Episode 5

Can addiction and mental health work together?

What do I need to be able to work with addiction?

What role do specialized addiction treatment programs do and how can we work together?


This last episode of the five-part discussion about why addiction is absolutely the business of mental health therapists and why we all need to know how to assess and treat addiction in our mental health clients. 


In this Podcast

  • Addiction and mental health belong in the same world.
  • We may not have gotten trained to treat addiction, but we can change that and get the training we need. 
  • Specialized addiction treatment can be a great addition to mental health therapy. 
  • Addiction treatment programs have specific processes for recommending treatment needs and steps for each level to meet a client’s needs. 
  • If you have one available in your area, and your client is willing. Refer them, but keep working with them also.
  • If you don’t have specialized treatment available you can treat them yourselves. 
  • We can evolve and get the information and training we need to meet our clients needs and help them gain more freedom

Helpful Links:

DSM 5 Criteria for Substance Use

Free Treatment Planning Tool  https://betsybyler.com/treatment-tool/


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice. 

I take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs.Bringing more hope, healing and freedom to the people you serve.

Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.

If you’ve made it this far with me, you too believe that you need this information and it needs to be added to your skill set to help your clients. So far, we’ve covered a lot of ground. We’ve talked about that the reality of being a therapist and what we thought it was going to be like, can be really different.

And that the ways that it’s more challenging are things we couldn’t really have predicted. We’ve talked about what it means to be a generalist and the different issues come up with having to see a number of different types of people, ages and issues. We’ve talked about the fact that people are using substances. Either our clients are using, their family, friends, loved ones, but that addiction and substance use touches almost all of our client’s lives. That the relationship is the biggest predictor in outcomes for therapy. And it’s not just the relationship like you like each other. It’s the quality of that relationship that allows that person to expand what they’re willing to share and willing to let you see about who they truly are.

That is where freedom and growth happens. We’ve talked about that we were not adequately trained to deal with substance use, that we got some tools, but that we were missing some very important ones. I think it’s a given that substance abuse is not a good thing. And please hear me when I’m talking about substance abuse rather than substance use. Sometimes, I use those interchangeably. And that typically means that I’m talking about evaluating someone’s use of substances to determine whether it’s abuse or not. 

I don’t know that anyone would argue that being addicted to something is a good thing. The trouble with addiction to substances is that the impact of it is far reaching. Even if it was just limited to the addict or alcoholic themselves. That their addiction wouldn’t impact other people. It didn’t make their family members worry about them. That it didn’t make their family members suddenly lose possessions, money, social, respect, sleep. And any other number of things. That it was just the addict or the alcoholic who dealt with the physical repercussions of using, or who dealt with the legal ramifications when they wind up being pulled over for a DWI or arrested for possession.

And we know that it’s not just the addict or the alcoholic. It affects them and anyone who loves them. Specifically, my passion is for the addict or alcoholic who still suffers. I wish that there was a way to bottle recovery and let people feel what it’s like. I was hanging out with a friend a couple of weeks ago and she’s celebrating two years of sobriety. She was someone whose alcohol use wasn’t super apparent. Because it was just part of the culture of being in the service industry, in restaurants and working in kitchens, alongside bartenders and whatnot. And she gave up alcohol a couple of years ago and her journey has been fascinating to watch. Because the amount of and growth and peace that she has now, she would never have predicted.

And I wish that there was a way for us to adequately share that with people who are still using, because that is the hope. The hope when they quit is that they’re going to be able to rise above and move beyond. And the promise is real. People do recover. They can get better, they can move forward with their lives.

And this can happen within your office and within your relationship with them, you can help guide them to that place of freedom and healing. Now, I started to talk about this a little bit in the last episode, but I want to take a side note here. It’s my belief that you don’t need a license for this. Now let me clarify. I believe that this is firmly a part of our scope. That just because we didn’t get trained in it, isn’t evidence for the fact that we shouldn’t be doing it. I believe that it’s in our manual, in the DSM and therefore our business. We do have the responsibility to make sure that we get trained adequately.

I am not suggesting that just because something’s in the DSM that we should run off and just practice regarding it with no education. That is absolutely not what I’m saying. I am saying that first we have to accept that it is our business and that just because we didn’t learn it doesn’t mean we can’t or shouldn’t.

If your state requires that you have a separate substance abuse license. Then that is absolutely what you need to do. And most States that I’ve looked into or worked in don’t need one. You can do this as a mental health therapist just by virtue of the license you have now. In some states, if you’re going to treat substance abuse only. So that would mean on your assessment, that you only have substance use disorder, that there’s no co-occurring depression, anxiety, et cetera. And I just don’t know that that’s going to happen very often. And so, as long as there’s a primary mental health diagnosis, that’s not a problem. Now in the state of Wisconsin, it used to be that in order to treat substance use only that you needed a substance use license and they changed that a couple of years ago to be that anyone who has a master’s level license can treat substance use. And the reason was that we needed to expand access. We know that access to mental health and substance use services can be very limited. And so what they were trying to do, I believe,  is expand access to those services. 

I want to take a sidestep here and I want to talk again about specialized chemical dependency treatment. So in different states, chemical dependency, counselors go through varying levels of training. Some of them have to be bachelor’s degrees. Some of them have to be associates. Some of them have to be a certificate program on top of a bachelor’s degree or on top of a different kind of degree. It just sorta depends. And substance abuse counselors stick only to substance use. They do not step outside of that realm. And I believe there is absolutely a place for substance abuse counselors. So let me explain how this would work.

So I ran a chemical dependency program for the last 12 years. I had amazing substance abuse counselors. They did great work and taught me a great deal about doing substance use treatment. I want to explain how a substance abuse program works just in case some of you aren’t really familiar with it. And if you don’t have one in your agency, you may not know. 

So for a substance abuse program, the first thing they have to do is an assessment. Just like the rest of us, except their assessment has some pretty specific guidelines. There are different subsections that they have to cover, and it sorta depends on what kind of measuring tool they’re using. One of the common ones is called ASAM. The American Society of Addiction Medicine. In ASAM, there are six dimensions that they need to evaluate before they make recommendations.

The first dimension is about acute intoxication or withdrawal potential. So they’re always looking to see, is this person intoxicated or under the influence as they sit here? Or are they in withdrawal as they sit here? Or do they have significant withdrawal potential? Dimension 1  is about whether or not the withdrawal is going to be dangerous for them and whether they need to be taken inpatient in order to go through detox.

Dimension 2 is about biomedical conditions and complications. So looking at someone’s individual health history, as well as their current physical condition. The third dimension is about emotional behavioral or cognitive conditions and complications. This is looking at an individual’s thoughts, emotions and mental health issues.

The fourth is the readiness to change. Exploring an individual’s readiness and interest in changing. And this is based on the Prochaska model that talks about pre-contemplation, contemplation, preparation, action and maintenance. The fifth dimension is about relapse, continued use or continued problem potential. And what this refers to is a person’s unique relationship with relapse or continued use. The counselor needs to judge what their potential is for relapse. Talk about their history of relapse and what problems could come up when they’re trying to get clean. 

The sixth dimension is their recovery or living environment. And so this is about exploring an individual’s recovery living situation surrounding people, places, and things. And so they take these six dimensions and they put it on a continuum of care, and this is how they make decisions about what kind of treatment level someone needs. Now, the specifics of each dimension and how you get to the different levels of treatment is actually kind of complex and can be a little confusing.

Now you get really used to it because if you’re doing assessment after assessment, the way we do diagnostic assessments, you sort of get used to it. Within probably 10, 20 minutes you’re getting a feel for where this person is and what level of treatment. So the process is the person comes in, they get an assessment and then the counselor gives them a recommendation for treatment.

This is not the same thing as the recommendation that we make. Where we say, I recommend weekly therapy for this person focusing on these issues, using this technique. This is very specific. So there’s five broad levels of care. Six, if you count no treatment. So if someone has no treatment recommendations, they’re at a level zero, nothing further would happen.

So the first one is early intervention and that’s listed at a 0.5. Early intervention has to do with the idea that the use isn’t quite problematic yet, but that is heading in that direction. And so some psychoeducation about addiction in use is typically warranted. So that’s the early intervention recommendation.

Outpatient services is level 1 and outpatient services can be sort of broad. So in the clinic that I was in, we had groups that were two hours per week, one night for seven weeks. Okay. So that’s 14 hours total. We also had a group that still was considered outpatient. That was three nights a week at two hours a shot for 12 weeks. So what constitutes outpatient can really differ, but most people fall into this category. 

Level 2 is intensive outpatient or partial hospitalization services. Intensive outpatient in this context is considered 12 or more hours a week. There aren’t a lot of these programs around that focus on substance use, but this is one of the levels of care.

Level 3 is residential or inpatient services. Within level 3 there’s a couple of distinctions between the different levels. So there’s a 3.1, a 3.3, 3.5, 3.7. And the differences between them is whether or not they have medical staff on site and how often they’re there. And whether or not meds are being passed or there’s nursing 24 hours a day.

So that’s kind of how it changes. And level four is medically managed, intensive inpatient. So this would be detox. So somebody who is at risk during the withdrawal period. So this would be alcohol withdrawal. Since alcohol withdrawal can absolutely kill you. It doesn’t necessarily always kill you, but it absolutely can and should never be attempted cold turkey.

Or if someone’s detoxing is so difficult that they’re not going to be able to make it through. So heroin and opiate withdrawal, there’s literally nothing more painful than withdrawing from heroin or opiates. And I know people are gonna say childbirth and honestly, not even that. Childbirth does not last 10 days, does not make you feel like your bones are on fire from the inside. Withdrawal is awful. So the level four is really those subjects. Sometimes it can be meth addicts, although the withdrawal from meth, while bad, isn’t as bad as opiate withdrawal and doesn’t last as long. 

So when a person comes in, they see the substance abuse counselor, they get an assessment, the substance abuse counselor makes a recommendation for what kind of treatment they need.

And then they’re referred to whatever that is. Now, whether or not they follow through is a totally different thing. That was always a thing was trying to figure out how to help people go from the assessment to treatment without losing them in the middle. Because one of the things about addicts and alcoholics is when they’re ready to talk about it, you have to do whatever you can to strike while that iron is hot.

Because if it’s more than a day, maybe two days at the outside, They can change their mind. Think about the times that maybe you’ve tried to go on a diet, right. Or change something else, started an exercise program. And it was super important to you. And you were like, yes, I’m going to do this and you plan it and you get ready.

And then yay. Two days, three days later, you’re like, Oh, maybe it’s not as important as I thought, maybe I’ll just stay where I’m at for now. I’m not quite ready. I’ll do this in the future. Or it wasn’t as bad as I thought. So that’s what happens with addiction. And remember addiction wants to stay hidden.

And so that means when they start thinking, wow, I got to quit. That’s when we want to get to them. Once the assessment and the recommendations are made, they start treatment and typically treatment involves group work. And individual work as well as drug testing. And typically some kind of outside support is usually introduced.

The idea is that you want to have them have unity within the group at the treatment center. And eventually you want them to, to build a recovery system outside of the treatment center. So all their eggs aren’t in one basket, so to speak. And so I think how this can work with mental health is that a therapist who knows how to treat substance use may decide that as they’re helping their person talking about getting sober planning, when they’re going to quit, you’re thinking about, do they need detox? Where are we at? Do they need more support? 

And so the person might go to group while they’re seeing you, you would talk about mental health issues. And when they’re in group, they would be learning about addiction, triggers, all sorts of stuff. And there are tons of really great curriculum out there. For substance abuse, counselors and treatment centers, and more common than not treatment centers are using evidence based practices to run their programs. And you could even get a copy of what it is they’re covering. There is a really great way to be able to work with substance abuse counselors. 

Now, some of our clients aren’t going to be willing to go to treatment and they might not be willing for a number of reasons. It could be that they’re not ready to say that they’re an addict or an alcoholic yet.I had a woman I worked with who truly did not know she was an addict. The first time I used the word dealer with her, when I said, “well, your dealer”, she looked like I slapped her. And she was like, “my what”? And I was like “your dealer”. And she was like, “I don’t have a dealer”. I said, “well, where do you get the pills from”? She’s like “my friend”. And I was like, “he’s your friend”? And she’s like, “yeah”. And I’m like, “do you hang out with your friend”? She’s like, “well, when I go to pick stuff up, I might stay for a little while” and I said, “does he come over and like, hang out with your partner”? And she was like, “no”. And then she sat for a minute and goes “Oh”, and I just kinda, kinda chuckled about it.

Because she truly didn’t know. And she was not ready to go to a treatment program now that did make it harder on her. And I really feel like she should’ve gone and we talked about it and I encouraged her, but she just wasn’t ready to say that in front of people. And she was worried about what people would recognize her and that’s okay. I had the skills to work with her and she was able to get sober while being in therapy with me. I think it would have been easier if she’d been willing to go to treatment and we still may go that route, but for the moment she wanted to stay with me. And so we did. 

Doing treatment, you start at whatever level you’re at. Let’s say you’re at level 3 and you go to residential and then you drop down and you come home. And you probably won’t go to intensive outpatient unless it’s available and you really, really need it, but you’ll probably go to outpatient services. And so it’s hard to go from residential, where you’re in a closed environment. This is 28 days, maybe 21. It should really be longer, but insurance companies just won’t pay for that. So you go from that to just being dropped back in your home environment. One of the hardest parts is that nothing has changed at home. No one has changed and they don’t really know what you’ve been through while in treatment.

They don’t know what you’ve learned and what you’re planning on doing differently. And that’s, it can be really hard. So having the support of outpatient services immediately when they get home is really helpful. So after they finish outpatient services, typically they’ll move to an aftercare. And so aftercare is like a step down. It’s usually once a week, in addition to whatever kind of recovery activities they’ve planned. And so they slowly phase out.

A treatment episode might be six months. It could be a year, it could be longer. Some people when they’re getting sober, stay with their substance use counselors for a really long time. And there’s nothing wrong with that. Substance use counseling does not typically have an end date. It’s one of those things that someone might have completed treatment, but now they’re staying on and coming because they feel like it’s necessary. 

The last part I’ll talk about is a typical group. So in a group setting, there’s always going to be some kind of psychoeducation. And so they’re going to be learning about things like the process of addiction, the stages of recovery, triggers, dealing with friends, dealing with jobs, dealing with relationships, all those sorts of things that while they were using kind of gotten neglected such as medical health. Most people, when they’re using, they try to avoid the doctor as much as possible.

A lot of times they end up getting into the medical system because they have some sort of problem they can’t ignore, or it’s a dental issue, which is often the way people get back into the medical system. So in a group setting, they’ll do some sort of checking in with the other members of the group. There’ll be a topic for the evening and the clients that are in will talk about how that relates to them. There’ll be a drug test that’s randomized. And most clients know that the drug test is absolutely necessary. Yes, it can feel invasive. And for some of them, they will talk about that. And addicts and alcoholics who are being honest about their use, know that they need the accountability because otherwise they will try to find loopholes and play a game. Which is just the nature of addiction.

So, if you have the ability to refer your clients to a chemical dependency program, I would absolutely encourage you to do it. If they’re willing. Also, I’d like you to have enough skill that you feel like if they refuse that you don’t have to put that on hold, but that you could start moving them in that direction. And if it’s not available, that’s okay. It’s not imperative to someone’s success. I just believe that the group aspect and hearing from other addicts and alcoholics helps normalize the experiences you have while you’re using and can really help alleviate the shame in a way that as therapists, we just can’t do. 

The truth is that we, as mental health therapists are called to bring freedom and hope to people’s lives. We got some great tools and there were some that we missed. And the tools that we missed could have very serious consequences in someone’s life. And we don’t have to just live with that. We can evolve, we can add to our skillset and get the training we need to be confident in our ability to work with substance use.

I don’t think you need extensive training. I believe our skills are sufficient, but that we need the right information to add to it. Because of this, I’m creating a comprehensive course that will cover all of what I think you need to know. It’s not ready yet. And won’t be for a while, but when I’m ready to beta launch, I’ll let my listeners know. The plan is to offer it as a live group program.  And then as a self study course.

And my course is not the only way to go. You can decide that you want other kinds of training that you can find and some stuff online that you want to learn. Or that you kind of want to build your own thing. Either way is just fine. The reason I’m creating a course is that over the last 17 years, I believe that I understand what it is that you need in order to feel competent and confident that you are ready to assess and treat substance use in your clients. Until then I wanted to offer two things.

One is this podcast. Each week, I’m going to cover a topic that is relevant to the work we do, about substance use, from a mental health perspective, You can sign up for my email list and you’ll get a notification when an episode goes live. I promise not to spam you. I super hate emails that are unnecessary, and I know we all get tons of them. So promise I’ll just be sending out relevant information. 

The second thing is that I created a treatment planning tool that will help you with case formulation and planning areas of interventions for your clients. The treatment planning tool is free. To get the treatment tool go to betsybyler.com/treatment tool. When you sign up for the treatment planning tool, you’ll also get 10 companion emails delivered over the next two weeks. The companion emails go into more detail and we’ll help you get the most use out of the tool. You can choose to open the emails and follow along or not. My desire is to be helpful not to fill your world with more noise.

This work we do is my passion. I am honored that people invite me into their lives and share themselves with me. It’s why I’m here on this earth. I want to make sure that my fellow therapists get access to the information they need without spending a ton of time searching and trying to figure out what they need.

I hope that you’ll take advantage of a treatment planning tool. And that you will continue to join me on the podcast each week. And if you have questions, please feel free to reach out to me. You can email me at betsy@betsybyler.com. Thank you for sticking with me this far. And I hope that you too are convinced that substance use is our business and that we can evolve.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s 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.