Episode #128

Avoiding topics of conversation is super normal for people. We work hard to help our clients talk about the hard things and to face the things that need to come to light. There’s an area that we might not be asking about that could make a huge difference in our work. 

Everyday we see clients, we try our very hardest to give the best care possible. There are some days where we feel like everything is clicking along and we are doing a great job. There are other days when things feel harder. But either way it’s always on our minds to be a great therapist. Our jobs are hard! There’s so many things to think about and take into consideration each time we do therapy. Today’s topic is one area that sometimes gets missed for a variety of reasons. I’m going to make the case that we need to evaluate our client’s substance use.


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 128. Today is April 17th. In the part of the United States where I live in Spring is just happening. I realize that for a lot of folks who are south of me, spring has been there a while. You might even be planting things in your garden. Where I live though, there’s still snow on the ground. We have maybe two feet left that needs to melt, but being as though it was 70 degrees yesterday,  that is slowly happening. You see kids outside playing in shorts and t-shirts while playing with snow and having snowball fights. It’s just part of living in the north country. 

This is the time of year when clients start having a little more energy, sometimes a little more hope about the future. Winter can seem really long for a lot of people. I’m not somebody that suffers from seasonal depression, and even I am feeling the draw of spring. Of the hope that comes from the winter being over. 

Spring is also the start of new things for a lot of people, things that maybe they’ve been putting off. And today I wanna talk about something that some of us might have been putting off.

I know this won’t apply to everyone, and so  if you already incorporate this into your practice, I am excited and happy that you’ve been able to do it. For those who haven’t yet, you’re the ones I wanna talk to today.

One of the things that I can guess about almost all therapists is that we are trying our best. We wanna give our clients the best care possible. We want them to feel better. We want them to find a path through whatever the difficulty is that brought them to our door. Every time we’re with people, we wanna give them what they need. 

We balance that with managing our own lives and there are some days where we’re better therapists than others, but generally we’re all trying to be on top of our game. After we got outta grad school, we found out that there was a lot more to being a therapist then maybe we realized. It was taking all of the things we learned and putting them all together at the same time.

I’ve talked before about how it’s a little like learning to drive. In the beginning of learning how to drive, you’re paying attention to the lines you’re trying to stay in. You then are trying to take care of your speed and make sure that you’re going fast enough, but not too fast using your turn signals, checking your mirrors.

It can feel like a lot of things to track at one time. If you’ve ever tried to teach someone how to drive, then you’re familiar with that. Trying to tell them,  you need to check this, or don’t slam on your brakes without checking behind you and be aware of all the cars. Over time, some of that stuff fades away and it just becomes second nature.

Something that you don’t do. With a lot of conscious thought therapy can be a lot like that. In the beginning, I remember thinking that there was no way I was gonna remember to do all the things at one time. That I was gonna be able to pay attention to what they were saying and what they weren’t saying, what I was thinking, what I was feeling, what their face was doing, what their body language was doing, what my body language was doing, what direction to head in, making connections, saying the right things. And remembering it all so that I can document it later, all while checking the time to make sure that I could end on time. 

20 years later those memories are old now, and I’m grateful for the way that our brains are able to learn and set aside information  that can be muscle memory. It’s what helps us become better at our jobs. Over the years, as I’ve learned new modalities  and learned more about our field in general, I’ve added new things to my repertoire of skills. Some of the main training experiences I’ve had have made incredible impacts on how I do work.

One of the examples I could think of was when I went through a training based on development from what happens from from zero to. That is definitely not my population of people, and so I was actually only going to be of support to my staff who did work with that population.

I didn’t expect that what I learned that day was going to completely affect what I did in the future, how I worked with people, except that in the end, that’s exactly what it. I knew about development of course, but I had fallen into the trap. I think that a lot of people do, is thinking that babies were sort of like lumps. They were taking in information, but it wasn’t really an important time. 

Those of you who work with or have worked with zero to three, know that that’s not at all the case. It’s an incredibly important time that can shape their entire future and their entire personality, the way they interact with the world, their temperament.

I remember at the end of those two days feeling a little bit shocked that I really hadn’t understood what was happening during those times. It was after that that the ACEs study came out, and that’s the Adverse Childhood Experience study that was done through Kaiser Permanente in California.

It’s pretty famous now for showing us that early childhood trauma has an effect on future choices and even future health.  Early childhood development wasn’t something I asked about very often when it came to my teenagers or, and especially my adults.

After that training though, I added it to my assessment of people. I had an experience recently where someone’s prenatal and early childhood development actually had a tremendous impact on the way that their brain functions and how they interact in the world.

Understanding that and helping the client understand that has been vital to their ability to accept how their brain is different and how they’ve been able to make really brilliant accommodations. Having these pieces of information, learning these new things over my career has been, have always been exciting and somewhat stunning too.

I remember feeling that way when I first started going through D T training. I remember going to a two day training first and coming back to talk to my husband and my brain moving a mile a minute because I was sort of astounded and overloaded  and excited. I was making a ton of connections and thinking about all these ways that I could help different people on my caseload and the things that I would wanna do with them.

It happened again when I started training in TF-CBT. And again, when I started training in EMDR, each of those experiences was revolutionary for me.  I didn’t expect it because I felt like the growth that I had done as a therapist maybe had happened already. It’s kind of arrogant, I suppose, to think that I was past learning, maybe.

But it was just kind of this assumption in the back of my head. I’ve since learned  that learning new things can really shift everything. I wasn’t necessarily as open to accepting those training opportunities in the. In fact, I remember avoiding doing training for EMDR.

I didn’t really understand it. It didn’t seem like it was gonna be my kind of thing, honestly, it seemed a little like voodoo magic and a little woo woo for me, and so I avoided it. The reason that I ended up training an EMDR was because I needed more skills.

I had people with significant trauma who weren’t getting better. I remember one client in particular who I had done TF-CBT with when they were in high school, and while they got some better, it wasn’t enough. That’s what ended up pushing me towards EMDR. If you’re here today, then there’s something about substance use that is calling to you.

Part of the reason I wanna talk about this today is that in four weeks I am hosting a free webinar on Screening Skills for Substance Use: My top three questions to jumpstart your interventions. You can register for this free webinar at betsybyler.com/skills. It is important to me  to not just encourage you to talk about substance use, but to give you the skills to be able to do it.

I know a lot of folks avoid asking about substance use. There are a variety of reasons why therapists avoid asking about it. Today I’m encouraging you to increase the amount that you talk about substance use with your clients.

Perhaps you already discuss it, and I’m really excited that you do so. For you, I’m asking you to increase what it is that you do for those who don’t ask about it, but are interested and want to know what to look for. I’m encouraging you to get started. To begin asking to not wait and to not avoid it. 

We as humans tend to avoid things that are uncomfortable, that can seem scary or unknown. When it comes to mental health therapists and talking about substance use, there are lots of reasons why people might, why therapists might avoid bringing.

It could be that they feel like they don’t have time. Getting everything in and talking to a client about every part of the assessment can seem really difficult. We found out when we went into the field that we had a limited amount of time to get intake information. Having to diagnose in an hour is really complicated. And we have to be really thorough in our diagnosis and in the symptoms.  All while trying to help a client feel comfortable enough to come back. 

Substance use can be one of those things that feels scary to ask about. What if we offend somebody? Are they gonna think that we are accusing them of having a problem?  Sometimes substance use can feel like it’s not a part of our scope of practice. Most of us didn’t have a ton of training in it, and there’s plenty of us who didn’t have any at all.

So if we weren’t trained in it, then perhaps it’s not part of what we should be talking about. Sometimes it also can feel like it might not be relevant. That isn’t the thing that the person said they were here. And what we’re doing in therapy is dealing with the problem at hand, not trying to divert a client to talk about something else.

What if it’s a mistake though? What if not asking about substance use is a mistake? For me that changes things. If I was making a mistake in my practice, I would want to know, and I know you would. I believe that not asking about someone’s birth history and early development is a mistake. When it comes to adults.

I don’t necessarily spend a ton of time there, but I do wanna know if I’m working with someone who was born premature  and had significant developmental delays or significant early childhood trauma or  parental stress during that time, I would want to know.

I have seen this in a couple different instances where it changed the direction of what we were talking about. I remember one particular client who was the next child born after  their mom had given birth to a full term stillborn baby. The trauma that that mom would’ve gone through would have been immense.

The next child who was born within a year after the stillborn would have had experiences that the other children didn’t. That mom would have been thinking  about her late child, about what that child would’ve been doing, about what they would’ve been like At this stage. Those things are going to affect how that mom interacts with their newborn baby. How the family responds to the death of a child is going to affect the other children. It would have been a mistake for me to not ask those questions. 

When we don’t ask about substance use, I think it’s a mistake. There are lots of times when we ask, there really isn’t anything, and in those cases it’s just like checking a box. I know this information, there’s nothing here, and so I don’t need to worry about it. It’s similar I think to medical history.

Medical history is something  that I always cover with new clients because I wanna understand what’s happened. I wanna know what medications they’re on, what chronic illnesses, if any, that they have. I wanna know if those illnesses are being treated. I wanna know about surgeries and potentially any medical trauma in their history.

I wanna know if they are avoiding any medical care. I remember working with a woman who had avoided the doctor for six years  when they had been experiencing significant symptoms for the last six years. When I worked with them, getting them to the doctor was  one of my very first courses of action because the symptoms made them afraid that it was cancer. That they were slowly dying. What could I be doing in therapy that would be more important than helping them determine how their health is not asking them about that would have been a mistake.  

Avoidance is a powerful tool. Sometimes it can be really beneficial. One of the ways I talk about avoidance is when someone’s dealing with an existential crisis. In some ways, you have to solve an existential crisis to a small degree. The problem with those kinds of crises though, is that they’re unsolvable. None of us can know what’s happening after we die. None of us can truly know the purpose of life and why we’re here. All we can do is figure out how to manage that fear and then frankly, avoid thinking about it.

In that way lies madness. It’s like staring into the abyss. In that case, avoidance is really adaptive. In other ways of course, it’s not. When therapists avoid things. I think that there can be a lot of shame attached to that. Like we’re supposed to be better than. We shouldn’t shy away from hard conversations. We shouldn’t not address things because we’re supposed to be the one encouraging people to do the opposite. And we are human and just trying to do the best that we can. 

One of the things we know from research is that the quality of our therapeutic relationships is one of the most healing factors in therapy. It can feel really risky to do something that might blow that out of the water. If you have a client who has an addicted relative that has particularly caused them pain, it can be hard to ask your client if they have any trouble with substances. We might worry that we would offend them. We might worry that we’re gonna blow our rapport out of the water, and because of that, we might not ask about it.

I think asking about substance use can feel extra. Can feel like if we were doing a full psychological evaluation, then maybe, yeah. But a diagnostic assessment just to start therapy. Probably not important. I think it’s vitally important and clearly you have some interest in it, otherwise you wouldn’t be listening.

The case I wanna make is that not asking is a mistake. It’s certainly not intentional as we all wanna do the best job we can for our clients. So I want you to think about your caseload. I want you to think about the people that you’re gonna see the next day you see clients, whether that’s today or whether that’s tomorrow or next week.

Who’s on your schedule for the next time you work? As you think about each of those people, or maybe you need to pull up your schedule and take a. I want you to ask yourself what their history with substance use is. What kinds of substances have they used? Were there ever any difficulties? Did anything bad happen?  What’s their current  substance use history? Are they drinking anything or using anything? I want you to think about if you could answer those questions.

If you had to answer questions from someone else about whoever your nine o’clock was or your 10 o’clock would you know the answer? If you don’t, there is no shame to be had here. Me asking this question is not meant to point a finger or cause any kind of shame, it is simply to show that there is an area of your client’s life that you might need to ask more information. 

There are instances where substance use would change the entire course of what you do.  Imagine that you’re treating someone for  major depressive disorder. They’ve come to you and they’ve been in a pretty dark depression for a while. There’s some suicidal ideation, although no plan at this time. There doesn’t seem to be any situation that is currently pressing on them that’s making it worse.

You send them to their doctor  so that their doctor can check on  any medical conditions that could be increasing their depression. The doctor prescribes them an antidepressant  and you continue seeing your client week by. 

You check in to see if they’re taking the medication, because sometimes people struggle with that. You’re checking in on side effects and about benefits. The person is reporting after the four to six weeks that there really hasn’t been a change and you haven’t noticed one either.

So they go back to the doctor and they get a different med and they do this, and now we’re through three medications. The person is frustrated, it’s been months, and they’re not feeling better. What would it change if you knew that they were drinking on a regular basis to manage the feelings of despair? What would that do to what you would recommend? What would that do to the conversations that you were having? 

Sometimes we have a tendency to think that people are gonna talk about their substance use, so they’re gonna bring it up. The thing is, people don’t. There are probably lots of reasons for that. The reason I think that people don’t in general is that there is a lot of shame and stigma around letting something quote control you of not being able to stop doing a thing that you know is bad for you.

We tend to hide ways that we do things in excess. Whether it’s spending or eating or drinking or smoking. Nobody wants to believe that they have something that is controlling them, so to speak, and they don’t wanna admit that out loud. One of the reasons people don’t talk about substance use is because they don’t wanna let it go most of the time.

People who are using substances in order to cope, there are certain moments where people do want to stop. When it comes down to it, that’s when they start feeling like, I don’t know if I can do this.  It’s easier for them to decide that it’s not that big a deal.

 A friend of mine, Jean McCarthy, who shared her story with us last August, talked about this. She said every morning she would wake up, thinking this is the day she’s gonna stop drinking. Jean had a successful career, three really successful children, and a happy marriage. Enough money in the bank to be able to do the things they needed to do. She was just anxious. an overachiever, a perfectionist. Yet she was drinking a couple bottles of wine a day. 

Never intoxicated where someone would ever see her. She was drinking, timing it so that she could fall into bed and fall asleep. Tolerance though is an issue and so she ended up having to drink more and more. But every morning she said for years she had hope that today was the day. Today she was gonna stop drinking. Today, she was gonna be able to get through this. 

She shared that in the morning, if she had called our office to get into therapy, probably, she would’ve planned on talking about her alcohol use. However, as the day went on, she said that the alcohol use would’ve been taken off the table as a discussion. Because as the day went on, she was starting to experience withdrawal and the anxiety that comes with withdrawal and the anxiety that she had underlying was also kicking.

And if she hadn’t made an appointment, then by the afternoon she wasn’t gonna call at all. She desperately wanted to quit drinking. She knew that it was bad for her and that it was out of control. However, in the span of a couple hours she realized that she wasn’t ready to talk about it yet, let alone share it with a therapist.

If you’ve listened to the recovery stories on the podcast, you’ve heard people talk about having been to therapy. One of the things I usually ask them is if their therapist knew about their substance use. For the most part, the therapists didn’t. I don’t blame the therapists for that.

The therapist likely was doing what we all do, trying to stay on the topic the person presented. Trying to help them with the current problem. The problem though, was impacted by their substance use. So in the case of the person with major depressive disorder, that person’s depression was going to be worsened by their continual use of alcohol and the battle they had internally.

It’s much easier though to say that the meds aren’t working, and so now they’ve been through three trials of meds and none of them worked and the person still feels hopeless. The suicidal ideation would also get worse while they were intoxicated. While someone is drinking, can be really risky for people with suicidal idea.

Because while it’s supposed to help them forget, it can also make them get stuck on the things that are hard, on the things that are sad, where all they can think about then is how they’re in this hopeless cycle  and they feel like they’re never gonna get out.

Not checking in about substance use would have been a. And not one made out of negligence. When you were being taught how to do an assessment, I wonder what are the things that were drilled into your head that you had to ask about? Was your training really big on making sure you asked about sleep? Was your training really big on making sure You asked about medical history? 

What if it had been drilled into our heads to ask about substance use? The thing is, there isn’t one standard for assessment. We all got taught, however we got taught. We all were trained and supervised in different ways. The way we were shaped as therapists is absolutely related to who trained. . If you weren’t encouraged to ask about substance use, it is likely that it is not natural for you to do so.

That is so understandable. It wasn’t natural for me to ask  about birth to three. I had to train myself to ask about that so that I could understand it.  For the most part. When I ask about that, there’s nothing remarkable and I just set it aside then. 

Once in a while though, I do come across something and I’m really glad I asked  because it does shift things. And it helps me understand how this person became who they are. 

I’ll give another example. Let’s pretend that we have someone coming in for trauma therapy. This person clearly has some PTSD whether it’s full-blown or not is irrelevant at the moment. We’re working on getting them ready to start doing some trauma. We wanna talk with them about dissociation. We wanna talk with them about their symptoms. We wanna figure out their distress tolerance and how much they can talk about their trauma while staying in the window of tolerance.

In my case, I’d be getting ready to start EMDR. What if that person was using marijuana on a regular basis? What if that person was using marijuana while they came to therapy? People who smoke weed all the time don’t see it as being under the influence or intoxicated.  They get used to it to the point that they function what they feel like is “normally”. They go to work high, they drive high, they take care of their kids, they go to appointments. It’s not deviant behavior. It feels normal to them. And so coming to therapy under the influence would make sense to them, especially if they’re having trouble dealing with their trauma.

Well, the thing about marijuana is that it separates you from space and time, which is dissociative. It puts a barrier between them and whatever else is happening on the outside. Even if they’re not actively like blown out of their mind or anything, there is still a separation, so they’re not going to be emotionally, fully present with you. 

That means that we aren’t going to be able to tell what’s really happening with their symptoms and if something is going up or down. They could be having their symptoms increase and therefore increasing their marijuana use. And they wouldn’t tell us because they managed it.

Additionally, we can’t be doing EMDR while someone is high. It’s contraindicated and I’ve seen it go badly. We have to remember that marijuana is also psychoactive, that it has some hallucinogenic effect at times, depending on the strain. It also has a depressant effect and sometimes can even have a stimulant effect. It  depends on what kind of weed it is and how the person’s body responds. We need to know the information that the person is using marijuana. 

Lots of people who use marijuana say that they do so for their anxiety. The problem is that marijuana is going to impact their therapy, their memory, and the use of medication. We need to know so that we can set some parameters around therapy and talk with them about possible interference with medications and lots of other things. 

So as you’re thinking about your caseload list, as you’re looking at those names, you wanna know what’s their history with substance use and what’s their current use of substances. If there’s nothing of note, then you can be assured that those pieces are not gonna be interfering in the background. If there is something to know, you will be super grateful that you asked. 

This doesn’t have to be a full substance use assessment. There are a few questions that you can ask that will tell you whether or not you need to ask more questions.  And we’re gonna talk about those specific questions  in the free webinar on May 16th. Screening skills for substance use will be a one hour online training for free that you can register for at betsy byler.com/skills. 

I wanna address the idea that you might offend someone by asking about substance use. It is true that somebody could take that the wrong way. I think that there are ways around that, though. You really can set up the conversation in a way that’s gonna help make it more comfortable for you and for them. 

I talked about this in a training that I did, which you can watch for free  over in the Learning Hub on the website.  It’s a new section that I just made live on my website. You can go to betsy byler.com/learn and the very first training on that page it’s called Five Steps. That training will teach you the steps to bring up substance use in a way that will feel good to both of you.

If you have an internal resistance to asking about substance use, I encourage you to look into that a little more and figure out what that’s about. Logically it makes sense to ask about substance use, their mood altering, mind altering substances, and what we are doing is dealing with mood and mind. It would make sense for us to know the information if  they’re altering their mind and mood. 

So if there is that internal resistance, what is that about? You might find that you didn’t realize it was there and sort through it and realize that it’s okay and that it doesn’t need to be there. If you don’t know how to ask these questions, that you feel competent to do so, or you may find that you’re feeling like you don’t have enough information, whatever the case may be. Whenever we’re avoiding something, having an understanding of what that is, I find it super helpful. 

When I get that sense inside of me of something I don’t wanna do, I’m always thinking, what is that? Why am I avoiding that? Why don’t I just go get it done? Why can’t I just stop thinking about it and go do the thing? I love finding out new information about. About how I work and what’s happening subconsciously.  It’s part of the very psychodynamic underpinning to my training. 

My encouragement in talking about this is not to point fingers or suggest that you aren’t doing your job . It is to show you that I have found that this is a really helpful thing to know about. That if they’re using substances problematically, it’s going to negatively affect your work. It’s going to make things harder and it’s going to mask certain things and potentially push therapy in a different direction than where it should be going. And you won’t know that and your client won’t tell you because they typically don’t.

Substance use is something that we hide and minimize. None of us wanna look bad in front of others. We already know that we have to watch to make sure our clients aren’t faking good, that they aren’t trying to tell us they’re fine. The same way they tell people in their life that they’re fine, that with us within the hour they’re in our office, that they have the opportunity to be completely and that they aren’t hiding things from themselves or from us. 

What I have found is that talking about substance use helps take the shame out of it and helps people be able to look at what’s happening in their life and make some decisions about how they want to live. If they’re not ready to stop using a substance and we talk about harm reduction. We talk about  how to make it impact their lives less. 

They get to make decisions about whether they want to do anything or not. I am a mirror. Simply holding up what I see and helping them take a look at it. Not having secrets and not having substance use be a secret is incredibly freeing. You get to be that person that helps them find that freedom. You get to help them uncover any areas that are blind spots for them or that they are trying to.

We ask about a lot of really sensitive things. We talk about self-harm, we talk about suicidal ideation. We talk about sex. We can talk about substance use. . If you don’t know how to bring it up, you can check out my training on the five steps to confidently ask about substance use@betsybyler.com slash. 

If you already feel like you know how to bring it up, but don’t necessarily know what to ask, I encourage you to  head over to betsy byler.com/skills to sign up for the free webinar on May 16th, Screening Skills for Substance Use. There will be a replay after the event. So those of you who aren’t in the United States time zones don’t need to worry about being up at three in the morning or stopping midday  for our friends who are even further afield. 

Next week we’re gonna be talking about a common myth about substance use treatment. 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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