Episode 80

Adding  a substance use lens for our work is at the heart of my message. We already use a mental health lens, a trauma-informed lens and a lens for whatever our main theoretical orientation is. Adding a substance use lens is looking at the presenting symptoms and life history and asking the question “How has substance use impacted this person?” There are plenty of times that it won’t have impacted them that much. I think it’s rare though that someone has zero history with substance use. It might not be their own use, it could be a relative or a partner. In today’s episode we’ll talk about the assessment we do at the start of therapy with every client and look at what adding a substance use lens would look like.


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

Welcome back to the All Things Substance podcast. This is episode 80. We’re back after some technical difficulties last week that meant we didn’t have a podcast. That hasn’t happened  very many times since I started the podcast, but we’re back this week and we’re continuing on with our topic about assessment. We’ve talked about all the reasons to do an assessment about substance use and we’ve talked about how to set up the conversation. 

Today we’re going to be talking about Assessment capital A that we normally do with people. Sometimes called a diagnostic assessment, sometimes called an intake as this is something that we’re all really familiar with. It is one of the hardest things when you become a therapist to figure out how to do efficiently, quickly and accurately. 

Sometimes the word assessment can be difficult for our clients to determine whether they’ve had one or not. They get asked questions wherever they go to a provider, whether it’s the doctor, a substance abuse counselor, a mental health therapist or someone else. The first thing I want to clarify is that there are actually different assessments that are required sometimes for someone who’s having issues with substances. That can sometimes feel confusing to them and to us.

Suppose you have someone who comes in because their lawyers suggested they get an assessment as they’re facing a DWI charge. A DWI for those who aren’t in the United States is a driving while intoxicated or an operating under the influence or any other number of combinations of those words. Sometimes before they even go to court, a lawyer will suggest they get an assessment.  

For the client they’re just calling their local mental health agency and asking for an assessment. Sometimes they’ll get sent to the right place because the intake people know what this is and other times they’re not really sure.  In this case, there are actually two different kinds of substance use assessments. 

Generally in the substance use world when somebody needs an assessment what they’re asking for is an assessment of the person’s substance use history by someone who is qualified to make that determination and someone who can give recommendations on what to do for treatment.

The majority of the time when that is requested, they are asking for someone with a substance use license. If you feel that you have the experience to do so, you are able to say that you have the expertise to make that determination about next steps and that this counts as a substance use assessment.

I have been able to do that for numerous clients as I am duly licensed, but in general, even if I didn’t have the extra license, I do know how to do the assessment and what kinds of things to recommend. Typically average therapists aren’t going to be including substance use assessment for a court ordered thing. Even though that isn’t necessarily what you’re going to be doing. I wanted to explain. 

When it comes to a DWI, though, there is a separate assessment that most states have. This is often called a DWI assessment. So let me explain how this works. In my state and in my county. If you have a DWI, you have to call the county government Health and Human Service office. You have to pay upfront to get an appointment and you go in and they do a specific screening measure and then send the recommendation to a treatment center if there is one. 

If it’s a first time offense, sometimes they won’t recommend treatment. Sometimes they’ll recommend a Driving With Care program or some other kind of program that’s approved by the state. Then the referral would go on to that agency. 

However, if the person called, say a clinic for the first time and got a chemical dependency assessment at that clinic that might not count towards the court ordered assessment. It’s sort of an issue with having to go through the right gate in the beginning to have everything after it counts, so to speak.

In this scenario, the person went to the county, had the DWI assessment by one of the staff there who isn’t necessarily a therapist, but has been trained in this particular model of assessment. And they were recommending treatment, which usually says something between one and 48 sessions. Leaving room for the therapist to say, no, this person doesn’t need treatment they had their one session and they’re good or to make recommendations. 

Now 48 sessions isn’t necessarily the end either because the caveat says and follow recommendations. And so what that means is that they are then required to follow the one to 48, but also any other recommendations that the assessor makes.

So when somebody comes to an agency and sees a substance abuse counselor, they could recommend mental health, they could recommend being seen by psychiatry, and then those recommendations stand. Every state is going to be different in how they handle driving while intoxicated issues or other legal issues like possession of paraphernalia or something else where they have to get these assessments. The Driving While Intoxicated is the only one I’m aware of that is a really specific one that has to be done in the correct way or else it doesn’t count for court purposes. 

When somebody needs a substance use assessment or a chemical dependency assessment, usually what that means in that context is that someone is being evaluated by someone with a specific substance use license. In that case, a client would call a substance use treatment center and say that they need a substance use assessment. You can see how confusing this would be because we all use the same word. 

When it comes to what we’re doing as therapists and what I’m encouraging you to do  in adding this to your practice is we’re thinking about things from a substance use perspective. So what I want to do is go through our regular assessment and talk about it from a substance use perspective. When I am doing an assessment and I’m focusing on mental health there’s different reasons why I ask certain things. 

So let’s take the introduction for instance, the presenting problem is usually what we start with. We want to know what brought this person here today. Usually there’s something about the level of functioning, symptoms, stress, and some way that they want to have a better experience in their day-to-day life. As a mental health therapist, I’m looking for a statement about what it is that brought them in and what they’re wanting out of therapy. 

Additionally, that’s when I get into the presenting symptoms. Typically, this involves understanding what kind of treatment they’ve had before, whether it be therapy or they’ve been to psychiatry or been on psychotropic medications. In a substance use world, you still want to get this information.

The extra is wanting to know how the substance use impacted their mental health symptoms, whether they feel like it was helping or exacerbating those problems. The difference here is the lens that the therapist is looking through. 

In a typical assessment, we’re going to be checking on primary symptoms. We’re going to be asking about sleep and eating and mood and days that they feel good versus days that they don’t and whether or not they have racing thoughts versus more depressive symptoms. We’re going to be checking on all these different symptoms. Well, in a substance use assessment, basically what we’re doing is dropping an extra lens down in front of us.

Imagine being at the optometrist and they’re putting different lenses down in front of your eyes.  A substance use lens is simply one more view. The difference here is that you’re not just asking about symptoms, but you’re also asking about this extra factor and how it affects their mental health.

So if somebody comes in with significant anxiety presenting with some PTSD type symptoms, the potential that they’re using some sort of depressants to manage that is actually really high. Typically it’s not going to be a stimulant unless they’re significantly depressed and need the energy. A lot of times it’s alcohol or marijuana or something in the depressant category, further down the road, like opiates. Depressants help slow down the central nervous system and when someone’s really anxious and really hypervigilant, that feels better. 

So as the therapist is getting these symptoms down and going through the different ways of functioning, like memory concentration, energy during the day, relationships, tearfulness, all of the symptoms that we would normally ask the substance use lens is adding just that one more dimension.

If they’re falling asleep okay. I’m wondering how. If this person has some PTSD or high anxiety symptoms in general, usually that causes some trouble sleeping. A lot of times I find out that they’re taking a lot of medication in order to sleep. Could be Benadryl, could be melatonin or they could be drinking or they could be smoking weed, whatever it is.

Oftentimes they wake up exhausted, even though they’ve been sleeping. Part of that is about stages of sleep. They’ve now pushed themselves down into the lowest stage of sleep and they just kind of hang out there. They’re not doing a normal rhythm in the sleep cycle. And so they’re not getting as much repairative sleep as they would normally, if they were able to do that without chemical assistance. 

As we move forward in the assessment, as we move forward in a typical mental health assessment, the following categories are going to be in different orders, just depending on how your assessment is written. Somewhere, we’re going to ask about trauma. 

This is something that people have an interesting reaction to. Sometimes they’re very aware of the trauma they’ve had and they’ll be able to speak about it very succinctly. They’ll say there was sexual abuse when I was a child or I had physical and emotional abuse. And sometimes they won’t say it simply because they haven’t really talked about it and they’ll say things like, well, things in my childhood weren’t awesome or my parents fought a lot.  We ask a little bit further to see  how to classify the trauma, when we write it down.

When I’m looking at this through a substance use lens, I’m also wondering about experiences that they might use over or things that happened while they were using. When I say the word using, I don’t always mean that the person has been chronically using substances. One of the things we know is that sexual assault and sexual abuse is common. 

Many of the women that I have worked with have had sexual assault experiences during high school and early college during a time when they were partying. This has nothing to do with their responsibility, for drinking or anything like that as consent needs to be established always. 

A lot of times there’s conflict in their own minds about whether or not something constitutes assault, because maybe they were drinking. Maybe they were high. Maybe they were at a party and felt like they shouldn’t be there. Those are things I’m betting that we all hear all the time. When I’m doing an assessment and using a substance use lens, and I’m looking at trauma, I’m also thinking about this. When there are substances involved, which the majority of adults have used a substance at one time or another, there is a possibility of having bad experiences while someone was using alcohol or some other substance.

Next on my assessment format is family and psychiatric history. And in this section, at least on my intake paperwork, I have questions about history of anxiety and depression, ADHD, schizophrenia, history of mental health hospitalizations, suicide, domestic violence, and alcohol and drug problems. This is usually the first place on intake paperwork that I see that there might be a history of addiction in the family. 

I look to see which relatives that they put down. If it’s aunts and uncles, grandparents, that kind of thing, but not parents that’s telling. If they have their parents and siblings there then I know that it’s a little closer in terms of genetic link and so I’m paying attention to that as well.  This is something that’s easy to add to assessment paperwork and gives you a glimpse into the substance use history in the family.

Next on my intake are medical conditions in history. So the thing that I’m looking for when someone’s talking to me about their medical history is do they have a primary care doctor? How often do they see them? Do they have any chronic or ongoing illnesses? Do they experience allergies to medication, but also to other things? 

Have they had any surgery? When were those surgeries? Are there ongoing complications? Have they ever been hospitalized and how long? And in this case, I’m asking about hospitalization as it pertains to physical issues, not mental health hospitalizations as that would have been covered previously, when we were talking about mental health history.

Adding the substance use lens to this there are a few things that I’m listening for. If there have been a lot of surgeries and some chronic pain, then I’m thinking about the need for pain medications and I’m wondering how they’re managing that or how they managed it. 

There are a number of people who have had injuries in midlife or at some point, and ended up finding opiates and getting hooked on them during that time. A lot of times, those people don’t have a history of addiction at any other time in their life. But it started because of an injury. 

I’m listening for whether or not they’ve had recent blood work. What about liver function? Additionally, as I’m looking at the medications that they’re taking, I want to know what those medications are for and how they’re regulating things. From a substance use perspective. I’m looking at those medications and potential complications from substance use. 

So for instance,  if somebody is taking an SSRI and they’re smoking weed all the time, I’m not going to know  exactly how the SSRI is working because the marijuana is going to cover up some of the effects. What we’re looking at here is that a person’s medical history tells us about some things that are going on in their body. There are important things in medical history that affect mental health. Like thyroid brain injury, anemia, all sorts of different things that will affect mood, energy, sleep and those are just a few. 

Adding that substance use lens means that whatever medication they’re on, I need to be thinking about is that medication working effectively based on the fact that there are chemicals being introduced to the body that the Dr. may or may not know about.

When we begin talking about family history, this is one of the big places where I want to apply a substance use lens.  I want to know siblings. I want to know the birth order. I want to know what their parents’ relationship status was when they were born and now. I want to know what the relationship was like growing up and how they would describe the family dynamic.

Adding the substance use lens then I want to know about what the substance use was with the parents. Was drinking something that was common? Was it something that no one ever did? What was the narrative about it? What about other substance use other than alcohol? 

There are family stories and standards about pretty much everything. Lots of unwritten rules and lots of unspoken rules about what we do as a family in regards to this or that thing. I’ve talked about before that my parents didn’t drink much at all. 

I think I saw each of my parents drink something alcoholic a handful of times in my life. There was always the story about my grandmother being an alcoholic, although a very functional one,  as my grandmother would never have been seen intoxicated unless you were looking really closely late at night. And so the narrative was, we don’t really drink and there was some judgment about people who drank to excess and I remember some judgment about adults who were using marijuana. I know that was my family narrative. 

When I’m doing family history with someone I’m wondering about the narrative there. If somebody always had a beer in their hand, it might not be something that the person you’re talking to even thinks about as being different. It’s a background thing and they might not even think to mention it. 

The familial attitudes towards substance use of any kind do impact how we develop and our own beliefs. So when I’m doing a family history, sometimes I’ll ask about how holidays were celebrated. And I listened for things about alcohol. And I might just ask a question about, so what was alcohol like? Did people only use it on celebrations or was it more often? That’s how the substance use lens is applied for family history. 

When we move on to social history or relationship history. I am listening for that as well. When two people come together in a partnership, they are bringing with them their invisible suitcase of beliefs and history and expectations. Those things can often be vastly different. What one family believes about a thing versus another family all the way down to whether you should hang a dish rag over the faucet or not, and what should be done with the trash when it gets full.

Everybody has opinions about how things are supposed to be done based on what their experience is.  Looking at relationships and partnerships with a substance use lens means that I want to understand not just my client’s history and the beliefs around substance use, but also their partner’s belief about that and their family history. Again, this isn’t the focus of my questioning. It is an add on to the end of my questioning. I’m finding out what their relationship is like and the things that they do together. And then I’ll ask what their partner’s family is like. I’m listening for potential problems because typically those are the things that are going to be coming up. 

When it comes to their education or vocation history, I’m asking them about whether they graduated high school, whether they had any schooling past high school, what their jobs have been like, what their current job is like. 

Adding a substance use lens if they went to school after high school, what that was like in terms of substance use, I’m listening for whether or not they ended up struggling in the beginning of school as is pretty common because once kids are out of the house for the first time and they go to college, it can be kind of a time to let loose. And that’s pretty normal. 

However, I’m just listening for whether it was in a normal range or not. It’s an easy way to ask about what their experience was with drinking culture at school, or if we’re talking about occupations and jobs, I’m listening for the culture of the place that they worked. From a substance use perspective is this where the work culture is that people get off work and go to happy hour. Is it really fast paced work that you have to do by yourself? Is it something that’s highly stressful and therefore people might use in order to deal with the stress of the job.

And then there’s legal history. Legal history isn’t something I think that every therapist asks about, because if they don’t volunteer, it might not occur to us to ask. If I were to go in to see somebody they’re going to assume just by my job and looking at me that I don’t have and haven’t had any legal issues.

Well, if they ask me that question, my answer would be well, none present, but before I was 18 I had a number of them. The person who’s asking me would be like, okay, so what was going on before you were 18? They would have found out that I had hit and runs, driving without a license, possession with intent and other police contact. 

When you’re hearing about someone’s legal issues, you might end up hearing about a dispute with a neighbor, custody battles, tickets, DWI, whatever.  Asking about legal history can give you some insight into an area of their life that they may not have mentioned.

Adding the substance use lens tells me if there was any time that substance use ended up getting court and or police contact. So an underage drinking ticket in college, it doesn’t seem like a big deal. The majority of college students don’t get underage drinking tickets. And so I’m interested to know what was the story around that sometimes it’s the wrong place at the wrong time, but typically what I have found is that it’s not someone’s first rodeo. There were a number of instances where they were in places where they could have gotten picked up for underage drinking. But it was just this one time that they ended up getting a ticket.

If the person has a legal history as an adult, of contact with the court or police related to a substance, that is something to pay attention to. Most people do not get busted or contacted by police. The very first time they use a substance, it happens further down the line. And so that is always in my opinion, going to raise a flag of something that I need to look into.

All of these areas of assessment are ones that are typical for mental health assessments. All we’re doing is adding one more lens to look at it from a substance use perspective as well. This is all done in service to helping our client find a place of more healing and freedom moving towards the life they want.

None of this is ever about trying to bust someone or trying to find out the dirt on them or anything like that. For me, it is about making sure I’ve looked at this from all angles. 

 That brings us to a big section I haven’t talked about, which is the substance use assessment. Typically I’m covering that in the middle of my assessment, kind of around trauma and family history. It seems to fit in there and usually that’s when I ask about those questions. 

When someone is doing a substance use assessment specifically, they typically start with a substance use history and then do the rest of it later. When it comes to the actual assessment of substance use, there are specific things that I want to know and that I will ask about for each substance.

What I’m encouraging all of you to do is to add substance use as a section in your assessment. Some of you may already do that and if you are, that is great. It means that you have this covered. For those of you who aren’t sure what to ask, that can be a little confusing at times, knowing where to start.

Part of it is starting with the assumption that substance use is normal and part of a normal adult experience. It isn’t necessarily universal in the sense that every single adult has used substances. It is very common and more likely that most of the adults that you will see or have seen, have at least one experience with substances. What we want to know is what that is. 

So for instance, I recall talking to a client of mine who really likes beer, specific craft beers and gets excited about new beer that’s coming out. The craft beer industry is huge and people love different kinds of beers that come out. That can be really normal and non problematic. What I want to know is, is it problematic or is it within a normal realm? So I want to explore that a little bit. 

I want to know about what the craft beer scene was like in her life. Did they go to different tastings? Are they making it at home? How much of the activities that they do revolve around alcohol. I want to know what happens to the beer that is in their house after they’ve tasted it. I want to know what happens if they don’t really like it. I want to know how many days a week that they’re trying these things or drinking, and I’m just exploring the edges of this person’s use.

In this particular case, this was maybe two times a week, usually on a weekend, but it might be a weeknight, but usually it’s just one or two beers. This person told me that they have a basement full of the remnants of other six packs that they bought that they didn’t like. And so oftentimes when somebody comes over, they’ll hand one to them to take.

This person talked about not getting intoxicated unless they were going out with their partner, which because they have kids happens very rarely. That all sounds pretty normal to me. I asked about the culture of alcohol in both of their families, both hers and her partner’s family. Just to see what I was noticing. I checked on the different edges of what her use was like when she was in college, what her extended family’s use is like, and what their use is like together to determine the fact that I don’t think it’s a problem. My client’s drinking didn’t appear to be related to functioning or depression or coping or anything. It truly seems like it is just about tasting different beers.

There are other times though, where I’ve had things like that mentioned and wrongly assumed that it was at a normal level. And if I had asked just a question or two further, I would have uncovered the fact that there was more of a drinking problem there than I realized.

That’s what I’m encouraging you to do. I’m encouraging you to include the substance use lens in what you’re doing. You’re doing all the assessment work. What I want is at the end of each section so to speak, that you’re dropping that lens down and looking at it. What would change if this person were using substances?

How would their mental health symptoms  look different to you if you knew they were drinking  4 or five days a week? What if you knew they were smoking marijuana at night in order to help them sleep? That would change your perspective of what’s happening and what to do about it.

Let’s hypothesize that your client is taking an antidepressant and they feel like it’s not working. They feel sort of numb. They don’t feel happy and don’t really want to do anything and you’re thinking, okay, maybe this isn’t the right antidepressant.

Now drop that substance use lens down and find out if they’re using anything else. Well, if they’re smoking marijuana, that is going to do a couple of things. It’s going to separate them from time and space in sort of a dissociative way. That is going to make them feel a little numb. Additionally, depending on how much they’re smoking, the amotivational syndrome that comes with it could be part of it. So do we really know that it’s the SSRI that’s not working? Or is it something else? 

How about another example? Let’s say that your client is having issues with their partner and they’re arguing. It typically ends up being on weekends during the week they do okay and then on the weekends, when they have more time together, they’re fighting often. Well, if you drop the substance use lens down and find out that when they’re drinking together That it usually ends up devolving into an argument that’s going to change what you do and how you help them with that problem. 

There may be nothing there. I don’t think that there’s substance use around every corner. All I am encouraging is that you have that lens. That as you’re looking at it through our mental health lens that you add this to the thing that you’re listening for.

If you are hearing things that sound like there might be more substance use there than what sounds like an average level to you. That’s the thing we’re going to talk about next. When you hear those things, what is it that you need to ask and at what level does that become a problem? 

All of this is the same way that we determine whether or not someone has anxiety or depression or trauma or ADHD. We’re basically checking out each area to see if there are enough symptoms in that area that that is likely the culprit, or if it’s from something else. 

We have these skills already. This is stuff that we do all the time. Adding substance use might feel daunting at times and it really is just one more lens. Next week. We’ll talk about  the substance use part of an assessment.  We’ll talk about questions that you could ask, questionnaires that you could choose to use and what to listen for. I hope you’ll join me for that podcast. And until then have a great week.

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

Helpful Links

Assessing Addiction: Concepts and Instruments

Clinical assessment of substance use disorders – UpToDate

The Clinical Assessment of Substance Use Disorders

Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT) | SAMHSA

NCDAS: Substance Abuse and Addiction Statistics [2022]

Free Treatment Planning Tool https://betsybyler.com/treatmenttool/