Episode 143

Screening for substance use allows you to provide comprehensive care to your clients. By assessing their substance use patterns, you gain valuable insights into how their substance use may be contributing to their mental health challenges. This holistic approach enables you to tailor treatment plans to account for how they are using substances in their lives. But how do we start? Today we’ll talk about this topic as we prepare for the main event, Braving the Course, coming up 1 week from today!


 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 143. This week is the third out of four episodes that we’re gonna be doing in preparation for the event Braving the course. This event is our second annual, and it’ll be happening on August 28th at 6:00 PM Central Time, going to about 8:30 central time.

For those of you who aren’t able to attend live, there will be a replay afterwards. All you need to do is sign up and register. Event is free. It’s at betsybyler.com/braving-the-course. We will say that again, probably maybe a couple times. It’s on my website, and you may even see stuff in our Facebook groups and wherever there are therapists, we’re trying to get the word out.So please feel free to invite colleagues. Jenny’s and my desire is to support all of you as you do this really important work. 

Today we are talking again about how trauma and substance use intersect. In the last two episodes, we talked about how they intersect and that substances are actually a pretty effective way to deal with feelings in the moment. We’re not saying that people should, it’s not necessarily adaptive. It is effective, and in fact, a lot of our techniques are gonna have a really hard time competing with substances like alcohol or marijuana. So then we got to talk with Jenny about what it is like to do that balance between being vulnerable and open in session and not getting burned out and overwhelmed and drained.

She walked us through a technique called Soft Front and Strong Back. If you haven’t heard that episode, you can head over to betsybyler.com/podcast and check out episode 142 or wherever you listen to podcasts. It’s the All Things Substance Podcast, and again, it’s episode 142.  For today, the question that comes up is, substance use is a thing. Yes, I have clients I know that are using, I don’t know what to do next, and I’m not sure where to start. And so that was the thing that Jenny and I, when we talked today, discussed about how we wanted to bring this up. And I get that question a ton. And so that’s where we’re gonna be starting.

Again, I’m Betsy Byler, if you don’t know me, and I am an EMDR therapist and a substance use counselor. I am a mom of two grown kids and a cat mom and live in the northwest woods of Wisconsin, even though I am a Chicago girl at heart. So I’m gonna turn it over to Jenny. So for those of you who don’t know Dr. Jenny Hughes, she can introduce herself and we have a guest with us today. So if you hear him. He is  our special guest. 

Yeah. So for everyone watching, we also have this posted on YouTube. You’ll be able to see a little baby head. My son is with us today because of life. That’s just how things are working out today, and that’s okay.  So thank you so much, Betsy. I am a psychologist and a trauma therapist. And I too am a mom of two kiddos and I live in Houston, but I’m from Colorado, which is where I am right now at this time of the recording, which feels so nice compared to being down in the south and all of that awful heat.

So I’m really grateful to be here.  And I also run the Brave Trauma Therapist Collective. That is a big part of the work that I do as a trauma therapist, is helping to support other trauma therapists in the work that they love. And what you brought up, Betsy, about the theme of our episode today. Episode of, okay, so where the hell do I even begin? You’re saying that we need to be meeting our clients where they’re at when there’s an intersection between trauma and substance use and, okay, cool. I can be open to it, but then what? It can be so hard to just ask some of these questions and to have these kinds of conversations.

I think a lot of times for me and other therapists that I’ve spoken to, there can be a hesitation because you don’t wanna come off as judgmental. It can feel like it’s, you’re prying. Like it’s too personal, even for a therapist to ask their client about substance use. And so even when we’re in agreement that yes, trauma and substance use are linked, yes, we wanna be open to this work because we know that it is and can be incredibly rewarding. Still we’re hesitant. We don’t know what to do. So how do you help to support therapists in just taking that first step?

I wanna start by dispelling a couple of, I don’t know if they’re myths necessarily, but fears, assumptions about what it is  I want folks to do and  I have been in this field 20 years, I’ve been a supervisor and I’ve walked a lot of folks through this beginning step. 

My goal is not to work with substance use counselors, although I have done that, to teach them mental health techniques, but to help your average outpatient mental health therapist, how to step into this and not specialize, not get into the deep end, but to be in this problematic use. 

So I differentiate between problematic use and addiction. So I’m talking about this space between full-blown addiction and normal use because using substances is normal. This is just something that  we do to celebrate or to when you are with friends or whatever. So there’s a really normal range. It’s when it starts causing problems that’s where I’m talking about and for us, when people are using it to cope, if that’s their only coping mis mechanism or their main one, it’s not super awesome.

Because tolerance is a thing and progression is a thing when it comes to substance use, it’s not gonna work forever. So you don’t, as a therapist, your job is not to get them sober. That is not the goal. If they want to like, great, you can support them, but that is not the goal here. The goal for you is to allow substance use to be in the room so that they can talk with you about it, that you are normalizing it, that you are like, Hey, I get it. The trauma that you’ve been through is overwhelming and this helps immediately. I totally can see why that is. 

So you are not trying to make them quit. You’re not trying to convince them. You are not trying to force them. You are not pulling them in any way forward. You are helping them determine for themselves what they want and to see if their substance use is in any way getting in the way. 

A couple things come up for me around that. So one that sounds great. If you do it at intake. Because it’s like you’re already asking all of the nosy questions and so anything is fair game. So that’s one piece of like, how do we do this if we haven’t asked about it? And coming back to the, like feeling judgy or nosy.  I agree with you in terms of supporting therapists and trauma therapists in addressing the problematic range, but I feel like that is exactly where it does feel judgy.

Because, in that problematic range, our clients, depending on their level of awareness, may or may not realize it’s a problem. And it can come across as I’m not an addict. Like, why are you asking me these questions? And it can feel really scary as a therapist and worrying about the therapeutic relationship and things like that. 

I think those are really important. So one of the things that I have talked about, and in the show notes on the web, on my website, there will be links to things that we’ve talked about. And so when you go to betsy byler.com/podcast, you can find this episode.

But I’ve done a, I did a one hour training on how to bring up substance use, but I’ll just be really brief and say, Oftentimes when we bring up topics and especially substance use, even for me, I don’t want people to be like, do you think I’m a drunk? Or whatever. And so I’ll have to say, if I’ve known someone and I maybe didn’t assess or whatever, or I’ve asked them in the past and their answer was no.

And now I’m like, I don’t know about this, and so let’s revisit, right?  The way I do stuff in session is I’ll say, tell me about your week, and then I’ll say, is there anything specific that you wanna talk about today? And I might say there’s something I was thinking about that I thought we could talk about, but I wanna check in first about where you’re at about what you wanna talk about today. And if they’re like, no, I don’t really have anything, just say, okay. 

So I was at this training the other week, or I was listening to this podcast about trauma and substance use. I know that we’ve worked on trauma and substance use is  so we’re talking like drinking or smoking weed or whatever. And I’ll use those phrases. Rather than substance use I’m gonna cut it off. Because if your person is using anything bigger than that, you likely will know.

Because after a certain limit, people don’t wind up in outpatient therapy. They just wind up in treatment because they’re involved with the law. So anyone who’s using like heroin, meth, cocaine, they might be dabbling in it and still be in your office, but when it’s really severe, those people don’t show up often for us. That’s just how that works. 

And so I’ll say, I don’t know much about your history with drinking or marijuana use and I wanna check in about it ’cause I just, I don’t know. Because it can be people’s go to, especially when they’re younger, I just wanna check in. And so finding a way that is not clinically stilted and whatever goes with your style of taking it from substance use and being like, so lots of people when they experience trauma might be drinking more or they might start smoking weed and I just wanna know what your history is and if that’s ever been something that you’ve used to manage trauma when it was overwhelming.

If they feel defensive if you get that, you can back, on your own, just be like, so I want you to know, I don’t have any opinions about  whether you’ve been drinking or smoking weed. I just wanna know if any of that is how you’ve coped. You’ve done a, and you use that, your relationship with them to say you have survived a number of things that were really hard and whatever you did to do that or are doing to do that my goal is not to take away what you’re doing to cope.

I just ’cause it’s valid. Like of course you are doing whatever you need to do to cope. And so I think about finding a way to ask the question. There are a number of places you can get in there. You could ask I don’t know what your history was with drinking. What, how did you grow up in your house? Do people drink? Is that a thing that people look down on or is that acceptable? And so you find a way that they can talk about their family. 

Or I think with some of my younger adult clients, I’ll say, so what was the party scene like in your high school and you can go there. And so in some places in the country and probably in other countries, it’s similar that sometimes alcohol seems to be more popular and sometimes weed is more popular. And so I’ll just tell them , in my high school it was alcohol, how about yours? And so we go there and I’ll say so did you experiment much?  

And if they are defensive either they have opinions about their own use, right? And we’re poking on something, they might feel like maybe I’m drinking too much. Or somebody else has made a statement , you need to calm down. Yeah. And it is an opportunity, but finding Hey, I was listening to this podcast the other day. about trauma and substance use and that’s easy in .  Yeah, and like it’s having that excuse or reason or whatever to bring it up. And even if people are listening to this podcast today and then they bring it up in two weeks, just pretend like you just listened to it.

For all the non-clinicians listening to, I totally will blame things like the agency or stuff like that. Oh, sorry, this is just agency protocol. When it’s tough or I need an in. Not that I just same with this. Not that we’re trying to get a way out of it or to sidestep it, but sometimes you just need to break that ice and it can be helpful as a clinician to be able to have a little bit of an external way to then come back in.

Yeah. so I think finding that way suits you knowing that  you do not need to be asking about every substance on the planet. That’s not what you’re doing here. This is a brief foray.  What you’re listening for is moments when you’re like, oh, that’s probably not great, but you can hear that when somebody is shopping. And the retail therapy, right? Or when they’re eating a bunch and then they feel terrible about it, and so then they wanna go on some kind of crash diet. We don’t have to be eating disorder specialists to know that’s not a great cycle because there’s a lot of negative self-talk and a lot of shame and we don’t want that.

And so you’re just listening for if someone’s going out And they’re getting hammered and hooking up with rando strangers. Maybe they’re good with that.  I’m pretty sex positive as a human. Knock yourself out. But if you are doing that and then you have negative stuff in the morning, I don’t love that.

Yeah. Yeah. And so we’re for you, just, we’re just listening for that. Yeah. Because I don’t want shame and I don’t want criticism of yourself. And so I wanna help them, whatever their value is, be in line with that.

So then do we want listeners to then just tell every single client that they just listen to this podcast and they’re gonna ask them about , how much they drink and smoke weed, or like, how do we know which clients to have these conversations with?

So that’s a hard one. Caveat, I would love for substance use to be a competency. For everyone in the future. All therapists.  Most of us didn’t get trained, most of us. And there’s no conspiracy about why we didn’t. It just wasn’t included. And even when it was, I went to grad school in California. I took one summer course on drugs and alcohol, and it was a total joke. Yeah. It just hasn’t been focused. And so we’re all like, what do we do with this? Which is my passion.

But to answer the question in a hopefully more concise way when someone is highly symptomatic, they’re doing anything to survive. I wanna know what they’re doing. If they’re pretty stable,  let’s take EMDR for instance. If I’ve got someone and we’re processing often and their symptoms are getting better and their scores are going down and up like they’re supposed to. I don’t know if I’m really concerned about that. 

But if they’re all over the place or I’ve done sessions when someone was high not on purpose. And I’ve seen that go badly. And so if you’re having weird things, if you’re doing EMDR and some of the numbers are up and down and up and down, like those are all flags to me. Or when someone’s symptoms aren’t getting better when I feel like they should that something isn’t working. And so those are the folks that I would start with.

So those clients that you’re like, God, I don’t know what is going on, like I need to consult on this, or whatever it might be, or you’re almost feeling like you’re pulling everything outta your bag of tricks, trying every single intervention and nothing seems to give.

Yeah, that’s where I would start, because almost always for me, when I feel like I’m missing the middle puzzle piece, it’s like I have all these pieces and I’m like, something is not connecting. There’s either undisclosed trauma, either, they don’t know, don’t remember, don’t know about or haven’t shared, for me, what I found is either substance use or some pretty toxic stuff in the romantic relationship that they haven’t discussed. Yeah. 

Because those are really big things to hide. Yeah.  Or disordered eating, I think. Yeah. Can sometimes be in that camp too. Which there’s just so many disordered eating is another great way to cope with our traumas and our difficult feelings. It gives us a sense of control and then we have a lot of shame around it. And so , it falls into this grouping of things are helpful in the short term, but don’t make us feel good. They make us feel ashamed perhaps. 

We want, we don’t want people to know, so we’re keeping secrets. And substance use is just I think it’s probably the most common one in that problematic range. Especially drinking. Yeah. ’cause it’s just normal. People will actually comment if you don’t drink. And that’s like the only substance that people are like, why aren’t you drinking? And they won’t know, especially if you’re able to do it at home.

So let’s say you, you’ve identified some clients that you’re like, yeah, I wanna ask about this. This could be there. I could see that your goal is not. To, like I said, to stop them. The goal is to get the parameters. And we do this all the time. How bad is your depression? When did it start? What’s the highest that you feel and happiness in a day? And then  what’s the worst? Have you had any suicidal ideation? Like we’re finding the edges. Same thing with anxiety. Have you ever had panic attacks?

How often? When was the last time? And the same thing with substance use. We’re looking at, , how often are you drinking when you drink?  What is it that you like?  How much are you having? What is it that you like that it does for you? Instead of don’t, it’s bad, like it does something positive and so Totally you ask them like, why alcohol and not weed, or why weed and not alcohol?

What do you like about it that you don’t like about that? Yeah. And because people who have tried more than just alcohol have a preference and Right, exactly and they can tell you what that is. And so what you’re looking for is getting the parameters of whatever the substance is and listening for anything you’re like, all right, so if you’re drinking a lot before bed,  and you’re waking up feeling really tired, that’s probably not great because that’s a depressant. It’s gonna not let you go through the sleep levels as well. And you’re not getting as much reparative sleep and you’re just thinking this, right? You’re not necessarily talking through it. But that’s enough to start. 

Yeah. Because what we’re looking for is what’s gonna get in the way of their healing and the freedom that they want in their lives to move forward. And you are just going to look at that as a behavior of any other kind. That could be whatever’s a maladaptive coping mechanism, we want them to examine if it’s serving them. Exactly. And if they’re down with it and they don’t wanna change anything, that’s fine. We leave it alone.

But we have at least addressed it. And I document it. For those of you who are super risk averse I don’t know that there’s anything that’s gonna come of that, but you just are. It’s the same way with depression. I ask about when was the last time you had blood work? Have you ever had your thyroid tested? What about iron? What about vitamin D? If I’m looking for what causes it, and I’m not finding it, I’m not a medical person, but I wanna say,  have you been to the doctor? Maybe we should have an updated physical blood work. Maybe you should do that. And then let the doctor decide what’s gonna happen.

And at Braving the Course, you’re gonna be going into even more depth about this. Tell our listeners more about what you’re gonna be teaching at Braving the course. 

So I have narrowed down screening questions, and I picked three of the screening questions that I think are the most helpful, and I’ll be sharing those with you, why I believe they’re important and what problematic looks like in response to those questions.

So you’re gonna come away with really specific information and questions that you can use right away. Awesome. And that is all going to be part of the PDF workbook that we’ll be providing to people too. And you’ll be able to attend live, catch the replay, but also have an actual, just Like I’m definitely like, a paper person, even if it’s a PDF, where it’s really helpful for me to have resources like that, that I can like quickly scan right before a session when I don’t have time to re-listen to a replay.

So that’ll be available for folks there too. Great. Yeah , it is Jenny’s inspiration behind doing the PDF workbook. I I’m not a writer, and so whenever we do stuff together usually Jenny’s the writer on our team. Again, You just need to register. It’s free. It’s on August 28th at 6:00 PM Central time.

Go to betsybyler.com/braving-the-course and we are really excited to have you. If you can’t attend live, please register anyway. We will send you the replay the next morning and we look forward to any questions or comments and interacting as well. So thank you so much. 

Next week Jenny, and I’ll be back for the fourth and final episode, and we’re gonna be talking about how therapists getting support from other therapists actually can change what’s happening in you, prevent burnout, and really give you a chance to have more joy and energy coming from the work that you do.

So thanks so much for listening and we’ll see you next week. Thanks everyone.

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

Braving the Course Registration betsybyler.com/braving-the-course

Home of the Brave Trauma Therapist Collective braveproviders.com

Charting the Course betsybyler.com/course

Brené Brown on Strong Backs, Soft Fronts, and Wild Hearts https://brenebrown.com/podcast/brene-on-strong-backs-soft-fronts-and-wild-hearts/