Why should mental health therapists assess substance use?
Is that really in our scope? My answer is a resounding, Yes. In this episode I go through ten reasons why assessing for substance use is vital to our work and to our client’s well-being.
I often wonder what the reasons are that a therapist doesn’t ask about substance use. I’ve spent more time than I can quantify thinking about this. I don’t have judgment or criticism of therapists who don’t ask about it. I just figured they weren’t trained and it just seems like it’s out of their scope to do so. I’ll be addressing those reasons a therapist might not ask about substances in the coming weeks. This week we’ll start by talking about the main reasons why I believe it’s actually a cornerstone of our assessment and why our clients need us to add this to our assessment process.
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 69. We’re fully into the swing of 2022. Where I live, it’s a cold one. It’s about -17 actual temperature up here today, and I’m not sure it’s going to get above zero. It’s days like today that I love telehealth.
This week on the podcast, we’re going to be talking about assessments. We do assessments as a matter of course. If you’re a therapist in practice you know that doing an intake assessment is the very first thing we do when we meet someone. In some ways, it’s the best way to start. We ask a lot of questions and are able to get a lot of detail about the people we’re seeing. The hardest part I think about assessments is that we’re supposed to get them done in one session.
This is an hour to get to know someone. To get them to feel comfortable to ask them extremely personal questions and to make a diagnosis. I remember an early practice that seemed impossible. Yet, somehow over time, I figured it out as I’m sure you have. Our assessments at times are probably not what we want them to be.
I’d like to have a deeply thorough assessment every single time and it can be challenging depending on what we’re working with. People often struggle with what to say when they come to therapy. They know they need help. They know they don’t feel good or that they’re struggling or that things feel like they’re falling apart. They don’t necessarily know how to tell us all that information. The art of doing a good assessment gets easier over time, as we figure out how to ask questions and make people more comfortable.
So it might feel like too much for me to say that you need to be assessing people’s use of substances. While I would love for it to be in the initial assessment perhaps it can’t be. However we do continue assessing as time goes on and you can easily take a session and talk about substance use. In the coming weeks. I’m going to be talking about exactly how to do that, about what questions you should ask and what those answers might mean. Today, though, we’re going to start at the beginning as we usually do, which is why we even need to do this at all.
As I sat down to think about it. I came up with 10 main reasons that I think it’s vital that we’re assessing people’s use of substances. I’ve often said that substances are everywhere and they are. Humans have found a way to get high or drunk or in some other way alter their state of mind since there were humans. Whether it’s fermented drink or Coca leaves that get chewed on our plants that get smoked, this is just something that we do as humans.
A lot of times it’s attached to celebrations where people want to let loose and then there are other times it’s attached to other things like stress or trouble sleeping. This is just part of human behavior. It’s just something that we should be assessing, but there are other reasons that are really compelling and I want to cover those today.
Number 1: Statistically speaking, substance use is a leading cause of death among certain populations and the incidence of substance use is on the rise.
There isn’t a day that goes by that drug use or alcohol use isn’t in the news in some form. According to the National Center for Drug Abuse Statistics, it’s estimated that at least 32 million have used illegal drugs in the last 30 days. Accidental drug overdose is a leading cause of death among people under the age of 45. They state that overdose deaths increased at an annual rate of 4%. From 2015 to 2017 average life expectancy in the United States actually declined due to opioid overdose.
They estimate that over 20% of adults over the age of 18, have a diagnosable mental illness. When we add in different demographics, those numbers increase such as those with trauma backgrounds and those in the LGBTQ population due to the difficulties in navigating daily life with discrimination in all of its forms.
However, when you take just our population, which is primarily people who have a diagnosable mental illness. Of the population where 20% of people have a mental illness 38% are said to have both a substance use disorder and a mental health disorder. That doesn’t include people who don’t quite meet criteria, but have some problematic use.
If 38% of our population are struggling with substance use you have to think about what that means about the people that come into your office. It’s not necessarily going to be every other person that comes in and has an issue with substance use, but it’s more than we think. According to these statistics, it looks like almost two out of every five people has had some issue with substance use disorder or is having an issue with substance use disorder.
If we look at the number of people who are using versus the number of people who aren’t in the United States, of course the number of people who aren’t is much larger than those who are using. It can make it seem like perhaps it’s not that big a deal.
Number 2: People using substances are more likely to be involved in the care of a mental health profession.
Here’s why I say that: people who use substances in a non-problematic way aren’t going to be having the consequences that a person who is using them problematically is going to have. I think we can agree that the use of substances in a problematic way is not adaptive and is going to cause other issues in a person’s life.
It isn’t something that is separated from the rest of their life. It’s causing issues in their relationships, in their work or school, in their physical health and in their mental health. The use of substances can exacerbate these problems and push them to a place where they need to be involved in care of some kind.
Let’s take someone who’s struggling with depression, just average garden, variety depression. If that person is not using substances, their depression is going to continue along a particular path. If they are using substances their depression is going to worsen and have more complicating factors, such as: issues with money as there’s money being spent on substances rather than other things, there are issues of having to hide and cover up the use, there are issues of broken relationships because of the use. And so it’s going to exacerbate all of the things around the depression. This, I believe, can accelerate the need for outside help.
Number 3: People who are struggling with substance use rarely identify that as their primary problem when seeking help.
Here’s what I mean, I’ve spent the last 19 years as a therapist and for many, many of those years, I had access to the information of all the stated reasons that people were coming to therapy. The intake department at a given agency gets calls every day all year long and people have to say why they’re coming in.
The words that people choose vary for sure. People come in for all sorts of reasons. But if we look at the most common things, at least in the agencies where I worked, it was depression, anxiety, grief, stress, relationship issues and in about the last 10 years, the word trauma started popping up more when people were identifying what their issue was. And I think that’s because of the broadening focus on people’s trauma and how it impacts their lives.
So if we look at those reasons and we know that potentially two out of five of those people also have an issue with substance use disorders that is a large number.
They’re not coming in saying, oh, and by the way, I have a drinking problem or, oh, by the way, I smoke weed all day, every day, or I’m addicted to pills. That’s the kind of thing that when people do say it, it is because they’ve been to other treatments, they’ve tried other things and now they’re convinced that the use is part of the big problem.
That takes a lot of insight, and a lot of courage to say to someone that is a stranger on the other end of the phone. A lot of times they decide either they’re going to tell their therapist when they see them, or they may wait till it comes up.
Number 4: If we don’t ask, they won’t tell us.
Of course there are exceptions. As I’m asking people, my intake questions, we’re asking about all sorts of different symptoms. And if you don’t specifically ask about substance use, they’re going to answer your questions about anxiety, depressions, sleep, hypervigilance, intrusive thoughts, and all sorts of things that we ask but we didn’t ask specifically about their use of substances.
I’m not certain how everybody interprets our lack of questioning. Perhaps they think that we didn’t get to it yet. Perhaps they think it’s not a big deal or perhaps it’s not the kind of thing we talk about in mental health therapy. What I know is that we are the one driving the questions just by the nature of the questions we ask.
And by the nature of the questions we ask we’re telling them the things that should be happening, like being able to sleep, sleeping through the night, being able to control, worry, having energy, to do their day, those kinds of things. And by not asking, certain things were sideways implying that it’s not relevant.
The majority of people coming to therapy have no idea that we were not trained to talk about substance use. Whenever I have told someone this, who’s not a therapist, they are shocked beyond shocked. They assumed that mental health therapists would handle basically everything that wasn’t medical and that includes substance use. They don’t know that. And if we don’t ask, they’re going to assume something that probably isn’t correct.
Over my career. I’ve had the opportunity to find out why someone didn’t disclose substance use to their therapist and the answer more often than not is they didn’t ask. For us we know that it’s relevant, but to them they’re trusting us to ask what we need to know.
Here’s a different example that I think is relevant. I knew a woman who was in marriage therapy with her husband. They had seen the therapist for about six months. Randomly the woman mentioned something about being adopted. The marriage therapist stops them and says what? And she said, oh yeah, I’m adopted. Well, one of her main issues was about being abandoned and she had assumed that because she felt loved and accepted in her adopted family had never wanted to meet her biological family. That the adoption wasn’t an issue.
Adoption is a beautiful thing and children always wonder where they come from. This woman had some impact from being adopted. And this therapist was like, oh my gosh. I wish I had known that six months ago. And he asked her why she didn’t tell him. And she said, I didn’t think it was relevant. In the same way what we ask is what’s relevant. If we don’t ask things, then our clients may assume that that part of their life isn’t relevant to what we’re talking about.
Number 5: Substance use changes the presentation of mental health issues.
Let’s pretend you have a new client that comes in and they talked to you about being significantly anxious. Trouble controlling worries, difficulty managing it during the day, panic attacks, heartburn, gastrointestinal issues, headaches the whole nine yards.
And you’re asking about sleep, because we would think that sleep would be impacted and they’re like “no, I sleep okay”. And the therapist might ask, “so you fall asleep okay”. “ Yep” . “And you stay asleep okay”. “Yup”. The person’s like, “no, sleep’s fine”. That seems odd doesn’t it? I wouldn’t expect that.
What we don’t know is why that person’s sleeping well. What’s causing it? Well, maybe they’re drinking before they go to sleep every night, because that’s how they get to sleep and so it doesn’t seem like an issue or maybe they’re smoking weed every night before they go to bed.
And the weed is what keeps them asleep. We know that that’s not ideal for a number of reasons beyond addiction. They could be going down into a stage of sleep where they’re not getting much reparative sleep. They’re going to have to be using more of the substance for the same effect. It’s going to make sleeping without a substance more difficult among other reasons.
If you don’t ask them about that, you may not know. What if during the day part of their anxiety is due to withdrawal. What if the gastrointestinal issues aren’t necessarily from anxiety, but because their body’s reacting to the amount of alcohol that they’re having to use. What if the conflict in their relationship is because the person that they’re with doesn’t like the fact that they’re using a substance to fall asleep.
A person who’s smoking weed all the time is going to feel kind of numbed out. They’re not going to be as connected. They’re going to be somewhat forgetful and they may struggle with motivation. Those sound like depressive symptoms to me and they may be, but if I don’t know that they’re smoking weed because they don’t think it’s relevant or they don’t think it’s a problem, or they feel like it’s the only thing keeping them afloat. Then I’m not able to assess appropriately what’s going on.
Let’s take another example that I’ve actually seen numerous times over my career. Someone comes to me and tells me that they have been diagnosed with bipolar disorder. There was a time, I don’t know, 10 or 15 years ago where I felt like people were popping up with a bipolar disorder diagnosis pretty much everywhere. Because of that I’m always a little skeptical. If somebody truly has bipolar disorder or if the person who was asking them the questions might not have asked them every question they should have.
So I asked somebody, have you ever had periods of time where you stayed up for days at a time and they say yes. And I ask them, “well, how many days at a time?” “ I don’t know, three or four”. “And did you feel really good? Like you had a lot of energy”. “Yeah. Felt great”. “And what was it like after?” “Well, I crashed and was really depressed for a while”. Okay. That sounds like bipolar disorder. And if I don’t ask them, if they’re using substances, then I may not know that that’s what using meth is like.
I have had probably 15 or more that I can think of instances where someone has been medicated for bipolar with some fairly serious medications, including Depakote, lithium, those kinds of things. And what the problem was is that the person was using meth and that manic episodes look like meth episodes.
Another example. Let’s say somebody comes in and they say that they have ADHD. They can’t concentrate, they feel like they’re all over the place, they’re forgetting things, they can’t sit still, those kinds of things. They tell me that they think that they need a stimulant for their ADHD. That could be really reasonable.
There are a number of people who are in adulthood now getting diagnosed with ADHD, who weren’t diagnosed as children. We know statistically speaking that stimulants work for 70 to 80% of people with ADHD. Stimulants are really effective. However, is this person that we’re talking to using any other kinds of substances or do they have a history of.
If they have a history of using stimulants and other forms, such as meth or cocaine, they really are not candidates for taking an ADHD medication for a number of reasons. A lot of times, ADHD medications end up being abused by people who use stimulants as a stop gap until they can find the thing that they’re actually looking for.
I talk about this at length in the episodes about ADHD medications on the podcast. Additionally, it’s not likely to fix the thing that’s going on because what’s happening with them may not be ADHD. And definitely could be something about withdrawal. They could be in between use cycles.
They could be struggling with the after effects or the damage that was caused by a drug. If we assume that what they’re presenting is not substance related, we’re going to be missing an entire portion of a presentation. And the last side note, anytime someone comes in with psychosis, This is key because a lot of people are unaware that marijuana has a relation to psychosis.
Marijuana in and of itself is not the thing causing psychosis necessarily. It is interacting in a way in their body that can push psychosis forward. When someone is having psychosis, I want to make sure that we’re not dealing with alcohol withdrawal, which can cause hallucinations, chronic marijuana use, which can also look like psychosis and dealing with meth in the mid to later stages of meth use, psychosis is almost a given.
What we don’t know is if that’s going to resolve when they quit using or not, sometimes it does, sometimes it doesn’t. It just sort of depends on the person’s biology and that’s not something we can predict. A person’s substance use will change the presentation of what you’re seeing. And trying to figure out where symptoms are coming from what they’re using for substances is an incredibly important question. And in fact, I think one of the most important questions.
Number 6: Progress in therapy will not be what it could be if there is substance use involved.
Substance use is going to interfere with mental health, period. Because of that, it’s going to interfere with progress in therapy. I know for myself that I have been in situations with people where I’m not understanding why progress isn’t happening, or I’m not understanding why a certain thing keeps popping up or why we’re not moving in a certain direction.
Usually when that happens, I catch myself thinking about it and then I’m like, okay, let’s back up a minute. What am I missing? And it feels like there’s a piece missing. Like if I could just get this one piece of the puzzle, then the whole picture would make sense. And more times than not that piece is substance use that hadn’t been told to me before.
It could be that someone was minimizing their use, or it could be that as time has moved on in therapy, that their answers to my questions about use are different now. Maybe when they started seeing me the use was at a certain level, or it wasn’t there at all and now might be six months later and they are using, but I didn’t ask them and so they didn’t tell me.
If there’s something we have in common as therapists it’s that we want our clients to get better. We want people to feel better to be able to have more fulfilling lives. We are changing and pivoting often to meet our client’s needs. I don’t want us to have to work even harder because we don’t know a substance use issue is there. The substance use will impact their ability to proceed in therapy.
Number 7: Substance use is going to increase symptoms and potentially increased suicidal ideation.
One of the biggest risks we have as therapists is suicidal ideation and people committing suicide.
It is the thing that we worry about with people and that we’re always assessing. Substance use is going to increase their symptoms. A lot of times people will feel like it reduces their symptoms, but when you add something like a substance, it is going to cause other unintended consequences. For instance, if someone is smoking weed all day long, every day it is expensive and there are other things that are going to fall through the cracks.
Stoner subculture does not present chronic marijuana smokers as being hyper responsible or on top of things and organized because that’s not what weed does to you. There are people who function high all the time. Not saying that they can’t, what I’m saying is, is that things get dropped in the meantime.
Maybe they forgot to pick someone up. Maybe they forgot to pay some bills. Maybe they don’t have money for that. Maybe they’re going through withdrawal and they’re having to focus on how to get weed, how to afford it, where to smoke it, how to make it so they don’t smell whatever the case may be. Even if it’s being used to solve one problem, like going to sleep, it’s going to crop up with others.
Symptoms are going to shift and increase in different areas if there’s substance use. That is related to the progress thing that we talked about just a minute ago. The suicidal ideation, though, that is a really big risk.
The thing about a cycle of use for somebody who is using substances is that they go through a period where at one point in their use history were able to use “normally” or pretty close to normally, and it didn’t affect their life. Because substance use is progressive that is going to change. When people are in despair it is often when they are in the middle of a deep cycle of use.
I recall having crisis calls come in from people, sitting at a bar during the day, hammered drunk, talking about how they have nothing to live for and how pathetic are they, drunk during the day and they should just die. They’re not rational. They don’t have an ability to really see what’s happening in the long future. All they know is that they’re drunk and alone. Same thing goes for people who are using opiates or other downers. Same thing goes for people who are using meth and other stimulants and they find themselves feeling strung out, not being able to sleep. Their body is breaking down and they feel despairing.
Suicidal ideation is huge among people who are using. The amount of shame that goes along with substance use is astronomically high. When we are working with people we need to assess for substance use for so many reasons. And in this reason, it is because their symptoms are going to get worse and potentially their suicidal ideation may either increase or maybe they didn’t have it before and it’s just starting.
Number 8: We are uniquely positioned to be able to ask about substance use.
There is no other helping profession that has as long in an office alone with a client than we do. Doctors, PAs, nurse practitioners of all different specialties see clients and when they see them, maybe they see them for an extended time on their first visit.
While they’re in that visit, there’s a specific thing they’re there for. If it’s a primary doctor, the primary doctors check on all the major systems and particular issues that are popping up. They have to stay focused in order to get the information they need, because typically there’s a medication or a prescription coming out of it, or at least a referral.
Follow up visits are not going to be an hour. The medical community is getting more and more pressed to churn people out and get people through so they can bill more hours. It is causing a tremendous amount of burnout and moral injury to our medical professionals.
Prescribers and other specialists are seeing patients for 20 minutes or less. We see our clients for around 50 minutes to an hour. And in many cases we’re seeing them every week. Up until this point, we have been able to keep our timeframe for the most part. I have been in conversations where money people have suggested that we cut therapy down, have shorter sessions. I don’t know that they understand what it is that we do. It takes a while when somebody comes in, even someone who wants to be in therapy and knows you.
You come in, there’s a little chit chat. We do a check-in and we get into the meat of it, but it takes a little time. Then we have to wrap up and prepare the person to go back out into the world and not be walking out with their issues, just front and center. We are the only ones that I can think of in the helping professions that have this much time with people. Who else has the time to explore substance use the way we do?
We have a person alone in our office or in our virtual office. And their whole reason for being there is to help them get better. They are learning how to be vulnerable with us. Of all the other people who could ask about substance use in their life we have the best shot. The other people in this person’s life need us to do this. If they had time, they would ask. We are uniquely positioned to be assessing for substance use.
Number 9: Our clients deserve a good and thorough assessment.
There are therapists who believe that diagnosis doesn’t matter. And in some ways I agree. And in other ways I don’t. I think that assessment is far more important than just establishing a diagnosis or completing paperwork so that we’ve checked a box.
We have the ability to look at all the pieces of their life and see how they fit together. Our clients don’t really know what they need when they come to us. How many times have people been asked? What do you need from me? And the person doesn’t even know what’s available. So they don’t know what they need.
When it comes to an assessment. I believe assessments can be vital. I believe assessments can help people understand themselves. That as we ask questions and as we start pulling in different parts of their life into the picture that they will feel like, huh, maybe I’m not so fucked up after all. Maybe this makes sense. Maybe this is normal for someone who’s been through what I’ve been through. And that in and of itself is incredibly healing.
I have found that people really like having a collaborative discussion about diagnosis and symptoms. I believe that our clients deserve a thorough multifaceted assessment from us. And in this case, I’m not talking about the paperwork you do on the first visit. I’m talking about the ongoing assessment as we pull together a picture of this person’s life and we help map a way to move them into the life that they want. They don’t know that they need a thorough assessment, but we do.
Number 10: Whether or not we got trained substance use disorders are in our manual.
In the DSM-V are all of the diagnoses that we are able to diagnose. There are at least two main sections that we didn’t get a lot of training. It sorta depends on what school you went to and what discipline you went into.
One of those sections is sexuality, which our field doesn’t do a great job with and so we have to have sex therapists get looked at funny because they’re talking about sex even though sex is actually more prevalent than substance use. And the other section of course is substance use.
Most of us didn’t have a lot on that, if any at all. And so it can sort of lead us to think that it wasn’t relevant. That somehow, because we didn’t get trained in it, it’s not going to be relevant to our work. But when you get into the field, you know that that’s not the case.
I talk about substance use and sex constantly. In the last agency I was in, we would joke about the fact that we talk about sex, sexuality, and reproductive health, way more than we ever in a million years would have thought that we did. We talked about it with kids, with teenagers, with adults. It didn’t matter what phase of life people have an extreme lack of education about their own sexuality and their bodies and how that plays into the rest of their life.
We had to figure it out because our clients needed us to. This is the same way. Just because our programs didn’t teach us about substance use. Doesn’t change the fact that it’s in our manual. It’s literally in the book that we work from. We are allowed to assess it and treat it. All of these 10 reasons that I’ve talked about today are why we should.
I think a lot of times people feel overwhelmed with the idea of having to add yet one more thing to what they’re assessing for. And I hope that I’ve given you the reasons why it isn’t just one more thing.
Instead it’s a foundational thing that it will help with everything else you’re doing, because if there’s substance use there, it’s going to get in your way. And it’d be kinda nice to know what’s happening. Our clients also want to talk about it. They’re coming to us because they want to feel better and it’s hard to be vulnerable. They really are counting on us to kind of drag some things out in the most loving way possible.
Perhaps you’re feeling convinced that yes, this is something that you need to screen for. The next question and obvious question is, okay, how. How do I talk about this? How do I add this in? What am I even looking for beyond “do you use substances, do you drink? Are you smoking weed?” I’m not suggesting you assess in those ways.
In the coming weeks, we’re going to talk about exactly how and exactly what you’re going to be looking for and all the things around assessing for substance use. Next week we’re going to talk about the barriers to addressing substance use and how to work around them.
I hope you’ve enjoyed the podcast today, and I hope that it’s given you some food for thought. I am certain that there are many of you that regularly assess for substance use and I am so grateful that you have already added this in. And for those of you who haven’t yet, I am also very grateful that you are here and listening.
My goal is to help all of you feel like you have a little better idea, what to ask about and what to do with that information. All of this is in service to bringing more hope and healing and freedom to the people we serve.
I hope you’ll join me for the next podcast and until then have a great week.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to firstname.lastname@example.org. I’ll see you on next week’s podcast. And until then have a great week.
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