We don’t want to be wrong about what’s impacting our clients. We try really hard to assess what is happening in a client’s life that is getting in the way of their success. We ask all sorts of questions, compare it against all the information in our heads and perhaps online as well. We try not to float suggestions about what’s causing issues unless we are REALLY sure. Client’s need to trust that we know what we are talking about. If we guess wrongly or change our diagnoses, they lose trust in us. So we have to be careful. When it comes to substance use, it can feel really difficult to know if it’s a problem. Perhaps it’s not? Perhaps this person can drink this amount or smoke this much weed and it’s ok. Who are we to judge?
Well, it’s not judgment in the sense of moral judgment. It’s clinical judgment and our clients are coming to us specifically for our judgment on what’s impeding them or impacting their lives. When a client talks about substance use, it’s our job to help hold up a mirror. To help them see their substance use from a different perspective. It’s important that we have an idea of whether or not their use is problematic or not. So how do we even do that?
I’m going to tell you some of the things I believe are signals that someone’s use may be moving from recreational to problematic. You still need to use your clinical judgment, but there are some commonalities I’ve seen over the years when substances start to become an issue.
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 99. I’ve had a really great response to the story that I shared last week. It’s really an honor to share my personal recovery story with you. I also wanna thank everyone who was able to come out for the Braving the Course event that Dr. Jenny Hughes and I put together. It was so great to see so many of you there.
If you aren’t on the email list and you don’t wanna miss future events, you can head over to betsybyler.com to the contact page and sign up at the bottom of the screen. Or if you haven’t downloaded the Substance Use Decision Tree, you can sign up there and it’ll put you on the list. For that you head over to betsybyler.com/tree.
Today, we’re gonna be talking about how to tell if your client’s substance use is recreational, or if it’s starting to become problematic.
After all these years doing therapy one of the things I still really enjoy is when I’m able to read a person correctly. Every time I meet someone new, or even people I’ve known for a while and something comes up or something shifts, I love analyzing it and trying to figure out what’s causing it. And at the same time, what the solution is. It feels like detective work and when I hit the nail on the head, it feels amazing. I have one of those conscious competent moments where I feel like everything’s falling in line. I am relentless with figuring out where something started and what’s holding it up.
My clients have noticed this and even my teenage clients have commented before I even ask questions. Like, no, I wasn’t anxious yesterday. Yes. It happened when I woke up this morning. No, I don’t know what it’s about. Because they know that I’m gonna ask a series of questions to try to find out what is happening.
I think all of us love being able to nail something on the head and say, I wonder if it’s this and the person’s like, that’s exactly how I feel. I know for us, we are using parts of our brain that are analyzing more quickly than we can really realize all sorts of different things. We might notice somebody’s body language. We might notice that their eye is twitching. We might notice that every time we bring up a certain topic or say a certain word, that there’s a response in them. I remember in my very early career and especially in grad school, I thought I would never be able to pick up on those.
If however, I guess at what might be causing something in the person disagrees, and it’s not what’s happening, it kind of throws me for a loop. I have to quickly backtrack and think about whether or not I missed something. I always want my clients to tell me when I have misstated something or it’s not exactly how they feel, because this is not about my ego, this is about them getting better.
I do know that they’re coming to me for some, what they feel is expert advice. And in many ways we are experts. We definitely know more than the average public about mental health and are given areas of expertise. I know that I feel pressure to make sure that I don’t just throw a bunch of theories out there willy-nilly because I want the person to feel as though I am able to help them.
I know for myself, I won’t offer a suggestion unless I have some decent evidence to suggest that this is the thing that might be causing the problem. So when we’re talking about substance use, that can be a little tricky. Whose definition of substance use pushes it into a place where it’s problematic? How much is too much? Is there such a thing as normal use? What about normal marijuana use? What about normal opiate use? What about someone who’s dabbling in something that’s super illegal like cocaine.
How do we respond when someone is using? And the answer to that has to be whether or not it’s a problem. When someone’s coming to us, we are addressing their primary problem, whatever it is they brought in. The rest of that. Isn’t really our issue. We have to check our own bias and assumptions at the door and serve the client where they’re at. What if someone has relative normal functioning and uses cocaine a couple times a month? Is that problematic? It’s illegal , but there’s lots of things that are illegal and it’s not our job to be the morality, police or any other kind for that matter.
The other part that makes substance use hard is that we don’t wanna offend anybody. We don’t want anyone to feel like we’re calling them an alcoholic or accusing them of being a drug addict. People get really defensive about what it is they do to quote, let loose and specifically, people get defensive about drugs and alcohol. As a therapist, who’s trying to build rapport and focus on what’s happening and get to a place where the client can start making some changes we’re gonna be a little hesitant to start dropping bombs about substance use without being really sure it’s a problem.
The majority of folks who show up and have some substance use, aren’t really ready to say it’s a problem, because that would mean that something should be done about it. That is gonna be something they keep close to their chest. For us to make suggestions about that is gonna be really difficult.
I have been a part of many clinical conversations with therapists about their clients and should they say something or shouldn’t they? Oftentimes when I ask them, do you think that’s a problem and more times than not the answer is I don’t know. And so I thought that we would talk about that today.
Now I wanna have the caveat. Everyone’s life is very complex. The things I share with you today are generalities. There’s always going to be someone who does a thing that I say, and they’re not using problematically because of whatever the reason is. And I want you to always use your clinical judgment.
What I’m telling you is based on the last 19 years of being a therapist and my work as a supervisor in overseeing over hundreds and hundreds of client cases in addition to my own caseloads. These are the things I have seen that correlate with problematic use because average folks don’t do these things, people who are using in an average, non problematic recreational way.
I wanna clarify problematic. So by problematic, I do not mean that they are in active addiction. What we’re deciding here is, is there anything that suggests there could be a problem or not? What happens after that and how far down that road they are, that’s not something that we’re determining at this moment.
When a client comes to us for whatever the identified problem is. It’s our job to hold up a mirror. That mirror is to help them see what we see, what others in their life might see, including their substance use. We are not judging them in the sense of casting moral judgment on what they’re doing. We’re saying, is this a problem or not?
The other caveat here is that we have to take into account their age and developmental stage in life. What I mean by that is that there are some periods in our lives where there is more experimentation with drugs and alcohol, and that is a little more normal, so to speak. And by the time someone gets past that age, it’s a little more problematic. And so we wanna take that into account when we’re deciding, is this a problem or not.
This is not happening in a vacuum. You are asking questions of your client to clarify their use so that you’re not assuming things. However, people say things that they might not realize are more telling than they are.
So the first thing I find that isn’t average in terms of people who are drinking in an average way is preplanning. And by preplanning, I mean a couple things, one of those is thinking about what you’re gonna drink days in advance. Planning what you’re gonna drink or how you’re going to drink. That’s not really normal. That’s a discussion that usually happens when people are drinking to excess.
They’ll talk about I’m gonna have this first, because that way I won’t get sick, I’m gonna make sure I eat because then I won’t get sick and they’re doing all of that because they’re gonna be drinking more than is normal. They’re trying to get around the potential downfalls of drinking as much as they’re planning on drinking.
Similarly, making sure that nothing gets in the way of that coming event, whatever it is. That it doesn’t matter what happens at work. Doesn’t matter what happens with anything else that they are not going to miss that event. If it is a one time thing. Of course it’s not a problem, but if it’s a theme where they make sure that the most protected time in their week is the night they get to go out drinking, that’s probably something you should look at.
So I want you to think about someone in your life who drinks normally, you don’t think they have a problem. You think they know their limits, they’re not always talking about alcohol or obsessed with it. That’s normal. We have this need as people I think, to downplay our judgment of others. Because it feels wrong or rude or uncomfortable remembering that we’re not judging in a moral way. We are using our clinical judgment, just factually to say, Hmm, this could be a problem.
The pre-planning activity for drinking is not really typical. The preplanning usually starts before the day of whatever’s happening. It usually happens because somebody decides that they want to drink and then they’re gonna build an event around that to give them a reason to drink. The planning part of this is thinking about what you’re going to drink and how much, and imagining that days in advance.
I remember doing this in the days when I was using we would be talking about what we were gonna do at that or that party. That was how we got through the week by thinking about how we were gonna be able to do this or that thing once the weekend came. In certain developmental phases, that might be more normal, but during just average adult life that’s not really what goes on.
One of the other things I pay attention to is when someone talks about whatever activity, the sports activity they’re involved in, going out with friends, going out with coworkers, going to a barbecue, any of those things and they mention alcohol. We went out for drinks. We went over to so-and-so’s to drink. We went out to hang out at the bar. We went to the barbecue and brought a cooler of beer. We went and I manned the bar or whatever the case may be. Some of that is normal, but a lot of that is not normal.
It’s not normal to have every social activity revolve around alcohol, unless you’re an alcohol distributor. It is normal as an adult that there’s alcohol at a lot of events and probably most events, but it’s not normal that the person who is talking to you is commenting on it each time it happens.
Think about how you would describe going out with friends or going to a barbecue or going to a sports event. Most people who are not drinking problematically, when they say they went out for dinner with friends, they might say they had drinks if they went out afterwards, I suppose as part of this, this is the itinerary of the night, but typically it’s we went to so and so for dinner. If they go to a sporting event, we went to a Cubs game. They don’t typically comment on the alcohol part of.
What we’re looking at here is that the person who is mentioning it often is highlighting that as a part of the experience. Now, if we’re talking about wine tasting or going to a craft brewery, like that’s a totally different experience because the alcohol is the point.
What you’re listening for though is how often does this person talk about alcohol and how does that compare to your other clients? Because average folks who drink on a normal basis in a normal way, don’t talk the same way. If I had to label this, I would say this is alcohol as the focus point of the activity, rather than the people or the actual event that’s happening.
If your client is talking about alcohol either in relation to their recreational events or to events in general, that is a sign that something might be problematic. We’re not judging it. It’s just something that falls outside of what would be an “average experience” for other adults in the same age range or developmental stage of life.
So what goes hand in hand with the preplanning and the point of the event being about alcohol is the idea of not wanting people that could potentially bring down the mood, whether it’s the mood about the alcohol or drug use or whether it’s that the person might seem like they don’t wanna have that much fun or that they’re too cautious, but basically it’s wanting to have people around who are going to drink or use or whatever, to the same level, if not more than that person.
I hear it all the time from clients in recovery and from friends in recovery, who haven’t gotten invited to a thing, because there was gonna be alcohol there and that person didn’t drink, or they were gonna be eating THC edibles. And they weren’t invited because they don’t use anymore.
A lot of times that’s posed as we didn’t want to offend you, or I didn’t wanna attempt you. , but it’s really more than that. Now. If somebody has made a line or a boundary that they don’t wanna be there, if that’s happening, like that’s a different story, but usually it’s not wanting someone to be a buzzkill.
We want people to be all in with us. Let’s take overeating for instance, I wonder how many of you have sat at a restaurant? I don’t know if this is a guy thing, but I know it’s a woman thing that once the meal is over, nobody wants to order dessert unless other people are having it too, because then they don’t have to feel bad or feel like a pig because they’re eating dessert and these other women are watching their calories or whatever. They might want dessert, but they’re gonna do it later alone. Unless everyone else is like, oh, we should be bad. We should get some. It’s the same thing.
When it comes to alcohol or drug use of any kind, people who are using in a way that’s probably problematic don’t want others around to have any negative opinion about what they’re doing. If being around someone who doesn’t drink doesn’t seem fun that might be an indicator of a problematic relationship with that substance.
So up until now, we’ve been talking about what happens before the event where they’re using. So we’ve been talking about pre-planning, we’re talking about the focus and the point of the event being to use. And we’re talking about making sure that the people who are involved are on the same page.
Now we’ll shift over to talking about what happens while the event or the using is happening. So if somebody says I gotta work tomorrow, I’m only gonna have a couple. And then they’re 6, 7, 8 drinks in, that’s not super normal. People who don’t have issues with drinking, know how to draw boundaries for themselves and it’s not difficult for them to stick to that.
People who have decided that they’re not going to use at all this day or for a while that they’re taking a break that’s normal and doesn’t really affect them that much. They might have to remind themselves like, oh yeah, wait, I’m not drinking right now. It’s a dry January or whatever. Oh, well, let’s do something else.
The during part is the part where you have to listen and ask questions about do they set limits ever about how much they’re gonna drink? Have they ever gone past that? How often have they gone past that? How do they feel about the idea of being a designated driver? Is that something that they are willing to do, that they dread doing, that they would never do?
What about how they are when things start getting late, or what if they start feeling sick? Are they willing to go home? Are they willing to call it an evening? Because someone who isn’t committed to drinking, but just to being with their friends would call it a night. If they were feeling sick. They don’t do whatever it takes to keep staying out.
One of the things I listen for is whether or not they’re doing things that they wouldn’t normally do when they were sober. So for instance, driving, it is not normal for a grown adult to get behind the wheel of a car while they’re impaired. It happens a lot. But I’m gonna say that those people are drinking in a problematic way. It could have happened once. It has certainly happened where one time somebody decided to drink and they drank too much and they drove.
Normal is making sure they don’t do that again. It’s not normal to keep doing it and feel like, well, I’m fine, I’m safe. I take back roads. That’s not normal. And I realize in certain places it feels normal because it’s common, but that doesn’t make it normal. Normalized is different than what an average experience is.
It is not normal to bring alcohol or extra drugs with you to an event so that you don’t have to buy it there, it is not normal to pre-drink before you go out, because then the point is to get hammered or get high or whatever, and you’re doing it so that you don’t have to do it there. Maybe once for something really specific, but on a regular basis, that’s not a normal thing.
Yes. During the early twenties, 18 to 21, at least in the Us, that’s pretty common. But would we say that drinking’s normal just because it’s pretty common. Is that the model of what adult drinking looks like? I don’t think so. For me, the clincher here is. Are they making choices that they would not normally make because of a use of a substance?
I have talked before and in my story last week that I stopped drinking not because drinking was my go to but because it wasn’t, I was more of a drug person than I was alcohol. Alcohol was if I couldn’t find the drug I wanted. Alcohol was just there as a stop gap measure. But when I would drink, even though it was only a few times a year, I always drank more than I wanted, woke up with a hangover, drove drunk, even though I didn’t think I was drunk, but by the time I got home and started walking up the stairs, I was like, oh shit. And those things aren’t normal.
Like normal adults who go out and have drinks with friends. Don’t do that. Maybe once in a while, but not every time they drink. And that’s how I knew. That every time I drank, I did something dumb and there were times where I did something even more stupid than those things.
What I figured out was that my brain doesn’t view alcohol in a way that other people do. I do not understand having just one or two, like, why would you bother? There are people who are perfectly content with that. And they just like the taste. I am married to a normal drinker. He will get a 12 ounce Guinness and not finish it.
And I’m not understanding that at all. Logically I get it, but why would you bother? I didn’t know that that wasn’t normal. I thought everybody felt like that. And as I got further into recovering into adulthood, I realized, oh, okay.
Most adults who drink alcohol. Don’t drink in a problematic way. Most of them drink in a pretty normal way. There are pockets, of course, where communities drink a ton and they think nothing of it. But we’re talking about the people who would come into our office and whether or not their use of whatever it is is causing them problems.
It feels weird to judge people’s use. Even as I’m telling you, I have this internal oh, but that’s a little harsh. Is that being too conservative? Am I being like a killjoy? Am I being no fun? Even knowing what I know, I am not certain what it is that makes us not want to say here’s a line but it is in there and it’s in me.
What’s happening when people come to therapy is they want us to weigh in on their life. They want us to hold up a mirror. There are areas they may not want us to see yet, but they came in and they keep showing up and they keep beating their head against a particular wall and that’s why they came for help.
There is no harm in evaluating someone’s use. It can only benefit them. When you are unsure, this is where you need to get really specific about asking them these questions. How often do they use or drink? How much, what happens during what happens if their plans get canceled? What if they started feeling sick? What if they didn’t have money to go out? Would they spend more than they have? Would they borrow it from someone?
A normal experience with using a substance is that someone uses if it’s available, if they don’t have other obligations, if they feel like it and only to the extent that it’s fun. Not jumping into the deep end of the pool every single time.
The last piece is using to cope. As you’re listening to your clients, if it seems like whenever there is something difficult that they are going out for drinks with friends or going to smoke weed or whatever, that’s not great. Substances can be really effective, right. They work to make you forget. It is a really bad habit to get into.
Because what it does is make it so their distress tolerance isn’t growing, they aren’t learning that they can sit with negative emotions. They’re like, oh, I feel this. I don’t wanna feel this anymore. I’m gonna go out with friends. Whether they orchestrate it so that they have a reason to drink or whatever the case may be.
A lot of the mom wine culture is like this. There are book clubs and some of them are really just so that they can drink. In many of the stories I’ve heard it is the book club and their reading, but it really is about the wine. And if there wasn’t wine, they probably wouldn’t wanna go. There’s even exercise classes that pair with alcohol use like yoga and wine. The point of yoga is not at all in line with alcohol use. But it has this attitude. Like I did my yoga now I can have a treat. And my treat is wine.
Remembering back to the how much is too much alcohol episode nobody at those events is having five ounces of wine. Which is considered one drink. They’re having way more than that. Remember, I’m not judging them on their morality. Like I don’t give a fuck. They can drink what they want. What I’m talking about is as we’re looking at things, what are the patterns to problematic use? And these are the things that my ears are attuned to because I have found when I ask someone, what do you do at the cabin every weekend? And the first thing they tell me is sit around the fire and drink, is that all they go out there for? They could be at home and drink.
Well, what do you do if you run out of alcohol? Well, someone would have to go get more. Well, why? Well, because the point is to drink and I’m not judging the fact that the point is to drink, however it is telling. When there’s enough of those stacked together that’s when we start to notice that there may be a pattern of problematic use,
I’ve talked a ton about alcohol because it is the most common substance. Weed is becoming that way. And it’s kind of not clear how adults are using weed. Because there are plenty of adults who are using weed in problematic ways, but normal use of marijuana or in any form THC oil or gummies or whatever we’re not totally sure how that’s gonna shake out yet.
But it is similar to drinking. Making sure that they can afford it, making sure that their responsibilities are taken care of, It isn’t very often, that they’re not using it to cope, that it is simply for fun and only up to the point where it’s fun and not over. That is how normal use goes.
Summing all of this up here are a list of things that I notice and feel like are correlated with some potential problematic use: making sure nothing gets in the way of their use planning ahead of time, making sure that there’s no one there that’s gonna be a buzzkill, spending more than they have, making choices while they’re using that aren’t in line with their beliefs or character, using before an event so that they can spend less money or that they’re gonna make sure they have enough of a substance, planning events so that there will be the substance there and feeling like events won’t be fun if there isn’t a specific substance there.
All of this is in service to knowing what’s happening with our clients. When we hold up that mirror, we are also using it to see what’s happening with someone. We’re paying attention to their patterns, to the things they say, to the things they highlight. And all you’re looking for here is, do I need to do anything else about their substance use or not. This isn’t about judging whether or not everyone’s an alcoholic or an addict. We’re not doing that.
We’re evaluating it. Just like we would evaluate someone’s medical health. Do they have a doctor? Do they go to the doctor? Are they taking medications? Do they have any chronic illnesses? Do they have any current symptoms that they’re ignoring? And if all of that stuff is in line, then we let it go. And it’s the same way with substance use.
It’s just that no one else is really asking them about it. A medical person might ask, but they probably aren’t asking in depth. So who is asking? Are we trusting them to just bring it up? Because people don’t? Listen to the stories that I’ve shared in the recovery story section of the podcast. And you will hear time and time again, people hiding their use, not bringing it up, not wanting to admit it’s a problem.
I had a client yesterday tell me that they’ve been hiding their use from me and everyone else around them. This is what I do for a living. and that person still hid their use. And when I asked them why their response was, I didn’t wanna give it up.
I guarantee that there are people in your practice who are in that spot. Who are using in a way that is problematic and don’t wanna give it up. We’re not telling them they have to give it up. We are showing them what it looks like. We are helping them evaluate what’s happening in their lives, the coping skills, the events, the issues, and the good stuff. And we’re helping them evaluate what’s good. What might need to go? And what’s causing them issues. We are curious about their use of substances and how it impacts their life.
It can be really difficult for us as mental health therapists to walk into this area. Substance use feels like a subsection of someone else’s discipline. Like it’s adjacent to mental health kind of, but it doesn’t feel like ours. . And my whole purpose has been to show you that it is ours. It isn’t the purview of anyone else. It’s ours. It’s in our manual. It’s smack in the center of all sorts of other diagnoses that we use all the time.
We didn’t get taught about it and that isn’t because it’s not important. It’s just that the licensing exams didn’t test on it.. And the licensing exams were built on what schools taught. And it’s just this feedback loop and substance use got put to the side. You can specialize in substance use, but you can also specialize in treating trauma or OCD or eating disorders. But all of those are part of our world.
Substance use is showing up in your office. You may not know. For some of you, you do know it and that’s why you’re here is because you’re like, holy shit, I don’t know what to do with this. And that’s why you’re here. It shows up for us all the time, under depression, under trauma, under anxiety. We owe it to our clients to do a thorough evaluation of all the areas of their life, including their use of substances.
When someone is struggling with coping, the chance that they would never have considered or used a substance to cope is really slim. Check it out, ask your clients. If you feel like you don’t know enough, you are in good company. There are so many people in our field, most of us that don’t feel like they know enough. This is why I started the podcast. This has been the focus of my work as a supervisor. And it’s the focus of my work in my program coming out this fall.
Charting the Course is a six week live taught program aimed at helping therapists feel confident and competent in their ability to address substance use. I believe that I know what you need to know. And you don’t need to know everything about substance use. You don’t need another certification. You don’t need to go back to school and spend thousands and thousands of dollars.
We have the skills to work with substance use. We really do. We just need to know how to assess appropriately, how to evaluate what we’re getting from clients and how to intervene. And I can teach you how to do that. The doors are opening soon. I encourage you to go to Betsy byler.com/course, and check out the Charting the Course program.
Get on the waitlist by signing up and you will get word as soon as the registration doors open. I am so looking forward to working with a small group of therapists and showing you all the ways that you can incorporate this without having to learn a new modality and so that you will feel competent.
And that nervousness about what do I do if someone’s using or what if it’s a lot, or do I refer out that you will just know the answer to those questions? Again, it’s betsybyler.com/course. Next week on the podcast, we’re gonna be talking about a myth about our work as therapists and its relation to substance.
I hope you’ll 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.
Chapter 2 The Neurobiology of Substance Use, Misuse, and Addiction, The Surgeon General’s Report on Alcohol, Drugs, and Health – chapter-2-neurobiology.pdf