Episode 3

What is generalist therapy?

What is being a licensed mental health therapist like? 

What challenges exist that we didn’t anticipate? 


This is part 3 of a 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 

  • One of the first things a new mental health therapist notices is the difficulty with managing all the new clients at once. 
  • Doing generalist therapy is a necessity when first building a caseload and for several years afterwards. 
  • Being a generalist has an up and a down side. We learn how to adapt and treat a wide array of people. We also have to rapidly adjust to become all things to all people.
  • Having to be competent in so many areas can lead to feelings of conscious incompetence.
  • Addiction ops up all over and we find out we don’t have the training we need to address it. 

Helpful Links:

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

The Generalist vs Specialist


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.

This week, we’re going to talk about the reality we face as therapists. Last episode, we talked about how the path from grad school forward was pretty laid out up until we got our license. And then we’re sort of on our own. Some of us had really good direction from our supervisors or agencies. While some of us knew our population and planned trainings accordingly.

The vast majority though  didn’t have a ton of direction and sort of had to figure it out as they went. Now, those of you who have been therapists awhile, so 5, 10 years post license, you’ve probably figured it out by now; feeling a little more comfortable. I wonder how many of you wish it’d been a little different, with a little more direction. Thinking that it would have made it a little easier for us to be able to settle in and figure out the business of being a therapist and how to manage all the different personalities and issues that come through our door. 

One of the things that we see when we become a therapist is intakes. Intake, after intake, after intake. Whenever a new therapist would start, I always encouraged them to tell me when they were overwhelmed with assessments. And to try to plan that out a little bit, because most of us know when you tell the intake department to stop putting intakes into your schedule, they’ve already scheduled a couple of weeks out. And so there are certainly already some on the horizon. Some therapists did better than others. Some of us, well a lot of us, are the overachiever type. And so they wanted to hold out. And so sometimes that backed people up. And when you have 15 to 20 assessments to write you start misremembering details. And if your note taking skills are good, then that’s great. What I found out was that my note taking skills were not awesome.

I remember a day when I had three new people coming in, they were all teenagers, female, the same age. They happen to all be blonde. And each one of them lived with one parent as their parents were divorced. Now I would have sworn that I would have remembered who was who, but later when I went to write it  I couldn’t remember who lived with which parent. And so I kept having to just say the parent they live with, it was not stellar.

And that’s how it is in the beginning. When you start out at a new agency or when you’re starting out, taking on brand new clients after you get your license. The process of starting a new caseload can be really overwhelming. So I don’t know how it was at your agency, but at my agency, I tried to limit it to about five for the first week and then tried to limit it again to five the second week. There’s pressure coming down from on high, right. For productivity, to get intakes in. There’s also usually some pressure coming from the admissions department. Because they have people who want to see someone. And so there’s this weird balance of trying not to overwhelm the therapist, but also trying to get people in and not have the therapist just be sitting there bored because as we all know, just because someone has an intake appointment does not mean they necessarily always show up. And so as you’re gathering new clients, everyone that comes in has a different story, different background and different needs.

One of the things that stands out as a new therapist is when you get a new client and you realize how much they don’t just tell us information in a nice orderly fashion. So when we’re in school and we learn how to do intakes, and we learn how to assess people, how to gather history, how to gather current symptoms, and you’re going through all this process and you realize you have to do this in an hour. It is crazy overwhelming. And so we have to figure out this balance.

And I really think that doing an assessment is like an art form. Those of you who have been doing this for a while, I want you to think about the first few assessments that you did all on your own, where you weren’t an intern, you didn’t have luxury of all the extra time. And just remember that sense of like, holy shit, this is a lot of stuff. Once in a while, you’d get a client who was pretty simple, some garden variety, depression, anxiety, that kind of thing. Not a lot of trauma history, nothing really major going on in the family. Just anxious, just depressed. But those people were pretty few and far between for most of us. 

One of the things I remember from seeing therapists as a teenager, that I hated it when they wrote stuff while they were talking to me. Every time someone would write something down, one of my thoughts was they’re writing about how fucked up I am or what are they writing? And I had this desire to sort of lean forward and be like, what is that? Looking over my nose, trying to see what they’re writing down. Never was able to see, but I didn’t like that feeling of someone writing now.

Each one of us has to handle that a different way. Right. Some people write all the time and some people don’t. And so in the beginning I was trying to balance that, right? Like. I’m trying to balance taking notes so that I have them later, but also not taking notes. So when I had those three girls in my office and my notes, chicken scratch, super ridiculous, like couldn’t remember stuff. And I really thought I would, because I have a really good memory, but it was just too many details. And I wasn’t writing those assessments the very same day. Right. Oh, I would love to be able to write an assessment the same day that I saw the person. But those of you in outpatient know that that is just not the case.

Now I’m sure that in residential and in other places, it’s also not always the case. In outpatient though, one of the challenges is that you can go from client to client to client. And in one hour you can have a five-year-old who is being defiant. The next hour, you can see a 35 year old, who’s going through a divorce and the next hour you could see someone totally different and you have to switch over and over. And it is difficult at first. We do figure it out. And we do get comfortable with it. 

So there’s this concept that my professors talked about in grad school, and I know it’s not original to them. And as I looked it up, there are references to it all over. And so I couldn’t really find whose idea this was to give proper credit.

So the idea is about the four stages of competence. Okay. So the first stage is unconscious incompetence. The second stage is conscious incompetence. The third stage is conscious competence and the fourth stage unconscious competence. Now, I have used this over the years and I find it super useful. 

So the first stage. Unconscious incompetence. So this is where you don’t really know that you’re not doing a great job. You think you’re doing a good job, but you don’t totally know that you’re missing some things.  I would say for myself that this was before I went to grad school.  I was working with kids in the mentoring role that I had talked about. And I think I was doing a decent job, but I wasn’t doing like, therapist  job. I definitely had my own emotions into it. I definitely was doing a lot of advice giving. Definitely things that as therapists we try to steer away from, but I didn’t know that. So I want to tell you about my first conscious incompetent moment.

So in the start of grad school, we had our person-centered class. And in that class, we had to do triads. So we got into groups of three and that was going to be our triad for the semester. And our goal was to practice doing therapy with each other. And I know that a lot of us had these types of situations in our programs. I don’t know whether you had to take video of it or not. Hopefully at some time in your career, you’ve been able to see that because it is eye opening. 

So what we would do is we would go to this particular room. And we would take turns. One would be the therapist. One would be the client and the other one would be sitting outside the room, watching the feed along with the teacher’s assistant. And so I don’t remember who of us went first. I don’t think it was me. But I know that when I went, it was me and my friend. 

We were supposed to bring a real issue, not something made up, but also not something super deep because this was for practice. And so I was in this room and I remember, first of all, being really hot. Like feeling like my face was on fire. And it’s not that it was hot in there. Cause it wasn’t. I was just feeling really nervous, which is unusual for me. And these guys were friends of mine. I used to hang out with them, sometimes; we’d play guitar or whatever. And I really dug these guys and so it wasn’t like I was nervous to be around them and the TA was totally cool.

So it was just this moment of, Oh, I’m the one who has to drive the session now. So we’re sitting there. And he’s sharing and I’m talking and I realize I am like rapid fire questioning him and I couldn’t seem to stop myself. And I had these like, moments of like, stop asking questions, just shut your mouth and listen. And so I was trying to stop, but I just couldn’t, I don’t know something happened. And I was just like ugh, it was hilarious now, but embarrassing then. And so we finished our 10 minute session and we go out and the TA is like, that was really great. You were mirroring him really well. And I’m just like, huh? And he’s like, yeah, he leaned forward and you leaned forward. I don’t remember any of that. At all. And so I just was like, Oh, thanks. Yeah. And I left there and I am still on fire. Totally embarrassed. And just thinking, Oh my God, I suck at this. We had to go back and transcribe this. 

Now in my memory, we had to transcribe the whole session. But it’s possible that the trauma of that memory is making me think that it was the whole thing instead of a section. I don’t remember. I just remember it being awful. You guys might think that maybe I was being hard on myself. Right? Like really it was a good try. It was good for your first time. And that when I watched it, I would see how much better it was than I thought. Hell no, it was worse than I knew. 

So I’m sitting there on the floor in the living room. With the VCR and I’ve got a notebook and I’m writing down what I’m watching. It was like a slow moving car crash. I watched it and as it moved further, it got worse and I’m not kidding. It was so bad. I was asking questions. I wasn’t paying attention to what he was saying. And it seemed to work, like, yeah, I saw that he was leaning forward and engaging, but I swear to you that was sheer luck. It was a super cluster. And there was just like the sense of, “Oh my God. God, I’m terrible at this”. 

So based on what I had learned so far in grad school, cause remember this was the first semester. We were supposed to be paying attention to their affect, their body language. What they’re saying, what they’re not saying, what we’re feeling, how our body language is, what we’re thinking, what we’re saying, putting things together and paying attention and trying to create this therapeutic atmosphere. And I was like, there is no fucking way I am ever going to figure out how to put all those things together. Add that to it, that I’m supposed to gather a lifetime of information and be able to put it together in a coherent sentence. 

It’s been 19 years since that day. And I have less of those moments. Thankfully most days are filled with conscious competence and some unconscious competence. And we have that as we move forward, we get over those moments. We start knowing what we’re doing. It starts becoming easier, more routine, and we get good at it. And that feels amazing. Even the intake thing, even the therapy thing that I talked about. I liken it to like driving a car. 

Okay. When you first start driving, staying in the lines takes a lot of effort. I’m not saying that you’re trying hard to not like, steer into oncoming traffic. What I mean is that you’re really aware, aware of the lines and trying to stay within them. And when you’re doing that, you can’t really pay attention to the way we drive now. So if you’ve been driving a while, well, I’ll use myself as an example. When I’m driving, I’m paying attention about five cars ahead of me. I’m paying attention to the left, to the right and behind.  I’m watching my speed. I’m paying attention to where my car is. I’m watching other people’s movements. I’m thinking about where I’m going and where I have to turn. And that is the result of hours and hours and hours of driving overtime and the lines, they’re kind of irrelevant.  And I’m not saying that I just drive all over. What I’m saying is, is that you just stopped noticing and they become background. 

And the longer you’re a therapist, the more a lot of the stuff that we’re paying attention to in the beginning becomes background, and we just get better at it. And we move into that place of conscious competence and it feels really good. As we proceed, we even start to have these unconscious competent moments where we leave a session and we’re like, hell yeah, that was awesome. And we realized that we just did the perfect interventions or whatever, and it was effortless. And it’s so cool. 

I would ask my staff when they were working on their hours to talk to me about the therapy brilliance scale. Now I didn’t come up with that. It was a guy that I saw at a training who’s from Chicago, and I looked everywhere and could not find his information. I think his name was Matthew, but he talked about the therapy brilliance scale. And he asked people to rate their therapy sessions on a scale zero to 10, 10, the most awesome session you’ve ever had in your entire life. So I want you to stop and think about that for a minute. Think about what was the best session you ever had. Now I could ask you to pause the podcast so that you can think about that. But when people ask that when I’m listening to things, I never do it. So I’m not going to bother so your best session ever.

And then I want you to think about your worst session ever, like the worst session where you’re like, Oh my God, that was, that was a shit show. And, um, Wow. So most of our sessions are going to fall between four and six, right. Evenly distributed. And they’re in that, well, those sessions that are like four or five and six, when you’ve just got your license and those sessions that are four or five and six, when you are 5, 10 years out from your license, that’s a huge difference.

And so our sessions shift up. And so what’s normal for us starts to shift downward because most of our sessions are pretty decent as we get better at this. What’s hard is when you’re in this place of pretty conscious competence and feeling pretty good. And then you get someone who comes in and it blows all that to hell.  And it’s nothing they did. It’s just that their life is a train wreck and they come in and it’s like, they’ve spent however many years tying their lives knots, and then they hand it to you and it’s like, boom, figure it out. And it can be so difficult to know where to start. 

That’s the other part that we get good at because that’s what happens is nobody comes in thinking like, well, I’m going to tell you this, and this is what I want. This is what I want to get out of therapy. This is what I like. This is what I don’t like. We just have to figure that out. But when you’re later in your career, not necessarily in late career, but as you’ve had a few years under your belt. And one of these comes in, it’s always a little bit of a shock when you have that moment of “I am in over my head”.

And part of this is because a lot of us are in community mental health. And what that means is that there are a ton of clients who need to be seen and we have to be generalists. We often don’t have the luxury of specializing. And so when we can’t specialize, we have to see whoever comes into our office. And when people call the intake office, they don’t typically tell them exactly why they’re there except what they have decided they will share. Which I totally understand. And I don’t think people should run around telling everybody all the issues are now. Sometimes they do. And the intake people are always a little overwhelmed by that, but most of the time we don’t get a lot of information.

You’d get a sheet of information and then you’d go from there. You’d look at the name, gender age, go out to the lobby, call your person. And as they’re walking towards you, you’re starting to get an image of what they might be like by looking at how they’re dressed, how they walk, whether they’re looking at you in the eye, how they’re feeling about being there, all of those sorts of things.  And they could be coming in for any number of reasons. And so being a generalist, we do learn to kind of roll with things as they go, and it is helpful, but it isn’t necessarily the thing that we want to stick with. So we can do a lot of things. But that doesn’t necessarily mean we’re great at it. 

For instance, I’ve worked with little kids I’ve done in home therapy. I can do it, but I’m not that great at it. I could work with middle schoolers. I loathe middle schoolers. Not that I mind them as humans and I loved mine when they were in middle school, but I find it really hard to talk to middle schoolers. Getting them to tell us what’s going on. Is. A trick. You ask a middle schooler. 

“Tell me about your week”. And the school could have imploded yesterday and they’ll be like, “It was fine”. Anything happen? No. At least that’s my experience. And so while I can do those things, it’s just not a good fit for them or for me. In our early careers though, specializing, isn’t something that we get to do.

So you have all these people and you’re working with them and you have to change gears each time one of them comes in. I recall when I first started at the agency up here in the twin ports, I had a 6year old. I had a 67 year old. I had a bunch of teenagers. I had a child with autism and I had a couple of men who had schizophrenia. Now, that’s not all the people I had, but it’s just to give you this cross section of what it means to be a generalist. So during that time, between, when you start at an agency you’re in or your early career and the time in your career when you get to specialize, that’s the gap I’m talking about. Because that’s the part where you don’t know what you don’t know.

You don’t know those things until somebody comes in who has a problem or an issue of where you’re going. Um, I don’t know what this is about. And this is where the substance abuse issue starts to come. So I know that there is a huge stigma about mental health and there’s been a lot of work done. And I think that the message is getting out there and that more and more people are willing to seek mental health services.

The stigma for getting help with substance use though is still a really large barrier. People don’t often identify their substance use as the reason why they come in. To be sure there are people who call an agency and say, I need help with my alcohol problem, or I’m using drugs and I need help. That takes a whole lot though. And most people aren’t at that point yet. Because we aren’t taught about addiction in grad school. We’re left to treat it the same way we do other things. Which is either one of two things, either we don’t ask and we figure they’ll tell us, or we ask them and figure they’ll tell us the truth. The unique thing about substance use is that people aren’t going to tell you the truth.

This is not because I think all addicts and alcoholics are liars. I don’t believe that. I do believe that addiction needs to hide. The Big Book of Alcoholics Anonymous says that addiction is cunning, baffling and powerful. And through my own experience and through my work over the years, that is absolutely true.

Addiction needs the darkness to thrive. It doesn’t want to be found out and the addict or the alcoholic instinctively knows that they have to hide how bad it is. Sometimes they have to hide it from themselves, even,  because they can’t deal with the fact that they’ve let things get as far as they have. And there’s an incredible amount of shame associated with it. Even though the science tells us that it’s a brain disease, they still feel like it’s a moral failing. And indeed a lot of the population still feels like it’s a moral failing. So I can tell you two things. One is, if you’re not asking, they’re not telling. Of course there’s going to be exceptions to this particular rule, but generally this is the case. People don’t want to tell you. 

And the second thing is, if you ask them, they’re not going to give you the whole truth. And this is not because they don’t want to tell you the truth. It’s because they’re scared to tell you the truth and it’s not because you’re going to call the cops or anything like that. It’s because if they have to do life without it, they’re not sure what that’s gonna look like. Ask anyone who’s quit smoking cigarettes, and they will tell you that it was scary in the beginning. Because they wondered “what will I do if I need to smoke and I can’t”, “what will I do if I’m having a rough day and that’s not available to me”? Doing, without things that brought you comfort is scary. Even if the thing isn’t bringing you as much comfort as it used to. 

So I want you to think about clients that you have that you’ve seen for, I don’t know, a couple months and their identified problem was anxiety, depression, et cetera. So let’s pretend that you’re starting to hear things about substance use that are making you a little bit suspicious and wondering if there’s more than maybe you thought there was. And let’s say that you are able to get them to talk with you and you get the sense of this being a real problem and something that needs to get addressed. So then what? Do you have to refer them? Some of you have chemical dependency services nearby, maybe in-house. And so that seems like a natural fit. Yeah, no problem. Just refer them. 

I remember that being the directive of some of the therapists that I worked with in my early career. Talking about a case and they’d hear substance use and say, wait, substance use, just send that to the chemical dependency people. And I have to say, I don’t know that we have to, and I don’t know that we should. Because by the time a client has been with you a couple months, they’re fully engaged in a relationship with you.

Research tells us that all sorts of factors contribute to someone getting benefit out of therapy. It could be internal factors like ego strength. External factors, like family support, but that the biggest factor overall is the quality of the relationship with a helping professional. 

Our techniques aren’t the top thing. Now that doesn’t mean that we didn’t need techniques or skills or go to school. We absolutely needed those things and they’re super useful, but that overall that’s not the thing. And so having to transfer them, isn’t great. And I’m telling you, they don’t want you to transfer them. They want you to be able to work with them and to have their space with you. 

So the reality we face as therapists is that we have to be generalists and see numerous people at different ages and with different problems. And we have to figure out how to use our tools to become basically all things to all of those people. We aren’t able to specialize until later in our career. And in those first 5 to 10 years, we’re not even sure what specializing would totally look like. And when we’re seeing all of these different people, there are things that pop up that we weren’t prepared for. And one of the really big things is substance use.

And we are left with what do we do to help these people? There are different schools of thought about whether you have to treat the addiction first or treat the mental health first, or whether you can do them both at the same time. And that’s not the topic of this particular podcast. I’ll probably address it at some point in the future. But for now the question is, what do you do when they’re there in your office? Because that is our reality. And we need to figure out what it is that we can do with that reality. 

In the next podcast, I’m going to be talking about why I believe that it is you, specifically you, that your clients need, and that they need you to know addiction and substance use.

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.