Episode #146

Many therapists shy away from asking about substance use.  There are some very common and very valid reasons for this. Today, I want to share the top 5 most common reasons I’ve heard for avoiding talking about substance use. Then I want to share my top 5 reasons why I really believe we all should be assessing for substance use. If you resonate with any of the reasons why folks don’t assess, you are not alone! My hope is that you will end the podcast feeling encouraged to give screening a try. I’m going to be showing you some great assessment questions in our live event Braving the Course on Monday September 18th at 6pmCST.


 You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use 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 146. 

In the last episode, we ended up talking about how trauma and substance use have a bidirectional relationship that trauma. Is a risk factor for substance use and that substance use is a risk factor for trauma. This is well supported and documented by trauma experts all over the world.

There is so much information on the impact biologically of trauma, of how we store trauma in our bodies and how it literally changes the landscape of our brain. We also know that substance use can change the landscape of our brain, and that’s kind of the point. It can help deal with overwhelming emotions and intrusive thoughts or help someone feel quote something instead of feeling numbed out all the time.

It is no wonder that those two things are related. When someone has been through trauma, survival is key. Shutting down the thoughts in their head, making themselves be able to get through the day to live another minute, another hour, another week, another month.

Substances don’t judge. They don’t ask questions and they don’t fail you. I have heard time and again from folks about how substances felt like their only friend, and it’s not pathetic as some might think it’s understandable. Humans are flawed. And all dealing with our own pain and shortcomings. And trying to love people the best that we can and trying to survive ourselves. It makes sense that those two things go together. Trauma and substance use. 

What we ended up talking about in the last episode was about how even though that’s true, that many therapists would say that they don’t work with substance use, and I understand why.

I don’t recall being told that I should. I had pretty excellent training, I think, in my master’s program, but the substance use part was optional. What message does that send? I ended up needing to know about it because with my own experience as a person in recovery, it was in my nature to ask about substance use because it was part of my own history. A huge part of my history.

So today I thought I would share with you the top five reasons that I have heard that therapists don’t work with substance use. And then I wanna share with you my top five reasons that you should.

The biggest reason is usually stated as substance use isn’t in my scope, to which I always wanna say, why not? And what they say is, I didn’t get trained to work with substance use. So let me address that real quickly one could reasonably assume that because we didn’t have a focus on substance use in our training, whether it be Master’s or doctorate level, We could reasonably assume that it’s because it wasn’t important or that it wasn’t going to be part of our job.

However, if we step back a minute, let’s take a look at all of the other things that we didn’t get specific training on. And I wanna tell you just a shortened story about why substance use isn’t a core competency yet. When I think about training and I think about the therapists that have worked with me over the years, I have had probably 20 to 30 therapists working for me, not to mention probably the same number of interns on top of that over my career. 

I’ve gotten to know lots of therapists and what they’ve had in their history for training and supervision and continuing ed and all of that. And what I found is that our training varies wildly. There are lots of folks who got generalist social work degrees  and they had tons of different classes, but it wasn’t clinically focused. They got classes on social justice, on macro level social work on other kinds of issues and case management things that I never had anything about. 

Then there are other folks who went through, say, marriage and family, and they had more emphasis on family counseling and marriage and couples counseling as well as human sexuality. There’s lots of us who didn’t even have human sexuality and there’s literally nothing more important to the human race than sex. We wouldn’t exist. Yet that isn’t a core competency. What? Why is that not a core competency? 

And then there are other folks who had extra emphasis on certain schools of thought versus other schools of thought. People who went to Adlerian schools and that’s what they mostly learned. And other folks who had extra doses of humanistic theory. And other folks who got a big emphasis on research and design. We had really different training. 

Licensing is meant to capture the majority of what we need to know. So plus one minus one, standard deviation from the mean, right? 68% of what we need to know. But even there, our competencies are different. So in order to be an LPC, to take the NCE, the National Counselor Exam, one of the eight core competencies is career development.

What? Why is career development a competency? But sexual development is not. I didn’t have a course on career development. Yet when I moved to a state where it was required that I have had that class, I had to quick take it and I had to memorize the things that they wanted me to know for the test only so I could pass the test. And I have literally not used my career development information once, not in my entire career. Our competencies are not giving us what we need to be a therapist. They are tests, that’s all they are.  

Back in the fifties it was like the wild west of licensing where all of the different schools, which would end up being social work. MFTs counselors and psychologists were all trying to figure out licensure for themselves. There were, I think, eight different social work organizations that came together  to create the N A SS W. The MFTs, I think, had six of them. Everybody was trying to come up with what are we gonna agree on? And nobody was really leading it. It was just hodgepodge. 

Because if you think about the number of therapists in the country, we had no internet at the time, and they’re all trying to just communicate via phones and correspondence. This was kind of a mess. What they did was create standards based on what the schools were doing, but the schools weren’t necessarily talking to each other. They were just going off what they saw other universities doing, and a lot of that was based on what PhD programs were doing because that’s all we had. All of this was just people in a group picking from a smorgasbord of topics and deciding what would be core.

Yep. We had the DSM certainly, but the DSM was again happening in the fifties, and it wasn’t until 1980 that substance use was even included. Because let’s think about what was happening in the substance use world when all of this wild west of mental health therapy licensing was happening, AA was happening, Alcoholics Anonymous, and that’s it.

And that started in the late thirties and forties. It was a grassroots, peer led organization. They were not at the table talking with people about addiction and substance use. There wasn’t anyone talking about that because it was only being treated medically at the time and not well, I might add. The American Society of Addiction Medicine existed, but they had a hundred members at the time that all this was going on.

The only reason that substance use isn’t a competency is because of that. Not because someone decided it wasn’t worth it or it wasn’t our job. Changing higher education is damn near fucking impossible. Changing licensing boards well, that is not a trick I would ever try personally. What happens at the licensing board level and what happens in those tests that we take has jack shit to do with whether or not we’re good at as therapists. Right? 

When I took that test, I studied for the test. I studied probably more for that test than I did in all of undergrad put together. Because I had known extremely smart people who had failed it.  I studied for the test alone. And you know what? That test was not a predictor of what kind of therapist I was gonna be. It was my ability to memorize information. I don’t believe that those tests are the end all, be all. 

So if they’re not, then why is substance use not in our scope? If we didn’t get training? Do you know what we’re supposed to do? According to our ethics in each of our domains, whether it be social work, marriage and family, our responsibility to expand our scope is to get training. That’s what we’re supposed to do. It doesn’t say you have to specialize. It doesn’t say you have to go back to school to do it. It just says that you will get relevant training. That’s it.

Even for those who did get training, sometimes they tell me that they don’t feel like they know enough about substance use. Number two on our list is that they don’t feel like they know enough about substance use. They may have had a little bit of training, but  they don’t feel competent. They don’t have any confidence that they would know what to do, I wonder when they feel like it would be enough. I’m not trying to be shitty about that. I truly am wondering. What is going to be enough for them? What is gonna make them feel like they know enough? 

Because the truth is, think back to when you started as a therapist. I know there are some people who listen to the podcast who are new therapists, and so you’re gonna be right in the smack center of feeling like, I don’t know enough about most things, and I will tell you, hang in there. None of us did. And you figure it out as you go. Just know how to be with people and you’re gonna be all right. 

For the rest of us. I want you to think back to what it was like getting your first clients. Most of us didn’t work in a specialized atmosphere. Most of us had clients of all types and ages and issues, and you never really knew who was gonna show up in your office, and it felt a little bit like trying to fake it till you make it. Huge bouts of conscious incompetence for me, of being aware that, oh my God, I think I suck at this. I don’t have any idea what the fuck’s happening. And I might have a moment where I felt like, Hey, that was pretty good.

But most of all, I just remember not feeling like I knew enough, and the only way to know enough is to keep going. Is to keep learning about people, to keep figuring them out and finding the patterns because we are good at that. We are good at putting things together and remembering connections and tying things together. We really are. But very often not feeling like they know enough about substances is one of the answers that people give me.

Number three on our list is that they’re concerned that they’re gonna get in over their head. That when they start screening for substance use, that someone will be using more than they can handle. And I wanna tell you that’s a hundred percent gonna happen. I guarantee you that somebody is using more than you expected and that you’re gonna have a moment of, whoa, okay, don’t panic. You’re gonna handle this the same way you handle it when somebody has more suicidal ideation than you expected, or their depression is deeper, or you realize that there might be psychosis, people surprise us. 

Over time, I think they surprise us less because people aren’t as different as they might think they are. But every so often we get somebody who really surprises us. And if you’re newer to asking about substance use to really asking about substance use, someone is gonna surprise you.

I promise you, you know how to handle this. It’s about determining imminent risk and finding out what they wanna do about it. Because if they’re not imminently at risk, in the same way that we would be worried about someone killing themselves, if they don’t feel like changing their substance use, you can’t really do anything about that.

What I can tell you though is that the majority of people who are in your office as an outpatient mental health therapist are not going to be using at a super severe level. It’s just not gonna happen, and I can tell you why. 

Number one, the more intense the use the more legal problems pop up. When that happens, the legal system gets involved and they push the person towards substance use treatment, not towards mental health treatment.

When I ran a treatment center for substance use, I did reports every year about referral sources, and what I found was that 90% to 96% of anyone who came through our door were there specifically for legal reasons. That only four to 10% at max, and that was one year were there because personal reasons. And of those people, I can promise you the majority of them were there because a relative or a loved one was pushing them to do so, not because they decided one day they needed help. And that’s just the cold stats of it. 

The legal system pushes people towards treatment, and that is because their use has gotten more severe and there’s consequences. And so probation or parole was a huge referral source. The district attorney’s office with a lot of deferred prosecutions, people who got DWIs or driving while intoxicated tickets, folks who were involved with child protection or people who were dealing with custody issues or work problems where they had gotten in trouble at work or needed like a Department of Transportation clearance.

Those folks are ending up in treatment situations with people’s specializing in substance use. The other folks are typically using problematically. Could be into the addiction stage, but maybe not. But generally in this middle ground, they’re the ones who show up in outpatient mental health. They call and they talk about stress, or they talk about anxiety, or they talk about depression or relationship problems, and they’re pretty functional.

In order to show up in outpatient mental health, they gotta be pretty functional. Now with telehealth, I think there’s a barrier there where we might not see it quite as quickly, because it’s easier to sort of fake functionality when you’re on a video rather than having to show up and be in someone’s physical presence. But while there will be people who are above your pay grade, so to speak, when it comes to substance use, it’s not gonna be everyone. It’s not even gonna be most. And it’s not even gonna be a lot. The majority of these folks are gonna be in a problematic use range. That is a hundred percent doable and a hundred percent in scope for us.

 The fourth reason I’ve heard of why therapists don’t screen for substance use or don’t work with substance use is that they’re not sure what to ask and they’re not sure what to do with the answers. There are lots of therapists who have said to me, I wouldn’t even know where to start. And then if they answer yes, I don’t even know what to do with that.

Super valid. I think we make it more complicated than we need it to be. I. We need to treat substance use like any other behavior that somebody is doing that isn’t super adaptive, right? So let’s think about someone who’s shopping a lot, or blowing money on stuff or making choices with partners that are causing havoc in their life or self-injury.

There are tons of behaviors that people do that go from mild to moderate to more severe, that we help them curb. Substance use is the same. Yes, it can turn into addiction, and there is some point where problematic substance use does start to affect the brain and causes changes in the brain. But that isn’t really a part of what you’re doing here. 

You’re looking at. Here’s the behavior that the person is doing. Let’s figure out the parameters of it. How bad is it? How deep is it? How long it has been going on? How detrimental is it? And how much, if at all, does this person wanna change? And then we help them make small changes.

Our job is not to fix people. Our job is to help them figure out what it is that is bothering them, that is getting in the way of their life and helping walk with them as they seek to change it.

Okay. Whether it’s helping them with referrals to medication management and helping them learn coping skills and helping them get toxic relationships managed and set good boundaries and come up with good self-care routines. Our job in this sense with substance use isn’t to judge their substance use as being good or bad.

It’s helping them look at it and determine for themselves , is this causing a problem? Are you totally okay with this? Because here’s what I notice is that when you do this behavior, you end up talking like this, and I’m wondering if that bothers you. We are a mirror to help hold up to them what it is that things look like from the outside, and that is all we’re doing, not trying to get people sober.

The fifth reason that I hear often is that they believe that you have to be specialized to work with substance use. I’ve had lots of therapists tell me that they’re not specialized, that it is out of scope in the sense that it would be illegal or unethical for them to do so. And what I’m here to tell you is that’s not true.

Substance use is included as part of mental wellness, emotional health, and physical health. There is no separate category for substance use. Yes, there are specialties, but there are specialties for eating disorders and trauma and developmental delays, and working with zero to five or working with geriatric populations. There are specialties of all the things that we do. Substance use work that is just substance use requires a bachelor’s level education in many states and in some states a associates level education. This is not something that is above our level of education. 

They created those programs because they needed more people who were willing to work with substance use and they’re treating it as a behavioral disorder. They decided to make programs and certificates just for that. Substance use is in our D S M, it’s in our wheelhouse. It literally is in our manual and you totally can work with it.

So those are the top five reasons that I have heard of why people don’t ask about substance use or don’t work with substance use.

So I wanna share with you my top five reasons why I think you should  ask about, and work with substance use. You don’t need to specialize, I promise you. You don’t need to specialize. I have done a lot of reading on different programs around the country at schools, as well as those available on the internet for helping therapists learn about substance use. 

And what I have found is that they’re either super niche. Like dealing with postnatal withdrawal syndrome and mothers who are taking, opiate replacement therapy or super broad, like the history of addiction treatment. A lot of the programs I’ve seen, they’re either covering a tiny thing in great detail or they’re covering a giant, broad bunch of topics that is mostly theory and not necessarily applicable to the day-to-day world that you and I inhabit.

That was what led me to create my program to begin with. So over the last 20 years of my career, being a new therapist, specializing in substance use, all that time as a person in long-term recovery and then becoming a supervisor and a director, I have helped train numerous therapists on how to work with substance use as a mental health therapist, a non specializing mental health therapist.

I really believe that I have come up with what you need to know in order to do this work, and I put it together in a program and I teach it so that one piece stacks on another, and then the rest is practice and figuring it out with the clients that come into your office and get in consultation.

And the reason why it’s so important to me to encourage regular therapists just like you to work with substance use are these five things.  Number one is that one of the quickest ways to manage a negative emotion is to numb it out or change it with substances. They are fast, they are effective, they are cheap, they are available. Nothing that we will teach people is gonna be as good as a substance. It’s just not. We can’t compete deep breathing. Is not gonna compete with alcohol or weeded. It’s just not.

I have people coming into session who are suffering, as do you, and they hate how they feel. And they only see us an hour a week, and then they have all of the rest of the hours to manage. And substance use is really quick and easy and secret. And for the most part, they can keep it hidden and they can keep it cheap.

Because that is the case for substances we need to ask. It’s an available resource that they are most likely either using now or have used in the past. And we need to know how they got into it and how deep they went into it. And it’d be nice to know  that if they got out of that, how did they get out of it? Are they at risk for that happening again. This is simply a factor that we need to know, that suffering people try to find a way out of their suffering, and because substances are part of our everyday life that they’re gonna exist. 

The second reason that I believe that we all should ask about substance use and work with it is that trauma can make people more vulnerable to the effects of substance use than those without trauma. Trauma is a risk factor for substance use that is all over the research. We know that. 

What we also know is that, maybe not entirely, but to a large degree. Trauma is responsible for people developing mental health disorders, and our job is to work with mental health disorders. We know that trauma drives a lot of it, and we know that trauma is a risk factor for substance use, and so therefore, our people are at risk for problematic substance use, and because that is true, I believe that we should be screening everyone for substance use that is problematic and that we should address it if the client is open to it.

Number three. Is that substance use used for coping will get more intense over time. When someone is using substances in order to deal with their emotions, it’s effective, right? It allows them to forget. It allows them to numb out. It allows them to sleep. It allows them to have energy. That all of course, depends on what it is they’re looking for and which substance they’re using, but it’s effective, right?

And it would be fine. Like it would be no big deal except for one thing, tolerance. Tolerance is a bitch. Tolerance is what makes substance use a problem. And partially it’s the tolerance you’re thinking of where somebody has to use more of a substance in order to get the same effect.

Partially, it’s that the other part is that the brain gets used to a certain level of a substance and it requires more in order to deal with it. And it forms a habit around it, and the brain makes it so the person is more sensitive to distress. That’s an actual real thing that happens, and so it requires more substance. And because the substance isn’t really working the right way anymore and it’s not getting the same spike, then the person has to use more.

So what I mean is that if somebody is drinking and their dopamine spike goes up to like 200, which is about what it is, Over time,  if they’re drinking on a consistent basis, they’re not getting 200 every single time, it starts to diminish because the brain is really used to what that is and it’s like, oh yeah, we know what to do with this. And so the brain wants hits 200 units of dopamine. And so it pushes up the distress so the person needs to drink more. And it gives them this restless feeling of having a habit. And so they have to use more as well.  If someone is using substances to cope with their life with stress or trauma, it is going to get more intense.

And because of that, we don’t just need to assess at the beginning. We need to assess ongoing to see if any of that shifts. The same way we would as we check in about depression or anxiety or whatever habits they’re working on. When I have someone who has been involved in self-harm, I don’t assume that it’s over and then never ask about it again.

I may not ask about it every time, but I’m sure gonna ask them every now and again to make sure it didn’t pop up and I didn’t miss it because I have found that my clients don’t wanna tell me if they feel like they’ve quote messed up. I want them to, and I want them to not have shame about it, but people are people and shame tends to be our go-to.

So, number four, in the reasons why I believe that you should screen for and work with substance use is that problematic use will get in the way of therapy. If someone is using substances in a problematic way, eventually it’s gonna butt up against what you’re doing in therapy. There is no way to keep it separate because it will bleed over.

There are so many different ways that this can happen, and it could happen because the person’s getting more and more consequences from their use. It doesn’t have to be legal consequences, right? Consequences is kind of a big word. But by that I mean relationship difficulties. Somebody’s worried about them. Friends are commenting about their use. They’re starting to hide their use. They’re spending more than they have to spend. They are not getting as much sleep because they’re drinking to the point of dropping too far in the sleep cycle and they wake up groggy every day and then they’re like, oh, I must need an upper so I can function better today. Or whatever the case may be. It’s going to bleed into the rest of their life. 

If you wait until you notice, what I will promise you is that it’s worse than you expect. Whenever we see someone’s behavior and we see them being erratic, whether it’s a client or whether it’s family member or we need to remember is that they are likely trying to hide this behavior. They’re likely trying to keep anyone from noticing.

It’s like holding a bunch of things in your arms, knowing that one of them’s gonna tumble out here and there. And trying to keep them all balanced so you don’t lose stuff outta your arms. People are trying to hide anything that they’re ashamed of from everyone else. So if you see it, it’s because that’s the part they haven’t been able to hold back. That’s what’s bleeding over into their life. I have never found this not to be true when I suspect a certain behavior that’s happening, whether clients or kids or family, and I’m like, huh, I’m noticing something.

This is a little weird. I end up finding that it is more than I expected, and that is just because the person was probably doing a decent job at hiding it and now they’re not, and it’s starting to bleed over. Because of that once you start noticing it getting in the way of your therapy work, it’s gonna be much more in depth than you thought. 

We all should be screening and that we need to work with substance use. This idea that we don’t work with substance use needs to go away because we do, we might not specialize, and that’s the phrase, I don’t specialize in substance use, but you do work with it.

Just like you may not specialize in working with trauma or eating disorders or anxiety or depression or bipolar or whatever it is, but you do work with it. I don’t specialize in working with people with schizophrenia, but I still work with it. And we work really hard to help our clients. We really do. 

We’ve been talking for the last month or so about how working in this job, in this field is hard and that it can lead to burnout and secondary traumatic stress, and that we need to care for ourselves in a much broader way than just self-care in order to protect ourselves and our lives and the work that we love.

I don’t want the work that you’re doing with your clients to get fucked up because you didn’t know about their substance use, because that sucks. You’ve been working really hard and then to find out that something was actively sabotaging you, that sucks. Now, sometimes people just don’t tell us even if we ask.

I have definitely had that experience where I ask someone, I’ve asked them more than once and then it comes out later they’ve been using drugs the whole time and I’m like, oh my God. And I sort of wanna bang my head into a wall. , and once I know it’s like, the piece of the puzzle I was missing has now come to light.

And the fifth reason why I believe that you should screen that you should screen and work with substance use is that you really do have the skills to work with substance use. You really do. Like, I’m not just saying that and blowing smoke like truly.

You have these skills. You use them every single day that you do therapy. You just need someone to show you how to apply it. The sixth module in my charting the course program is about this, where we talk about different modalities and different techniques and how they work with substance use. And what I love about teaching that is I love watching the light go on in the students and they’re like, oh yeah.

Oh wait, I could use this one from a c t or I could use this one from D B T, or I could use this one from relational cultural theory. There are so many ways to work with substance use because remember, it’s a behavior. Substance use does not have its own modality. Like it doesn’t exist. There isn’t one.

Substance use is a smorgasbord , and it all depends on the individual counselor, what techniques they use. A lot of it’s based on C B T because it’s the most accessible, I guess, the most common,  but there isn’t a modality you need. You have the skills, I promise. What you need is some guidance

in this series, what I have wanted to share with you is all leading up to the Braving the Course event. Braving the course is happening in one week. It’s a week from Monday, September 18th, live 6:00 PM Central Time to 8:00 PM Central Time. This is the encore session of this training.

This training is being done because my very good friend, Dr. Jenny Hughes and I are passionate about supporting other therapists. We have similar passions. We just come at it from a little bit of a different perspective. Jenny has the experience of having been working in a trauma center and feeling the isolation of not having any support and feeling herself heading towards secondary traumatic stress and burnout from not having what she needed as a trauma therapist.

That sparked her passion to wanna support other therapists and create a community where we can get our needs met, even if our agencies don’t do it for us and for those of us in private practice so that we can get what we need and not have to figure out who we can trust and whether we have time to do such a thing. Jenny has curated a group  called the Brave Trauma Therapist Collective.

For me, I am seeking to give regular therapists, non-specialized therapists  the tools and competence and confidence they need to work with substance use. So I give you everything that I believe you need to do the substance use work, and additionally give you the consultation that you need to go over cases and to troubleshoot along the way for the next six months.

So what Jenny and I did was come together and we’re gonna talk about these two things. We put our programs in a bundle so that you can get both her membership and my program, for a lower price tax deductible for those of you who itemize your business expenses and give you the support that you need.

We know that having six months of solid support with clinicians that you trust is gonna be life changing. And I know that’s kind of sounds fucking dramatic, but I believe it and we’re gonna be talking in the next two weeks about what we know regarding what therapists need, what leads to burnout, what’s protective in terms of keeping us from burning out and what the research tells us regarding all of it.

All of this is to give you a good frame for when we go to Braving the Course on September 18th at 6:00 PM If you haven’t registered, head over to betsy byler.com/braving-the-course and sign up. If you are signed up, you don’t need to do anything else. Oh, and I should mention that the reason we’re doing an encore event is two reasons.

One is there are folks who really wanted to attend live who couldn’t, and two is that there were people asking about CEUs. Now, I would love to be able to give CEUs to everyone who watches a replay video. Unfortunately, I can’t with this particular training, and the board that is approving it, it has to be live. And so I know that not everyone’s gonna be able to attend live, and I wish that you could. 

I still will have a replay for you if you wanna still watch the training, even though you won’t get CEUs. There is a workbook that goes along with it, and I promise you will get something out of it. However, I wanna offer this live and it’s gonna be happening on Monday, September 18th. 

So clear your schedule, get into your jammies, get something to drink. And hang out with us for two hours and let us talk with you about how to protect yourself as a therapist and why it’s so vital that we have the support of each other as well as I will be giving you my top three questions for starting to screen for substance use.

I am really looking forward to having you all there and I will see you on the next podcast. And until then, have a great week. 

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

Braving the Course Registration betsybyler.com/braving-the-course

Home of the Brave Trauma Therapist Collective braveproviders.com

Charting the Course betsybyler.com/course

Brené Brown on Strong Backs, Soft Fronts, and Wild Hearts https://brenebrown.com/podcast/brene-on-strong-backs-soft-fronts-and-wild-hearts/