Episode #129

I’ve been suggesting that regular mental health therapists can work with substance use. But what does that mean? Doesn’t treatment have to be some specific techniques, length of  time and process?  What is treatment really like?

Substance use treatment is a lot of different things. Just like treatment for depression or anxiety, treatment varies based on severity. There is a large subset of clients that are treated with individual therapy and don’t need formalized treatment. For some this is a surprising thing! When the phrase substance use treatment comes to mind, we tend to picture one specific thing. Check out this episode where we’ll talk about what treatment really is.


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 129. Today we’re gonna be talking about a myth. Saying the word myth makes it seem like there’s some big conspiracy when there isn’t. I think it’s simply misinformation. And the myth I wanna talk about today is the idea that substance use requires formalized treatment. 

When you stop and think about substance use treatment, I wonder what comes to mind. For some, it’s going to be residential treatment where people stay overnight, they attend groups during the day and go to meetings. It’s true that residential treatment is an option. It’s a great option for a lot of folks. However, the majority of people I know never went to inpatient or residential treatment.  

For others, maybe you picture a specialist’s office, someone who’s a substance use counselor, or maybe you picture a 12 step meeting. Problematic substance use is way more than we tend to think it is. There is a huge spectrum, and because of that there are lots of options for treatment.

One of the things that I hear when I talk with mental health therapists about substance use is  that they don’t know how to treat that. The truth is that you do, you just aren’t aware of it. Certainly there might be some missing information, but the actual skills that it takes to do the work, those you already have, in fact, you do them every day.

It is a myth that substance use requires specialized treatment. There are some levels of substance use that may require something more intensive, but that is the case with a lot of mental health and medical issues. 

Saying that substance use requires formalized treatment is similar to saying that people who have major depressive disorder have to go into inpatient treatment and I’ll explain why I say that. The way depression is treated, has a wide spectrum of options. Yes. Inpatient hospital treatment is an. Typically, for a lot of folks, it’s only going to be three to five days at least if you’re an adult in the area of the country I live in.

There are folks who spend longer at some of the state facilities. However, you can’t really get someone to pay for that kind of treatment, and so it’s actually pretty rare. We don’t send our clients to the hospital unless we need to. For most of us. We do our very best to keep our clients out of the hospital. We do our very best to give them the amount of autonomy that they can have in making these choices. 

The hospital is difficult at times. I think sometimes. I think it’s absolutely necessary. I have had clients of mine go inpatient because they were suicidal and weren’t able to keep themselves safe. At times it godsend for them to be able to go. It was what saved their lives. At other times, it hasn’t been a great experience. They came out feeling worse. It all depends on the person. It depends on the staff. It depends on the facility. 

The goal in treating major depression is not for them to go to inpatient. It’s to find the least restrictive level of care that they need and help them engage in that. We only go up in levels if the need warrants it. Substance use is the same way.

When we’re talking about depression. There are folks that are treating their depression with medication and never step foot in a therapist’s office. There are people who are treating their depression with therapy. There are people who are combining therapy with medication or people who are treating their own depression by using a sun lamp or exercise  or supplements and homeopathic remedies.  There are people who are treating their depression with TMS, with ketamine, with ECT. 

All of these things are treatments for depression. They vary. Intensity. They vary in intrusiveness, and I think we would put them on a spectrum and put some of them lower in terms of least restrictive and least invasive, all the way up to ECT and inpatient treatment. We wouldn’t refer someone directly to the highest level of care unless there was a great need.

It is the same way when it comes to substance use. We don’t necessarily refer someone to residential treatment for substance use. we don’t even refer them  to a treatment. Everybody has a different level of need when it comes to substance use. 

Certainly there are people who are going to need higher levels of care. That is something that you can easily screen for. So when somebody says, I don’t know how to work with substance use, I wonder what they think they’re being asked to do.

For the last couple years as I’ve been doing the podcast, I’ve been sharing with you that you don’t need specialized training and that you can work with substance use as a mental health therapist.  So I thought today I would talk about what treatment is when it comes to, a formal treatment center, and we could talk about what happens when someone’s not informal treatment, 

 When we’re talking about residential treatment, that’s one type of treatment and one level of care. There’s actually quite a few different ways of doing treatment, and they’re on a spectrum . I’ve talked about the ASAM criteria in other episodes, and so I won’t get into a huge amount of detail here, but I will do just a short overview. 

The criteria was meant for people to be able to look at a client’s use and say, how about these six dimensions  and they’re looking in each one to see where the person falls. We’re looking at withdrawal. We’re looking at biological medical concerns. We’re looking at mental health concerns. We’re looking at the living situation and whether or not the living situation they’re in is conducive  to being substance free. 

All of these factors go together to create a recommendation for a level of. And this is level one through four. One is outpatient, two is day treatment, three is residential, and four is medically managed inpatient.

The first two are probably pretty self-explanatory. No one is staying overnight anywhere. The difference between level one and level two is the amount of hours that somebody is participating in therapy or treatment or whatever word we wanna use for that. 

When it comes to level three and four residential and the medically managed, Think of medically managed as detox or when someone goes into the psych unit for suicidal ideation on an acute basis, it is a briefer stay typically, and in terms of substance use,

It’s something that we use to deal with withdrawal. And medical issues. Imagine that we have a diabetic who’s an alcoholic. That person coming off of alcohol is going to have some complications. It is dangerous to deal with alcohol withdrawal without medical intervention, or at least without it being monitored that way.

When people don’t have a risk of physical withdrawal or medical complications, but they have a high risk in other areas, then typically they’re gonna be in level three, which is residential. The only difference there is that they don’t have 24 hour medical oversight. There are different levels of this, depending on the state and what they require.

It is mostly counselors and people who might pass out medication that the person the, that the patient brought with them. But it’s more therapeutic services rather than medical. So we have these four levels of treat. 

Level one being outpatient actually is a huge spectrum of services. This could be one hour of mental health therapy, or it could be up to 12 hours of therapy slash treatment. a week And still fall in the level one category. When we get over 12 hours, which is considered intensive outpatient, then we’re dealing with day treatment. So this is gonna be similar to partial hospitalization. That is when people attend groups from 9:00 AM to three or 4:00 PM  four out of the five weekdays.  That exists for substance use as well. It’s not necessarily super common, and I haven’t seen it offered in a number of places.

It’s more common for there to be intensive outpatient, which typically is 10 to 12 hours of therapy slash treatment a week.  The majority of people that use substances in a problematic way, are in level one. They do not need day treatment, residential or inpatient. The chances that you have level one folks in your office is extremely high. I have talked in other podcasts about how to screen for when someone needs a higher level of. 

A lot of times those folks are not gonna show up in outpatient therapy because showing up in outpatient therapy means that you had to call, you had to fill out paperwork, you had to set an appointment into the future. You had to show up for set appointment. You had to be coherent and engage in the session and continue doing that on a week by week basis. 

When somebody is using to the level that they need a higher level of care, they typically can’t sustain that. Lots of things start to get in the way, and so if the person is engaging in regular mental therapy with you, the chances are that they’re not gonna need a higher level of care. It’s not a guarantee. Of course, there are people who can hide their problematic use more efficiently, at least for a time. But in general, it’s probably gonna be a level one.

So let’s talk about what treatment looks like. Here’s what typically happens: when someone is referred to a treatment center. They go and they get an assessment. This assessment is a little different than ours.

The primary thing they’re looking at is their substance use history, past and current. Then they’re gonna ask other questions about co-occurring mental health issues, current medical issues, and living situation, which is about what atmosphere do they go home to at night or after treatment is done. 

Once someone has an assessment, the counselor makes a recommendation based on need. They’re looking at certain criteria and deciding whether this person needs something small, meaning an hour or two a week, or if they need something more intensive. It also depends on how many times they’ve been through treatment before. 

If this is somebody’s fifth time through treatment, then we’re gonna look at a higher level of care because their relapse risk is really high. If this is somebody’s first time coming in for an assessment for substance use, Then we’re gonna start with something small. , we’re looking at the lowest level, least restrictive, and least intrusive level of care.

Treatment in an outpatient setting is either individual or group. Lots of folks have both. Very rarely will someone only have group sessions. Group sessions are fabulous. This is not a process group. These are groups talking about psychoeducation and skills similar to a DBT group. This isn’t where people are sharing their trauma and sharing deep feelings, because that’s difficult to do in a group setting,  and in a setting with all genders represented.

There are nuances to people sharing their stories, and you can’t really control for all of. Additionally, everyone coming in is gonna be at differing levels of sobriety, and that also affects how people interact with each other. 

 Treatment, could be all individual sessions and that’s gonna follow whatever that counselor chooses to use in their interventions. It could be something that’s more structured. It could be something  that is evidence-based, or it could simply be that they’re doing the same thing we are: sitting down with someone  and looking at different areas of their life to make a plan on how to help them overcome it.

 In the treatment program I was running, we had a group that met once a week for seven weeks. We had a group that met twice a week for 10 weeks, and we had a group that met three times a week for 12 weeks. That gave us levels within outpatient in terms of severity. 

Typically, we always added individual sessions and for some folks, and we would add mental health assessments so that we could make sure that we were paying attention to their mental health as well.

When someone was in formalized treatment, we weren’t asking the therapist to manage the substance use part. They needed to be knowledgeable and be able to speak intelligently about it with their client, but that was being handled. Remember though that those folks had use that was at a much higher level.

There are a lot of treatment programs that a person could choose from to run in a treatment center. If you were to go to Hazelden, which joined with the Betty Ford Clinic, they are a well known source for treatment programs. They have a shop on their website of all sorts of different types of programs that could be instituted and by program we kind of have to think about modality a bit.

Well, there might be CBT involved. This is a specific curriculum that was designed and tested on a specific population. The main governmental department that covers this is SAMHSA, that’s the substance use and mental health services department of the United States government.

They are the ones who are responsible for putting a stamp on what is approved by SAMHSA. That’s usually an evidence-based sword,  there are so many. And it will depend on the age of the people in the group and sometimes the gender  and the referral source, is it coming from corrections or are these people there because they elected to be there?

In my experience, the majority of folks in outpatient substance use treatment are court mandated to be there. 90 to 96% of the people that we served in the treatment program that I ran were there because of a court related reason.

At any given time, 90% of the folks there were there because they had to be. That 10% or less were there sometimes because they wanted to be, but usually the other reason was because of a partner or a family member. That person had gotten. And had given some kind of ultimatum, 

This is why I explained that doing substance use work isn’t treatment. It is dealing with substance use  as a behavioral problem. When somebody is at an addiction level, when they have surpassed all of the earlier stages. That’s when we go to treatment. Think about that number, 90%. 

The reasons that people get court ordered to treatment are varied, but they generally come from three departments. One is a district attorney’s office,  the second is child protection, and the third is probation and parole. I will say that there is a small fourth category that isn’t legal necessarily, but is coming from an authority, and that is when clients come in because they’ve been sent by their workplace. They had some kind of infraction or some kind of trouble, and they had to go through EAP using their employee assistance program and they needed an assessment and to follow recommendations. These are the types of things that show up in a substance use treatment center.

There are people who come in because they are sick and tired of the life that they’ve been living with their substance use and they want to get it. And that isn’t the majority. You know where they show up? Your office. They end up calling the intake department because they’re feeling depressed, because they’re feeling anxious. That’s the thing that they can identify. The substance use is secondary. It’s a symptom of the bigger problem. And so they end up in our offices.

I wanna take a minute and talk about the spectrum between harm reduction and recovery. Sobriety is gonna be on this spectrum closer to recovery. As I talked about last week, sobriety is not everybody’s goal and recovery is also not everybody’s goal, nor is it everyone’s need. 

Harm reduction is perfectly valid. Harm reduction in this case is what it sounds like. Do less damage. How do we make this fuck up your life less? If you’re getting in trouble for drinking and driving? How do we ensure that you don’t drive? If you end up getting blacked out while you’re drinking, but you don’t wanna give up alcohol, how do we help you not blackout? Because it’s the blackout that’s causing the problems. 

Harm reduction is going to anything and everything that people do to try to make things less damaging. We do the same stuff when it comes to, say, eating. Use smaller plates, take smaller bites, drink a glass of water before you eat, have one piece and walk, make sure that you only eat when you’re hungry, don’t snack between meals, whatever the advice is, it’s trying to minimize the amount of impact that something’s having. 

Harm reduction in the substance use world can sometimes be a hot button issue, and it can be for me too. I fully support harm reduction. I also fully support abstinence. I don’t believe that if someone is truly addicted, that they will be able to moderate ever. I believe that when somebody’s body and brain has crossed over this line into addiction, their ability to moderate if they ever had one, is now gone. Harm reduction will only work to a degree for those folks.

It is not up to me to decide whether they should try harm reduction or not. That is everybody’s personal decision. A lot of times people need to figure out what they can and can’t do and where the lines are for themselves before they can accept it. 

Think about people who quit smoking cigarettes and they try to only smoke when they drink or smoke when they’re with so-and-so. Sometimes that works for folks. A lot of times it doesn’t. They end up starting to smoke again and they might go through this same pattern 10 times before they figure out This never works. I always end up smoking again. Maybe I can’t. 

Harm reduction is simply that, and it’s on one end of the spectrum. On the other end, we have recovery and the reason we have recovery and not sobriety is that recovery is gonna look really different for everybody. The pathway to get there is also going to look different. 

It’s kind of a newer statement to say that there are multiple pathways to recovery. In the past, what we’ve had are the 12 steps typically of Alcoholics Anonymous, but later to Narcotics Anonymous, Gamblers Anonymous, and that has been our standard. Follow the steps, follow a higher power, and choose abstinence and that was the only way. 

The trouble is, that lots of folks don’t really jive with a higher power. If they aren’t comfortable with that, then how do they follow the steps? There are a number of steps that are totally involving the higher power concept. Does that person have no hope of changing their lives and their relationship to substances?

What the recovery community has become is a more loosely associated group of folks who identify as being in recovery and have their own plans of recovery. For some, it might even be 12 step meetings. For others, it could be something totally d.

I interviewed a man on the podcast named Sean,  Sean  did in fact go to detox and to an outpatient treatment setting. Of course, this was during Covid and so he went to detox to deal with alcohol withdrawal since it is so risky. And then he did virtual treatment every day on his computer at home.

 After that, he was encouraged to try support meetings, which he did. It just wasn’t for him. What he found instead was a sober crew of people who were into Peloton. Peloton, if you’re not familiar with it, is an exercise group. I’m not really sure what to call it. It started with the bike and people who are really intensely into these Peloton bikes, but there are also other classes and treadmills and Peloton folks are kind of.

They’re kind of intense, like CrossFit folks are kind of intense. And for Sean, this was a huge part of his recovery, was talking to these other people who were also in recovery. How I met Sean was through another man that I interviewed named Casey.

Now Casey is part of that Peloton sober support group, and Casey’s part of another group called Life Ring that is a secular recovery group.  They have meetings, and the difference is there is not a higher power aspect to it. There are some other differences that are more nuanced than we need to get into here.

Those men have totally different pathways of recovery that are completely valid. That is a newer concept. The old timers , as they get called an AA maybe, wouldn’t have considered that to be a valid form of recovery. As culture has changed. There has been a bigger need for other ways to find freedom from substance use. 

Now, I put sobriety on that spectrum, but not necessarily all the way into recovery because sobriety is a different thing than recovery. Recovery is an ongoing process that is living and changing and has to be maintained. Sobriety is somewhat a destination where all you’re required to do for sobriety is not use anything.

However, recovery is more about changing. It’s not just about being sober, it’s about looking at the other areas of your life that either could have contributed to your use or led to it, and things that might lead you back to it.

Understanding what treatment is and understanding what the goal is, I think is really important to helping you understand your role when it comes to substance use. You are not a specialist. You don’t plan on being a specialist. You do work with folks who have a ton of different issues  and you never know when someone is struggling with problematic substance use unless you.

Speaking of which I want to remind you in case you missed the email that I have a free webinar coming up on May 16th. It is at 8:00 PM Eastern, 5:00 PM Pacific called Screening Skills for Substance Use. I am gonna share my top three screening questions to help jumpstart your interventions. You can register at betsybyler.com/skills. 

When you ask about substance use, you will find the places where you can intervene. Substance use that is not at an addiction level means that they can pull clean days. That they are able to have days during each week where they don’t use.

If they don’t want to do that, then of course you’re not addressing substance use. If they’re identifying that it could be an issue for them, the very first thing is to start seeing  if they are able to maintain some distance from the substance, and then we treat it just like any other behavior.

I wanna tell you that there is no modality like DBT or CBT or EMDR, that is for substance use only. It doesn’t exist. There is a modality  that tends to get mentioned when substance use is brought up. And that’s because we have research putting motivational interviewing and substance use together and that there’s some efficacy there.

However, that’s not the only reason that it was developed. So there isn’t a thing that you need to get trained in  in order to quote work with substance use. You’re working with your client’s use because it’s interfering in their life or impacting their mental health. That is the extent of what you’re doing.

You are not needing to get into doing formalized treatment. You are looking at how this person’s use is impacting their day-to-day life and finding out if they have any desire to do anything different about it. If they do. And if they don’t, then they’re in the pre-contemplation stage and you let that be.

This idea that substance use requires formal treatment can keep people stuck and not just us. There are lots of folks who decide that they don’t have a problem because they don’t need treatment; they aren’t like those people. When really they have a problematic relationship with their substance.

Formalized treatment is just on one end of the spectrum. There are lots of ways to intervene with somebody’s substance use that don’t require that. I firmly support substance use treatment programs, and I do think that they’re highly beneficial. I would love for more people to be able to go to these groups.

It is so helpful to learn skills and to be around others and to hear that other people have experiences like yours. I wish that we had more of that in our day-to-day lives, just as regular human beings. When it comes to using substances to cope with life there are lots of people out there who can understand just how that person is.

It takes a lot though for somebody to walk into a treatment center like that and offer up that they might have a problem. Typically, they’d rather talk about that with you in a private setting alone, where they don’t have to worry about being labeled an alcoholic or an addict.

This is simply a behavior. If it ends up being outside your scope, you will be able to tell. It’s that sinking sensation of, oh shit, this might be a little much. Then you can refer. Until then, though, you might be just the right person to help them.  

If you’re not sure where to or even if you just wanna know what questions to ask, go to betsybyler.com/skills and register for the free webinar on May 16th. There will be a replay after the event, so if you can’t make it, don’t worry about it. Go ahead and sign up and I will send you the replay as soon as the event is.

Again, it’s on May 16th at 8:00 PM Eastern, 5:00 PM Pacific. For those of you not in the United States, there will absolutely be a replay. Again, you can register for free at betsy byler.com/skills.

Thank you so much for choosing to spend your time with me. I know that the work we do is hard and that we have a limited time for other things.  I am honored that you chose this podcast to listen to. Next week we’re gonna be  talking about a misconception when it comes to working with substance use. I hope you’ll join me for that 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.

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