Episode 73

We can ask all the perfect questions, but sometimes a client’s answers aren’t as clear as we’d hoped. There are lots of reasons for why a client might not want to share about their use of substances. Today we’ll discuss the most common responses and how to work around them. 

Sometimes it can be hard to get accurate information from clients. They don’t instinctively know what we would find relevant or know why we might want to know certain things. Lots of people see their mental health as being separate from whether or not they drink or use other substances. Our field actually sees it that way too. So we’re moving a little bit against the flow here by combining them. However, we know that we are one body and that everything we do impacts the other areas of functioning.  The three  main problematic  ways I see clients answering substance use questions is with defensiveness, denial and minimization. Our clients really want to get better and may not understand why this line of questioning is necessary. It’s our job to help them be as open as possible by creating a safe space to do that.

Transcript

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 73. We’re in the middle of talking about assessment of substance use. I want to point out that the reason I’m not saying substance abuse is that we’re kind of moving away from that kind of language in the field.

It’s a subtle shift. That’s moving us away from using the word abuse. The idea is based on the fact that they’re not abusing the substances, they’re not doing anything to them. They’re using them in potentially a problematic way.  The majority of adults have some experience with substances. It may be a small amount it could be something that’s more regular or even into the problematic area.

Substance use is common and something that is normal to talk about is going to help people in the long run, be able to share any struggles they’re having. We started talking about how asking about substance use can be a little scary and even a little confusing. We weren’t trained on it and so what questions do you ask? Are we even allowed to ask that stuff? Is that in our scope? What do we do with the answers? You can go over to the website, betsybyler.com and  episode 69 and episode 72. Talk about our use of diagnosis and incorporating substance use into our assessment. 

Today, we’re going to be talking about client responses to our substance use questioning. There are a number of ways that people can answer these questions and some of those responses can be challenging. In my experience, asking people about their substance use is a little different than asking them about their depression and how deep it is, their anxiety and how they manage it.

It’s a little closer to asking about suicidal ideation. And I say that not to be dramatic, but because it’s one of those things that people  may not want to admit for a variety of reasons.

When it comes to suicidal ideation, lots of people are afraid to say that they had it at all because they’re afraid of being “locked up” as they call it.  They don’t know where the line is, where it’s okay to say that and where we start getting really concerned and what they feel might be overreacting.

Same thing goes with self-injurious behavior. People aren’t sure what’s going to make us be overly concerned and potentially suggest something that’s uncomfortable. Substance use falls somewhere in the middle between asking about depression and symptoms and asking about suicidal ideation.

Most adults will admit that using a substance is normal. The question is nobody really knows how much is too much. That’s a really hard thing to tell. I find that there are a few ways that people answer these questions and I think it’s useful for us to talk about it. 

I find that people who are drinking  in a “normal way” or what they believe is a normal way will answer pretty honestly. I always ask follow up questions just to make sure I’m not assuming too much. If it’s truly not been an issue and never been an issue, I tend to get the truth. It’s the follow-up questions, I think, that is important. 

There are some problematic ways that clients will answer some of our questions. The first one is defensiveness.  When someone feels defensive, they might pull back a little, even in the way they’re sitting. They might change their facial expression. They might look at you aside and say, “what do you mean by that”? Or” you think I’m a drunk” or “it’s fine. I do it sometimes, but it’s not a problem”. When you hear that defensiveness, a lot of times people’s instinct might be to back up a bit and abandon that line of questioning.

I find that defensiveness is an indicator that something’s going on. When I work with clients, and I get a sense that there’s some defensiveness going on. I am aware of it. I note it, but I usually lean in. I have found that immediacy is the best policy. Immediacy is a technique of talking about what’s happening in the relationship right now.

Defensiveness is usually a sign that there is something that is getting poked, some kind of button, some memory, some correlation that typically doesn’t have a whole lot to do with us.  Using immediacy I’ll step into it and I’ll try to find out what they heard me say when I use the word substance or I use the word alcohol. 

Sometimes it’s about who they don’t want to be compared to. Potentially they have a family member or somebody they know who is an alcoholic or using substances and they have a lot of feelings about that and don’t want to be put in the same category. Noticing what’s happening and allowing them to explore that as well is helpful in knowing what might be in the background. So even though everything about their posture and their tone of voice and their facial expression and their words might be telling me to back off, I like to lean in.

Otherwise it becomes this tension point where in order to bring it up again, I’m feeling a little nervous about that. And as soon as I bring it up again, then the defensiveness is still there.  I also want to set the precedent that if I notice some defensiveness and it doesn’t abate really quickly, then I want to talk about it.

Perhaps their doctor asked them this question, perhaps someone in their life is irritated with them about their substance use, and they feel like someone’s nagging them all the time about it. This is all really useful information. 

When we’re working with someone, we are teaching them how to be in a relationship with us, how to do therapy with us and what the process is like. In the beginning, clients don’t know what to think when they show up. They know that we have an appointment at this time and they’re supposed to show up and either be on a screen or sit across from us. What happens after that? They have no idea. Once they’ve been in therapy with you for a few months, they know exactly what’s going to happen.

My clients know that when the video comes on, as I’m doing telehealth right now, I’ll ask them to tell me about their week. If they’re looking particularly upset, I’ll say “so how are you feeling today”? Checking in with people about their week is just something that I do every single time.

Then I’m going to ask them, “is there anything in particular you want to make sure we talk about today”? If they’ve been with me a while, they know that they don’t have to have an answer for that. I just want to make sure that there isn’t something that they don’t want to forget to mention.

If they have nothing, then we’ll move on and I’ll say, well, here’s what I was thinking. How does that sound to you? My clients, after a period of time, know exactly what to expect from me and how I do sessions. That is how we teach people how to do therapy. And so when we’re met with defensiveness and maybe you haven’t seen it before, that is what you’re noting is that they’ve been potentially open and this is the thing that made them want to back up or close down. That is useful information. And so if you get defensiveness,  I would encourage you not to see it as  this is a no go unless they say so, but instead to gently press in and find out what that defensiveness is. 

Defensiveness  is usually an old coping mechanism that they’ve used to keep people at bay about certain topics. In our therapy rooms though, that’s something that we want them to be able to set aside. It is a great teaching moment.

Another response I’ve had is to deny any substance use at all, which is always a little interesting. Usually it’s somebody who’s quick to answer, like, “nah, I don’t use at all”. Okay. That could be the end of the questioning right there. But again, I press it a little bit. And I’ll say, so you’ve never drank or you just don’t drink now, or what is your experience with alcohol? The chance that your adult has never, ever drank or used a substance in their life is pretty low.

If they are part of a religious culture or some other kind of cultural expectation that they don’t use, then that’s possible. However, most adults have had some experience however small. I found that clients aren’t going to deny all use unless there truly wasn’t anything. They will usually say, “well, no, of course I’ve drank before. I just, I don’t really do it much. It’s not a problem”. Well,  most adults have drunk alcohol or something like that at one point,  I just would like to know what your experience has been with it. 

Same thing goes for if I’m like, okay so we talked about alcohol. How about other stuff? And I’ll usually avoid the word drugs at first. And I’ll say, what about weed or marijuana, depending on which word is more comfortable for you to use. Marijuana is a little formal for me. I use it a lot when I’m talking professionally, but in session, I don’t use it a whole bunch.

If my questions are being met with a lot of resistance, I need to revisit how I set it up and how I’m seeing things. Potentially there’s a word that they don’t like. Sometimes a word substance is also really formal. I tend to use it instead of drugs, because if I say drugs, then I get a whole bunch of different responses.

Denial of all use is an interesting response and I definitely get it from people. Usually it’s not an accurate statement. What they’re telling me is I don’t have anything to talk about in this realm and sometimes that’s accurate, but most of the time I find that there’s something else behind that.

I find that when I asked them “so you’ve  never had alcohol at all?”. The overstatement of that seems to push them to correct me. The never as opposed to rarely or not a lot is what makes them have to say, well, not never. So the overstatement here is what helps with this conversation. I’m quick to normalize, as I do believe that using substances is normal. I want to make sure that they know that I’m not going to be judgmental of them for whatever it is they say to me. Again, teaching them how to be in therapy with me.

The third response that is, in my experience, most common is minimizing. Minimizing feels so normal that I think a lot of people don’t even see it as really much of anything to think about. We minimize and edit ourselves all the time for various reasons. Sometimes that editing or minimizing is protecting private information. Not everybody needs to know all the things about you, and they’re not entitled to that kind of private information. I fully support people, setting limits and not sharing all their information with people. 

We as humans minimize all the time. How many cookies did you eat? How fast were you going? How much have you had to drink? How much did  you spend on that? How much of your day is sedentary? How much of your day is spent in front of a screen? How much time do you spend on social media? How much time do you play video games? What time do you typically go to bed? How much credit card debt do you have? And so on. 

These types of questions instinctively make people run through it in their head really quickly and decide how much they’re going to share based on what they think is socially acceptable. Here’s an example. Let’s say you’re in your doctor’s office and this time the scale went up a little bit and your doctor has been noticing this upward trend. And the doctor says, “how often do you eat fast food?”

If it truly is very rarely or once a week or whatever it is, then you might say that, but let’s say that it’s been a hectic few months and fast food is just really easy. Are you really gonna say that you ate fast food, five out of seven. You need to eat just like all of us and it is food and you do have the money and you’re an adult, so you get to choose, but something makes us want to minimize.

We want to tell the doctor, oh, maybe once a week, maybe twice a week. I think it’s the human condition to try to make ourselves better, healthier, more successful, etcetera to whomever we’re talking to.

We minimize stuff a lot sometimes to get out of trouble. If it’s a cop and we’re getting pulled over and they ask, “how fast were you going?”  Do most of us really say the exact speed? Now, perhaps we don’t know. One of my favorite responses to this is actually in a Jim Carrey movie called Liar Liar. There’s a whole litany of things he says, but in this instance he’s pulled over and one of the things he says to the officer is “depends on how long you’ve been following me”. 

There are socially accepted standards for what we think is ideal. And I believe this varies by culture. I hear this a lot when it comes to certain things like parenting, how much screen time some kids should have, what kids should be eating, what time they go to bed, what they’re allowed to watch on TV. All sorts of different things. 

Some of this is promoted online and from other parents and some of it’s sort of just this culturally agreed upon this is best practice kind of thing.  I remember working with a mom who really struggled if their child watched more than an hour of TV a day. It was as though she was a failure as a parent.

The child in this case was a toddler and an only child. Kids at that age are up most of the day, as a lot of us know that they’re not taking naps anymore. This hour-a-day limit meant that she had to be somehow entertaining and interacting with the child all day long every day. She had this in her mind as being best practice and it was a sticking point continually when we talked about what she was doing during the day and the anxiety she had around getting everything done. 

I also noticed that she had anxiety about what her child was eating. She felt badly that she wasn’t cooking what she would say, whole food meals for her three-year-old. The child likes hotdogs and chicken nuggets and she felt super guilty about this and worried that she was doing a bad thing as a parent. 

In my experience with kids, they don’t eat super well.  If we’re at dinner together or eating a meal together, then yeah they probably eat a modified version of what we’re eating. If you’ve ever had picky eaters or struggled with getting kids to eat, you know that the goal is sometimes just to get food in them, especially if you have kids that are lower on this percentile chart and feeling like, “oh my gosh, my child’s not getting enough to eat.” 

Well, you’re going to feed them what they’re going to eat. Kids are stubborn creatures. They’re not like dogs who will pretty much eat whatever you put in front of them. They’re a little more like cats. Cats can and will starve themselves and kids they can dig their heels in and get incredibly stubborn. 

Similarly with adults, there are things that we find to be ideal. We should get eight hours of sleep a night. We should get moderate exercise most days of the week, we should be drinking a lot of water. We should be eating fruits and vegetables. We should be limiting our time in front of screens because we don’t want to be sedentary. We should limit our intake of bad foods or desserts or sweets or alcohol or any of those things, because we want to have a moderate diet that is generally healthy more days than not. 

Whenever we deviate from those standards and someone is asking us about it, I don’t think it’s necessarily pride. I think it’s about fear of judgment and shame. I think that the majority of people have a desire to change their answers. I don’t think that we’re all a bunch of liars. I think it’s human nature, bred in us to present our best face to whomever is asking. It can also depend on context though. 

Let’s think about asking someone, how much did you have to drink that night? Well, it depends on who’s asking. If it’s someone who would approve of drinking a lot, then maybe they won’t minimize as much. But if it’s someone who’s going to disapprove of it, they’re going to find that line where it’s not totally an out-and-out lie, but it’s also not the truth.

Now, if the person asking also drank a lot that night, they might even overestimate what they drank. In reminiscing about times that they got hammered or higher or whatever it is, people can even exaggerate that.  That is a similar wanting to fit in, wanting to be in the normal range, whatever that appears to be.

Then we think about talking about sexual partners and our history.  So in the United States, I can’t speak for other places. If a woman is asking a potential male partner about his sexual history,  he may not want to tell her the accurate number because there is a societal bias about how many partners is a lot, quote unquote. So maybe he rounds down. 

If he’s talking to his buddies, maybe he rounds up or maybe he tells the accurate number because with his guy friends, there’s less judgment to be had because there’s a societal thing that men tend to sleep with more partners and that that’s okay.

I don’t know that anyone’s saying it’s awesome societally to have a lot of partners, but amongst their friends, it’s going to be seen as more normal. Now for women.  If a woman has very many partners at all, there’s a societal thing that it’s too many.

If a man says that he has had 15 sexual partners, I don’t know that people blink much at that. If a woman says that she’s had 15 sexual partners, that is a different response. I do think as a society, we’re moving a little bit, but not quick enough and there’s definitely not equality when it comes to expectations about sexual experience.

In the same way. When we talk about substance use minimization is nearly universal in my experience.  Even people who drink on a relatively normal basis will tend to round down. As I thought about why this is, there are a couple things that I think come to mind. Of course there is  the reason I talked about before of people wanting to have their best foot forward and not be judged for whatever it is they’re doing or engaging in or whatever.

I think that it’s more than that though.  I think that most of us have found that our clients have a baseline fear, that they are somehow flawed. And that, that means that they are broken, unhelpable or responsible for all the pain that they’re experiencing. What we’re doing when people come in. Is doing some detective work to find out what the problem is, how severe it is, when it started and then what’s causing it. Minimizing happens all the time and I think people do it without even realizing it. With substance use I believe that it is far more prevalent. 

I don’t know if people minimize to us to the same degree as they do with their doctors. Sometimes people are a little more honest with doctors because they figure the doctor needs to know. A lot of times though, the doctor is the place that they don’t want to get in trouble. And so maybe they’re not going to tell their doctor at all.  I’ve had the experience a lot of times with my clients, when I do some assessment and find that there’s some substance use, I find that their doctors don’t know anything about it.

I’ll just ask them, have you talked to your doctor about this and they know why not? Well, sometimes they’re worried that their doctor is going to yell at them, quote unquote, or that their doctor might not want them on a certain medication or some other kind of unknown fear. That’s just in the background.

It’s not just the engaging in or lack of engagement that people tend to minimize. It’s also the consequences of those things. Once I find out how much someone has been using of a given substance. I want to know about the consequences. 

Consequences can be anything from social consequences of someone being upset with them or breaking some trust in a relationship. To legal consequences, like getting a DWI, which is a driving while intoxicated for those not in the United States, or it could be a minimizing natural consequences. So physical consequences, like being hungover and having to go to work the next day, because those consequences tend to make whatever they said about a substance look worse. 

This minimizing thing gets really complicated because we need to know accurate information. Sometimes people are so used to minimizing what’s going on and hiding what’s real that they’re not even aware they’re doing it. I find one of the interesting things I have found when I ask people, things is, it’s always a couple, a couple of this. I had a couple of cookies. I had a couple drinks, had a couple of hits.

Why is it a couple or two? I don’t know, maybe three sounds bad. Maybe one is too inaccurate. This minimization can actually get really intense. In running the program that I ran, we did a lot of drug testing, including for alcohol, because that’s something that is a part of treatment when someone is working on getting sober. It’s not necessarily something that has to be a part of all treatment, but it is accountability. And a lot of people who are sober will tell you that those drug tests can actually be helpful. 

It’s the same premise as having a way in when someone’s working on losing weight. Now, whether or not people should have weigh-ins and their relationship to the scale is a totally different conversation. But it is the similar idea of being able to have some accountability. So when we did these drug tests, It was really fascinating and sometimes humorous the things that people would tell us about why their test was going to come back positive or did come back positive.

I have seen people swear on the lives of their children that they didn’t use and that we could do a hair exam and that it would come back negative. This is even in the face of multiple tests, concrete evidence, eye witness accounts and they will hold to that. I have had someone who actually had a hair analysis done and it confirmed that they had been using and her response was still, Nope, I didn’t. It must have been from the environment that she was in a place where someone was using, but it wasn’t. 

It is astounding to me always, and  it happens more than people would think. So I was thinking about some of the reasons that people have told me  why their test came back positive.

I’ve been told that somebody licked their debit card. And what I mean by that is that they had a debit card and they were with some friends who were using meth. And their friends needed something to cut up the meth and they handed their friends, their debit card.

The friends used it to cut up the meth and handed it back and the person licked it before they put it in their wallet as one does. And that was the reason they gave for failing a drug test.  That story was told with a totally straight face as though this was a hundred percent accurate.

I’ve been told that somebody was carrying a powdered substance, like cocaine or heroin in their hand to bring it to someone, not to use it themselves, but they were selling it to someone and then it must have seeped through their skin. . I had another person tell me that they failed their test because they clean hotel rooms and there must have been some residue from the cocaine that showed up in the hotel room.

Lots of people will say  that they failed for marijuana because they were in a vehicle with someone called hotboxing or that they were in a room where people were smoking. That’s not how that works. So if anyone says that to you, Certainly there are substances that can get found in hair like meth and that’s most often used when we’re talking about examining children’s hair, like toddlers to see if they were exposed to certain drugs, hair analysis course is really rare.

Not something that we do all the time, but it is something that can happen and it’ll show up in the hair. However, They seem to be able to tell whether the person ingested that substance or whether it just was there and absorbed into the hair that way. In general, these are adult people coming into our offices for help.

Most of those people in the mental health system are coming in voluntarily. I say that because in the substance use world, if they’re going in for treatment, it isn’t generally voluntary the way we think it is .When I ran the substance use program, about 96% of our clients were there because of some sort of outside force. It was child protection. It was probation or parole. It was the district attorney’s office because of disorderly conduct or driving under the influence or something else like that. They had to be there and so that’s really different when you have clients that are mandated.

So in your office, most of your clients are probably there because they want to be, or at least they feel like they need to be because something’s not going well. This doesn’t mean though, and you’ve probably noticed this, but it doesn’t mean that they’re ready to share the whole truth. When we are meeting with someone there is going to be this innate sense of wanting to present themselves as not as messed up as they think they are.

We don’t need them to present that way and in fact, we would rather them just state the whole truth and not edit anything they’re saying, because it helps us get to the bottom of it and help them move forward faster. It is hard though and it takes building trust. I want you to think about clients where you have found out that something was happening more often, or even that something was an issue pretty far into therapy with them. 

It is a matter of them feeling like they can trust that you aren’t going to judge them, think they’re awful. Be upset with them, fire them as a client even. My experience is that this is almost all coming from shame. And if not, shame, fear.

Shame and fear and addiction are incredibly powerful and are the drivers of substance use not already accounted for by biology. Certainly biology is driving substance use primarily. It is not a choice. It is not a moral failing. Although societally, I think we still think it’s a moral failing and we’ll talk about that when we talk more about shame. But after biology, shame and fear tend to drive it. 

In the recovery story from February, Sean talked about having written his wife this letter to tell her that he had a drinking problem. And that every night he was going to hit send on this email, but he just couldn’t do it. It wasn’t that he didn’t know that it was wrecking him. It wasn’t that he didn’t know he had a problem. It was that he couldn’t bring himself to tell her. He was too ashamed. 

Shame drives an incredible amount of what happens in substance use. In the next episode, we’re going to talk about shame and fear in addiction and how it manifests and how it drives it. Understanding these concepts and how they relate to substance use helps a lot when talking with people and understanding the role of shame and how it impacts their responses to our questions. 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/

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