Episode 74

Fear and addiction always show up together. Being in active addiction fills a person with fear of so many things. That’s going to show up in our therapy sessions.  Our whole job is to hold a safe space for people. We know that, but they don’t always know that. Many people are suspicious of those in an authority position (whether we think that’s us or not). They are afraid of documentation and people finding out the truth. We know that we have strict confidentiality requirements, but that does little to allay their fears. They need us to assure them and speak the words out loud: that they are safe with us.  With the fear handled, we can help them move towards a place of having no secrets, which is beautiful. Today we’ll explore the interplay between fear and addiction.


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 74. Last week, we talked about client responses to our questions about substance use. Substance use is one of those things that I think a lot of us can shy away from asking about in our assessments. It seems like maybe we’re accusing them, or it might be offensive if we ask them about these questions.

The things we talked about last week were more surface issues: things that people do in order to not have to talk about their substance use or look at it. This week we’re going to talk about what’s underneath it. We’re going to be talking about fear and how that interplays with addiction.  This fear can be very overwhelming and it can get in the way of us getting accurate information.

Fear shows itself in a few different ways. Most commonly I found that fear shows itself in defensiveness and anger. That there’s a lot of deflection that goes on in order to avoid having to say something that once it’s out loud you can’t bring it back. When you spot defensiveness or fear, you’re on the right track.

We’re not looking to expose our client’s secrets for our own gain. We want our clients to be able to get free from whatever it is that’s bogging them down. Having these kinds of secrets is going to get in the way of therapy.  

Fear keeps us from a great many things.  I remember an instance in my internship with a young client. We were doing equine therapy and we’re out with the horses. I’m not necessarily a horse person and didn’t have a ton of experience, but I have been around horses here and there.

This young client who was probably nine or 10 going on 30 or 40 was always acting like a tough guy. He had grown up in a family that was deep in gang culture and where men did not show fear of any kind. His behavior had gotten to the point that he wasn’t safe at home and was sent to the residential treatment facility that I was working at. 

So we’re standing outside and it’s a hot Montana day. I think we were in the midst of no rain for something like 65 days with 17% humidity and a hundred degree temperatures. It was very warm and there were lots of flies. We were standing there waiting for someone to saddle up a horse and he was standing by my side. 

The horse stamped its foot because of flies and the client jumped and wrapped his arms around my leg. This child was not a touchy feely kid and definitely didn’t hug people or touch them. His fear  of this extremely large animal was instinctive. He reached out and clung onto my leg, I looked down, he looked up at me, pushed away from me and was like, why are you afraid of the horses? I just raised an eyebrow at him. 

Even at that age, he had learned that fear was not acceptable. Fear is super normal. It is something we all have. It is our fight, flight or freeze response. Fear can be adaptive in showing us what is scary and what is dangerous. The work we do often is helping people get their fear to a place that’s more average so they’re not reacting to everything under the sun, but instead, only reacting to real danger. 

How this relates to substance use is that the fear that people have is instinctive for them. It doesn’t necessarily have to be rational or based on any kind of real data. Even though these people are adults and have autonomy over their lives, fear can still rule them.

That seems sort of like, well, of course, everybody feels afraid about sharing things  they’ve done. But I do want to discuss it a little further because with substance use, there are some specific things that I think are somewhat unique.

When we talk about fear, let’s talk about what we mean and what they’re actually afraid of. One of the first things that people are afraid of. If they share about their substance use is getting in trouble.  Most of you work with adults. There are some of you here who may also work with  teenagers and certainly when teenagers are using there’s fear involved because they can get in trouble for a lot of things. With adults, we don’t often think about them being afraid of getting in trouble. 

The fear of getting in trouble has to do with law enforcement, their partner finding out or child protective services. The phrase “mandated reporter” is getting more and more common. Lots of people who come to therapy know that there’s some sort of way that we have to report certain things. This is why as part of our informed consent and usually in our first session, we talk about what the limits of confidentiality are.

For adults we’re talking about if they’re going to hurt themselves or others. When it comes to kids, we’re talking about that, but  we’re also adding in if they’ve ever been abused and it has not been reported already. Different states have different requirements. I’m sure in some states the requirement is that  even if abuse has been reported, you have to report it again. Where I live and work that isn’t the case. 

The suggestions and advice that I gave you are just that. Advice and suggestions based on my experience and also where I live. You should always be checking your own statutes to see what it says. It can sound daunting to check statutes for those who haven’t done it. I encourage you to go find the mental health statutes for your state and read them.  They’re not super long but they are detailed and it is good for you to read the wording because the wording means everything. 

That said, sometimes what our responsibility is, can be difficult to know. We know that we can’t tell anybody about things people say for almost any reason. The only way we break confidentiality is if someone is an imminent threat to themselves or has made a specific threat against a specific person, that’s our duty to warn. But this can feel gray if you find out someone’s involved in some serious illegal activity. 

What if your client’s dealing drugs? What if your client witnessed a murder? What if your client beat somebody up? What if your client killed somebody? Those are things that make therapists nervous. The statutes don’t say anything about those instances. Our codes of ethics also don’t say anything about those instances. The reason is that it falls under confidentiality. 

What if a murderer is coming into our office and telling us those things. While I suppose that could happen, that isn’t going to happen. People who are committing those kinds of crimes, just aren’t coming to therapy and talking about it.  

In my experience, working with people who are using substances is that there is some illegal activity going on. Even with alcohol, it could be that they’re driving drunk. It could be that they are operating heavy machinery and therefore violating the policies at their job. It could be that they’re stealing alcohol. I think we know that those things are not reportable.

When it comes to drugs and specifically, once we get past sort of marijuana stage drugs, I think it can make us feel a little more nervous. The truth is someone could be dealing drugs heavily, and there is literally nothing we can do about that. If you aren’t able to work with people who are doing that, then that’s something you have to decide. Typically, people who are dealing drugs are doing so because they got to the point where they have to support their habit.

If they’re dealing drugs to the level where it’s getting dangerous, typically those people aren’t going to show up for therapy either. So at a baseline, we do not have the responsibility to report drug use, sale of drugs, illegal activity, theft, any of those sorts of things to the police.

We are not Crimestoppers. We do not report crimes. Remember we’re talking about adults here. We have almost as much protection as clergy or religious people. They’re the only ones who have more protection under the law in terms of confidentiality than we do. Certainly a judge could subpoena our records and I don’t know that we should be writing all sorts of things down in our records that aren’t necessary to the conversation. 

Our clients don’t know this information and so it can be helpful to just mention it. I’ll talk a little more about that in the next assessment episode when we talk about setting up the conversation. Once they know that we are not going to be talking to the police about them, they can relax just a little bit. The part about child protection gets a little more sticky. 

When children are involved, it makes all of us rethink what we need to report and what we don’t.

If you call your local child protection agency and ask them what they do about parents that are using, they will tell you that your job is to make a report if you feel like there is a threat to a child and let them sort it out. Not terribly helpful information, but also they can’t really provide you more because it is a case by case basis.

I know that the idea of a parent using drugs might make people believe that we need to report it. We need to go back and realize that what our responsibility is, is that if we are aware that a child is being neglected or abused,  that is reportable. A parent using drugs does not necessarily mean that there is abuse and neglect that is reportable. 

The majority of people that I have seen in my career with substance use problems have, or had children in their custody while they were using. This is not immediately reportable and is almost never reportable, in my experience.

Let’s take alcohol for instance, if you have an adult client who is using alcohol problematically and they have children, is that reportable? Alcohol is legal. Alcohol is something that adults can use. It’s also dangerous in terms of a substance when used in excess. A parent could pass out. They could be addicted to the point that they have withdrawal and end up dying because of it. They can be erratic, they can black out, they can be violent. We still don’t think about reporting that. Not unless we have some pretty serious information. The thing about drugs is that it’s the illegal nature of it that makes us reconsider.

So if your client is a parent and smoking marijuana every day, that can feel like a gray area. Do we report that? My answer is no. The parents smoking marijuana are not going to be passed out and unable to function. They might be unfocused. They might be not taking care of themselves or their kids as well as they might, if they were sober. But the risk there is fairly low. 

I don’t love that they’re smoking marijuana all day, every day.  When I do work with people, I will talk with them about their use and about how they can minimize the kids’ exposure to it. I remember a case where a third grader knew his dad was angry and brought his dad the tray of marijuana and suggested that his dad needed to calm down. Is that reportable? I think some people would say, yes.

Why? Why is that reportable? The answer might be because there’s drugs in the house and there’s a kid present. The line for breaking confidentiality is either active harm or imminent danger to a child. There being marijuana present is not imminent danger. 

When I heard that story I was kind of appalled and thought about it, like that sucks that the kid clearly was paying attention to their dad’s moods and understood that when the dad was smoking marijuana, he was less angry. My instinct is to get the kid into therapy, not to report it to child protection. 

Let’s move to other drugs. Let’s talk about cocaine. Let’s talk about meth. Let’s talk about heroin. Certainly there’s more risk associated with those drugs than with marijuana. If your client is using those drugs to the point that it is endangering their children, they probably won’t be the ones caring for their children anymore. 

Typically by that point, the school has noticed that something is wrong or the relatives or neighbors, or whoever are helping take care of that child if they’re not school age, Here’s what I mean when someone is using meth heavily, they have to spend most of their days awake and then crashing for days at a time. 

If there are children who are not school age, they have needs that are consistent. Yes, there certainly are kids who are just being extremely neglected in those situations and typically that’s not going to be showing up in your office. We’re talking about use that is a little more middle of the road than end stage use.

What typically happens when someone is using meth, heroin or cocaine in a significant way, meaning often, and it’s taking over their lives. I find that those children are already being taken care of by a grandparents and aunt, a cousin, a neighbor or somebody else, because the parent has been spending days out of the house in order to get and use their drug of choice.

When I find that I do check in with the parent about who is taking care of their child and what they do to keep their child away from the drug. I have never, in my experience, had a parent not know how to answer that question and express that their kids just hanging out around this stuff all the time.

Could they be lying? Yeah. But when you’re using heavily, you don’t want kids around because you don’t want that kind of responsibility.  I just haven’t seen that. We worry about child protection and what we report. We have to come back to what the letter of the law is here. The letter of the law is threat to self or others or threat of harm to a child. Harm in this case is neglect like no food, clothing, shelter, medical care, that kind of thing, or actual abuse.

I agree and believe that children should be protected. I absolutely want to make sure that that’s happened. That is a topic of conversation that I have with people. I want to establish that their children are being cared for in a “good enough” way and that as much as possible, the child is shielded from my clients’ use.

When you are an outpatient mental health therapist, you are likely not going to have people who are using at that level. They typically aren’t going to be able to make regular appointments. They are strung out, totally in chaos and therapy is not necessarily an active priority. So I want to encourage you to be able to relax about this a little bit and be able to talk with your clients about it if they have children. 

If you get the sense that they are not willing to tell you the truth, you can ask them if they feel nervous about answering those questions and find out exactly what the answer is. I never promise that I don’t have to report something. I do let them know what my parameters are. Ultimately, our goal is to help our client. In order to do so we need to know the truth. The fear that they have of law enforcement or child protection gets in the way.

The majority of the parents that I’ve worked with do have concern for their children, even in the midst of their drug use. When they realize that they can’t care for their child, they usually have given care of them over to someone else. Either deliberately by telling that person, they need them to take care of their kid or leaving the child in the care of someone else, whether or not that person realizes they’re going to be gone for a while.

When it comes to the people I’m suggesting that you work with, we’re not going to be at that level. We will eventually get to talking about what happens when you do have a client come in and their use is surpassing the level of outpatient therapy. That is a different issue and we will talk about that. It’s just not going to be as common that that is the kind of person who’s coming through your door. 

The one piece that is unpredictable is whether or not you have to report if a pregnant person is using. It depends on the state. Each state has laws about whether or not that is a crime. In the state of South Dakota, when I lived there many years ago, it was a crime. You could get arrested for using while pregnant.

However, in other states like Minnesota and Wisconsin, that is not a crime. You cannot be prosecuted for that offense. Certainly,  I have seen pregnant people involved with child protection, typically because they’ve had other children that are involved in the system. I have seen children taken at birth because the parent and the child tested positive for a drug .That also depends on the state.

If they both test positive for THC, I have not seen a child removed because of that, yet. It is entirely possible that it happens. I just haven’t heard of it. It’s more likely that a child is immediately removed at the hospital because of testing positive for meth, crack cocaine or heroin. That is far more common.

Partly because we’re dealing with neonatal abstinence syndrome and that’s where the newborn is going through withdrawal and that’s pretty evident to the medical staff because of how the newborn is responding. Whether or not you have to report if your client is pregnant and using really will depend on your state.

If they’re using marijuana. The answer is probably not. If they’re using alcohol, I would also think probably not because it’s not illegal. It’s inadvisable and causes irreparable damage to a child, which yes is a risk of harm. And we can’t prove that it’s causing damage. 

I have seen people report that they’re pregnant person was using meth or heroin. That is going to have to be a judgment call. Based on the definition of a fetus and based on imminent risk I don’t believe that it’s necessarily reportable. The system is not perfect. So however you feel about people who are using while they’re pregnant, the system isn’t able to weigh in on all of that. This is what freewill is about. 

A lot of the pregnant people that I have known try very hard to not use while they’re pregnant. They know that it’s bad and they try really hard to get off of it. Sometimes the person did not know they were pregnant, which I know seems like the kind of thing you see on TLC. There have been a couple of those  in the area that I live in the last couple months where people didn’t know they were pregnant until they were giving birth to a baby. So it absolutely happens. 

The majority of people I have worked with that have given birth, tried their best to not harm their child. People who are using drugs and alcohol typically don’t want to hurt other people. They don’t want other people to suffer because of their use. They will usually isolate themselves, hide it, lie about it anything they can to keep others from being hurt emotionally or physically by their use. 

For yourself I would read the statute in your state related to pregnancy and substance use. If you don’t find anything, the chances are that it is not a crime.  If there aren’t laws protecting a fetus, then their legal status as a person removes them from this reporting requirement. This is a touchy subject. I recognize that and that there may be people listening that have a really hard time with that. I do understand that. 

I have worked with therapists who do have a boundary about if someone is pregnant and using that they can’t work with them because they can’t be objective. And so they will transfer them to another therapist who can work with them. 

The bottom line here is that we can assure our clients that their information is safe with us. It isn’t about condoning behavior.  It is about confidentiality and the laws that protect them and us. That said I would not be documenting things that you don’t want to answer for. 

Progress notes are an interesting thing. In the next student edition episode, I am going to be talking about this a bit because I’ve had experiences in court and have seen progress notes that were good and progress notes that became a disaster in court.

What we document is not every single thing that happens in the session, of course, but generally what we discussed the client’s  statements, interventions, and things like that. Details about them dealing drugs, or going through withdrawal or whatever that’s going to be something that you need to be aware of what you’re documenting and whether or not it’s necessary. We give the minimum necessary information in our notes.

The last part of fear after the cops and CPS is the fear of having to quit. There is a tremendous amount of fear about getting sober. I have often talked about that by the time someone is having problems with using they are not having fun anymore. There may be moments where they have a wild night with friends and it’s fun. Eventually that stops being the case.

The fear of getting sober is typically about a couple of things. One of those things is what will they do without it? I hear things like what if I need it? What if I can’t handle things that are going on? How will I get through without it? People are often worried that they won’t have any escape from the pain of life.

They know that their drug of choice or other substances are available. That if in need, if they couldn’t handle it, they could go get something, whether it’s alcohol or something else to numb out and not have to feel for a little while. They are afraid of a life without it. We see that all the time with our clients who have significant trauma. They are terrified of having to face it and deal with it with good reason.

I always tell people who are struggling with dissociation, that it’s really normal to have dissociation. There’s a reason that their body and their brain are telling them to not look at this stuff. It’s because it is alarming and grief filled and traumatizing to have gone through and to have to relive. A lot of times, the fear of getting sober is about that.

The other fear I hear the most often is the fear of never feeling happy or having fun ever again. If there is anything in someone’s life that they feel like without, they will never have fun again: that thing might be a problem. It could be food, it could be gambling. It could be some kind of substance. 

Many times people who have a problematic relationship with a substance, even if they’re not fully into addiction, feel like in order to enjoy their life, to relax, to have fun that they have to have that substance.  Even if it’s just a little bit. They feel like if it suddenly vanished from the earth, that life would be gray and dull, that can be a hard thing to work through. 

Typically I don’t challenge that. I just try to bring them back into the moment and say:  “we’re not thinking about long-term, we’re thinking about right now. I don’t know what the future holds for you and you may not always feel that way. It’s a valid feeling because in your life so far, how you have relaxed and how you have had fun, did involve this substance. I can see why you feel like that. It’s causing an issue right now. So let’s focus on the right now and we’ll deal with the future later.”

In our recovery story coming out next week, you’ll hear from Jonny.  Jonny tells us his story from using drugs and alcohol to recovery. You’ll hear that his fear of not being able to use, kept him stuck. He spent at least a year and a half in therapy, lying to his therapist about his use because he just couldn’t imagine being without it. His depression was so deep that he didn’t believe that he was able to live without it. I wonder if that therapist saw that fear. 

Sometimes when clients aren’t making any progress in therapy, it can be because there’s something they’re holding back.  I have heard often from people in recovery, how, when they were in services with therapists, or even in substance use treatment, that they didn’t get honest right away. That they were afraid to say how much they were using or any other number of things they were afraid to say. To be in an active addiction is to have fear.

So know that when you start asking about it, there’s going to be fear in the background. Our role is to find out why and help allay those fears. Next week on the podcast, you’ll get to hear Jonny’s story of overcoming fear in order to find recovery. 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/