Episode 92

Therapists love tools. We love learning new ways to help our clients live more skillfully and have more ability to manage their symptoms. There is no shortage of tools either. We can choose from a multitude of modalities from every kind of theoretical orientation. One of the things that eludes most of us is what to do with substance use. I often get asked for specific techniques, tools, modalities work with substance use. The truth is, they don’t really exist. Wait now, hear me out.

Substance use treatment gets studied, sort of. Studies of people using substances have lots of problems because of recidivism, follow up measures, locating people, and accuracy of the information. Plus, there isn’t a lot of money in treatment modalities and studies take money. We have TONS of studies on what drugs do to us. How to treat it? That’s another story. Luckly, we have a ton of tools ALREADY that we can use to work with substance use. This week I’ll be talking about  how to take your DBT training and repurpose those skills to work with substance use.


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use 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 92.  It’s technique week. That means we’re gonna be talking about a specific technique or set of techniques in the mental health world, and we’re gonna see how you can use those techniques or skills with substance use. 

I am passionate, as you know, that we don’t really need more skills to work with substance use. What we need is information. We need to know more about substance use and how it functions, and then we can employ the skills we already have. 

We all wanna feel competent and confident as therapists. We wanna know that we have the skills to do the work that comes before us. We wanna be able to help the people that come into our office. It can be really hard when you have stuff pop up that you’re not used to. For some that’s trauma, maybe they aren’t specifically trained in trauma therapy, but it shows up anyway. Because trauma big T and little T shows up everywhere.  Or it could be substance use, which we didn’t get really trained in helping, which we really didn’t get a lot of training on.

A colleague and I created an event that’s coming up on August 16th. It’s called Braving the Course. The event is gonna feature my colleague, Dr. Jenny Hughes and me along with two other speakers who are experts in the area of substance use and trauma. We’re gonna be talking about some actionable steps to work with trauma and substance use without the burnout.

You all have heard from Dr. Jenny Hughes before she was on the podcast just a couple weeks ago on the episode we did regarding Roe V. Wade. The event is free and going to be in the evening on a Tuesday in August. You can check out the page betsybyler.com/charting-the-course. You can also look at today’s email that came out and if you’re not subscribed, head on over to the website and get yourself signed up to get updates. If you have signed up for the Decision Tree and gotten that you’re already signed up for updates. So the link to the event will be in that email. 

I really hope that a lot of you are able to attend. Jenny and I are very excited to be able to prepare and present some things for you to help along this path. She is passionate about working with therapists, experiencing burnout and vicarious trauma. 

Many of us have had some sort of training on DBT. DBT is dialectical behavioral therapy. It was originally created by Marsha Linehan out at Behavioral Tech on the West coast of the United States, to work with people who have Borderline Personality Disorder. Borderline Personality Disorder is very difficult to treat because there’s a number of factors at play that make it very difficult for the person, with the personality disorder, to interact with others in what they would call skillful way.

We’re gonna do a brief background about DBT and its components before we launch into talking about the techniques. DBT was based on CBT Cognitive Behavioral Therapy. She took CBT and added components for distress tolerance, acceptance, and mindful awareness. In  DBT balance is the key.  I think that is part of what makes it really excellent for work and substance use. As we go through this today, I’ll explain that further. 

So DBT is really unique and DBT in its truest form is multi multifaceted, and it’s not just an individual approach. Lots of us have been trained in DBT skills because they translate really well to individual therapy, but DBT in its design has four main components. Three are for the client, one of them is for clinicians.  Someone participating in DBT would attend a group DBT session once or twice a week and an individual session with a DBT trained therapist.

There are also coaching calls that would happen after hours or on holidays. These coaching calls are meant to be approximately 15 minutes and focused on helping someone through a crisis. The idea was that having a group and individual was just fine. However, people with Borderline Personality Disorder struggle at other times, and there are lots of triggers that can push them into a state of dysregulation.

The idea is that they can have contact with a DBT therapist to help get them back on track. This is not a processing session. It isn’t about talking through a narrative. It is explaining how they’re feeling and using a skill to get to a place of better regulation.

The fourth component is a consultation group for the therapists involved in the DBT program. Working with people who have Borderline Personality Disorder can be really challenging. There are a lot of behaviors that come up that are part of maladaptive coping skills that people who have this personality disorder tend to engage in. It’s really about not knowing how to signal for their needs and not being able to communicate that effectively. 

Typically what Marsha says is that you take an extra sensitive person and you put them in an invalidating environment. Well, not everybody develops a personality disorder, but at the more severe end of childhood neglect, whether it be emotional or physical or both. A personality disorder can develop.

When we’re infants all the way through childhood, we’re developing an internal sense of self. Those early years, zero to five are super important in doing that. The difficulty with someone who has Borderline personality Disorder is that they don’t have a stable, internal sense of self. The outcome is that if they need to check in and say, am I okay? 

They don’t often have the ability to respond with. Yeah. We’re okay. They really need a mirror and someone to tell them that they’re okay. Well, we know we can’t have that all the time. That battle happens in the mind and these skills are built to help them manage that.  When you read DBT literature and you go to the training, there are a lot of things that I recognize from many other modalities in mental health.

There are even some concepts from the 12 steps that are in there. That may not be exactly where she got it, but it’s strikingly similar. Even the way DBT is set up is similar to what substance use treatment with a specialist would look like. In a substance use program and that’s not what we do. That’s what a specialist and a program does. The person would probably have group sessions and they would probably also have an individual therapist.

Additionally, they’re encouraged to have support people outside of it, whether it’s other group members or other kinds of outside support. That sounds pretty much like what’s happening when it comes to DBT. It’s just that the support comes from peers rather than from therapists.

However, those people who work in substance use treatment know that we often get calls from people who are struggling with interpersonal stuff or cravings or any number of issues that they need some guidance on. Avoiding a relapse isn’t really about managing deeply held opinions and emotions and past trauma. It is in the long run, but in the moment it’s about handling the feelings in that moment to get through it. It’s very similar to DBT.

The DBT group is a skills group. It is not a process group and the same is true for substance use groups.  When someone’s in substance use treatment, the group is not group therapy so to speak where people are talking about deep issues, it’s about skills. It’s about learning about different facets of addiction and what’s happening in their brain and body, talking about triggers and all sorts of things that relate to daily life. The processing is left for individual therapy and that’s where you talk about the things that are happening with your family or with your children or with your spouse or partner. 

The individual session as part of DBT has a structure too. There are three things that they address in order. A lot of times there can be what they call a crisis of the week. Well, if you focus on a crisis every time the person comes in you kind of never get anywhere. And so there has to be a little bit of structure. When I was supervising and running the chemical dependency program, I often would refer to these steps.

The first thing you address is life threatening behaviors.  In most cases, we’re not talking about substance use. We’re talking about suicidality and self and injurious behavior like cutting in DBT. Here are the steps. First they talk about life threatening behaviors. Second, they talk about therapy, interfering behaviors, such as not doing homework or showing up to therapy late or missing a group or any other number of things that get in the way of doing the work that’s in front of them. The third thing that they would focus on then is quality of life interfering behaviors.

So talking about things that are going to decrease their satisfaction in their life. Only during that section and beyond, do they talk about other issues. It’s a way to make sure that someone doesn’t stay stuck in this crisis cycle and then never get any farther.

Similarly with people who are using substances, we’ll find out how their week went when it comes to using.  We wanna know whether they relapsed. We wanna know what that use was like if they did, we wanna make sure that they’re not high as we sit there or intoxicated in any way. When you are working with someone on substance use, we do have to consider life threatening behaviors slightly differently.

If the person is using a substance that could kill them. Immediately that is something that you’re gonna need a specialist’s help with. I do not recommend that a typical mental health therapist work with someone who’s using heroin or opiates on a regular basis, without some outside support and assistance.

It is not that we’re not capable. It’s that there is other support that is needed like weekly groups and peer support. So I would recommend that you get them involved in an outside program, but you can definitely stay with them and do their mental health work. In fact, it will probably go better and the person will likely follow through better with the substance use work. If you stay by their side. Not always, but people don’t like to feel like they’re being handed off to someone else. I have found that it works pretty well to work alongside a treatment program 

We also wanna talk about therapy interfering behaviors, like missing a group, or showing up high or any of the other things that get in the way of therapy. Then we talk about things that are getting in the way of their sobriety or if we’re using a harm reduction model, it’s the same thing. We check in about how that worked when they tried to go out and have just a couple drinks or were going to avoid a certain thing. 

There are four stages of DBT and they rotate. DBT in its design is supposed to be a year long  and it finishes the curriculum in six months and then starts over again. So that by the end of the year, they’ve gone through the curriculum twice. 

The four main components of DBT are mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.

Mindfulness is absolutely necessary in working with substance use. Substance use is about taking people out of the moment; about not having to be present in their body or in their emotions.  People who are trying to either cut back or to quit using or struggling with using need to be able to be in the moment and paying attention to what’s happening right now so that they can respond in a better way.

Interpersonal effectiveness also impacts people using substances as they end up doing a lot of things that wreck relationships around them. It’s not on purpose, it’s just a byproduct of substance use. People who are using oftentimes are actively trying to not impact others, but addiction being the way it is and being progressive, that ends up going by the wayside at some point.

Distress tolerance is huge in substance use. Part of the relapse cycle has to do with the uncomfortable feelings that come from not having a substance on board. Very often people end up using because of not being comfortable in their bodies and in their emotions and so their distress tolerance is fairly low. 

The last component of emotional regulation goes right along with that. Being able to manage intense emotions without using is one of the most necessary skills in sobriety.  When you are working with someone that is using substances, you wanna evaluate these four areas.

How do they do with being in the present moment? Are they spending a lot of time trying to avoid it? Do they talk about the future or the past a lot and avoid right now? When it comes to their relationships, what’s the quality of those relationships? Which relationships have the most turmoil? Where are their cutoffs? How do they relate to people? And what is their skill in being able to state their needs?

For distress tolerance you wanna find out how long they can go without their substance before it starts getting a little hard, and then moderately difficult to extremely difficult. We want a baseline of those times so that we know when that is getting better for emotional regulation.

We wanna evaluate how well they do at managing overwhelming emotions. Does it go from zero to 60 really fast, or is it something that slowly builds? Once it’s up there and they’re feeling really overpowered by their emotions, what is their ability to manage that and bring it back down.

Those are the four areas that are really important to know where your baseline is and to be checking in about. So let’s take a couple specific techniques that DBT recommends. 

Within the distress tolerance module there’s a skill called TIPP and it stands for Temperature, Intense exercise, Paced breathing and Paired muscle relaxation. So let’s pretend that our fictional client is in a situation where they’re having really bad cravings to use their substance of choice. We could imagine someone struggling after work with the stress of the day and not having a drink. Or having to interact socially when they’re not really used to it and not using alcohol marijuana or whatever else they typically use to manage those situations.

This is sort of like a panic attack. It’s not the same mechanism per se, but it is very similar and can feel very similar to the person going through. Having a craving can be mild and then too severe. It can be mild in the sense of, oh man, that would be really nice right now to a more in your face kind of moment of you should really do this. It would help right now, this situation would be way easier if you just had a drink or fill in the blank. To a more severe degree where they have some really physical sensations that are very similar to a panic attack. 

So this TIPP skill talks about temperature. Temperature refers to the temperature of the body. The idea that the body increases temperature when someone is distressed. What they wanna do is get themselves into a position where they can lower their body temperature. This could be using cold water on their hands or wrists. This could be holding ice cubes. This could be taking a cold shower until their goosebumps are talking to their goosebumps. 

Up here where I live Lake Superior is one of the largest freshwater lakes in the world. Typically I’ll use that as an example, I’ll say to somebody, “have you ever stood in Lake Superior? And they’ll say, yeah.  I’ll say to them, what are you thinking about when you’re standing in Lake Superior? And their answer is it’s cold”. Yep. That’s the only thing you’re thinking about. 

Your feet feel like they have an ice cream headache and your body starts sending out danger signals that you should get out of this water. No one is thinking about emotions or the meaning of life or using drugs or anything like that. When they’re in that kind of cold, it is really effective at diverting someone’s mind into something physical. 

This is why cutting works. This is why punching a wall works. Is because all of a sudden the physical sensation of pain is overriding the emotional sensation. So with this skill, the idea is lower. The temperature, get something that is going to take the heat out of the body in a way that is safe. That will help lower that sensation. So it’s not increasing the desire to use. 

The “I” is intense exercise. This one can be a hard sell. Lots of people don’t wanna do intense exercise or movement, but this isn’t talking about going for a 20 mile run. This is about running up the stairs or running in place or even walking quickly. Eventually your body stops paying attention to the emotions because it’s focusing on what it needs to do to manage the physicality of what you’re doing. This will help distract them from the craving. 

The paced breathing is something we are very used to teaching people when we’re talking about helping them get control of their breath. I often teach people, grounding breathing as part of EMDR. Where they’re focused on drawing air and energy up through the midsection and down and out. We want people to feel their breath being directed and when they focus on that, it’s really helpful in avoiding the cravings. One of the reasons that people use paper bags for people who are struggling to get their breath is because it’s a focus. You have to focus on blowing up the bag and then breathing in. I don’t know that the bag itself is magic but more so their focus on their breathing. 

Muscle relaxation again, is about physical sensation and focusing on. It’s really helpful to focus on a muscle group, contract it, hold it, relax and can do that a few times and move on systematically through the body.  This TIPP skill is meant for people to help them through a situation to get the high, emotional level down. Most cravings for substances last about 15 minutes, maybe upwards of a half an hour. Which also is similar to a panic attack. This tip skill is helpful when people are trying to get through a moment where they’re feeling really pressured to use. 

Another skill in this module is focusing on the pros and cons. We probably have talked a number of times about the pros and cons of decision making. In substance use that applies, but it’s a little different. One of the things we’ll talk about is playing the tape forward. And you can tell that that phrase is kind of dated since nobody’s playing VHS tapes at. But instead playing the video forward. 

So oftentimes what happens when someone is having a craving to use is that they’re imagining all the times that they used and how it felt. They’re imagining themselves getting ready to use, going through the act of using and the after feeling. Usually that’s where the video stops. However, we ask people to play it forward. What is going to happen afterwards? 

So let’s take drinking for instance. Someone imagines going to a social situation on a Friday night. They’re uncomfortable and they wanna be able to drink. They imagine themselves at the party, they imagine themselves feeling uncomfortable and they decide how to make that better. It’s natural in our brains to try to fix things on the fly. So they imagine going to the bar, getting a drink, having that drink, feeling it wash over them. What they don’t do is play the video forward into the night.

Where they have too many drinks where they start getting belligerent or getting in an argument or passing out or getting sick. And they don’t think about the next day when they’re hungover and struggling to take care of their responsibilities for the day. They’re not thinking about having to clean up after the night before, or having to explain their absence at something because they were too sick to get there.

.We very often, in working with substance use, have to remind people to play it forward. Sometimes people will say, that’s not gonna happen. I can stop that. Okay. Well, let’s see. Even in the AA literature, the recommendation is to try controlled drinking. The original founders, Dr. Bob and Bill W say, if you can do controlled drinking, “our hats are off to you.” The idea being that if someone can control their drinking, then they’re probably not an alcoholic or an addict. 

However, for a lot of people drinking gets outta hand, even if they’re not quite at the alcoholic and addict level. They drank too much. Their body has trouble recovering from hangovers and it could take more than a day to feel like themselves again. The older people get, the less our bodies seem to be able to manage the hangover. For instance, in our early twenties, you can drink and get hammered and get up and go to work and feel fine.

However, in your thirties and forties, that becomes more difficult. And the person needs to play it forward to decide if they drink on a Friday, they’re gonna blow their whole Saturday feeling hungover and it isn’t until Sunday afternoon that they start having energy and then they have to go back to work the next Monday. They can often then make a more informed decision about what they’re going to do. 

We’re not trying to move people ourselves. We are trying to walk with them and help them accurately evaluate the situation. When someone is in a situation where they’re trying to not engage in a behavior. We tend to gloss over negative things and promote things that seem like a really good idea. Get a little bit of tunnel vision. 

Our job is just to expand that view so that the person can see all of the factors in front of them. The pros and cons in this skill. Isn’t about the pros and cons of quitting use altogether. That is a discussion and something that people do need to go through at times. In this instance, though, we’re talking about getting through a moment, getting through one day or one instance in a more skillful way than they normally would have. This is about stopping and thinking rather than a more existential conversation. 

Another skill in this module is radical acceptance. Radical acceptance is very commonly associated with DBT, but not a new concept. Acceptance is very prominent in the 12 step literature and in recovery literature in general. Acceptance is not about resignation, it’s about accepting what is. Trying to change the reality of something or trying to make it one way versus the other way doesn’t work.

Part of the thing in substance use is it’s typically all or nothing. I’m either going to drink or I’m not.  It’s not about the person not understanding that there can be a balance, it’s that something in them is pushing them to do more, to consume more, to go all out. Those sorts of things. That’s why people end up continuing to drink. If a little bit is good, then more is better. 

Acceptance is when I drink I never stop when I say I’m going to. When I drink, I end up doing stupid things. When I drink, I end up making a fool of myself and saying things I regret. When I drink, I end up waking up hungover and it takes me two days to recover. There’s no judgment there. It’s not about feeling bad. It is the reality of. 

The unreality is when someone ignores what happens and thinks that it’s gonna be different this time. That this time they’ll be able to control their drinking. Radical acceptance is also holding two things to be true at the same time, even though they seem opposite. Someone’s parents may have done the best they could do, and the child needed them to do better. Both can be true. We do that work all the time in helping people deal with childhood trauma and with other issues in their lives. 

Understanding that it is not black or white, that there is a lot of middle ground. There’s a ton of freedom that comes with having some radical acceptance about things in their life. Maybe their boss is an asshole and they’re not in a place where they can quit their job right now and so we need to work on helping them manage while they still have an asshole for a boss. We use this skill a lot in reframing how people perceive things in challenging thought processes and actions and it works really well with substance use. 

Let’s say that someone’s using marijuana. On one hand they feel like marijuana helps them and they feel like it’s not harmful and it’s not going to kill them. On the other hand they tend to use more than they intend and they’re spending a lot of money on marijuana and it’s not really getting them the high that they used to have. Additionally, it’s also making them kind of cranky when they can’t use, because they don’t have money to do it. 

So they may have had experiences where marijuana was helping them. Maybe they felt better. Maybe there was a time when marijuana worked better for them and where it wasn’t too expensive and where they were able to smoke a little bit and therefore could afford it. And where they are now, that isn’t the case. Where people get stuck is they’re trying to go back to before they wanna rewind. 

They’ll take tolerance breaks or tea breaks as they call them, which don’t really work. When you hear that someone’s gonna stop smoking for a month or whatever, or eating edibles or whatever it is. Maybe they will make that. But remember that distress tolerance is gonna get kicked up here because they’re used to being able to numb out whatever feeling that was. 

Let’s say they successfully stop for a month and then they go back and use. If they go back to the use that they were previously at, they’re going to be at their old tolerance within about a week. These tolerance breaks are very short lived and it’s not the fault of the person using that substance it’s just how the body is. The body recognizes it and gets really used to it really quickly. 

The last skill we’ll talk about  is in the emotion regulation module. The acronym is PLEASE Master. DBT does love their acronyms. So the PL stands for physical health and treating pain or illness. E stands for eating, having a balanced diet. A stands for avoiding alcohol and drugs. S stands for sleep. Getting regular sleep. E stands for exercising regularly. And the word Master refers to having daily activities and sort of a master plan of how you spend your days. 

If you were to look at treatment literature for substance use, you’re gonna see all of these things represented. Part of the work when someone is trying to cut back on their use or quit their use all together is making sure that the other areas of their life are balanced. They need to treat any underlying physical issues. They need to be eating on a regular basis and focusing on some nutrition. They’re trying not to use or cutting back so the a is taken care of. S is for sleep, which is a huge part of recovery for anything, whether it be depression, anxiety, or substance use. Regular exercise or activity is also a huge part of helping people manage the feelings in their body.  

The last part master is one of the first foundational things in substance use treatment, which is planning out their days and what they’re gonna be doing because when someone is using substances, the daily schedule can sometimes get haywire, where they’re kind of doing things all over the place. And in the beginning, of course, or  even with problematic substance use, perhaps people can keep their days handled. Maybe they’re going to work and doing an okay job. It’s the days off that might end up getting hijacked. 

This skill of PLEASE Master is something that can be definitely used with substance use. This is just a little foray into DBT. There are a ton of skills and far more things that I could talk about. And I had a really hard time figuring out which ones to pick. DBT is a great thing to be using with substance use. In fact, behavioral tech, the company that Marsha Linehan founded, has even had some research done on substance use and they have some protocol for it. It’s very similar to regular DBT, but just a few changes to wording and to some of the skills. However, I don’t know if you need that part. 

The DBT skills we’ve talked about and that you can Google are really useful. DBT is also just one modality that can be translated into substance use. There. There’s a lot of modalities out there that we use. And it’s my belief that we can find skills in each modality to work with substance use.

If you have a modality that you use, that you wanna see if I can help you figure out how to use it with substance use, send it to me. Write me an email  to betsy@betsybyler.com about your modality. I would be happy to talk with you and I would love to be able to use it on the next technique week podcast. This series will be coming out in the third week of the month and I’ll be covering a new modality or new techniques each time. I believe we can do this work and that we just need information and maybe a little guidance.

Don’t forget about the Braving the Course event that’s coming up in about three and a half weeks. It’s a free online event and you can read more about it at betsybyler.com/braving-the-course. 

Next week is recovery week and we are gonna be hearing from one of the speakers that’s going to be at the August 16th event. Jean McCarthy has had an incredibly popular podcast called the Bubble Hour. She’s gonna be sharing her story of recovery with us. I hope you join me for that 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

Dialectical Behavior Therapy for Substance Use Disorders – Behavioral Tech

Dialectical Behavior Therapy: An Essential Guide for Therapists – Psychotherapy Academy

Core Evidence and Research – Behavioral Tech