Quite generally, psychotherapy and psychoanalysis are under great pressure today to account for what they are doing, to prove their scientific validity and their therapeutic efficacy. Those of us who use clinical experience in conducting their practice in ways which seem optimal, as judged both by them and by their patients, are increasingly challenged to respond to a canon of scientific method and validity that claims its brief for truth. What I am going to say will not live up to such high standards of proof, but will simply reflect my clinical experience: what helps and what fails with most patients that come to me, often after a string of previous treatment failures. What I am going to say claims practical usefulness, not ultimate scientific truth. I would like to highlight a number of issues that have proven themselves as of special importance for the long term treatment of substance abuse dependent patients. The first is the role various forms of denial play and how these might best be approached. Multiple layers of denial entail usually some form of split identity--rapid alternations from one part identity to the other. Then I shall briefly study the role of impulsivity and of various forms of impulsive action. These topics of denial, split identity and impulsive action dictate some reflexions on attitude and technique necessary for the long term psychotherapy of patients with prominent problems of substance abuse and impulsivity. I shall conclude with some more general recommendations for the future of psychotherapy with substance abusers.