
The Importance of Theory 2
A Possible Roadmap to Theory Utilization 5
A Word about Evidence-Based Treatments 8
▶ Case Study: The Case of Michael 9
Multicultural Issues in Substance Abuse Counseling 12
Summary 13 • References 14

Part I  asic Concepts of Substance Abuse and

B
Addictions Counseling 15
Chapter 2 Terms, Models, and Ethical Issues in Substance Abuse
and Addiction 16
Introduction 16
The Scope of Substance Abuse and Addiction 17
Basic Terminology of Addiction 19
Models of Addiction 20
Ethical and Legal Issues Related to Substance Abuse
and Addiction 26
Other Ethical and Legal Issues 28
The NAADAC Code of Ethics 30
Summary 31 • References 31

Chapter 3 Substance Classifications, Effects, and Associated

Dangers 33
Introduction 33
Physiological and Pharmacological Aspects Related to Substance
Abuse and Addiction 35
Mechanisms of Action 35
Routes of Administration 36
How the Brain becomes Addicted: A Theory 37
Additional Terminology 37
Substance Classifications, Effects, and Dangers 39
Central Nervous System Depressants 40
Central Nervous System Stimulants 43
Opiates 45

xii
 Contents xiii

Hallucinogens 47
Marijuana 49
Inhalants 50
Federal Drug Administration Schedule of Substances 50
Summary 51 • References 51

Chapter 4 Assessment, Diagnosis, and Treatment Planning 53

Introduction 53
Evaluation and Diagnosis 54
Screening for Substance Use Problems 54
Assessment 57
Substance Abuse Screening and Assessment Protocol:
An Example 62
Assessment Feedback 64
Substance-Related Diagnoses 66
Substance Use Disorders 66
Substance-Induced Disorders 68
Dual Diagnosis 69
Diagnostic Changes on the Horizon: DSM-V and Substance Use
Disorders 70
Treatment Planning 72
Treatment Settings 72
The Treatment Plan 75
Do a Client Map 78
Sample Do a Client Map 80
Summary 82 • References 82

Part II  heoretical Approaches Supported by

T
Empirical Evidence 85
Chapter 5 Motivational Interviewing 86
Introduction 86
A Bit of History 87
Goals of MI 87
Influences on MI 88
Ways to Implement MI 89
The Major Tenets of Motivational Interviewing: Basic Overview 90
MI Spirit 90
Principles of MI 91
The Four Key Processes of MI 94
xiv Contents

Application of Motivational Interviewing 94

Increasing Importance 94
Resolving Ambivalence 98
Enhancing Confidence 103
Strengthening Commitment 105
Motivational Interviewing in the Treatment of Diverse
Populations 106
▶ Case Study: Using MI with the Case of Michael 108
Strengths, Limitations, and Ethical Issues Related to MI 113
References 114

Chapter 6 Cognitive Behavioral Therapy 116

Introduction 116
The Major Tenets of Cognitive Theory: Brief Overview 118
Cognitive Schemas 118
Automatic Thoughts 119
Cognitive Distortions 119
Cognitive Models of Substance Abuse and Addiction 120
Complete Cognitive Model of Substance Use 121
Application of Cognitive Therapy with Substance Abuse
Problems 122
Therapeutic Relationship 123
Assessment 123
Session Structure 124
Cognitive-Based Techniques 126
Behavior Theory, Counseling, and Techniques 130
Behavioral Techniques 131
Cognitive Behavioral Therapy Examples 133
Cognitive Behavioral Therapy in the Treatment of Diverse
Populations 139
▶ Case Study: Using Cognitive Behavior Therapy in the Case of Michael 141
Strengths, Limitations, and Ethical Issues Related to Cognitive
Behavioral Therapy 145
References 146

Chapter 7 Relapse Prevention in the Treatment of Substance

Abuse and Addiction 148
Introduction 148
The Major Tenets of Relapse Prevention: Brief Overview 149
What Is a Relapse? 150
 Contents xv

Recovery and Its Relation to Relapse 151

REBT and Relapse 157
Application of Relapse Prevention in the Treatment of
Substance Use 157
Relapse Prevention Goals and Style 158
Relapse Management 164
Behavioral Chain Analysis: Breaking Down What
Happened 166
Emerging Relapse Prevention Strategies 169
Relapse Prevention in the Treatment of Diverse Populations 170
▶ Case Study: Using Relapse Prevention Strategies in the Case
of Michael 173
Strengths, Limitations, and Ethical Issues Related to Relapse
Prevention 176
References 178

Chapter 8 Applying Group Theory in the Treatment of Substance

Abuse and Addiction 180
Introduction 180
The Major Tenets of Group Therapy: Brief Overview 183
Inpatient vs. Outpatient Addictions Group Counseling 183
Therapeutic Factors 183
Stages of Group Therapy 190
Application of Group Therapy with Substance Abuse and
Addiction Problems 191
Working with Client Defenses 192
Other Considerations in Substance Abuse Group Counseling 194
Common Substance Abuse and Addiction Group Formats 195
Other Techniques 200
Substance Abuse and Addiction Group Counseling through
the Lens of Theory 201
Mutual Support Groups 202
The Range of Mutual Help Groups 203
Incorporating Mutual Group Attendance into
Therapy 204
Group Therapy in the Treatment of Diverse Populations 206
▶ Case Study: Using Group Therapy in the Case of Michael 209
Strength, Limitations, and Ethical Issues Related to
Group Therapy 212
References 213
xvi Contents

Chapter 9 Applying Family Systems Approaches in the Treatment

of Substance Abuse and Addiction 216
Introduction 216
The Major Tenets of Family Therapy: Brief Overview 218
Boundaries 219
Homeostasis 219
Subsystems 220
Rules 220
Bowen Systems Family Theory 221
Does Bowen’s Work Have Any Empirical Support? 223
Characteristics of the Addicted Family 224
The Addicted Family 224
Family Roles 224
Enabling 226
Codependency 226
Application of Family Therapy with Substance Abuse Problems and
Addiction 228
Bowen Systems Family Therapy 228
Techniques and Strategies 231
Sequential Family Addictions Model 234
Other Family Therapy Approaches 237
Family Systems Therapy in the Treatment of Diverse Populations 238
▶ Case Study: Using Family Systems Therapy in the Case of Michael 242
Strengths, Limitations, and Ethical Issues Related to Family
Therapy 246
References 247

Part III Theoretical Approaches with Less Empirical

Support 251
Chapter 10 Solution-Focused Therapy in the Treatment of
Substance Abuse and Addiction 252
Introduction 252
The Major Tenets of Solution-Focused Therapy: Brief Overview 254
Underlying Assumptions 254
Role of the Solution-Focused Clinician 256
Theory of Change 257
Criteria for Effective Counseling Outcomes 257
Application of Solution-Focused Therapy with Substance Abuse and
Addiction Problems 258
Solution-Focused Based Techniques 261
 Contents xvii

Solution-Focused Therapy in the Treatment of Diverse

Populations 266
▶ Case Study: Using Solution-Focused Therapy in the Case of Michael 269
Strengths, Limitations, and Ethical Issues Related to
Solution-Focused Therapy 272
References 274

Chapter 11 Adlerian Therapy in the Treatment of Substance

Abuse and Addiction 276
Introduction 276
The Major Tenets of Adlerian Theory: Brief Overview 277
Lifestyle 278
The Importance of Goals 282
The Tasks of Life 283
Social Interest: The Heart of Healthy Human Functioning 283
Application of Adlerian Therapy with Substance Abuse
and Addiction Problems 285
Goals of Adlerian Therapy 287
Interpretation 291
Reorientation and Change 292
Adlerian-Based Techniques 292
Case Study 295
Adlerian Therapy in the Treatment of Diverse Populations 299
▶ Case Study: Using Adlerian Therapy in the Case of Michael 301
Strengths, Limitations, and Ethical Issues Related to
Adlerian Therapy 309
References 310

Chapter 12 Gestalt Therapy in the Treatment of Substance Abuse

and Addiction 312
Introduction 312
The Major Tenets of Gestalt Therapy: Brief Overview 314
Figure/Ground 314
Contact 315
Gestalt Cycle of Experience 320
Awareness 321
Here and Now 322
The Creative Stance and the Role of the Gestalt Clinician 323
Paradoxical Principle of Change 324
Criteria for Effective Counseling Outcomes 324
xviii Contents

Application of Gestalt Therapy with Substance Abuse

and Addiction Problems 324
Clemmens’s Addictive Cycle Model 325
Working with the Person–Drug Relationship 328
Multiphasic Transformation Process 330
Gestalt-Based Techniques 332
Gestalt Therapy in the Treatment of Diverse Populations 337
▶ Case Study: Using Gestalt Therapy in the Case of Michael 339
Strengths, Limitations, and Ethical Issues Related to Gestalt
Therapy 342
References 343

Chapter 13 Existential Therapy in the Treatment of Substance

Abuse and Addiction 344
Introduction 344
The Major Tenets of Existential Therapy: Brief Overview 346
Dasein (Being-in-the-World) 346
Self-Transcendence 347
Authenticity 347
View of Human Nature 348
The Four Givens of Existence 348
Existential Psychodynamics 354
Process of Existential Therapy 354
Application of Existential Therapy with Substance Abuse and
Addiction Problems 356
Development of Maladaptive Behavior 356
Goals of Existential Therapy with Substance Abuse and
Addiction 357
Existential Techniques 358
Existential Therapy in the Treatment of Diverse Populations 364
▶ Case Study: Using Existential Therapy in the Case of Michael 365
Strengths, Limitations, and Ethical Issues Related to
Existential Therapy 370
References 371
Index 373
 1
■ ■ ■

Introduction

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enhance your understanding of chapter concepts. You’ll have the opportunity to
practice your skills through video and case based Assignments and Activities as
well as Building Counseling Skills units, and prepare for your certification exam
with Practice for Certification quizzes.

Year after year in the substance abuse counseling class I teach, when I ask students
how many of them know someone close who struggles with a substance use problem,
at least 75 percent raise their hands. As a follow-up question, I ask how many have
family members or close friends who have suffered serious negative consequences
as a result of substance use—again, the majority raises their hands. As a professional
counselor and counselor educator, I continue to be astonished at the pervasiveness
of substance use problems in our society. Statistics on the prevalence and scope of
substance use and its associated consequences in the United States provide students
with hard quantitative data, but that simple survey conducted at the beginning of
class tells it all. Simply looking around the classroom, one is hard-pressed not to run
into someone who either struggles with substance problems themselves or is close to
someone who does.
The pervasiveness of substance abuse and addiction begs the question of what
or how is the best way to address these problems clinically—that is, what is effective
substance abuse treatment? What does effective treatment look like? Scores of scientific
research has shown that a variety of approaches are effective in treating substance
abuse and addiction, many of which are covered in this text. Some approaches have
amassed an impressive amount of outcome research support, whereas others are
more conceptual in nature. A survey of the substance addiction literature suggests that
1
2 Chapter 1 • Introduction

much more information is related to the first question (What is effective substance
abuse treatment?) and less information is related to the second (What does effective
treatment look like?). In this text, which is constructed with the practitioner in mind,
I attempt to address both questions, with a strong emphasis on the gap related to the
latter question—the how to—with theory as the foundation.
In this introductory chapter, I set the stage for the rest of the chapters by discussing
the importance of counseling theory and how to incorporate it with greater intentionality
into substance abuse treatment. This is followed by a brief overview of each theory
presented in the text. A roadmap as to when certain theories are most useful in
substance abuse treatment is provided, followed by clarification of what is meant by
evidence-based approaches and associated research. The running case study for the text
is provided, in full, in this chapter. The chapter concludes with some general comments
regarding multicultural issues and substance abuse counseling.

The Importance of Theory

The concept of theory has traditionally held an important place in the psychological
sciences. Theories of Counseling and Psychotherapy is one of the first courses students
take in mental health training programs and is most certainly required before students
begin their internship experiences and see bona fide clients with real-life problems
for the first time. On a practical level, theories offer an organizing philosophy for how
problems develop. They also provide grounding from which to develop and implement
techniques within a counseling session. Theories contain assumptions about people
and have in common the desire to help others live more effective lives (Sharf, 2004).
Traditional substance abuse and addiction treatment has generally consisted of
loosely defined and organized approaches based on mental health techniques but with-
out a central, organized set of principles (Rawson, Obert, McCann, & M ­ arinelli-Casey,
1993). This has led to a somewhat random application of therapy techniques to address
substance abuse problems (Rawson et al., 1993). Some clinical settings bear more of
a resemblance to case management or crisis intervention (Rawson et al., 1993) rather
than facilities designed to assess, treat, and monitor those on substances. The inten-
tional application of psychological theory and associated techniques can provide this
structure. The field of substance abuse counseling and addiction treatment has moved
too far astray from psychological theories, which can offer clinicians a comprehensive
way to conceptualize clients struggling with addiction as well as provide a system of
techniques and strategies to help clients on the road to recovery. Put differently, the
theories presented in this text can provide the clinician with a set of organizing prin-
ciples from which to operate when counseling those struggling with substance abuse
and addiction issues.
It is no longer adequate to treat addictions in isolation of other problems. Indeed,
many, if not most, clients who present with substance abuse and addiction issues also
have other problems in their lives. Theoretically grounded approaches can be help-
ful guides when addressing clients with co-occurring disorders (discussed in greater
depth in Chapter 4). Psychological theories were created to address problems in living,
whether these problems stem from depression, anxiety, substance abuse and addic-
tion, thought disturbances, or a combination of some or all of these. The sheer rich-
ness of theories makes them ideal for complex issues that characterize co-occurring
 Chapter 1 • Introduction 3

problems. As we will see in Chapter 4, the literature on effective treatment of co-

occurring disorders calls for an integrative approach, one that draws from many dif-
ferent schools of thought, theories, and traditional substance abuse and addiction
treatment ideas. Theories give us ideas, ways to think about a problem or problems,
and strategies for how to intervene.
Overview of Theories The selection of theories for this text was based on a com-
bination of empirical support, conceptual literature, and my own clinical ­experience.
The theories presented in Part II of the text generally have more empirical support
compared to the theories presented in Part III. However, all theories have a substantial
literature base from which much of the information in this text was drawn. In select-
ing theories to include, I also relied on the successes and struggles of my own clinical
experiences. I have implemented evidence-based practices, such as relapse prevention
strategies, as well as less evidence-based approaches, such as Gestalt ­therapy. When
positive experiences are not forthcoming, I have learned (and continue to learn) that it
is okay to switch approaches and try something new if a theoretical application is not
a good fit for a client. Let’s now turn to a brief overview of the theoretical approaches
to substance abuse and addiction counseling presented in this text.
Motivational Interviewing (MI) Any textbook on substance abuse and addiction
counseling strategies must have a chapter on motivational interviewing (MI). Not only
was MI born out of the addictions field, but it has also amassed an impressive array
of empirical evidence. MI is an excellent strategy to use at the beginning of counsel-
ing, which is one of the reasons it is presented first. (MI is not technically consid-
ered a theory; however, its concepts are derived from many theoretical approaches
and can be used as a stand-alone strategy with clients.) In a survey of the frequency
with which substance abuse treatment facilities used certain clinical approaches,
55 percent reported using MI “always or often” (Office of Applied Studies [Division of
SAMSHA], 2009).
Cognitive Behavioral Therapy (CBT) Most counseling theories textbooks have
separate chapters on cognitive therapy and behavioral therapy, with some mention
of how the two have been combined as cognitive behavioral therapy. In doing the
research for this text, it became clear that in the application of substance abuse and
addiction counseling, cognitive and behavioral methods were almost always together
and in conjunction with one another in the empirical literature. As such, attention is
given to cognitive and behavioral theories separately, followed by a focus on their use
in combination (CBT). Current approaches that heavily rely on CBT principles, such
as dialectical behavior therapy, also are presented as examples. CBT and its varia-
tions are well-known, evidence-based models used in substance abuse and addiction
counseling. The amount of literature and empirical evidence to support their inclusion
is impressive. In a survey of the frequency with which substance abuse and addic-
tion treatment facilities used certain clinical approaches, 66 percent of those surveyed
reported using CBT “always or often” (Office of Applied Studies [OAS; Division of
SAMSHA], 2009).
Relapse Prevention Much of substance abuse and addiction counseling is
relapse prevention. Although this is not a traditional counseling theory, it leans heav-
ily on cognitive behavioral, person-centered, and motivational interviewing principles.
4 Chapter 1 • Introduction

Its inclusion is supported because of the strong empirical research base showing its
effectiveness as an intervention to manage and prevent a return to substance use. In
the OAS (2009) survey, 87 percent of substance abuse treatment facilities reported
using relapse prevention “always or often.”
Group Therapy Group therapy and practice have a theoretical and empirical
base of literature supporting this modality as a best practice in substance abuse and
addiction treatment. In this chapter, I discuss general considerations in the formation
and functioning of a substance abuse counseling group, keeping consistent with gen-
eral group theory. Mutual help groups (i.e., AA) are also discussed. Twelve-step group
facilitation was used by 56 percent of facilities that treat substance abuse and addic-
tion issues (OAS, 2009).
Family Therapy The problem of substance addiction often impacts the entire
family, making family therapy an important part of any text on substance abuse coun-
seling. In this chapter, I focus on family systems theory as well as other approaches
and techniques clinicians can implement in their work with addicted families. The
material from this chapter comes from many different sources: clinically generated
concepts, the experiences of family therapists, the writings of family systems experts,
and empirical studies on family-based models.
Solution-focused Therapy (SFT) Solution-focused counseling is a brief, behav-
iorally based intervention that is quite applicable to substance abuse and addiction
issues. SFT complements MI (the two share similar philosophies) and can even serve
as an extension of MI. In addition, there is a growing, impressive base of empirical
support for counseling addicted clients through this approach.
Adlerian Therapy The inclusion of Adlerian theory is based more on clinical
wisdom and experience than empirical evidence, although some empirical support
exits. Adlerian theory is comprehensive in that it is analytic, cognitive, behavioral, and
systemic. As such, comprehensive theory has much to offer substance abuse treat-
ment. Adlerian theory assumes substance abuse is secondary to general psychological
problems and provides an appropriate contrast to the “addiction as disease” concept.
Gestalt Therapy Gestalt therapy can be an effective and powerful approach to
those struggling with addiction. A growing theoretical base of literature supports this
notion, although the empirical work is scant. However, the lack of empirical support
is not because this approach is ineffective but because the concepts and philosophy
underlying Gestalt theory are not as amendable to empirical investigation. A Gestalt
approach can help an addicted person live with greater awareness, integration, and
authenticity on their recovery journey.
Existential Therapy Existential theory, like Gestalt, is difficult to study empiri-
cally; however, a foundation of literature and clinical experience suggests that sub-
stance use often manifests as crises in meaning and other “givens” of existence. The
role that lack of meaning, existential isolation, and anxiety plays in substance abuse
has been well established. However, relatively little has been written about what an
existential exploration of substance abuse would look like with clients. As you will
see in this chapter, I have found that clients, even younger, adolescent clients, often
respond well to discussions of existential topics and themes.
 Chapter 1 • Introduction 5

Each theory presented in this text, no matter the level of empirical support,
can be effective if the “how to” is demonstrated. Of course, not all theories will be
a fit for every client; some clients might respond better with an explorative existen-
tial approach compared to a structured CBT approach. In addition, clinicians may
be more comfortable with some approaches versus others. In all chapters, I cite
empirical research (if available) and note that more research may be desirable
for some theoretical approaches. However, no approach is discussed willy-nilly;
that is, each approach has empirical support, conceptual support, clinical sup-
port, or all of them. It is my hope that this text will provide students, clinicians,
and researchers a template or model to apply in their practice or research. From
a research perspective, understanding the “how to” can help one design treatment
protocols for future research studies. In essence, that is the way much outcome
research is generated; theory is presented first, followed by empirical investigation
to test effectiveness.
The 2009 Office of Applied Studies report demonstrated that many substance
abuse treatment facilities use approaches that are well established in the substance
abuse field—MI, CBT, Rational Emotive Behavioral Therapy (REBT), relapse preven-
tion, and 12-Step facilitation. However, the report also cited that 96 percent of facili-
ties engage in substance abuse and addiction counseling “always or often.” Substance
abuse counseling was defined as generally short-term treatment that included sup-
portive techniques, expressive techniques, approaches to enhance interpersonal rela-
tionships, and strategies to increase self-understanding. All the theories presented in
this text promote one or more of these general counseling strategies, offer a con-
ceptual framework, and provide techniques to assist in accomplishing therapeutic
goals. Furthermore, the National Institute on Drug Abuse (NIDA), based on decades
of research, included “counseling and other behavioral therapies” as part of their
13 Principles of Drug Addiction Treatment (NIDA, 1999) and specifically noted that
counseling and behavioral therapies are “critical components of effective treatment for
substance addiction.” Activities such as building motivation, building drug resistance
and refusal skills, improving problem solving, improving interpersonal relationships,
and replacing drug-using activities with rewarding non-drug activities were mentioned
as key benefits of addictions counseling.1

A Possible Roadmap to Theory Utilization

It is fair at this point to wonder where in the recovery process should each theory
be utilized (active use, transition [abstinence], early recovery, or ongoing recovery;
Brown, 1995, 1997) or which theory best matches inpatient versus outpatient settings.
Unfortunately, there are no firm guidelines in terms of specific theoretical application
for specific recovery stages or settings, although some suggestions can be inferred
from the literature.
Brown (1995, 1997) outlined four stages in the recovery process (Brown’s
Developmental Model of Alcoholism and Recovery was intended to focus on alcohol-
ism but can reasonably be applied to other substance addictions). The first stage is
active drinking or use, where denial is the main defensive structure because clients

1
For a complete listing of the 13 principles of drug addiction treatment, visit www.nida.gov.
6 Chapter 1 • Introduction

believe they have control over their use (when they clearly do not) and thus minimize
subsequent problems. The second stage is transition, where clients develop little inter-
est outside substance use, and drugs have become the central organizing principle of
their lives. Negative consequences begin to pile up. When clients come to see that (a)
they are an “alcoholic” or “addict” and (b) they have lost control, they transition into
the end of using and the beginning of abstinence. This is a critical and vulnerable spot
for clients because depression, anxiety, eating problems, and other addictions rise to
the surface to fill the void (Brown, 1997). According to Brown (1995, 1997), funda-
mental building blocks of recovery need to be in place for clients to move on toward
recovery. Relapse is a constant possibility. The third stage is early recovery, where the
client begins to gain some momentum in the recovery process, experiences a decline
in impulses, and is committed to attending a 12-Step mutual support group in addition
to regular counseling. Those in early recovery begin the shift from external support
to internal support. Their world begins to open as they catch their impulses and make
alternative choices to using. The fourth stage is ongoing recovery where the client is
firmly in recovery and has expanded his life interests and pursuits. Clients generally
engage in deeper levels of self-exploration in this stage (Brown, 1995, 1997). Twelve-
Step attendance is still an important component but is at a maintenance level. It may
take several years for a client to reach ongoing recovery (Brown, 1997). Notice how
abstinence is in the middle of the model as the client transitions away from using or
drinking. According to Brown (1997), many have wrongly assumed that once a client
is abstinent from substances, then treatment stops. As one can see, abstinence is really
the start of treatment, rather than the end.
Brown’s model is helpful in understanding the recovery process and provides
insights into where certain theoretical approaches might be most useful. In gen-
eral, the earlier in the model the client is (active use, transition, beginning of early
­recovery), the more one should rely on the theoretical approaches discussed in Part II
of this text: Motivational Interviewing, CBT, relapse prevention, group therapy, and
family therapy, in addition to assessment and evaluation procedures. As a client pro-
gresses from early recovery to ongoing recovery, approaches such as Gestalt ther-
apy, existential explorations, and Adlerian interventions become more appropriate.
These latter approaches may invoke greater emotion and generally involve deeper,
more philosophical explorations that the client may not be ready to experience during
active use or early recovery.
Indeed, Brown (1997) noted that for much of active use, transition, and even
early recovery, clients are not ready to deal with deep psychological explorations or
therapies that may have the potential to dig up old emotional wounds. Motivational
interviewing can be quite effective when a client is actively using or has reached
abstinence but may be less effective and even unproductive when the client is sol-
idly in recovery and is motivated to stay there. In the early stages of Brown’s model,
clients benefit more from practical considerations related to motivation (motivational
interviewing), negative thinking processes that maintain substance use (CBT), relapse
concerns (relapse prevention), staying in therapy (both group and individual), and
12-Step mutual help group attendance. As clients build their recovery and are ready
to delve into topics such as personal choice, emotional processing and exploration,
meaning, and awareness, Gestalt, existential, and Adlerian therapies become more rel-
evant and useful to strengthen one’s life free from substance use.
 Chapter 1 • Introduction 7

The preceding guidelines can generally be applied to inpatient versus outpatient

treatment. For clients in inpatient treatment (who are most likely actively using), in
transition, or in very early recovery, the theories in Part II of the text are a good fit.
For outpatient treatment, where clients may be more firmly established in recovery,
additional theoretical approaches would be appropriate. There is risk, however, in
oversimplifying the matching of theory to stage of recovery or location of treatment.
For example, I work primarily in an outpatient facility and have used Motivational
Interviewing, relapse prevention, and CBT with my clients. In addition, I also have
used Adlerian, solution-focused therapy, and Gestalt in relatively early stages of the
recovery process. When determining which theories to use, perhaps the more critical
aspects to consider are what would be the best fit for the client, good clinical judgment
and intuition, familiarity with the theory, client motivation, input, resources, and the
cultivation of the therapeutic relationship. Buchbinder (1986) added that one’s choice
of a theoretical approach depends on many variables, including individual personality,
professional training, peer and academic influence, and supervisory consultation. By
and large, no firm “this is the only way to work” mandates exist in substance abuse
and addiction treatment. Table 1.1 outlines one possible set of guidelines for which
theoretical approaches fit best with the stage of recovery the client is experiencing.

Table 1.1 B
 rown’s (1995, 1997) Developmental Model and Possible Approaches
that Fit Best with Each Phase1
Phase Approach Description
Active drinking or use Motivational Interviewing, CBT, Treatment is usually focused on
Group Therapy, 12 step group stopping or seriously limiting use,
attendance, Family Therapy (if rather than psychological explorations;
family’s goal is to help member client motivation and consciousness
stop using) raising are important considerations
Transition (to abstinence) Motivational Interviewing, CBT, Client is in emotionally vulnerable
Relapse Prevention, Group position; Assessing motivation, relapse
Therapy, Family Therapy, 12 step potential, and providing support
group attendance via group and family care become
important
Early Recovery (1-3 years) Relapse Prevention, Group Treatment begins to move away from
Therapy, Family Therapy, 12 step motivation issues (although these
group attendance, Solution- could still come back) and more toward
Focused Therapy; Existential, preventing relapse and putting together a
Gestalt, Adlerian as client is solid plan for recovery. Support continues
ready and with caution to be important; slowly introduce other
approaches with caution
Ongoing Recovery (3-5 years) Existential, Gestalt, Adlerian Client solidly in recovery and more
amenable to deeper psychological
explorations.
1
This chart is only one possible way to approach substance abuse counseling using theoretical approaches. For
example, motivational interviewing may be important to come back to even in later stages of recovery. For some clients,
Adlerian or Existential therapy might fit earlier in the process, depending on client motivation, pattern of use, emotional
vulnerability, and so forth.
8 Chapter 1 • Introduction

A Word about Evidence-Based Treatments

Evidence-based treatments (EBTs) or evidence-based practice seem like common buzz-
words in today’s mental health practice. Many managed care and insurance companies
mandate that clinicians use only “evidence-based” approaches lest they not get reim-
bursed for their services. Clinician training programs and agencies espouse the critical
importance that treatment approaches be tied to the outcome literature. Traditionally,
EBTs have referred to psychotherapeutic approaches, often grounded in theory, that
have been supported as effective in clinical trials.
In the landmark book, The Heart and Soul of Change, Hubble, Duncan, Miller,
and Wampold (2010) presented a cogent argument that scores of research has shown
psychotherapy to be effective, yet little evidence suggests that one particular theory
is superior to any other. Further, the authors argue, the clinician-client relationship,
among other common factors, is one of the most important ingredients in success-
ful client outcome, based on hundreds of empirical studies (Duncan & Miller, 2006).
Hubble et al.’s (2010) analysis suggests an overemphasis on EBTs, to the exclusion of
the common factors and other treatment variables that have a much greater contribu-
tion to successful client outcome. According to this research, clinicians who incorporate
an exclusive focus on “manualized” treatment protocols or other EBT-style interventions
are “missing the boat.” In addition, too much emphasis on EBTs has led clinicians to
ignore other effective theoretical approaches that may not be as amenable to traditional
scientific research. Lack of empirical evidence does not render an approach ineffective.
Does this mean that EBTs have no place in counseling and psychotherapy prac-
tice? Not at all. EBTs and theoretical approaches provide a bevy of options for the clini-
cian to consider (Mee-Lee, McLellan, & Miller, 2010). EBTs and theoretical approaches
also provide a comprehensive roadmap for how to conceptualize client problems and
contain a plethora of interventions that may help a client on the road to recovery. The
critical factor, however, is client feedback (Mee-Lee et al., 2010)—that is, does this EBT
or theoretical approach appear to be a good fit for the client? Is the client improving?
Emerging empirical evidence suggests that EBTs and theoretical approaches should
be utilized based on direct client feedback to better inform practice (Mee-Lee et al.,
2010). I couldn’t agree more.
The work of Hubble et al. (2010) has led, in part, to the reconsideration of what,
exactly, “evidenced-based treatment” means. For example, the American Psychological
Association created a task force to examine the meaning of evidence-based practice
and settled on this definition: “Evidence-based practice in psychology is the integra-
tion of the best available research with clinical expertise in the context of patient
characteristics, culture, and preferences” (APA, 2006, p. 273). Clearly, this definition
suggests that psychological treatment is a collaborative process with clinical decisions
based on client characteristics, values, and needs. The concept of EBT seems to be
moving away from a one-size-fits-all approach to one that is unique to client circum-
stances. Research may still inform practice; however, it is integrated with a strong
consideration of contextual factors.
EBTs, and the theoretical approaches upon which many are based, are best con-
ceptualized as possibilities, strategies, recommendations, and approaches rather than
the end-all, be-all to clinical treatment. If imposed as the final word, without flexibility
and client input, therapeutic success is on a slippery slope. One approach will not fit
every client, which is why client feedback and input are so important. Mee-Lee et al.
 Chapter 1 • Introduction 9

(2010) noted that a current trajectory in the substance abuse and addiction treatment
field is a more “consumer-driven, outcome-informed treatment system” (p. 396). As
such, a blending of EBTs (and theoretical approaches), the therapeutic alliance, and
client factors appear to be a worthwhile stance in the therapeutic endeavor.
This text is not about comparing the effectiveness of different psychotherapy
approaches for substance abuse and addiction counseling. Rather, the purpose is to
show how theoretical application can enrich substance abuse counseling by offering a
multitude of ways to better conceptualize client problems, explanations for how sub-
stance use begins, and treatment and intervention strategies that align with theory. In
its essence, this text addresses the how to of substance use counseling with theory as
the foundation. However, it is important to note that the therapeutic alliance and what
the client brings to therapy must never be lost in one’s application of any theory to sub-
stance abuse and addiction problems. Use of theoretical approaches without taking into
account the alliance, client factors, and client feedback is barking up the wrong tree.
So, where does that leave us and how should we make meaning out of EBTs? The
arguments posed by Hubble et al. (2010) cannot be overlooked. Perhaps the good news
is that that psychotherapy is effective, although no one approach really appears to be
any better than any other approach. Regardless, no matter what theory is implemented,
clinicians need to have a strong grounding for the interventions they use, lest they fall
into the trap of using a hodgepodge of strategies without any roadmap, direction, or
underlying philosophy. Of course, based on client feedback, this roadmap may need to
be tweaked or adjusted along the way. If the therapeutic alliance is of critical impor-
tance, competent, skillful, and flexible use of theory can enhance this alliance.
For readers who have a strong allegiance to EBT approaches, the chapters in Part II
of the text might be of most interest. However, as Duncan et al.’s (2010) work suggests,
this does not mean that the theories in Part III are any less effective or important to
implement.

Case Study
The Case of Michael
Throughout the text, a running case study will illustrate the theoretical approaches
described herein. As such, the case study is presented, and each chapter includes how
the client would be counseled using each particular theory. The case is based on a
composite of my own clinical experiences. It does not represent a unique individual
but incorporates characteristics and real clinical issues drawn from several clients over
a number of years. Although some may argue that composite case studies obscure or
distort actual clinical events and the course of therapy for a particular client, there are
several advantages to their use (Sperry & Pies, 2010).
Composite case studies may actually have more pedagogical worth than real-
life case studies (Sperry & Pies, 2010). They allow for writers to better illustrate a
theory or approach rather than be limited by a single case that might not be broad
enough in its elements. Composite cases represent more than one individual, often
several clients, and, therefore, no identifying information can be recognized; the use
(continued)
10 Chapter 1 • Introduction

Case Study (continued)

of composite clients has support in the literature because it has been suggested that
this approach balances the need to protect client privacy and provide a case example
of sound pedagogical value (Sperry & Pies, 2010). Composite clients are effective if
they are based on real-world experiences, problems, and situations clients are likely
to face. Every attempt has been made to make the case as real life and authentic as
possible, drawing from many clinical examples instead of just one. The “running case
study” approach has been used in popular counseling theories texts (Corey, 2009).
The following case study describes the background information of Michael L.,
a client coming to counseling due to increasing substance abuse and several associ-
ated problems. In each theory-based chapter, the reader will see an example of how
the clinician operates from different theoretical perspectives to help Michael with his
substance abuse problems, emphasizing select strategies and techniques used from
that particular theory.
Michael L. is a 32-year-old male who recently became verbally and physically dis-
ruptive at home. Michael worked at a local mill since he graduated from high school,
and within a few years moved up to supervising manager. Although Michael enjoyed
his job, he became edgier with his direct reports, prompting his boss to encourage
him to seek help. Although his boss wasn’t sure, he suspected alcohol played a role in
Michael’s recent poor performance and behavior. Michael was arrested one year ago for
public intoxication after a local sporting event but has never had a DUI. Michael’s wife,
Julie, has grown increasingly frustrated with his recent behavior and said he is just not
the same man when he drinks—describing him as “ugly and angry.” She has threatened
to leave him and take their two children, Zach and Maria. According to Michael, Julie
is at the “end of her rope” with him, and his recent struggles at work have made her
question his love and commitment to his family. Michael admitted that he likes to drink
and have a good time and that he has one too many now and then. However, he some-
what minimized the extent of problems caused by his alcohol use. Michael said that he
began alcohol use in his 20s. He reported that his father was an alcoholic.
Alcohol was the presenting substance-related concern, but upon further inquiry,
Michael reported using cocaine to help him cope with the stress he was under at
work and at home. He noted that he struggled with boredom and loneliness and that
his bar buddies introduced him to cocaine about two years ago. He has been using
it ever since. Asked what he gets out of using cocaine, Michael stated that he feels
“alive” and “energized” on coke and that it allows him to temporarily forget about life.
It takes away the anxiety, boredom, and daily grind of having a difficult job and rais-
ing a family. Michael admitted that Julie does not know about his cocaine use. This, he
reported, makes him feel all the more guilty about where his life is heading.
Michael stated he feels like “half the person I used to be.” Complaining of fatigue
and feeling down and angry, he struggles to find meaning in his life. He cares deeply
for his family but can’t seem to connect with them in the genuine, loving way he did in
the past. If Michael has a bad day at work, he often displaces these angry feelings on his
wife and children. Julie confirmed in subsequent sessions that Michael just seemed like
a different person, yelled at the kids for no reason, and seemed “down in the dumps.”
Michael noted that he has always struggled with low feelings, but they had recently
intensified. He did not see any connection between his substance use and depression.
 Chapter 1 • Introduction 11

Michael’s background seems to go a long way toward explaining many of his cur-
rent struggles. He grew up as the older of two children. He and his sister, Amanda, lived
with their mother and father until Michael was 12 years old, at which time their father
left the family. His father drank excessively, and Michael called him an “alcoholic.” As a
result, the relationship between his mother and father was tumultuous to say the least,
and alcohol seemed to play a large role in the conflict. Michael denied any physical
abuse in the household but noted that his father’s verbal abuse was rampant, especially
toward his mother. When asked to give one word to describe his household growing up,
Michael replied, “Angry.” He cannot remember a time when his parents were not fighting
with each other. At times, the incessant fighting and screaming became so unbearable
that Michael would retreat to his room and cry himself to sleep. Michael vividly recalls
going on trips to the local store with his mother, looking over at her, and seeing tears
run down her face. He recalls several times when he heard his father’s car coming up the
driveway at 3:00 a.m. and his keys jingling outside the door. His father would stumble
into the house, intoxicated, with a very worried and upset spouse waiting for him.
To this day, Michael loves his sister and stated they have always gotten along.
They were close, especially during the years when their father was drinking at his
heaviest. Because his father left when he was 12, he was forced to take care of his
mother and sister, often fulfilling the husband and fatherly roles before he was ready.
Based on Michael’s description of the presenting issues, the clinician proceeded
to complete a five-axis diagnosis2:

Axis I: Alcohol Dependence, With Physiological Dependence

Cocaine Abuse
Major Depressive Disorder, Recurrent, Moderate, Provisional
Axis II: No diagnosis, prominent use of displacement and denial
Axis III: Pre-diabetic
Axis IV: Marital problems; Occupational problems
Axis V: GAF 53 (current)

Michael clearly met criteria for an alcohol problem (Axis I), and this most likely
made his other problems worse. He met criteria for Alcohol Dependence because he
reported symptoms related to both tolerance and withdrawal. In addition, he would
continue drinking despite numerous negative consequences (arguments with spouse,
problems with work). The clinician also believed that Michael was struggling with
cocaine abuse and depression (Axis I), as evidenced by feeling down, low energy, and
weight gain. However, at this time, the depression diagnosis is provisional because
more information is needed to confirm.
(continued)
2
The diagnosis presented here is based on the DSM-IV-TR (2000). As of this writing, the DSM-V is due out
in May 2013. Many changes to the titles of disorders and criteria are being considered. A review of these
changes relevant to substance abuse diagnoses is presented in Chapter 4. Nonetheless, a review of the
diagnosis just presented suggests that Michael struggles with significant substance use issues in addition to
mood problems.
12 Chapter 1 • Introduction

No personality disorder was present (Axis II). However, Michael used the defense
mechanisms of displacement and this was placed on Axis II.
After a receiving a recent physical for work, Michael’s physician stated he was
pre-diabetic (Axis III) and that he need to watch his weight and diet. Michael used to
exercise regularly but lately has let that go. Michael’s moderate-to-severe symptoms
warranted a GAF of 53.
Overall, the clinician noted that Michael was struggling with issues of substance
use and depression, was in danger of developing diabetes, and was functioning subop-
timally. His struggles were especially salient in the marital and occupational domains.

Additional Information
Additional information became evident in the initial assessment. Alcohol was the key
organizing theme in the household when Michael was a child. It was everywhere—in
the refrigerator, his father’s stocked bar, the cabinets, and in the basement. Alcohol
was always served at family gatherings. Michael’s father grew more and more emo-
tionally distant as alcohol slowly consumed his life. The angry emotional tone fright-
ened Michael and Amanda because they were never sure which father would come
home after work. Michael reported that the sadness he saw in his mother was espe-
cially difficult. His father’s departure left the house in chaos, without any structure.
Although Michael was secretly glad to see his father leave, he admitted that he still
loved him because of their father-son connection and because “not all times were
bad.” Michael subsequently took on more responsibility at home, taking care of his
sister and mother. Michael felt he had to “grow up” quickly during that time. He har-
bors resentment because he could not take part in typical teenage activities.
The preceding case study provides the background for the long case demonstra-
tions in each theory-based chapter. Unless otherwise stated, the reader should assume
that Michael is in the transition-abstinent-early recovery stages related to the theories
presented in Part II of the text (Motivational Interviewing, CBT, etc.) and the early
recovery–­ongoing recovery stages related to the theories presented in Part III (Adlerian,
Gestalt, etc.). Other parameters of the case may be provided in each theoretical chap-
ter. Additional smaller vignettes are used throughout the text to illustrate key points or
techniques; in all cases, names and identifying information have been disguised.

Multicultural Issues in Substance Abuse Counseling

Just as clinicians must understand one’s cultural background to better conceptualize
say, depressed feelings, the same holds true for substance abuse and addiction prob-
lems. When formulating tentative hypotheses about substance abuse and addiction,
a thorough understanding of diversity issues greatly increases the chances for an
accurate assessment and competent treatment. Given that today’s minority population
will make up approximately one-third of the U.S. population in the next two decades
(Fisher & Harrison, 2009), sensitivity, awareness, and knowledge of diversity issues in
substance abuse counseling are needed now more than ever.
According to Miller (2005), multicultural refers to working with differences.
Working with differences, of course, is not limited to ethnicity or race but can include
 Chapter 1 • Introduction 13

working with someone who is a different gender, who is disabled, or who experiences
challenges because of their socioeconomic group. Miller provided general suggestions
for substance abuse and addiction clinicians who want to be sensitive and effective
with individuals from other cultures. Among them were the following: (a) clinicians
must be aware of their own cultures and how these impact their lives, (b) clinicians
should be aware of the socio-historical-environmental aspects of some groups and how
they have traditionally been treated in the United States, and (c) clinicians need to work
at developing a “dialogue-friendly” milieu to help communication across cultural lines.
The following example might make these guidelines more concrete. Assume a
Caucasian clinician is working with an African American client struggling with heroin
addiction. A multiculturally competent clinician would be sensitive to the social strug-
gles African Americans have endured throughout U.S. history, from slavery to contin-
ued racism and oppression. A disproportionate amount of African Americans live in
poverty in our cities due to institutional racism and inadequately funded social ser-
vices. Keeping this history and background in mind, it also is important for the clini-
cian to create a dialogue-friendly atmosphere: being genuinely interested, appreciating
cultural differences, and getting the client’s perspective on his current substance use
problem, rather than assuming it is the same as with any other client. This counseling
stance builds rapport and encourages an atmosphere of respect and collaboration.
Substance abuse and addiction treatment is unique in that there might be some uni-
versals in the experiences of all clients struggling with substance use issues (Matthews &
Lorah, 2005). Substance addiction is an “equal opportunity disease”—it doesn’t dis-
criminate. People come together across gender, culture, ethnicity, and religion in their
suffering and triumph. Yet substance abuse, addiction, and recovery may have differ-
ent meanings and interpretations depending on one’s gender, culture, ethnicity, or
religion. For example, the 12-Step mutual help group process of “giving yourself” to
a higher power and “admitting that one is powerless” may offend many women who
have had to endure a long history of societal oppression, limited rights, and feelings
of powerlessness. Women for Sobriety, discussed in Chapter 8, was created to address
this gender bias in traditional venues of substance recovery by emphasizing encourage-
ment and empowerment for women who struggle with addiction. Multicultural con-
siderations are critical to successful substance abuse and addiction counseling and are
infused throughout the text, with each theory-based chapter focusing on the multicul-
tural implications of using that particular theory. For a good overview of multicultural
issues in addictions counseling, see Fisher and Harrison (2009) and Miller (2005).

Summary
This introductory chapter contains a general out-
line of each theory in the text and emphasizes the
importance of theories and how their application
can enhance substance abuse counseling. A pro-
posed road map to implementing different theoreti-
cal models is offered. Clarification of evidence-based
treatments is provided; clinicians must always honor
what the client brings to therapy and the therapeu-
tic alliance, in addition to theory application. The
running case study will serve as the main vehicle
from which each theory in the text is demonstrated.
Finally, multicultural considerations in substance
abuse counseling are of paramount importance, and
thus are given focus in each theory-based chapter.
14 Chapter 1 • Introduction

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Washington, DC: National Institutes of Health.
Rawson, R. A., Obert, J. L., McCann, M. J., & Marinelli-
Casey, P. (1993). Relapse prevention strategies in
outpatient substance abuse treatment. Psychology
of Addictive Behaviors, 7, 85–95.
Sharf, R. S. (2004). Theories of psychotherapy and
counseling: Concepts and cases (3rd ed.). Pacific
Grove, CA: Brooks/Cole.
Sperry, L., & Pies, R. (2010). Writing about clients:
Ethical considerations and options. Counseling
and Values, 54(2), 88–102.
Substance Abuse and Mental Health Services
Administration, Office of Applied Studies.
(2009). The N-SSATS Report: Clinical or
Therapeutic Approaches Used by Substance
Abuse Treatment Facilities. Rockville, MD.
Retrieved from www.oas.samhsa.gov/2k10/
238/238ClinicalAp2k10.htm

70
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­Diverse Cultures in the site (www.mycounselinglab.com) for Substance Abuse and Addiction
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Diverse Cultures along with the national standards that connect to these outcomes.
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 Part

I
■ ■ ■

Basic Concepts of
Substance Abuse and
Addictions Counseling
In Part I, I address several common terms, concepts, models, and issues related to substance abuse
and addiction counseling. Much of the information in this section is unique to the substance abuse
and addiction field. For those who are new to the language of addiction, the material may need
additional attention to fully understand the terms and concepts. In Chapter 2, terms, models, and
ethical issues commonly found in substance abuse counseling are reviewed. In Chapter 3, I discuss
the physical mechanisms of addiction, with a focus on the brain and neurotransmitters, drug clas-
sifications, and common effects of the drugs of abuse. I attempted to provide a basic overview of
these concepts as a way to avoid complex jargon and medical language that is best left for texts
that focus exclusively on the physiology of addiction. In Chapter 4, evaluation, assessment, and
diagnosis of substance use and addiction disorders are covered, in addition to issues surrounding
treatment planning. It is my hope that the reader finds this chapter particularly relevant for their
day-to-day practice counseling those struggling with substance addiction.

15
 2
■ ■ ■

Terms, Models,
and Ethical Issues in
­Substance Abuse
and Addiction

70
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70
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enhance your understanding of chapter concepts. You’ll have the opportunity to
practice your skills through video and case based Assignments and Activities as
well as Building Counseling Skills units, and prepare for your certification exam
with Practice for Certification quizzes.

Introduction
Substance abuse and addiction have become enormous problems in our society,
exacting a staggering financial, personal, and societal toll. As a counselor educator
and clinical counselor, I am astonished at how substance use and addiction problems
ravage the lives of my clients. Well-meaning individuals, these clients in search of
a better life lost their way by turning to drugs and alcohol. Drug and alcohol use
often are at the center of family and relationship problems; I have observed spouses
pleading with their significant others, or parents with their teenage children, to stop
using. Popular media shows, such as A&E’s Intervention and HBO’s Addiction series,
16
Another random document with
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN