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Episode 81

Good therapy depends on both us and our clients. We need to show up ready to work, but our clients need to show up ready also. Substance use can get in the way. There are two ways that substance use interferes with our work. One is when a client’s brain and emotions are being impacted by therapy in a longer term manner (damage from alcohol or meth as an example). 

The other way that good therapy can get impacted is if clients show up under the influence of substances or in withdrawal from them. A client isn’t going to be able to focus and be emotionally available. In today’s episode we are talking about how to set boundaries around the time we are with clients so that we can help ensure that we are able to provide good therapy.

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 81. The topic today is a little bit of a diversion from the track we’ve been moving on. We’ve been talking about the assessment and we’re going to keep doing that, but there was a topic that I wanted to cover that I hadn’t done yet.

I wanted to talk about protecting the therapy hour. When we’re seeing someone we have an hour, maybe 50 minutes, depending on how your agency runs to see a client. That’s one hour out of the hundred and 68 we have in a week. So they’re with us for one hour and 167 hours they’re elsewhere. 

Providing Good Therapy

During that time we’re trying to accomplish a lot of things. We do our best to be on top of our game and ready to work. What happens though, if substance use gets in the way of that hour? There are two ways that substance use can get in the way of therapy.

One is what’s happening in their brain that could be impacting their emotions, their ability to follow through on things and their view of themselves and the world around them. That’s a topic for a different time. Today we’re going to talk about the other way that substance use can interfere  with therapy.

When I think about somebody who has substance use issues, there are a few things that come to mind and one of them is about the standard day in the life of someone who is using substances. How often and how much does change things. So let’s talk about the two most common substances that we’re going to see in outpatient therapy. 

How Alcohol Interferes with Good Therapy

The first would be alcohol. Alcohol is legal everywhere in the United States and is seen as being socially acceptable. I saw a t-shirt the other day for a toddler talking about being mom’s wine buddy. It just seems really odd, but the mom wine culture is very well-established. It’s not just moms though of course. Lots of people drink in the evening. 

There are some people who are going to be drinking all day. Typically though, when someone’s drinking all day, every day, they don’t usually show up in our offices. They might be a little bit, and I have had times where people have shown up to session intoxicated or still intoxicated from the night before or in withdrawal and we’ll talk about that in a little bit. 

Typically when someone has some problematic use, they’re trying to function in their daily life and keep their alcohol use until the evening. When people get home from work, there’s usually a few hours before they go to sleep. Could be two, could be four, could be five, but typically we don’t spend more than that between the time we get home from work and the time we go to bed. 

The later the person works the shorter that time is. Here’s what I mean: a person who works an eight to five, they get home and they probably end up getting ready for bed around like 10 o’clock. That is about five hours.

If a person works till say 10 30 or 11, on a second shift, they’re going to maybe stay up until, say two o’clock, maybe 3. If a person’s working till midnight or beyond, then they might stay up for a couple hours. A bartender for instance, might not get home until three or four in the morning. And once the sun’s hitting the horizon, that’s the time they go to bed.

So we have this narrow window of being home. The reason that matters is that the more you drink in a shorter period of time, the greater effect. A person who’s working an average eight to five is probably going to have dinner when they get home their biggest meal of the day. Then they’re going to have some drinks to relax.

Sometimes it’s in service to needing to sleep and sometimes not.  It is something that people can get into a routine of and it just becomes part of the evening; cocktail hour so to speak. Drinking alcohol on a full stomach does tend to slow down the rate of absorption and make the intoxication less intense.

So if we have a person who’s drinking in the evenings and they have a five-hour span, they’re going to be less intoxicated then someone who’s drinking a similar amount in a two or three hour span. 

There have been multiple studies that talk about the impact of alcohol on sleep. Alcohol does decrease sleep onset, meaning that it does make it easier for the person to fall asleep. However, it also delays the onset of REM sleep and increases the percentage of deep sleep. 

As we move through the sleep cycles, REM sleep is really important. We need reparative sleep in order for our body to get better and to help us feel rested. When someone has been drinking, it increases the amount of deep sleep they have. 

Deep sleep is a little more like hibernation, I guess. Where we’re just asleep and it’s not necessarily active sleep and it’s not really reparative sleep. It does something for the body. So it’s not that we don’t need any deep sleep, but considering that REM sleep typically only is 20 to 25% of our entire night’s sleep decreasing. That is not great. 

So as the person who’s drinking in the evening they are going to be waking up in a way that they feel more tired. They may have had a full eight hours of sleep or whatever, and they’re going to wake up feeling like they didn’t get that much sleep after all. This is something that can affect what happens in therapy. It can also affect their ability to get up and get moving. 

The implication here is that if you have someone who is drinking in the evenings, you need to think about when their appointment is going to be during the day. An 8:00 AM appointment probably isn’t great. They’re going to be groggy. It’s going to be hard to get their brain online because they’re tired and they may not be totally focused. 

I would think that a better time for someone who’s drinking is probably around noon or after the workday, like four or five, depending on their schedule and yours. That is going to increase the chance that the person is not intoxicated anymore awake and able to engage in the session in a better way.

If we’re talking about someone who works second shift, say a three to 11 shift. They’re going to be coming home by probably 1130 or midnight. They’re not going to be going to sleep until maybe 2, 2: 30 or three o’clock in the morning.  For them, a normal wake up time is going to be pushed back a few hours. So maybe they’re not going to be getting up until 10 or 11 in the morning.

Again, they’re going to need a little bit of time to wake up again. For them starting the next day at three o’clock, perhaps a good appointment time would be two o’clock if it’s tele-health and they’re able to move directly after that, to their work. I have a lot of people who do their therapy in the car right before they’re going to go into work.

Now that’s not ideal of course, if we’re working on trauma work or if sessions are particularly difficult. But when someone’s using substances often, I’m typically not doing that deeper work with them because the substance use is still an issue that’s getting in the way. So when you’re scheduling appointments for them, I would make sure that it’s not first thing in the morning. Those appointments are going to get missed and if they do show up, they’re not going to be at their best and able to engage with you in that one hour, out of 168 during a week.

Sometimes we have people who work third shifts and for them it seems like an appointment right after their workday might be okay. Let’s say they get done at seven and they come in for therapy at 8. They’re tired, but they usually have to wind down a little bit before they can go to sleep anyway. So that tends to be a decent time. For some people they need to do it later in the day, but after they’ve had a chance to sleep. 

Additionally, Mondays are really hard for people who are using because the weekend,  assuming that the weekend is their weekend and they’re not working through it. The first day after coming off of their weekend can be really hard and typically they’ve been drinking the whole weekend and so might want to give them a day or two before you do that.

If for some reason, somebody shows up intoxicated to your session, there are a few things that you should do. Your agency may have a policy about this, or they may not. A lot of places don’t really think about it because they figure why would someone do that? Well, people do, and over my career, I’ve had that happen a few times to either myself or one of my staff people. And so I want to tell you what we did as an agency, as a suggestion about what you might want to consider. 

If somebody comes in and you smell alcohol on them, what you want to do is find out when they were drinking. Is this from the day before?  Or is it from today and so they’re currently intoxicated. That’s the first piece. 

If it’s from the night before you want to find out when they went to sleep. So that tells us when they stopped drinking for the most part, although you do need to clarify. So I would say to somebody, all right. So when did you go to sleep last night? Well, I think I passed out around three o’clock. Okay. Have you had anything to drink since then? Yes or no. 

If the answer is no, then I’m less worried about them getting in a vehicle and driving away, if it was only a couple hours of sleep, then clearly they’re going to be still intoxicated and the thing is, is that we can’t let them drive away. That can be a very difficult conversation. 

It’s the same thing that you would do if you were at a bar with a friend or had someone else who was drinking that you knew was going to get into a vehicle. The difference here is that you have knowledge that they were drinking. You establish how they got there, which in 90% of our cases unless you’re in a giant city where it’s public transportation is that they drove there. 

So my recommendation is that you do not do a session. If someone is under the influence period. You talk with them about it and then you establish how they’re going to get home safe. We cannot trust people who are intoxicated to do the thing that would be most responsible. In this case, they might tell you they won’t drive and they’ll call a friend, or they might tell you that they’ll walk somewhere and sober up and you can’t really count on that.

As therapists I know this is stepping into territory that we do not want to have to get into and hopefully you don’t have to experience this. If you do, though, I want you to at least think about what you would do in that situation. For myself, I’m in private practice and so if I was seeing people in person, I would be basically the only person knowing that this person was here and that they’re intoxicated and that they drove to my office. 

So after I establish when they stopped drinking and how intoxicated they are at the moment, in most cases, I’m going to want to make sure they get home a different way. So at this moment, I’m having a pretty frank conversation. No judgment, no shaming. Just saying we’re not able to do a session today because you’re not totally sober. I think we need to reschedule and we need to talk about how you’re going to get home. If they say they’re going to drive my answer is I can’t let you do. You might be fine. And we don’t know that. And I can’t have you leave here, not knowing that you’re going to be safe and that other people on the road are going to be safe. 

So the options here are for them to call a cab or an Uber or Lyft or whatever it is that’s available in your area. If there isn’t anything available, then they can call a friend or a family member or walk to a place where there’s public transportation. You might be wondering what’s to stop them getting in the car and leaving once they walk out of the building. 

And this is the hard part and it is my recommendation. You let them know that if they leave in their vehicle, that you will have to call the police and let them know that there’s an intoxicated driver on the road. The alternative is that you’ve let this person leave, knowing that they’re intoxicated and if something happens, you absolutely would feel liable, but you also might actually be liable.

You weren’t serving this person alcohol, but you talked to them, you knew they were intoxicated, you knew they were driving and you let them leave anyway, that can’t happen. There was a time when the agency used to have people leave their keys at the front desk, but there’s some liability issues there in case the car got broken into or stolen or something. And so I don’t recommend that. 

You can’t sit on top of the parking lot all day and see what’s happening. If the person walks away from the building and they’re not getting into their vehicle, you’ve done your due diligence, there’s not much you can do. Hopefully this won’t happen, but I do encourage you to think through the issue and decide what you will do if this ever comes your way.

It can be hard to ask someone, have you been drinking for fear of being wrong. Typically I’ve known that this person drinks and I’ll say what time did you go to sleep last night? And then I’ll just ask him when the last time was that they had a drink.  

Wrapping up the conversation about alcohol is a conversation about withdrawal. If a person is drinking to the point that they would be in withdrawal during the day, that is a different level of treatment that is needed. Alcohol withdrawal is incredibly dangerous. It is one of two withdrawal syndromes that can be lethal. This has to do with the risk of cardiac arrest from the withdrawal and so if someone’s in withdrawal, we want to be really cautious about what we’re doing with them. 

Our goal then is to try to encourage them into inpatient detox, or to at least get withdrawal help from their doctor, which can be done on an outpatient basis. Nobody who’s been drinking on a daily basis should go cold turkey or try to quit without medical assistance. 

How Marijuana Can Interfere with Good Therapy

Moving on to the second, most popular substance that people use marijuana. When people are smoking marijuana, we have a little bit more leeway about how we handle things. And this is because marijuana in and of itself probably isn’t going to kill them.  There is a small risk of THC poisoning, but you really have to work pretty hard at that. 

Most likely what we’re seeing in therapy is that people are smoking anywhere from once a week to every day. Marijuana on a daily basis is a little different than someone coming in, intoxicated on alcohol.

Lots of people who have smoked marijuana, can’t imagine working, going to school, taking care of kids all while being high, because their tolerance for marijuana was really different from someone who’s smoking all day, every day. When you’re not used to smoking all day, every day then you can’t really function normally. You don’t go to work or interact with people because it feels weird and you’re distracted and spacey and all sorts of things. 

 

However, when someone’s smoking marijuana daily, their tolerance is different. Instead of feeling high, they smoke to feel normal. When they’re not high, they tend to feel jumpy, agitated, and anxious. However, smoking makes them feel normal and they can go about their business. When I was using, I absolutely went to school and work and did everything while high. And for the most part, nobody knew. I would have had to be extremely high for anyone to notice.

 

It was just part of the day to day. For people who smoke marijuana daily, that is what it’s like for them. They drive high, they take care of their kids high. They go to work high, they do everything high and they believe that there’s no difference. They believe that they act really normal and that it just lowers their anxiety.

 

That’s one of the main defenses that people who smoke marijuana will tell you is that it doesn’t really affect them in a bad way, they’re just able to be more themselves. The problem with this is that marijuana is a depressant. Biologically it is going to slow down their central nervous system which in turn slows reaction times. There is no way to make up for that. 

 

 A lot of people who smoke marijuana will tell you that they’re better drivers when they’re high, because they’re more careful. They might feel more focused because marijuana can make you feel like you’re hyper-focused on something. However, the slowed reaction times are still there. There’s research to back that up as they’ve done studies on that, but the perception of people is that they’re perfectly fine. 

There’s also some issues with depth perception when it comes to marijuana and with decision-makers. Because marijuana is a depressant and it also has some psychedelic properties there is a separation from time and space. This has implications for us in therapy.

Addressing someone’s marijuana use can be a tricky affair. There isn’t another substance where I have found people adamantly defend it and also promote the idea that it’s somehow beneficial. Nobody’s telling me that meth or opiates, or even alcohol is somehow healthy and beneficial yet with marijuana I’ve heard it all. 

It is a constant: it’s from the earth,  it’s natural. To which I say arsenic strychnine also from the earth. Cocaine is from a plant, heroin’s from a plant. Just because it’s natural doesn’t mean that it’s safe. This is not to say that marijuana is equivalent to those things because of course it’s not. just that the “it’s natural” argument doesn’t really mean much. 

People who are smoking marijuana can be very defensive about it. And we have no need to enter into some kind of battle with them about it. It is never in our best interest to get in a power struggle with our clients as we all well know.  When it comes to marijuana, our immediate goal isn’t necessarily to get them to stop smoking weed because that’s not our decision. All we’re trying to do in this case is protect the therapy hour. 

When someone is smoking marijuana, there is an impact. They do get emotionally distanced from the rest of the world. That’s part of what makes them agitated and anxious when they’re not high, they’re able to smoke and then again, they have this distance and it makes them relax.

That is not ideal when we’re talking about therapy. We have one hour in which to help someone find solutions, insight, and be able to connect with their emotions in a safe place. My opinion is that I do not do sessions with people who are intoxicated at all. Marijuana, alcohol, opiates doesn’t matter. That feels kind of pointless.

They may seem normal and fine and sober. Trust me, their emotions are blunted. It really doesn’t matter if they’ve been smoking daily for 20 years. It is a factor. So typically what I will do is I will find out how often they smoke. Some people smoke daily, but only at nighttime.

We do have issues, of course, that they’re going to have less REM sleep and that they’re going to have more deep sleep, just like alcohol. I don’t know the percentage differences, but I do know that it impacts. We know that one of the withdrawal symptoms from marijuana is vivid dreams and part of that is because there isn’t anything holding down the REM cycle anymore. 

Once I find out when they’re smoking, if they’re smoking at night, then I’m thinking about their appointments and I’m not setting an 8:00 AM appointment with someone who smokes daily. Because they’re going to be really groggy first thing in the morning. And if they’re smoking enough, they might wake up high also. 

That’s sort of how it goes when you are going to sleep and you’re really high or really drunk and you wake up that way. That’s what I want to avoid. If that person is smoking during the day also, that’s when I want to set a boundary. I’m not talking about weed being bad, or it being a problem or anything.

The way I explain it is I let them know that when they come to therapy that we need them to be emotionally present and that marijuana does separate them from their emotions a bit. It doesn’t matter if they believe that or not. You are setting boundaries around the therapy hour in a really simple way. 

It is not a big deal to ask someone who smokes marijuana to hold off smoking for a period of time before they come to see you. The withdrawal might be there, they might feel a little anxious. Maybe they feel like they forgot to do something because normally they would have smoked by now, but it’s not bad and they will be just fine and it’s really okay. 

What I will ask them is to not smoke marijuana within four hours of coming to see me. Four hours means that they’re not actively high, they’re on the down part and while there’s still marijuana in their system, and yes, they’re probably still slowed a little bit it’s going to be way less and they’re going to be way more able to be present with you. 

What this does is subtly, lets them know that marijuana does impact their emotions and does shift how they see things. All you’re asking is for them to not smoke before coming to see you. Sometimes you’ll be able to tell if they did or if they didn’t. Most of the time I can tell, but there are times when I haven’t. 

In fact, there was a time when I did an EMDR processing session, but didn’t know that the person was high because they were someone who smoked marijuana often and didn’t have bloodshot eyes, weren’t acting funny, and were normal. We went into EMDR processing. 

Well, what was happening was that the person was having trouble processing the image, the image was getting more distressing as we were working instead of less distressing and they were getting stuck. It didn’t take me very many sets to realize that something was wrong and it dawned on me I wonder if they smoked. So I asked and they said, yeah,  my friend came over and we ended up smoking and I didn’t think I would be still high by now. 

Okay we closed it up and ended the session and tried it again a different week. We did talk about it and the person knew my rule as I had set it up beforehand and we talked about that as well. Did it in a non-shaming way. It didn’t wreck my relationship. No big deal. It did freak them out a little bit and they were invested in never smoking before therapy again.

Smoking marijuana daily isn’t necessarily a no-go when it comes to EMDR for me,  I feel like setting boundaries around. Then, if the person will respect them, it’s still possible. This also goes for Delta eight. We talked about Delta in an earlier podcast, as Delta eight is basically a cousin to marijuana, which would be Delta nine. It is a milder form of marijuana, but it does have the same properties and so this boundary goes for Delta eight as well. 

How Opiates Can Interfere with Good Therapy

I don’t think typically that you’re going to have people who are high on opiates very often. It is possible and it has happened to me and numerous staff people. What you’re watching for is pin prick pupils, and what’s called nodding out. Nodding out is just what it sounds like someone is sitting and all of a sudden their head drops. Kind of like we would stereotypically think of narcolepsy, although that’s really different, but it can look the same way. 

Someone might tell you they’re just really tired, but unless they have narcolepsy and you’ve seen that before, that’s probably an opiate. Again, I would end the session and figure out how they got it. If they’re nodding out and again, this would be really rare for you as most of you are not working in a setting where there’s rampant substance use, but if someone is nodding out, they are not safe to drive.

If any of you have ever had surgery and had pain medications, remember what that was like. And even if someone is using opiates often they might be used to it, but opiates are extremely powerful and they don’t get less over time. Meaning when you smoke marijuana or you drink alcohol as time moves forward over the next few hours their intoxication levels are going to go down.

However, with an opiate, especially with pills they’re designed to release over time. And so the person isn’t going to be less Impaired two hours later, four hours later. It might not be until after six hours. It depends on how much they took and it depends on what they took. That’s not something you need to judge. If someone is nodding out, they don’t get to drive. You also don’t do therapy of course.

There are a lot of people who use opiates because they got hooked on them and we’re using them for pain. People you would not expect who can present as though they’re fine. The thing here that you’re watching for an order to protect the therapy hour, because remember, we’re not talking about addressing their substance use right now.  We’re just talking about that hour that you see them and setting it up so that you have the most time and ability to help them affect change.

When it comes to opiates, I am looking for this narrow window between when they’re not high and before withdrawal sets in. And this is a conversation I have very direct with them. So if I have someone who is using pain pills, I talk with them about what their schedule is basically for using them because there is one.

So let’s say during the day somebody gets up and they take a pain pill because it’s really difficult in the morning and they’re in a lot of pain. Well, the thing about opiates is they cause what’s called hyperalgesia, which is an increased sensitivity to pain. If you don’t know a lot about opiates and you want to, there are three different episodes that I did on opiates and treatment of it in an earlier season of the podcast. You can catch that over on the website at betsybyler.com. 

First thing in the morning is going to be hard because it will be the longest period that they haven’t taken a pill in that timeframe. So they’re going to be sore and they’re going to be starting to go into withdrawal. Even if someone isn’t abusing them to a significant degree, withdrawal can happen. And withdrawal from opiates is by far the most difficult withdrawal. The most painful and the most uncomfortable. 

I don’t want someone in my office in active opiate withdrawal. They will not be able to focus. It feels like the worst flu with the body aches ever. Now that grows over time. And so it’s not like they hit withdrawal and then they’re totally incapacitated. So we’re looking for this window between when they can feel their pills wearing off and how long it is until they get really uncomfortable.

So there’s this window a couple hours probably where they’re not actively nodding out in high and where they’re not sweating and achy. That’s where I want their appointment. And we just talk about it really, frankly. I’m not asking them to tough through it, I’m saying, okay. So if you are usually waking up around this time, when do you need to take the next pill in order to feel okay.

So you’re not really achy and hot and sweating by then. And they’re like, no, well, I should probably make an appointment around this. And that’s just what we do. There’s no judgment, no shaming here. Just trying to set therapy as this is an important hour. I want you present. I want you here and accounted for, I’m going to show up and help you as best as I can. And I need you to show up with your most present self possible.

It gets the topic out of the way and it also subtly introduces to them that the substances are getting in the way of their emotions. What we’re also doing here is we’re helping increase some distress tolerance. When people are using typically it is about emotions and blocking emotions. Certainly at some point, addiction takes over and it takes on a life of its own. That isn’t where everyone is though. 

A lot of times emotions and trauma and other, and stress are driving the substance use. If they’ve been numbing it out kind of a while they’re distress tolerance for emotions is probably pretty low. We want to help increase that. A lot of times I find that people feel like their emotions are going to overwhelm them and that they can’t handle them. I know that they can learn to handle them. And I want to guide them in small ways to get to that place. 

Increasing the Impact of Good Therapy

Once I’ve set up the boundaries around the therapy hour in terms of when they use, when withdrawal hits and the time of day that they’re doing their appointments, I will sometimes ask them to not use for a few more hours. 

Here’s how this goes. There are times where I work with someone who’s smoking marijuana chronically. They know about the four hour boundary and , 98% of the time they follow it. If they don’t, sometimes they’ll come in and say, I’m still really high.

I didn’t think I’d be this high. I’m really sorry. We decide how high they are and whether or not it’s worth having a conversation. I’m not going to spend 60 minutes with somebody who’s high. I just know, I don’t want to do that anymore. I don’t want to do that, that conversation. Isn’t going to mean much to them and they’re not going to be experiencing that conversation the same way I am.

I also want to show them that I’m holding to my boundary. And so ending the session does that, I just ended in a way that holds a boundary and doesn’t dismiss the fact that this interfered with their therapy today, while also making sure they know that our relationship is intact.

What I will do is that when they’re in therapy and we’re starting to talk about things that are difficult, if we have a particularly difficult session , I can predict that inside their body, they want to numb it out. That as soon as they leave my office, they’re going to want to go and smoke so that it stops being so strong.

There are times where I will ask them to hold off for a couple hours. If they smoke a lot, it might only be one hour and over time I’ll push that. And I’ll say, do you think you can hold off smoking for the next two hours? You are really used to numbing out feelings, and I know right now this is really uncomfortable, and I want you to just sit with it. I want you to feel what’s happening, and I want you to notice it before you numb it out. Not telling you not to smoke at all. I’m just asking you to hold off for a while.  

I’ve had really good success with this. When they come in the next week, I ask them if they were able to hold off and almost every time they were able to. If it was difficult, that gives us a lot to talk about. If it wasn’t as hard as they thought, that is something really cool as well. This is a great skill to help them learn that they don’t have to numb every feeling, every second that they have one. 

This is what I have found is a good and subtle way to start loosening some of the grips of needing to be high all the time. You can have the same discussion with someone who drinks, asking them not to just drink away the feeling right away. When it comes to opiates. That’s a little trickier because once the withdrawal hits, that is a matter of distress tolerance. That withdrawal is really bad. So I might ask them to hold off until the withdrawal makes it so it’s really uncomfortable. But it’s really a short window, typically.

If you have somebody who cannot come to sessions, sober or mostly sober, that’s an indicator that they need a higher level of care. And not saying that you can’t work with them, I’m not saying that you can’t stay alongside them as they work with a substance use specialist. But  if they aren’t able to make it the hour to see you and the time leading up to it, that is a really strong indicator of where they’re at with their use. 

Our responsibility is not to stop people from using. Our responsibility is to help be a mirror for them to see that this is where they are and to decide if this is what they want. We’re not casting judgment, we’re not being shaming or disapproving or anything. We can express concern. We can wonder about what impact something might be having, but ultimately it’s up to them. 

If we can take off that responsibility and simply set boundaries around our time that’s enough. We don’t need to control any other part of their lives. We just have our own boundaries about what we will do and what we won’t do. I won’t do sessions with people who are high or intoxicated. That’s a boundary that I have. That doesn’t mean they can never use. 

It just sets the limits around the therapy hour. This is part of meeting people where they’re at. We’re not requiring sobriety. We’re not requiring a certain level of commitment. They just need to show up, be emotionally present and engage in the session. The rest will come along as they progress.

I hope that this information was helpful.  I wanted to give you some practical tips to help protect the therapy hour and keep substance use from getting in the way. 

Next week. We’re going to talk about substance use assessment. And by this, I mean, a drug history. This is more specifically about what specific substances they’ve used, how much, how often, and in general, just getting a picture of what their experience with substances has been like.  

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/