Episode 100

I’m so excited to talk about today’s topic because I think it’s one of the main things that pop up when we think about adding substance use to things we are willing to work with. The question that comes to mind is some form of “Are we allowed to work with substance use if we don’t specialize in it?” The short answer is YES! The longest answer is what we are talking about in today’s episode. 

You don’t need another license or certification to work with substance use. There’s a myth that many folks believe and it keeps them from being able to practice with confidence. This myth suggests that substance use is not in our scope of practice.  In today’s episode I’m going to break down why this myth exists and what the truth is on whether or not substance use is part of our scope.


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 100. I know for many podcast hosts episode 100 was maybe a long time ago. I remember doing episode two, episode six, episode 10 all the way till today, episode 100.

I wanna thank all of my listeners. When I started the podcast, it was sort of abstract. I had no idea who would listen or if anyone would listen. And I knew that I would just have to show up and keep putting out podcasts in hopes that people would find me and resonate with my message. Every month, I’m able to see new listeners all the time. And I am so thankful. 

Time is precious. The time that you spend listening to my podcasts makes me wanna do more of them and provide excellent episodes for you going forward. It means so much to me every time I see episodes being shared, reviews being left and when people send me emails about an episode or a clinical question. I really, really love it and I’m so thankful for this community and all of the work that you are doing out there in the field.

I truly believe that we have a unique space. We are one of the last places where people can spend an entire hour just being heard. We don’t have to do a 20 minute session and rush on to the next person. We get to sit and bear witness to someone else’s life. It is an honor and a privilege  it can also be difficult and a heavy burden to bear sometimes. I am so thankful for every therapist out there that is doing this work and for all of those who are entering our ranks.

For episode 100 today, we’re gonna be busting a myth and I have an announcement of a new webinar coming up in just a few weeks. The myth that we’re busting today is really important. I believe that it can be the very first thing that comes to mind when people hear me talk about adding substance use to the list of things they’re willing to work with.

So here it is, you don’t need another certification or another license to work with substance use. Many clinicians believe that substance use is separate from what we do that by its very name. It’s not part of mental health practice.  I don’t know all of the reasons why people believe that substance use is separate from mental health.  but I have some ideas. It’s not a law, it’s not a statute. So today we’re gonna talk about it and where it came from, whether it’s true or not. And what that means for us. 

The first thought I had when thinking about this myth and where it came from was maybe we believe this because substance use certifications or substance use licenses exist. They’re a thing. Every state in the United States has some provision for the work of substance use. Perhaps that is the reason why we believe that we have to have that in order to work with substance. At first blush that can seem sort of self explanatory.

If there’s a license and we don’t have it, then we can’t do it. But we need to look a little deeper.   

We don’t have separate licenses for other parts of mental health care. We don’t have separate licenses for trauma therapists or for eating disorder therapists, or for therapists who work with OCD or specific phobias. They simply have a therapy license. That would lead us to believe that perhaps that is why substance use is separate and therefore outside of our scope.

Substance use licenses in each state are there for a specific reason. When you look at the education for substance use, it’s typically at a technical college level, which is a two year level here in the United States or for bachelor’s level folks for some states. It’s a certification that is a certain number of hours. 

For instance, in the state of Minnesota you have to have about 22 hours of substance use specific education, and you have to have a bachelor’s degree. In the state of Wisconsin, you need to have a specific set of hours from specific schools. You can’t just go to any given school and be able to get the terminal license. You can get a training license and an intermediate license, but in order to get the very top license that allows you to practice independently, you have to go to one of the pre-approved schools. This typically is a technical college degree, a two year degree. For instance, at our local technical college, it is part of the human service associates degree.

The theme here is that the degrees that are required are undergraduate degrees, not graduate school degrees. These licenses exist because initially the field wasn’t licensed. Back in the day, substance use was treated by AA folks by peers. I know for instance, in Wisconsin, you could have a certain number of years in recovery and a few classes here and there and you would be okay to do substance use work. That has shifted over the years with states requiring more and more, which is to be expected. Certainly our master’s degrees or PhDs are a higher level of education. So it’s not that substance use is somehow above our education. It actually requires less years of education than we have. That means that we are not under qualified to do that work.

The next question though is, well, what about the training? All of those degrees require specific substance use classes and they do. They require those classes because the person may not have a therapy background. A human service associates, depending on where you are, is gonna have specific classes, but maybe it doesn’t have the kind of interpersonal skills training that we have. Someone could have a certification in substance use or chemical dependency it’s called that in a lot of places and maybe they have a psych bachelor’s or a social work bachelor’s. Those are not therapy.

You do learn some in a bachelor’s in social work about how to work with people. I know that my bachelor’s in psych didn’t have anything like learning how to talk with people. And so they’re leaning on the substance use curriculum to teach people how to do that. I believe that this was a way to get people who were already working in the substance use space to have some formalized education. Additionally, when people wanted insurance to cover treatment. Well insurances are going to need some kind of qualification or at the very least a modifier in order to even bill it.

As I have said numerous times on the podcast, my website, all over the place, most of us did not get adequately trained in substance use. I do believe that programs by and large are doing a little better in the last decade or so. When I graduated about 20 years ago, we had an optional class and of course that was something I took, but it wasn’t something that we really learned a ton about.

I hear people thinking, well, even though we have a higher level of education we still lack the training. So let’s talk about the training that we all get when we’re in graduate school. If you are an LPC or some version of that, a professional counselor, we have a set of domains where we have to know certain things in order to get licensed. We have to have certain classes in certain sections and we have to have a certain number of hours in those specific topics. So for instance, human development or assessment or ethics. There isn’t a standard really for what type of program we go through.

There’s something called a CACREP accreditation that a number of schools have, and that I think may become the standard in the future. The people at the CACREP organization are certainly pushing to become the national standard. There isn’t one at this time, it depends on what state you’re gonna be licensed in. 

Those domains are set by the school and the programs are setting their own agendas. They set their curriculum based on as far as I can tell a few things. They are looking at licensing exams. They’re looking at state statute, they’re looking at other programs that came before them.  Schools are always looking at how to market their program to the widest amount of people. And of course, one of the things we all wanna know before we go to grad school is can I get a license? 

In the United States if you do not have a license, you cannot work. These schools, as they’re developing their curriculum, they can vary widely. Specifically in the professional counselor realm, we’re sort of a catchall in a way. Where someone might have a degree in clinical psychology like mine or someone might have community psychology or community counseling or counseling psychology or community in education, counseling, or clinical mental health counseling. You get the point. 

We take people in master’s programs that don’t have either the social work degree or they’re not in a marriage and family track. So our programs are going to be different. Some of them have really specific modalities that they teach. For me we had a specific class on psychodynamic theory, cognitive behavioral therapy, humanistic theories and family therapy. Colleagues that I’ve had, who were also professional counselors, went to other schools and their curriculum might have looked similar to mine, but it wasn’t the same at all. So we didn’t have to go through a specific set of things to say, you can now treat these particular diagnoses. It was, you can do mental health therapy.

If you look at marriage and family therapists, their degree programs also vary. There’s a lot of differences between schools in how they name things and what’s included in those classes. Certainly there’s a little more continuity between programs just based on the narrowing of the field, by saying marriage and family therapist. 

Marriage and family programs may not have some of the things that I had. I had a full on assessment class where we learned how to do the intelligence testing and a number of other tests that might not have been a focus for someone in an MFT program.

So some people might be thinking, okay, but we’re all trained to do therapy. We have clinical classes and so therefore that is what makes us able to do mental health. And we still don’t have substance use training. Okay. So those things are true, but what we have in our programs isn’t always clinical.

Social workers don’t always have a clinical concentration. Social work is so much broader than say a professional counselor track or a marriage and family track. It’s really different.  There are some schools that don’t have clinical classes per se, as their concentration. They may have some of them, but they have to cover so much stuff in order to meet the criteria that they’re gonna end up having things about social justice, about community, about case management and all sorts of macro and micro social work topics.

I have worked with social workers who have their MSW and can do therapy. But don’t feel like they got the clinical background they need yet they are able to do therapy, just like the rest of us. So it’s not based on clinical classes that we had in our graduate programs. 

There isn’t anyone that has said that substance use isn’t part of mental health. You just won’t find it. The schools built their programs to appeal to the widest audience. That means that they need to make sure that their people have the right classes in order to pass a licensing exam.

The licensing exam was built on the programs at the time. Sometimes those statutes get updated, but not super often and it depends on the state. Now, when we’re talking about PhDs, it’s widely recognized that PhDs can pretty much do all the things. They can work in any number of capacities.

And some of them are not things that master’s level folks are allowed to do. Certainly substance use would fall under a PhD purview. I don’t know that anyone’s gonna say that a psychologist isn’t skilled enough to do substance use work yet that’s also not part of a PhD’s education, nor is it part of their licensing exam. 

In fact, our licensing exams can have some random stuff on it. When I graduated from graduate school and I got licensed in the state of Michigan, I ended up moving very shortly thereafter to South Dakota. I didn’t know that I had to have this class in order to meet South Dakota’s requirements called Lifestyle and Career Development.

It was on the licensing exam for the national counselor’s exam. I hadn’t had it, I didn’t know about it. And so I had to quickly take it. It was a whole section out of the domains on the test. And yet I have literally never used it. Not once. I remember it. I remember some of the things we learned in it, and I have literally never touched it.

Career development, which is the main part of it, the lifestyle part is not totally a focus hasn’t come up. Yeah. I certainly talk with people about what their desires are, but career counseling is not my thing yet I had an entire section on a licensing exam and had to take a whole class for it. The things that we take in our graduate program are meant to be a catch all kind of. To give us some basics and add some things that are mostly useful and put an education together, pass the exam there you go. But there’s a lot of stuff that we don’t get taught about. That comes up more often. Let’s take human sexuality.

For instance, I have talked about how substance use is always part of human culture and it is, but you know, what’s more part of human culture sex. Literally the survival of our species depends on it. Yet that was not on my licensing exam. It’s not a domain. Now marriage and family folks have a better chance of having that as part of their curriculum, but it’s not a requirement. Like how messed up is that? 

Well, the AASECT people that is the American association of sexuality educators, counselors, and therapists. They know this all too well. They have created their own standards, curriculum, position, papers and statements on various topics in the realm of sexuality. Most therapists I know have never attended an AASECT training or anything like it. Yet we talk about sex all the time. 

Sex comes up with every age I’ve ever worked with. With children, teenagers, and all of my adults. Whether it’s about puberty and development or sexual relationships and what’s normal quote unquote. And yet we did not have to study that and we work with it all the time.

Let’s take eating disorders. We didn’t get trained on eating disorders much either. That’s not part of our licensing exams. Eating disorder folks know that all too well, because they are super niche in terms of getting treatment. But most of us, when we see people with disordered eating, we’re not necessarily able to refer them to a program. Those programs are not common in certain parts of the country. 

A lot of folks, their eating habits aren’t necessarily quite disordered enough. We enter into that all the time. Now there may be moments where we’re like, oh, that is a little farther than what I’m able to do. But typically when we’re at that point, we’re talking about someone who is at severe medical risk. Where they’re anorexic or have other stuff going on that we know is outside of our scope. And frankly, that’s the same thing with substance use. 

When we have someone who is at a really high risk for dying, we would absolutely wanna get all the people involved that we could just like with eating disorders. Eating disorders don’t have their own licenses, and sex therapists don’t have their own licenses. So why substance use? Is it really that different?

And here, I wanna point to the fact that substance use work and only substance use can be done with a level of education below a master’s degree. That means therefore people who have a master’s degree and above would have met the requirements in terms of education.

So let’s look at our ethics. Without going into  all of the ethics. I decided to look at the biggest one that will help with master’s level folks and I know that the APA, the American Psychological Association absolutely concur about substance use. And this is what the NAS w the National Association for Social Work has to say about substance use.

There is a 24 page PDF that I’ll link in the show notes that talks about the social work standards for substance use. The qualifications listed state that social workers shall meet the provisions for  professional practice set by the NAS w and related state and federal laws while possessing knowledge and understanding basic to the social work profession with regard to professional practice with clients with substance use disorders. 

The interpretation is that the social worker has a degree in social work. That degree is listed as being an MSW or a Master’s in Social Work. It says that working with people who have substance use disorders is a distinct specialty and scope of practice within the social work profession.

So this is a specialty inside the social work profession, just like trauma, just like O C D eating disorders any other kinds of disorders that we work with can be a specialty that does not mean that it is somehow outside of the realm of other therapists. It is part of the social work spectrum. It is part of mental health.

When you look at the American Association of Addiction Medicine, they list it as part of mental wellbeing. The four main types of licenses and ethics that we have in the United States include substance use as part of our scope. The specialty part is noteworthy.

People can specialize, just like we do with trauma. I would venture to say the majority of therapists work with trauma. Not that they specialize in trauma, but they work with trauma. I happen to specialize in trauma. I’m an EMDR therapist. Before I became an EMDR therapist before I became a TF-CBT therapist I still treated trauma. Substance use is the same way. 

You don’t have to specialize in it to work with it. You can specialize in it, but that isn’t required or necessary. What I am proposing is that garden variety substance use is in our scope. And that is the majority of people who are using substances in a problematic way.

The majority of folks, when we have to account for under reporting who are using substances problematically, or have aren’t going to be the most severe. The ones who show up in substance use treatment where specialties are, that is gonna be the most severe. But what about the rest of them? 

Most people aren’t gonna be thinking that their use reaches that level.  because statistically speaking it doesn’t. However people do use substances problematically because of a lot of reasons. First and foremost probably is that it’s accessible. Secondly, it’s effective. Uh, it’s not effective forever, of course, but it’s effective in making you forget about things.

I had a client tell me today that if they’re gonna get a little happiness in a bag that makes them not hate life, they’re gonna do that.  It takes them away just for the moment. I’m not saying it’s a great idea or an awesome coping skill, but it is effective for that moment. 

 Substance use. Isn’t something that requires us to have a higher level of education. We have that already. It doesn’t require us to have a specialty. It is part of each of our ethics. There is a level of substance use work that is a specialty that is on the more severe end where we would refer anyway. That would be the same for eating disorders, or if someone had really significant trauma and that wasn’t your training, of course you would refer out.

But in general, what happens in our field is that people are referring out at the hint of substance use. For a lot of folks with low resources in their area, end up having to do the work, but they’re really uncomfortable. Almost as though they’re practicing out of scope when in fact they are not, it is in our scope.

The only thing that could change some of how you practice is your state law. State laws vary, and they can vary wildly. What you have to remember though, is some of this is based on billing, what you bill under.  If you’re gonna bill under a substance use code as primary then yeah, you probably should have a specialty at the very least, and you need to know what your state laws are about it. 

So for instance, in the state of Minnesota, you have to have an L a D C a licensed alcohol and drug counselor in order to bill substance use as primary. It can be on someone’s diagnosis list. It just can’t be the thing you bill for. There has to be another diagnosis, non substance use that is primary, which is almost everyone who comes in with substance use also has a co-occurring mental health disorder. 

In the state of Wisconsin you used to have to have a substance use specialty, either attached to your mental health license or you could treat substance use with a substance use license, but not touch mental health. However, in recent years they changed the statutes to say that a master’s level therapist is competent to treat substance use and they can bill under it. 

So this myth truly is a myth. We don’t need another license. We don’t need a certification. I do think it’s wise for us to have some training. And that is just something that I think we all sort of agree on that. If you’re gonna start moving into an area that you don’t have a lot of experience with that, you wanna get trained in that. 

The last thing I wanna address is credentialing applications. So any of us who are billing insurance or have ever billed insurance, at least in the United States have to fill out credentialing applications. Many of these applications have everything you could think of listed as a specialty and has a checkbox next to it.

And I remember in the beginning being really confused well, of course I treat generalized anxiety and major depressive disorder and family issues. But that doesn’t mean I specialize in those things. What they’re looking for is simply for you to say these are the things I’m willing to work with. Not necessarily that you specialize. Substance use is always part of that. And I think most therapists don’t check it. Because they feel like it’s a specialty that they don’t have, and that may be true. However, it’s just the same as working with someone who has another problematic behavior, suicidal ideation, self harm.  Those can be specialized. However, we are generalists for the most part. 

If you are listening to this podcast, you have some interest in understanding your role as it pertains to substance use. I’m guessing that for folks who really don’t wanna touch it for other reasons, they’re not here and that’s okay.

There are folks who are not able to work with substance use because they struggle with it. Either they struggle with it because of a family member or a loved one, or they feel like they aren’t able to be as compassionate as they wanna be because people who are using sometimes do not-great things. And for those folks, that’s okay.

My encouragement though, is that for the majority of us, it’s a lack of information. And that is something we can solve.  I wanna help you get started addressing substance use with your clients. Because of that, I have put together a one hour free webinar that’s gonna be on October 18th. That’s a Tuesday at 8:00 PM. Eastern time and 5:00 PM. Pacific time. For my international folks, there will be a replay available by the time you wake up the next morning, assuming that technology cooperates with me. 

This webinar is to help you stop avoiding the substance use talk: the five steps to confidently ask your client about their use of drugs and alcohol. These five steps are going to help you develop your own script to ask your clients about their substance use in a way that feels good to you both. 

I am a hundred percent focused on my relationship with my clients. I wanna help you feel like you have confidence to ask them about their substance use in an effective way that is not going to alienate them. Again the five steps webinar is happening on October 18th at 8:00 PM. 

The only thing you need to do is register for it. You go to betsybyler.com/steps. That’s S T E P S. I’m excited to do it live for those who are able to attend so that we can talk and ask questions.

I love interacting with you in the small ways I’ve gotten to, but doing a webinar, I’m really excited about it. And I really hope that you are able to come. If you aren’t, you can certainly send me questions ahead of time. These five steps are actionable and you will be able to use them the very next day.

I hope you will join me on October 18th and that I will get to see a few of the faces from the people who are listening to my voice each week. Again, that’s Betsy byler.com/steps. I hope you’ll join me for that webinar and for 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.

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