Episode #131

People are complicated creatures. We work with people when they are confused, hurting, anxious or generally distraught. Sometimes that can impact our work with people and how they feel about us and their lives. We mean well and we work hard to give people the best care. But we can get blamed for bad outcomes even if we do everything right. Some therapists worry that adding substance use to their scope of practice will expose them to more risk and liability. I can understand the fear that people have. Our licenses are super important to us and we want to protect ourselves. Today we are going to be talking about what risk there is, if any, when we take on substance use clients.


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 131. My very first class in graduate school on the very first day was ethics. I know that my professor set it up this way to introduce us to the concept that our ethics were going to be of primary importance. In that class, we also got introduced to phrases like scope of practice, liability and risk.

When I talk with other mental health therapists about adding substance use to their scope of practice, I often hear one or many of those words and phrases. Each of us has our own license and we are responsible for it. I recall being part of agency conversations where I’ve heard clinicians say things like, I’m not gonna do that. I’m not gonna risk my license for that.

Even though many of us  work or have worked for agencies, we’re still very aware that our license is the thing that allows us to practice. It is our responsibility, individually, to protect our license.

So in the last several weeks, I have been sharing a few things as I encourage you to be open to adding substance use to the work that you do. Let me be really clear that I am not suggesting that you add substance use to your specialty. I’m not suggesting that you go back to school or that you get a special license. I’m not suggesting that you are going to be the person that only sees substance use clients. 

What I am suggesting is that substance use is on a wide spectrum and shows up far more often than we anticipated. That there are folks who are struggling with substance use that they don’t know. They aren’t talking about it with us for a variety of reasons. I am encouraging you as a mental health therapist to be open to talking about it  and to be open to asking questions regarding their current use of substances and historical use.

You don’t need to have a specialty. There are certainly times when a specialist is necessary, just like with lots of things. In this case, you’re kind of more like family medicine or primary medicine. When there’s a specialist needed in a department, then  our providers refer out. And that’s kind of where we’re at. 

Much of the substance use that shows up in outpatient mental health does not need a specialist. It is of a pretty garden variety type and can be treated by you. Of course, this is the moment where I say to use your own clinical judgment.

In this four week series, the very first week I encouraged you to not avoid the questions about substance use. Sometimes our clients are avoiding and sometimes we might be tempted to go along with that avoidance. 

To that end, I introduced that I’m gonna be hosting a webinar on May 16th. Screening skills for Substance Use is a one hour webinar that I’ll be doing live on Tuesday, May 16th. In this webinar, I’m gonna be sharing with you my top three questions to ask when screening for substance use. You can register at betsybyler.com/skills.

The second week of this series, I talked about this idea that people have about what substance use treatment entails or requires. 

What I shared with you is that in order for substance use to be treated, a person does not have to engage in a formalized substance use treatment program. Plenty of people manage their substance use all the time without treatment. I talked about how I did that very thing. I absolutely believe in treatment in formalized substance use treatment.

I just don’t think that everyone who’s using, and in fact probably not the majority of ’em, need that kind of level of treatment. And when I say they’re using, I mean using in a problematic way. Not just your average, normal and recreational use.

In the third week, which was last week, I talked about this misconception, the idea being that you need special skills in order to work with substance use. It’s simply not true. There isn’t some secret set of skills that you get put in your toolbox when you become a substance use counselor. It’s really information and very similar skills to what we’re using in therapy.

This week. I wanna address one of the final things that keeps people from adding substance use to their scope. And that is this idea of risk and liability.

I’m not sure what’s scarier for us, the idea of getting fired or the idea of getting brought before the board for our license. In a lot of ways, I think getting called before the board would be scarier. We can always find another job, we can go into private practice, but if somebody takes our license, we can’t work. And if you fuck up in one state, the other states are gonna know. . 

Our licenses are incredibly important to us, which is why we guard them so carefully. I think that is what  my professors, we’re trying to convey by putting our ethics class first, on the first day. It was a good point, and one that I learned well,

I have never wanted to have to report a colleague to the board. It is a terrible feeling. Whenever anyone talks about this in a Facebook group, they get jumped on. I think often we are terrified  that colleagues or clients will report us falsely. So everybody wants to be very careful that doesn’t happen to them.

I have had an experience of knowing someone who was reported to the board for practicing out of scope. It was a situation where the person who did the reporting was bitter, angry, resentful about something that had happened at the agency where they worked. The board contacted the therapist in question, gave them a copy of the complaint, and gave them a certain amount of time to defend themselves.

The therapist in question was able to defend themselves and the board decided that the person did not do anything incorrectly and close the file. Knowing that somebody did that to another colleague makes us nervous. Because of that, I wanna really talk about what the risk is with substance use and how to mitigate it.

There are three statements that I often hear when we get to this level of why someone doesn’t wanna do substance use work. They are, I’ll get in over my head, I won’t know what to do, and I’ll be putting myself at risk.

So let’s talk about those. The first one I’ll get in over my head is common. When someone doesn’t have the information that they need to help a client, that feeling of being out of place and getting in over their head is very prominent. There were times as a young supervisor where I felt this very keenly.

I was supervising folks who had been in the field longer than me, who were older than me, and people who had more experience in the business world than me. The only reason I had the job was because they didn’t apply. They said they didn’t want that type of responsibility. There were moments where I was very aware that I knew what I was doing at that moment, but that I didn’t necessarily have all the information that I needed to plan a way forward. I wasn’t actually in over my head, but I sure as fuck felt like I was in over my head.

I think in substance use work, people do feel like that. They wonder what if the client’s use is way worse than I thought? So let’s talk about that because it will happen. You will have clients that come to your office and present with issues that make you feel like you’re in over your head and that the severity of what they’re bringing to you is worse than you initially expected. That absolutely will happen and has happened. I am certain.

Substance use is a tricky beast. Nobody wants to admit that they are overpowered by the substance they’re using. None of us wanna admit that we have become somehow driven by this inanimate thing, that we end up putting it above all sorts of other obligations and even joys in life. Sub substance use must remain in the dark and in private, in order to thrive. 

In the face of other people’s care and love and concern, substance use doesn’t really stay alive. That’s why people leave. They don’t hang out with those friends anymore. They don’t call their families. They have to be around other folks who are also using because it’s too painful not to. The person’s use will almost always be worse than you thought. 

This isn’t to say that you didn’t do a good job screening or that you missed something. It is the nature of addiction. And it’s not just addiction, it is the nature of negative choices and negative behaviors. We are forever trying to downplay our role in anything bad or wrong and finding a way to make excuses for it.

Anyone who’s ever been around a child knows that this is the case. Trying to make an excuse for why they hit their sibling or why there’s chocolate on their face when they didn’t have any chocolate or why something got broken and how it’s not their fault. It is our nature to hide what makes us look bad. So yes, it will be worse than you think. 

The beautiful thing about that is that you just need to know that.  If someone is answering questions about their substance use and based on those questions, you’re sensing that there’s some problematic use going on, you need to adjust your expectations for faking good. 

This is something that happens subconsciously. Many of our psychological assessments account for it. In fact, it can make an entire assessment invalid if someone is seen to be faking good too often. Some of it, though, is totally normal.

When we talk about getting in over our heads, sometimes people are afraid someone’s gonna show up under the influence. To that I say it’s possible. That’s happened a couple times to me when it’s happened, though, it’s happened in a situation where I was working in a clinic and  running a substance use treatment program.

So the people who were involved were already at a much higher level of care and having a lot more trouble getting sober days pulled together. And yet it still only happened to me a couple times. I recall when I was doing just mental health work, a man came in who smelled like alcohol, and it was about 9:00 AM.  

I wondered to myself, am I smelling that? Does that smell like alcohol? The trouble is when you’re in a room with someone it can be kind of hard to keep a smell prominent when you just get used to it. Turns out that that man hadn’t drank in the morning and by morning he meant since he woke up. He certainly had been drinking until 4:00 AM So it is entirely possible that he was still intoxicated when he was in my office.

So what I did was talk with him about how we got there that morning. Which he had driven. Let him know that I’m not comfortable with him driving himself home. We talked about how he could get home and how he could come back and get his car. I let him know that if he drove away from the building, that I would have to call the police because he was driving intoxicated.

For some of you that just got your attention. Confidentiality, HIPAA laws. Yeah, that exists. And I just saw somebody that I believe was intoxicated in their vehicle heading northbound on this street. I let them know the make of the vehicle and a license plate if I have it. What happens after that? Not my problem. Oftentimes though, that alone is enough to keep the person from driving away. 

I’ve had people step over into a diner to go have some food and come back a few hours later. I’m not gonna keep an eye on the vehicle. That’s not my job. I’m just letting you know how I handled it and what my suggestion would be.

You have to decide what you wanna do ahead of time. Not at the moment. Just like you had to decide what you were gonna do if somebody was suicidal. You certainly don’t wanna wait till they’re in your office to decide, wait, I don’t think they should leave. I don’t trust them to be safe. 

So you think about it, what if someone shows up intoxicated, meaning drunk? What if they drove? What would you do about that? Because the truth is, it doesn’t matter if people know that you feel okay working with substance use. Sometimes it just shows up and it’s good to know what you wanna do. If you work in an agency, there should probably be a policy about that. 

I do not conduct sessions with people who are under the influence of drugs or alcohol, period. There are some people who don’t always agree with me on that. There are folks who might feel like if someone’s high on marijuana that that’s not a big deal, and to me it is.

It’s something that I have decided what I’m gonna do about it, and that I will have a discussion with my clients at that moment. The first time it ever happens, you might feel like you’re in over your head, but you aren’t. You’ve probably dealt with people under the influence at some point in your life, personally or professionally.

The only thing you can do is the thing that’s in front of you to do. You can tell them that you don’t feel like you’re able to continue with the session  but you would love for them to come back when they’re able to come back and not be under the influence. Help them reschedule. Help them get a ride home. Have them call an Uber, whatever you need to do. Once that is finished, that’s it. 

You don’t have an obligation to police their behavior. You do what you need to do in your office and then you let it go. Another way that people feel like they’re in over their head is if somebody’s use is really severe.  Well, we handle this the same way we do assessing for suicide risk. We want to know the extent of it. We want to know if there’s imminent danger.

Typically, there’s not going to be a substance use related reason why you would hospitalize someone. The only way is if somebody was actively passing out in your office or in your lobby  and that in itself is concerning and you’d be calling an ambulance. That’s not a common occurrence, especially in outpatient mental health, but it could happen. 

You would handle that like a medical emergency because if someone is passing out in your lobby or in your office, we have problems and you wanna get them the medical attention that they need because that is not our wheelhouse.

If somebody’s use is really severe in the sense that they need more treatment, that is something that you can manage. You do some further assessment. You figure out  if it’s something that you can address  or if they need something more. I’ve created a few resources to help with this very thing. 

The first one, of course, is the webinar that I talked about on May 16th. That is next week. That webinar  is gonna share with you the top three questions that I use when screening for substance use. You can register for that at betsy byler.com/skills. 

You can also go to my Learning hub on the website. There you’ll find a number of resources. There will be previous webinars, a Treatment Planning Tool and a Substance Use Decision Tree to help you make these choices and think through case conceptualization.

This is not as complicated as people seem to make it. I think people are making it complicated out of a place of fear of fucking up and not wanting to do anything wrong. I understand that. What I wanna encourage people is to step away from the fear of our boards and all of the laws and just take a look at what we’re dealing with. 

Most folks who are really severe with substance use will not show up in your office. They’re gonna show up in a treatment center, or they’re gonna show up on a crisis appointment, or they’re gonna show up in the emergency room. 

Getting in your schedule, waiting a couple weeks for the appointment, filling out paperwork, and showing up in your office. That is a level of functioning that people who are using in a significant way really won’t do.

How about the fear  that you won’t know what to do. Substance use for a lot of folks is somewhat unknown. They have their own experiences with alcohol or drugs, and   maybe some professional experience or personal experience in families, but they don’t have a lot of formal training or education. And sometimes it can feel like, oh shit, what am I gonna do with this?

It’s very similar when we run across a new thing in our practice. The first time I had somebody who had active psychosis was when they were in my office. That was something I was like, oh, okay. I’m not sure what I should do about this. Well, I figured it out. 

The person was extremely anxious and scared, and so my goal was to help them regulate. Make sure they’re safe and see who I can hand them over to to make sure they’re okay while I get a handle on what’s happening here. 

So with this young person, I did all of those things and I ended up communicating with his father even though he was a grown adult. And making sure that there wasn’t a reason to believe that the things that the client thought were happening were actually happening. Because I wanna make sure that I’m not just assuming that someone is having psychosis just because something sounds weird. I figured out what to do even though I hadn’t had that situation and wasn’t prepared for it. 

Or having someone show up in your office who is suddenly off all of their medications, new in town, doesn’t have insurance, and doesn’t know what to do. Well, I know that someone can always show up in an emergency room in the United States, and they have to be seen. That’s not a long-term solution, but it is an immediate solution. The hospital’s job is to provide them with the care that they need. They also would be giving the person follow up instructions. It’s not going to be perfect, of course, but it is an answer. 

The same thing goes for substance use. What you do in that situation depends on what’s .Happening is the person under the influence. If they are, you handle it. If not, then you assess their use. If you find out that the person is using daily and has significant withdrawal that is risky, then they probably need a higher level of care. If the person is using it and it’s causing problems in their life, but you’re not totally sure if it’s in your scope or not, do the best assessment you can.

Assessing people is really one of our top skills. We do it all the time. I met with a new client today and I’m talking with them about what their symptoms are like. Was it more anxiety when you were younger and then it became depression, or were they both there? How long did that last? When did it begin? When was it the worst? When was it easier? What makes that worse? 

It’s the exact same stuff for substance use. You’re just getting a feel for where the boundaries are. Based on what you find, you’ll figure out what to do. And if you don’t know the answer at that moment, I have found that clients are really open to me saying  that I need to think about this and that I wanna consult with a colleague and then give them my recommendations and some next steps.

Most people don’t expect us to know immediately what needs to be done. They know that we have to figure it out like everyone else. What they feel good about is that I give a shit enough to not just ramble at them, say a lot of words that mean nothing. That I really want them to get help and that I’m gonna give them a call and let them know what I think they should do next.

If you need more information and you don’t feel like there’s an imminent risk, schedule another appointment. Have them come back. Get more information. In the moment when someone’s in your office and you start getting that sense of like, oh, this substance use might be more than I thought. Set aside what else you’re doing and ask them about their willingness to explore this a little bit, to find out what kind of use is there and if it’s causing any problems.

If they aren’t open to it, then that’s information for you too. You will know what to do. You won’t necessarily know the perfect thing, but I promise that some part of your training and experience in the field will help you figure out what the next step is until you can do more research or consult with a colleague or listen to one of my podcasts or download one of the resources.

You only have to get through that hour then you have until the next appointment or until you call them to figure out what your recommendation is going to be.

The most common question is about risk and liability. We’re worried that we are going to be held liable for someone getting injured. I wanted to address this specifically because on my podcast,  as well as in my practice, I will often say that addiction is a fatal disease because it is. 

When someone is truly an addict or an alcoholic there are two ways out of that: they quit or they die. It doesn’t necessarily mean that that substance is going to be the thing that kills them because shit happens all the time that isn’t related to that. But addiction does not fade. It does not go away. It is not cured. It can certainly go into remission and the person can be in recovery, but addiction itself is a fatal disease.

Some substances have a high mortality risk to them. In outpatient mental health, the chances that someone who is fully in addiction will show up in your office are low, not impossible because alcohol is legal and it also happens to be incredibly damaging physically.

If someone is in active addiction where they are failing in numerous parts of their life, and as you assess them, they’re in the moderate or severe range in the DSM criteria. They need a specialist. That does not mean that you need to back out. You can certainly stay with them, and in fact, I would encourage you to do so.

The person who’s in active addiction is at risk. The person who is using a substance that has a high mortality risk to it, they are at risk. So let’s talk about what your liability is. 

We work with people every day who struggle with suicidal ideation. It is an extremely normal thing for people to have thoughts about death. It doesn’t necessarily mean that everyone has thoughts about actively taking themselves out, but nearly everyone, if not everyone, at some point in their life will have thoughts about it might be easier if I didn’t wake up in the morning.

As humans, the only way we know how to stop something for good is through death. When we feel hopeless, that is super normal to think about that. There is risk all the time that we face because of that.

So what do we do about risk? Well, we document, we consult, we document again. We make sure that our documentation shows all the things that we did, that we talked to our client about the risk, that we suggested that they get a specialist, that we gave them resources, that we followed up with a phone call that we consulted with a colleague. All of these things protect you when something happens.

I remember the first time that I faced true risk. I had a client who died, and my initial shock was there, of course. And then the next thought was,  did I miss something? When somebody dies, loved ones get irrational. I’ve been there myself wanting someone to blame. They could have blamed me and there was nothing I could do to change how they were going to feel.

There is no more risk with substance use than there is with depression. In fact, I would venture to say it’s less. With substance use the person typically isn’t trying to kill themselves. They’re trying to feel better. They want to stay alive to get to the next thing. This isn’t a matter of them checking out of the world. 

There are certain substances that have extreme risk to them, and  those substances have to do with alcohol and opiates, and we’ll put heroin in the opiate category for this. Meth does not typically kill you immediately. Heroin and opiates absolutely can, especially when there’s unknown amounts of fentanyl in them. Alcohol can absolutely kill someone, as can the withdrawal from alcohol. 

Other than that, where is the real risk? If a client dies from their substance use, either drunk driving or withdrawal, or an overdose? Your documentation would either show that you guys discussed it. Or that you didn’t. The risk there is that a family member might decide that you were negligent because you never assessed, or they could decide that you were negligent because the person didn’t attend treatment.

What the client did or didn’t do is not your liability. Our job is to do what most therapists would do if you have a client who is using heroin. Most therapists would see that as a risk, and then the person needs help you document it. And you document what you told them that they should do and you provide them resources.

Heroin is not something we’re fucking around with and it’s not something I suggest that you fuck around  with treating, they need a specialist period. That doesn’t mean you can’t work with them and stay with them. But there is absolutely a need for someone to have more resources to deal with that kind of an addiction. Nobody’s using heroin on a casual basis. That’s not how this rolls.

So what is the real risk? That they might get their kids taken? You can’t get sued for that. That you knew and didn’t tell anybody. Well, you can’t get sued for that. I think we’re scared that someone’s gonna die. We’ve gotten used to the risk when it comes to depression. I’m not saying that it isn’t ever scary and we don’t ever worry about it. And when it happens to you that you have a client die, it’s devastating and makes you question everything you’ve done in your documentation more than I can express.

What I can tell you about the kind of investigations that happen after a client’s death is that what the auditors look for is attendance at appointments. The things that were discussed, the questions we asked about this risk, whatever it is, and what we followed up with.

That’s something that we do and should be doing when it comes to someone who has depression and suicidal ideation and substance use. It’s a very similar thing, but the risk, honestly, is a lot lower.

Everybody is entitled to a solid assessment. You are not practicing out of scope when you do a solid assessment that includes their substance use. If you’re addressing substance use with them, it’s because either they’ve agreed to it. Or you feel like it is impairing your work enough that it needs to be addressed or has the potential to impair your work. And you’re documenting that. Client was open to the discussion about substance use.

This idea that you are putting yourself at risk is false. For someone who is really risk averse, they are going to see risk and liability everywhere. I personally cannot practice that way. I wouldn’t consider myself a risk taker. I also am aware of the need to protect my license. I also wouldn’t consider myself to be super paranoid about risk. 

What we do as a job is inherently difficult. People are complex and unique, and they make choices that don’t make sense. There are times when somebody has left my office and I believed I knew the course of action they were going to take, and the next time I saw them, they did the exact opposite thing or even made it even more bizarre what they chose to do. I have no control over that. I simply document what happened that day.

We take the steps we need to take to protect ourselves. When it comes to substance use,  you don’t need a certification, you don’t need special skills. You might feel that you need more information. That may be why you found the podcast to begin with. If that’s the case, you can get more information.

The reason I created the podcast was because therapists need more information. It’s the reason that I’ve done webinars. It’s the reason I’ve created the Treatment Planning Tool and the Substance Use decision tree.

It’s the reason that I created the main program that I have Charting the course. Charting the course is a six week live top program where I teach you what I believe you need to know about substance use in order to work with it effectively.

I have been doing this work for 20 years. I am a person in recovery. I have worked with and supervised a large number of people over the years. As I’ve looked at the education that’s out there online, it is incredibly confusing to know what you need.

Do you wanna dive all in on knowing about opiates? Fine. Pessie has tons of stuff. Do you wanna know about the science of addiction? Sure, you can look that up. It’s difficult to know how much you need. It’s like taking a sip from a fire hose.  That’s why I’m doing all of this, the podcast, the webinars, et cetera, is because it is confusing. And over the years, as I have taught other therapists to do this work, I figured out what is helpful information.

I encourage you, go check out the website@betsybyler.com. You can check out /course and that will tell you all about Charting the Course. The doors for registration are opening later this month,  and the next cohort begins in July.

You can check out the Learning Hub at /learn. There you can see previous webinars I’ve done  and downloadable materials. Some of them are there for purchase and some of them are free. You can also go to slash skills to register for the free webinar coming up next week. If there’s something specific that you’d like to know about that I don’t already have a podcast on, send me an email. 

Do you want some consultation? We can set up a time. I am happy to help walk alongside you in this process because I truly believe that our clients need more from us regarding substance use. I believe that we are one of the last places that gets the time to do a full and good assessment of people.

We get an hour with folks. Doctors and other providers don’t get that much time anymore.  We have a luxury that others don’t, and  I believe we need to be open to providing the space for people to explore their relationship with substances. And I am so happy to be here along the way in whatever capacity you need.

I know that your time is valuable and I am thankful that you decided to spend it with me today. Next week is the webinar on Tuesday, May 16th. It begins at 8:00 PM Eastern, 5:00 PM Pacific. And for those of you not in the US time zones, there will be a replay when it’s all done. You can sign up to get the replay by simply going to betsy byler.com/skills. And registering for the event. 

I am looking forward to interacting with you on the webinar. Doing the podcast is a lot of fun. I love hearing from people, and it’s not the same thing as doing it live. It also is going to give you a chance to see what I’m like in a live setting. So that if you decide that you wanna join us for the summer cohort of Charting the Course, you get a feel for what I’m like.

I’m looking forward to seeing you on the webinar 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