Episode 2

Did mental health therapist training really give us all we needed?

What happens once we graduate and become mental health therapists?

This is part 2 of 5 part discussion about why addiction is absolutely the business of mental health therapists and why we all need to know how to assess and treat addiction in our mental health clients. 

In this Podcast 

  • Grad school is necessary and the path they give us is good, but incomplete.
  • We don’t find out that there is more to know until after we are “released into the wilds” of being a therapist. 
  • One of the main things many of us missed was addiction training
  • This lack of information sets us up for being underequipped


-Content areas of the NCE

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


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice.  

I take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs.  Bringing more hope, healing and freedom to the people you serve.

Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.

Last week, we talked about why we’re here. This week  I want to talk about the message we get as therapists. Now, the message that I’m talking about is specifically the one we get in grad school. From the very start of grad school until the day we graduate, we are on a trajectory to learning, getting our hours and getting our license. And that is the end goal. 

Now, when I went to school, one of the things they did was talk to us on the very first day about licensing master’s level, counselor issues, getting our hours, internships. And it felt really overwhelming. I remember thinking like this feels like a really narrow path, does anyone ever really get to the end? They assured us that the therapists that got trained in our program, do indeed get their license and do indeed get jobs. I just remember that being sort of stressful at times. 

Grad school was amazing. Now it wasn’t always that way. Sometimes I super loved going to grad school and I felt like this is what college was supposed to be. Finally, I get to learn about stuff I want to learn about rather than random stuff that was needed to fill in my liberal arts education. It was so cool to be able to take a full load of just classes about psychology and clinical skills. It was so amazing.

And there were times that grad school was a struggle. Like you’re in family systems class, you say something. And since you’re in a room with 30 other therapists, they’re all like, Hmm. And you’re like, you know what, fuck you and your “Hmmm.”. It was definitely a crash course in facing your own issues. I know that it was necessary and I’m actually really super grateful that that’s the way it was built.

I just remember feeling like can’t you just say something without people being like, Hmm, what does that mean? And I also know that therapists, this is just how we’re built. We can’t just turn it off. The next step we’re told is to get our hours and to get our license. And so we do that. We get out of grad school, we find a job, figure out the whole licensing thing, which can be a thing in and of itself depending on your degree, what kind of license you’re going to get, making sure that the supervisor you’re getting can count for your license.

For instance, social workers have to have another MSW to do their supervision, a PhD. You won’t even count for that. LMFTs you also have to have another LMFT. There are so many restrictions depending on the state you’re in and depending on the license you’re going to get, it can be a lot. And I don’t know that there’s an easy way that we get to find out which States accept the things that we’re doing.

I remember when I moved to South Dakota and I called the board and asked if they had a master’s level psychologist license and they told me no. And I was like, Oh shit, this is where my husband and I are moving. And I don’t know how I’m going to work. And it was panic inducing for me. Well, the truth is they do have a master’s level license.

I just used the wrong word. I use the word psychologist. Well, because I had been licensed in Michigan and in Michigan at the time it was called a Limited Licensed Psychologist. And so when I called South Dakota, I just used one wrong word and the person on the phone was like, Nope, we don’t have that. And it almost totally derailed me. And I found out that moving to South Dakota meant that I had to start all over on my hours. That was super frustrating. And thankfully I wasn’t very far into my hours. 

So I got the job and started getting my hours. Now ahead of me was the giant test, right? For my license. It’s the NCE and it is awful. And in no way, determines whether or not you’re going to be a good therapist. I didn’t take that test until I’d been out of school for two years. If any of you are listening to this and you’re still in school, sweet Jesus. Try to take that test before you leave school. When I took my test, it was three weeks after I got married and I’ve been to a hell of a lot of weddings. We’re talking like upwards of 25 or 30, by the time I got married and I’d been in six or seven of them. So I totally knew what I wanted. And so I wasn’t bridezilla. I was super chill, but there’s still a lot to do. I remember just studying. Right. I would go to work. I would come home and I would study. And I studied more for that test than I did pretty much in all of undergrad, because I was terrified. I knew people who had taken that test who had failed it, and there were frigging way smarter than me.

I worked with a guy at the treatment center. I was at. He had been pre-med and he got waitlisted into med school. And so he was like, meh I think I’ll go be a therapist. He took the test. He was crazy smart and failed it. And every time I saw him, he just would walk past me and said, “you will pass like” straight up Yoda or something like that. You will pass. And he would just walk by me. And I was just terrified if this guy could fail, what luck did I have? Now, I studied. I did my best. I sat in the test filled in the little scan-tron circles and when I walked out, had no idea. I figured I probably did Okay. But there’s a level at which if you fail, even by one point, like, that’s it, you gotta take it over.

And at that time, the NCE wasn’t offered all the time. It wasn’t offered monthly. It was like four times a year or something. And it was a really big deal. Well, as you guessed, I did in fact pass it. I was so happy and I got that license. Getting my license was a totally different experience. It was sorta like, you know, on your birthday, when people ask you, do you feel older? And you’re like, hmm, no. Well, Graduation from grad school and from undergrad was kind of like that for me. Like, I didn’t really feel like any different that I had, I don’t know… accomplished something. Everyone was so happy and thrilled, but I don’t know. I, it just sort of was like, yeah, I graduated. Yay. I’m happy. Now what? But when I got my license that felt different. That was like a stepping stone in my career that I will literally never forget. It was this moment of realizing that unless I did something super jacked up, nobody could take this from me. And now I would have some kind of credit, I guess, in the professional community that I was a licensed counselor.  It was one of the coolest days.

So when we get our license, it’s sort of. Well, okay. Now what, it’s that same thing feeling when you graduate from undergrad? And you’re like, um, am I going to grad school? What do I want to do with my life? A lot of people end up in grad school because they don’t know yet. All they’re doing is for stalling the  I-don’t-know-what-I’m-going-to-do-and-I-have-to-figure-it-out for a couple of more years. After we got our license, it’s sort of that same feeling.  You’re supposed to just do therapy. Into perpetuity? I mean, we know we can specialize, right. But in what? And there really isn’t a way to figure that out. And it’s not like a smooth line, like, Oh, I want to do this now. I knew my population, but that’s because I had this really different experience that burned itself into my brain. But that was pretty rare. And I did know my population, but I didn’t know what, I didn’t know. Let me tell you the story. 

So I mentioned in the last episode that I had interviewed at a treatment center and that I had gotten a job there, but I want to tell you a little more about that story. So I interviewed at this place. And as I had said before, they were opening an adolescent girls unit. They had an adolescent boys unit where guys would come and they would stay 30 to 45 days and they primarily had substance use issues, but of course also had some mental health issues, trauma, bad stuff at home, that kind of thing.

And they were going to start this girls unit and. It was by far the coolest thing. And I interviewed, and I got the job. And like I said, I was really confident that I knew what I was doing; that I was going to be able to do this thing. No problem. So I get into the team and I find out I am the only one with a master’s degree.

Everybody else on the team, who’s a counselor has a bachelor’s level, substance abuse counseling degree. So they might be social workers with substance abuse training, or they had a substance abuse certificate or something like that. But I was the only one with a master’s in mental health. And so, I think I had some sort of like, Oh, I’m going to know more. What happened was, I didn’t know, more.

So in the days and months as we started, I realized that the substance abuse counselors knew things I didn’t. They approached things from a totally different perspective; from an addiction perspective. And I was watching them and thinking, Holy, I had no idea. So, I don’t know how many of you have worked in a treatment center where you’ve been there and the patients live there. So it’s a really different setup. There are no holidays. There’s no closing things down. The kids are there. They’re there for Christmas. They’re there at night. They’re there in the morning. And so when you have shifts, you’re either working a day shift or you’re working the evening shift, like a 2 to 10:30.

So the 2 to 10:30 was my shift. I am not a morning person. I’m still not a morning person. And so it was a great shift for me. My husband also worked that shift at his job. And so it worked really well for us. And so when I get there, the girls were done with school and they’re in groups. So every day there was a different group, after that, we’d have some quiet time in their rooms.

And that’s when we distributed mail which sounds like not a big deal. But it was kind of a big deal because all of the girls thought that somebody was going to write to them and they didn’t. And it happened over and over and it was always devastating for them. They were sure that their friends were going to write to them.

So we’d do the mail and then it’d be time for dinner. And then after dinner, we’d have a little bit of a break and then we’d have a meeting every single night. We had either an alcoholics anonymous meeting or a narcotics anonymous meeting and it just alternated. So for the two years I worked at this treatment center, I was at a meeting five days a week. That was a totally new experience. I got to understand the NA and AA basic texts really well. And it gave me a perspective on addiction that I didn’t have. Now let me clarify. I do not believe that AA or NA is the only way to get sober. There are plenty of people who have gotten sober without using the 12 steps. And I do think that the founders were onto something. 

What they figured out about addiction was that hearing from other addicts, hearing from other alcoholics was the key for them. And for the girls, I saw that. They would read the stories in the back of those texts and they would be like, this sounds like me, and they’d hand it to me. And it would be the shorthand of telling me “this is what my use was like.”

Each day I’d run different groups, do some individuals, talk with different girls. I got to work with these girls for the time that they were there and got to see them change before my eyes. And it wasn’t a focus on mental health. Yeah, their mental health was a thing for sure. Most of them had PTSD. However, once we got past the use, they got detoxed, they were calmer. We got down to the heart of the matter. And if we hadn’t been teaching them about addiction, they would have walked out that door and would be back to using before we knew it. And for sure that happened for some girls. 

Some of those girls, we sent them back to environments that it would break my heart that we were releasing them into. Because I would watch these girls, these hardened girls, involved in gangs or whatever. And they would be bringing a stuffed animal down to watch a movie on a weekend. And it was the sweetest thing. More than once I felt the sense of being so lucky that I got to do this for my hours. To this day. I remember some of those girls and I think about how old they must be now. And I just, my brain just breaks because I have no idea where time went. One of my former clients from there somehow found me and she sent me a Facebook message and told me that she became a therapist. And she told me about the things she remembered that we talked about when she was there. And the truth is I remember her, but I don’t remember talking about those things. I do remember it as being an incredibly formative time in my career and in my life.

When I got my license, I really needed to move to a position where I was going to be using it and getting more specific training on doing mental health and diagnostic assessments from a mental health perspective. And the treatment center, that’s just not how it was built. And so I started to look for another job. And at my exit interview, I remember sitting with the CEO and she had been there a long time and I just was sitting there thinking, wow, this has been amazing. And I said to her, I can’t believe you hired me. And she laughed. And she said, why?

And I said, I had no idea what I was doing. And I really truly didn’t. I felt under equipped and I realized that the substance abuse counselors knew a lot that I didn’t know. I wasn’t the one who was going to be teaching them about the job. They were the ones teaching me.

When I went into a full time outpatient therapy job, I felt really lucky. I was able to get the training I needed without my colleagues knowing that I didn’t know what I was doing. I know that sounds a little funny because at the time I thought that I was one of the only ones who didn’t get trained in substance use. I just didn’t know that. And so as I started listening, I’d be in staff meetings and I would hear people and I realized I wasn’t the only one who was under equipped.

The message we get when we’re in grad school directs our future. Depending on your program, perhaps you got a different message. Perhaps your message was really well rounded. And I don’t blame my program. I think I had great training. I loved my professors. They were real and honest with us and they talked about the different issues we would face. And I didn’t understand some of the things like why they were telling us this, but later on, it became really clear. I want to give a shout out to Dr. Mangis and Dr. McNeil, those two men are responsible for some of the biggest changes in my life. I’m so grateful for them and their patience and sharing their wisdom with me. That helped me be the person and the therapist I am today. 

The system of grad school can’t possibly share with you, all the things you need to know. And even if I sat down and thought about “how can I build a program that would give people all the things they need to know?” I don’t know that I could do it. What I do know is that the message that we got drilled into us in grad school, learn everything you can, do your internship and learn every single thing that you can out of an internship, graduate, get a job, make sure your hours are going to count and get your license. And that was sort of where it stopped.

I would look at these therapists, who’d been in the field a long time and they seemed so comfortable. They had found their niche. They had figured out how to get the training they needed and they just moved forward. And I really didn’t see a lot of instruction happening for people who were just getting their license.

So what about people who didn’t know their population yet? I think most of us just kind of stumbled into it, kind of saw trainings that we thought were interesting, or maybe our clinic was going to be doing something. For instance, the clinic that I worked in and the staff that I had, we did training for TF-CBT. So that’s trauma focused cognitive behavioral therapy. And we did it as an agency. So anyone who was working with kids did this training. And it was amazing by the way. And, and it was the first time I’d been part of a training that wasn’t like one of those overview trainings where you just, when you hear about a topic for like an hour and a half, no, this was like straight up days. And it was this whole model and it was really great. And I was like, okay, this is the kind of training I’m going to go to from now on; not sort of these overview things. Which are fine, and they’re fine for getting CEUs if that’s your goal, but if you want training, that’s actually going to help you change and do things better and give you more skills.

You’ve got to do it different.  The overview stuff, that’s just good for CEUs. And for some therapists, that’s all you want. No problem. But I found that going to the one that was like a whole model. That was awesome. When I became a supervisor, I had the opportunity to watch people’s transformation; to watch them change, to watch them develop a niche. And I got to help guide them. And I know that not everybody had a supervisor like that and not everybody knows their population. I’m not saying I did everything perfectly. And I did try to help the people who worked for me plan a path for themselves so that they could get to the place that they wanted to be.

There are some of you who didn’t get that, who got your license and have just been doing therapy and seeing whoever shows up in your office. A lot of us are in community mental health. And what that means is client after client, after client, after client. Intakes, coming into your office, you don’t really get a lot of information and you’re just doing therapy. And sometimes that can feel a little like, like a factory kind of, and it’s not that it’s not important because I believe what we do is super important, but it can feel like not a lot of direction. And that can lead to us feeling a little bit lost. 

So I want you to think about grad school on day one. I want you to think about what you knew was going to be happening, what you thought the future was going to look like, what you thought your career was going to look like. And then I want you to think about where you are now. And I wonder what things you wish you had known on day one.

There are other things that I remember thinking, wow, this would have been super helpful. I would have chosen my classes differently. I would have added stuff while I still had financial aid. I just would have done a few things differently. And I feel like we’re kind of left to figure some of those things out.

Some of the things we learned in grad school were absolutely vital and others, I don’t really use that much. Let’s take termination, for instance. I remember talking about termination all the time, how to terminate with clients, not abandoning clients, preparing them for termination, that kind of thing. And while it’s a useful skill, I can’t say that I’ve used it very much. My clients by and large do not want to terminate, not formally. Part of this is this desire to avoid goodbyes. And part of it is they don’t want to end because they’re afraid that something will come up and that they won’t be able to get back in. And so they just sort of disappear. They space things out. And then I don’t hear from them maybe not for a month, maybe not ever. And so I just thought about that skill and I kind of laugh about it because we learned a ton about it, but I really don’t use it now. Maybe there are some therapists out there who use termination all the time and it’s just not my experience.

I think the message that we get is that grad school is going to prepare us and that if we do all the things they tell us to do. And we get a decent internship and we graduate that we’re going to know what we need to know. And that’s not the whole story. And we figured that out. Those of us who’ve been five, 10 years past license. You’ve figured it out and you’ve done it largely on your own unless you had a really good supervisor. And many of us didn’t get great supervision. It’s not a top priority in a lot of agencies. And I think it should be, long after you have your license. Not just because we have to, but because it’s a good idea. 

And we kind of just have to keep going forward, making our way, deciding what we are going to do and working with clients. In the next episode I’ll be talking about the reality we face once we are post license and fully into the world of being a therapist. It’s really different than we thought it was going to be. In some ways, way better. And in some ways, more challenging. 

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.

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