Key terms on this page (6)
- HPA axis
- The hypothalamic-pituitary-adrenal system: the slower arm of the stress response, ending in the release of cortisol.
- Allostatic load
- The wear on the body from stress responses that are switched on too often or for too long.
- CBT-I
- Cognitive behavioral therapy for insomnia: sleep restriction, stimulus control and work on thoughts about sleep, usually over several sessions.
- AUDIT and DAST-10
- Short, free screening questionnaires for alcohol (AUDIT) and other drugs (DAST-10).
- ASAM Criteria
- The American Society of Addiction Medicine’s standard for matching people to a level of addiction care.
- MOUD
- Medications for opioid use disorder: methadone, buprenorphine and naltrexone.
Stress lives in the body
When a threat appears, the body answers in two waves. The fast one is the sympathetic nervous system: heart rate, breathing and muscle tension rise within seconds. The slower one is the HPA axis, a relay from the hypothalamus to the pituitary to the adrenal glands that releases cortisol over minutes and hours. Both are built to switch off when the danger passes.
In chronic stress, poverty, trauma or caregiving, they often don’t. The neuroscientist Bruce McEwen called the resulting wear allostatic load, and it shows up in the therapy room as poor sleep, headaches, stomach problems, getting sick often, and exhaustion clients may describe as laziness. Knowing this helps you explain symptoms without blame, and reminds you that a new physical complaint deserves a doctor, not only a therapist. Thyroid problems, anemia, medication side effects and many other medical conditions can look like depression or anxiety.
Sleep is a clinical sign and a treatment
Sleep appears in the criteria for depression, mania, generalized anxiety and PTSD, which is why intake asks about it. One pattern is a red flag: a client who suddenly needs very little sleep yet feels full of energy may be heading into mania, especially if they recently started an antidepressant. That calls for the prescriber promptly.
Insomnia is also something you can treat. The American College of Physicians recommends CBT-I as the first treatment for adults with chronic insomnia, and the American Academy of Sleep Medicine strongly recommends it, while advising against sleep hygiene tips on their own. CBT-I is a short, structured therapy that many clinicians add after training. Loud snoring, gasping at night or heavy daytime sleepiness point to sleep apnea, which needs a medical evaluation.
Medication literacy
Many of your clients will take psychiatric medication, prescribed by a psychiatrist, nurse practitioner or primary care doctor. Your job is to know enough to notice, ask and coordinate. Here are the classes you will hear about most.
- Antidepressants (SSRIs, SNRIs and others)sertraline, escitalopram, fluoxetine, venlafaxine, bupropion
- Take weeks to work. Common side effects include stomach upset and sexual side effects. A boxed warning covers suicidal thinking in children, teens and young adults. Stopping suddenly can cause discontinuation symptoms.
- Mood stabilizerslithium, lamotrigine, valproate
- Lithium needs regular blood tests because the gap between a helpful and a toxic level is narrow. A new rash on lamotrigine needs a prescriber the same day.
- Antipsychoticsaripiprazole, quetiapine, risperidone, olanzapine
- Used for psychosis, bipolar disorder and sometimes depression. Weight gain, metabolic changes and movement side effects are common reasons people stop.
- Benzodiazepinesalprazolam, clonazepam, lorazepam
- Since 2020 the FDA boxed warning covers abuse, addiction, dependence and withdrawal. Dangerous with alcohol or opioids. Stopping suddenly after regular use can cause seizures.
- Stimulantsmethylphenidate, amphetamine salts
- Used for ADHD. Controlled substances. Watch sleep, appetite, anxiety and misuse.
- Sleep medicationszolpidem, eszopiclone, trazodone (off label)
- Some carry a boxed warning for complex sleep behaviors such as sleepwalking or driving while not fully awake.
Substance use: why every therapist needs it
Substance use runs through mental health care. It is common alongside depression, anxiety, trauma and psychosis, it changes how symptoms look, and it raises risk. Assume you will meet it in every setting, not only in addiction programs. Asking every client, routinely and without judgment, is the first skill.
Screening is the usual starting point, often as part of the SBIRT model: screening, brief intervention, and referral to treatment. Two free, well-studied tools cover most needs. Try reading a score below.
Ten questions on alcohol, from the World Health Organization. Scored 0 to 40.
Zone II · hazardous use
The tool’s guidance: Simple advice.
For a therapist: Give brief, non-judgmental feedback on the score, ask what the client makes of it, and talk about cutting down.
What you say after a positive screen matters more than the number. Motivational interviewing, developed by William Miller and Stephen Rollnick, is the most widely taught approach: a collaborative conversation that draws out the person’s own reasons for change rather than arguing for it. One safety point belongs in every first conversation: withdrawal from alcohol or benzodiazepines after heavy regular use can be life-threatening, so a client who wants to stop suddenly should talk to a doctor first.
Levels of care
Addiction treatment is a continuum, and part of your job is knowing when someone needs more than weekly therapy. Most programs and payers use the ASAM Criteria to match people to a level.
Level 1: Outpatient
Weekly or less often. Where most therapists meet substance use: in ordinary outpatient work.
1.0 remission monitoring · 1.5 outpatient therapy · 1.7 medically managed outpatient
Level 2: Intensive outpatient and high-intensity outpatient
Several sessions a week, often for hours at a time, while the person lives at home.
2.1 intensive outpatient · 2.5 high-intensity outpatient · 2.7 medically managed intensive outpatient
Level 3: Residential
The person lives at the program, with round-the-clock structure; the x.7 level adds medical care.
3.1 clinically managed low-intensity · 3.5 clinically managed high-intensity · 3.7 medically managed
Level 4: Medically managed inpatient
For severe withdrawal or medical or psychiatric problems that need a hospital.
Hospital-level care, with daily physician care and 24-hour nursing
Intensity of care, from least to most
Medications for addiction
Medication is part of standard care for opioid and alcohol use disorders, and clients do better when their therapist understands it and supports it.
- Methadone
- Opioid use disorder
For addiction treatment, dispensed only through federally certified opioid treatment programs, often daily at first.
- Buprenorphine
- Opioid use disorder
Since January 2023, any practitioner with a standard DEA registration covering Schedule III can prescribe it; the old special waiver is gone.
- Naltrexone
- Opioid and alcohol
Blocks opioid effects and reduces craving for alcohol. A monthly injection is used for opioids, after withdrawal is complete.
- Acamprosate, disulfiram
- Alcohol use disorder
Acamprosate helps maintain abstinence; disulfiram causes a severe reaction if the person drinks.
- Naloxone
- Overdose reversal
Reverses opioid overdose. The FDA approved a nasal spray for sale without a prescription in 2023.
The substance use coursework some states require
Many states write substance use training into the license requirements. Accredited programs usually build it in, but if you study in one state and license in another, check that your transcript covers it. Some examples, as of October 2026:
- California LPCC
- Core area
Addictions counseling is one of the core content areas a qualifying degree must cover (BPC §4999.33).
- California LMFT
- In the degree
The degree must include instruction in substance use disorders, co-occurring disorders and addiction (BPC §4980.36).
- California LCSW
- 15 hours
Alcoholism and other chemical substance dependency training; built into California MSW programs, so recent in-state graduates need no separate proof.
- Texas LPC
- One course
An addictions counseling course for applicants whose program began on or after 1 August 2017 (22 TAC §681.83).
- Florida LMHC
- One course
A graduate course in substance abuse among the required content areas (Fla. Stat. §491.005).
Other states set their own rules, and some license addiction counselors as a separate profession. Check your state’s requirements or find it on the map.
Three clients, three bodies
Invented composites, not real people.
Denise
52, caring for her mother
Stress and sleepHer therapist used CBT-I alongside the grief work. Within two months she was sleeping through most nights, and the depression scores came down with it.
Arturo
29, anxious, new prescription
MedicationHe wanted to stop his antidepressant because of side effects. His therapist did not advise either way, helped him write down what he noticed, and he raised it with his prescriber the next week.
Jess
35, panic attacks
Substance useA routine AUDIT scored 18. Instead of a lecture, her therapist asked what she made of it. Jess said she drank to sleep, and the plan changed to include both.
How to get ahead before and during school
- Practice giving the AUDIT and DAST-10 in role-play until asking about substances feels ordinary.
- Learn the names of the ten most common psychiatric medications and their classes. Flashcards work.
- Take a motivational interviewing training during school. Many programs and agencies offer one.
- If your state requires substance use coursework, confirm early that your program’s course meets it.
- Carry naloxone and know how to use it; many states and pharmacies make it easy to get.
What to read
- Why Zebras Don’t Get Ulcers (Sapolsky), the readable classic on stress and the body.
- Motivational Interviewing: Helping People Change and Grow (Miller and Rollnick), the fourth edition of the core text.
- SAMHSA’s free Treatment Improvement Protocols, especially TIP 35 on enhancing motivation for change and TIP 63 on medications for opioid use disorder.
- The WHO AUDIT manual, free online, which explains the screen and the brief intervention that goes with it.
Myths worth dropping
Myth
“Medication for opioid addiction just swaps one drug for another.”
Actually
Taken as prescribed, these medications treat a medical condition, and they are standard care for opioid use disorder.
Myth
“Sleep hygiene tips fix insomnia.”
Actually
On their own they rarely do. CBT-I is the recommended first treatment for chronic insomnia.
Myth
“Therapists should stay out of medication.”
Actually
You shouldn’t manage it, but asking about it and coordinating with the prescriber is part of good care.
Next · Step 12
Ethics codes and boundaries
Part 3 begins with the duties you carry from your first practicum client. First, the ethics codes, boundaries and dual relationships, and a model for deciding when the right answer isn’t obvious.
Questions people ask
Do therapists need to know about psychiatric medication?
Yes, though not to prescribe. You need to recognize the main classes and their common side effects, ask clients how their medication is going, coordinate with the prescriber (with the client’s written permission), and never advise a client to start, stop or change a dose. Several states build psychopharmacology into the required coursework.
What is the AUDIT, and can a therapist use it?
The AUDIT is a 10-question alcohol screening tool from the World Health Organization, scored 0 to 40, with 8 or more generally treated as a sign of hazardous or harmful drinking. It is free and widely used by therapists. The DAST-10 does the same job for other drugs. Both flag who needs a closer look; neither is a diagnosis.
What are the ASAM levels of care?
The ASAM Criteria, now in a fourth edition published in 2023, describe a continuum of addiction treatment in four broad levels: outpatient, intensive or high-intensity outpatient, residential, and medically managed inpatient, with decimals for finer steps. Many state Medicaid programs and insurers use them to decide what care is covered.
Do I need substance use coursework to get licensed?
In many states, yes. California requires substance use content for LMFT, LPCC and LCSW applicants, Texas requires an addictions counseling course of counselor applicants whose program began on or after 1 August 2017, and Florida requires a graduate course in substance abuse for mental health counselors. Requirements vary by state and license, so check your board.
Can therapists treat addiction?
Licensed mental health clinicians treat substance use disorders within their training and competence, often alongside the conditions that come with them. Many states also license addiction counselors separately, and specialty programs and medications are part of care for many people.
Sources
Checked 28 October 2026. Coursework rules change and differ by start date; confirm with your state board before you rely on them.
- World Health Organization, AUDIT: Guidelines for Use in Primary Care (2nd ed., 2001) — The ten AUDIT questions, the four risk zones and the intervention for each.
- NIDA Clinical Trials Network, Drug Abuse Screening Test (DAST-10) — The ten items, scoring and the degree of problems and suggested action for each score band.
- American Society of Addiction Medicine, The ASAM Criteria — The Fourth Edition, released in 2023, and its levels of care.
- SAMHSA, Removal of the DATA waiver (X-waiver) requirement — Since January 2023, buprenorphine for opioid use disorder needs only a standard DEA registration with Schedule III authority.
- FDA, first over-the-counter naloxone nasal spray (2023) — Approval for sale without a prescription.
- FDA, boxed warning for benzodiazepines (2020) — Risks of abuse, misuse, addiction, physical dependence and withdrawal reactions.
- FDA-approved labeling for Zoloft (sertraline), DailyMed — An example of the class-wide antidepressant boxed warning: increased suicidal thoughts and behaviors in pediatric and young adult patients.
- FDA, boxed warning for certain insomnia medicines (2019) — Complex sleep behaviors, such as sleepwalking and sleep driving, with eszopiclone, zaleplon and zolpidem.
- Federal Register, Confidentiality of Substance Use Disorder Patient Records (2024) — The final rule updating 42 CFR Part 2, with a compliance date of 16 February 2026.
- American College of Physicians (2016) — CBT-I recommended as the initial treatment for chronic insomnia in adults.
- American Academy of Sleep Medicine (2021) — Strong recommendation for multicomponent CBT-I; recommends against sleep hygiene as a single therapy.
- California Business and Professions Code §§4980.36(d)(2)(I), 4999.33(c)(1)(K), 4996.2(e); 16 CCR §1807.3 — Substance use content for LMFT and LPCC degrees, and the LCSW requirement of 15 hours in alcoholism and other chemical substance dependency (BBS statutes and regulations book).
- Texas Administrative Code, 22 TAC §§681.82–681.83 — Addictions counseling course (§681.83(d)) for counselor applicants whose program began on or after 1 August 2017 (§681.82).
- Florida Statutes §491.005(4)(c) — Mental health counselor coursework, including a course in substance abuse.
- 988 Suicide & Crisis Lifeline — Call or text 988, free and open 24/7, including for substance use crises.