Episode #130

Do you feel equipped to work with substance use? If your answer is “yes”, what is it that makes you feel that way? If your answer is “kind of” or “no”, what would it take for you to feel ready to work with your client’s substance use? What do you need? I’m curious about this because I feel many therapists have expressed that they feel ill equipped to do this work. But in my experience therapists have all sorts of skills that are transferable to working with substance use. So I wonder what people think they need. Today, we’ll talk about what this all means. 


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 130. Well, it’s officially the 1st of May today. To me, this is when I really start believing that spring might be here. It’s such a weird change of seasons where I live. We just had snow, and as I was recording this, it was 30 degrees outside, that’s Fahrenheit, and by the time Monday rolls when this airs, it’s supposed to be 70.

I am excited about the month of May because there are a couple things happening that I wanna draw your attention to. You may have seen on social media that I’m hosting a free webinar. I like to do these a couple times a year to help provide a free resource for folks.

There are a couple other free resources on my website of course, but I like to do a live event and encourage people to come and be able to ask questions, and get some good information. 

Doing the podcast is fun. The thing that it lacks though is interaction. So I’m excited to say that on May 16th, at 8:00 PM Eastern time, 5:00 PM Pacific Time. I’m hosting a one hour webinar called Screening Skills for Substance Use. 

I’m gonna be sharing my top three questions to help jumpstart your conversations about substance use. You can register for this free event betsybyler.com/skills. If you’re not able to attend live, no worries, there will be a replay and it’ll be emailed out to all registrants after the event is over. I would love to see you there, but don’t forget to register at betsybyler.com/skills.

If you’ve been listening for any period of time, you’ve heard me talk about the fact that outpatient mental health is a perfect place to work on substance use issues. It might not seem that way because our training and usually our jobs haven’t told us that we can do that. When it pops up, a lot of us feel like, um, that’s not what I do, or I don’t know what to do with that. And the truth of the matter is, is that we actually do know what to do with that. We just haven’t been told that.  We already possess what we need. 

It’s not so much a certain set of skills that we need, it’s information.   How the substance use functions and what needs to happen in order to change the person’s relationship with substances. Today I’m gonna be talking about a statement that I have heard numerous times. 

I have had the opportunity over the years to work with a lot of therapists. When substance use comes up, I see people shake their heads. I hear people make comments like, I don’t know how to do that, or, I’m not trained to do that, or that’s out of my scope. I think in some ways there’s a lot behind that. It could be that truly, the person doesn’t have any training, which is true for a lot of us. It could be that there are people who really don’t want to work with substance use because of a number of reasons. 

One of my very best friends and colleagues feels like it’s too much for her to work with substance use because she has it in her family, and it’s been extremely painful. That to me, is a perfectly valid reason to not work with it. Every one of us has to know our limits and stay within those limits. If we can’t be objective and manage the transference in the room, then we probably should stay away from it. For others, they might be open to it, but they’re just not even sure where to start.

Last week we talked about treatment. Treatment is a word that can mean a lot of things. We don’t usually use the word in mental health unless we’re talking about a treatment plan. Treatment sounds really formal and distancing and clinical in a sense of being more cold and detached.

My experience being a therapist, being a supervisor and with colleagues is that we kind of shy away from things that seem cold and detached because that’s not our way. So when we use the word treatment for substance use, it can push a lot of us in mental health even further away  from looking at substance use as something we can address. So I find that the word treatment sometimes isn’t helpful. 

The point I was making last week is that formalized treatment with a capital T is not a requirement for sobriety or recovery.  The majority of people who struggle with -substance use don’t ever get treatment. They do a number of other things on their own that are more successful or less successful, depending on the person and depending on what they do. 

My personal story of recovery, there was no treatment, and this wasn’t even because I didn’t have access to resources. It’s because I didn’t know that I could qualify or would even need treatment. I knew that I was using drugs and that it was wrecking my life and I needed to stop, and so I had to figure out how to make that happen. 

I found out all the things that I would’ve learned in treatment later, after I had already had to work through all of that myself, it certainly would’ve been more helpful to have a treatment guide or someone to walk me through it. I can tell you that the therapist that I was seeing during that time didn’t have any idea how to talk to me about my substance use.

Somehow we have this belief that we’re not skilled enough as mental health therapists to do substance use. I find this sort of odd. We have all had moments where someone was sitting in an appointment with us, and we have that moment of, wow, okay. I am not sure about this. I’m not really sure how to do this, and we have to spend some time kind of thinking about if we had to work with this person, what would we do? 

I wanna tell you that you have the skills to work with substance use already. Truly, I want you to come to the free webinar that I’m offering in a couple weeks. I am gonna share with you  the top three questions that I think will give you the most information for your clients. Skill-wise, though you have these skills, you use them all the time every day. You just haven’t thought about it that way.

It’s sort of a well kept secret. And I know I’ve talked about it on the podcast before, and so perhaps some of you who are listening today have already heard me talk about this, and if you have, thank you so much for spending time with me again.

There’s this idea that there is something special about a substance use counselor, that someone who specializes in substance use has a unique set of skills. In some ways, I suppose that can be true. There are skills that I go to specifically when I’m dealing with substance use versus when working with someone who has garden variety anxiety or major depressive disorder.

But the skills that I go to are only because I’ve seen those work the best and I’ve used them the most. But I learned those skills from mental health interventions. I haven’t had a ton of training on how to treat substance use. Know why, cuz it doesn’t exist.

If you look up treating substance use, you’re gonna find a mix of things. One of the things you’re gonna find whenever you do any kind of search on substance use is treatment centers, residential treatment centers. They are called a number of different things, but they are essentially a treatment center that has put up a ton of webpages to draw people to their treatment center.

Granted, a lot of information is being put out there and I am glad for that because oftentimes people need that information in terms of what is addiction? What about this specific drug, what does it mean? And so the information is there, but it’s tied to an outcome. They want you to come to their residential treatment center.

Residential treatment centers are incredibly expensive and a very small minority of people struggling with substance use are ever going to access them. In addition to all of those links, then there are very well mined, the Mayo Clinic, those kinds of things, along with links to research articles. If you do a little further digging, you’re gonna find that the only things really stated are that treatment would be potentially individual group or family therapy sessions, a focus on understanding the nature of addiction and a discussion about levels of care like outpatient, residential, day treatment, et cetera. None of that is about technique or skill. 

When you look at things a little further, very rarely do you see a mention of specific skills. You’ll get pointed towards curriculum, and within those curriculum curricula, there are worksheets and suggestions and they have underpinnings based in psychology. 

For instance, CBT super popular, right? It is the idea that in order to change behavior, we have to change thinking, which  I’m on board with,  but none of that is proprietary to addiction and substance use. There is not one single modality that is the goal to standard for treating substance use.

More often right now, what you’re finding when it comes to strictly treatment is managing withdrawal and preventing overdose, and we’re talking about medical interventions like Naltrexone, suboxone, methadone, and naloxone. The first three have to do with dealing with opiate withdrawal and craving. And the last naloxone has to do with reversing opiate overdose. But you can’t find training where you’re just going to be taught the skills  for doing substance use work. 

Why is that, do you think? Why is it that you can’t just find a book, a training, a class to teach you specific skills to do substance use work. You actually would have to search a bit to pull that together. And it’s not that you’re not looking correctly, it’s not that you don’t know how to search to find the right information, it’s because they don’t exist.

There are skills that many of us use for working with substance use, but we’re pulling them from other places. The cognitive triangle that we find in CBT. So the antecedent, the behavior, and the consequence, is co-opted for use with substance use, and instead we have the trigger, the behavior and the outcome.

The focus is on changing the behavior, not the trigger, but the behavior so that the outcome is different. When we’re talking about CBT, we’re talking about changing the thought so that we can change the feeling and then change the behavior.

In substance use, we’re still talking about very similar things. The thing that’s a little different with substance use is that triggers aren’t something we are focusing on undoing. A trigger is just that. If driving by your dealer’s house or driving by the bar you used to hang out with is a trigger then we talk about how to avoid the trigger. Which is driving a different route, not going to a specific place, hanging out with different people, whatever the case may be. We find ways to avoid the trigger, and then if the trigger is unavoidable, then we talk about how to manage the trigger. All of that is based on CBT.

Let’s take D B T for instance. Dialectical Behavioral Therapy, DBT is well known as being the treatment for working with borderline personality disorder. What DBT actually is is pulling together a number of different schools of thought. When I first trained in DBT I noticed that a lot of what DBT is is pulling together all sorts of things from other schools of thought and putting them together. 

Certainly there was a lot of thought that went into it about specifically what people who have borderline personality disorder need and the unique challenges that an unstable sense of self presents. But it wasn’t that she found some sort of cure-all. She found a set of skills to put together in a way that was managing the different aspects of borderline personality disorder. 

 If we look at a modality like EMDR, certainly there are some differences with EMDR and other techniques. The bilateral stimulation is its own thing. But EMDR also, Thinks about CBT, we’re looking at a negative core belief and we’re trying to help someone change it. The method by which we’re doing it is different, but the outcome is still the same. A lot of our modern techniques are based on early understanding of psychology.

I think that our research has made it so we’re better understanding those things these days, but we have certainly built on what early founders of our discipline knew. Substance use is treated the same way. 

There are thoughts that impact feelings, that impact behavior. There are outside stimuli  that have been paired enough times that now we have classical conditioning happening and we need to figure out how to change the narrative so that when a person starts heading towards a behavior that they can choose a different path and make the outcome different.

The main differences in treatment of substance use do have to do with the medical issues, with withdrawal, with physical cravings and management of  the medical aftermath, or medical outcomes of the addiction. That is the nuance here. The other stuff is simply behavior modification. But you know how to do behavior modification.

This is something that we learned early and that many of us had in undergrad. How do you change behavior? How do you make new habits? A lot of the work that we’re doing is fairly simple in that way. The place that therapy comes into it is helping people understand how their previous interactions and their history impact their ability to make these changes.

We wanna know why this person is drinking as much as they’re drinking.  What is pushing that person to keep making that decision? Because if we can change that then that person has a better chance of making a different choice next time the opportunity to drink comes up. If you don’t feel like you have the skills to work with substance use, I’m wondering what skills you think you need to have.

I remember having a conversation with a colleague about how they handle things when somebody comes in for disordered eating. And this person was telling me that normally they would do A, B, and C. And as she’s talking about it, I’m nodding and I said, I think that’s completely appropriate for working with substance use. And she’s like, really? And I was, yeah, that’s a hundred percent appropriate. I would totally do those things. 

Talking with someone else who is very much into solution focused work, and they’re talking about setting small goals and trying to solve specific problems and staying focused on these things and not going into the background very much. Okay. That works for substance use too. 

The only thing that I would say that could be construed as different is that we avoid trauma work for quite a bit of time until somebody has some stable time under their belt. But those of us who work as trauma therapists, we do the same thing. EMDR is my primary mode of trauma therapy at this point in my career. 

I have a lot of folks when they come in that I can see that EMDR would be helpful for them. Some of those people have trauma, some of them have OCD. Some of them are anxious and others of them might have a specific phobia. EMDR can be effective in all of those ways. However, we don’t begin EMDR very early. 

There are a number of things I wanna check on to make sure that we have stability day to day in their regular life, and food and shelter and transportation and finances and all of that. I also wanna make sure they have the emotional resources to be able to do some extra work. I wanna know if there are major problems that are happening right now that need to be solved before we can begin EMDR. That process can take a really long time.

Almost never do people show up, ready to dive in in the next few sessions. Usually there are other things happening that need to be solved or managed in order for EMDR to be a good idea. Even when it comes to substance use and addiction, knowing that I am going to try to push out trauma work for a year at the least, if not two years into recovery, that isn’t that different.

What skills do you need to have to be able to say, I have the skills I need to work with substance use? What are those skills? What I’m telling you is there isn’t a list of skills. 

Let’s take important skills from different modalities.  Let’s say DBT, for instance.  Let’s talk about a common skill called the Cope Ahead Skill. The Cope Ahead Skill is designed to have us look at  how we might prepare ourselves for a specific event. 

This shows up in a lot of different types of therapy. This could be a future template in EMDR. This could be visioning in the future of the way someone wants something to come out. This Cope Ahead Skill is designed to think about a future situation, to examine what they used to do, what they want to do, and come up with a plan for how they’re gonna manage that. We use that skill in working with substance use all the time. 

What the person who is using substances has is a lot of data about how they act in certain situations. Family wedding coming up? Have you ever been to a family event before and what happened in relation to your substance use? Okay. Let’s talk about that. 

A work function where alcohol’s gonna be served? What has been your experience going to those before? If they haven’t been to that specific thing, then we try to find something that’s related. We’re looking at past data to predict what the current and future situation is going to look like. If they truly have no past data then we talk about what they know about the upcoming event and what potential downfalls might be.

That is a skill that is super helpful in a number of environments. I’ve seen it used for self-harming. I’ve seen it used for people who are on diets and wanna avoid certain foods. I’ve seen it used for arguments when a couple are trying to anticipate how they might respond if their partner says this or does that. That’s a DBT skill and yet  it’s also a skill for treating substance use. 

How about talking about IFS, internal family systems? Well, if we’re thinking about all of our parts working together for our good, what about the part that is responsible for substance use or addiction? That part is trying to keep the person numb. They’re trying to help the person avoid pain, and keep their feelings under control.

So the problem often is that the part that is responsible for substance use doesn’t trust the other parts to do their job, to keep the person safe. And so the substance use part is like the emergency button. Overwhelming, go get hammered. Struggling and feeling sad, go get high. IFS can be used to work with substance use.

EMDR can be used to work with substance use. There are some specific protocols that have been developed, but I find that the standard protocol can work perfectly. We don’t need to have other specific protocols. I can tell you that the different protocols and interventions that have been created and adapted for substance use came from the practice of therapy first.

I want you to think about what your favorite modalities are. What do you use the most? Which skills do you go to? If you had to pick five skills that you use on a daily basis, what would they be? I know this is a hard exercise, so I can tell you what mine are. 

Generally on a consistent basis, every day I ask people to tell me about their week.  I wanna know about crises. I wanna know about the stress that’s popped up. I wanna know about sleep. I wanna know about medication compliance. I wanna know about interpersonal relationships and if there’s anything that I should know about that happened. And I wanna know in general, if there’s anything current that needs to be addressed.

Next I ask the person if there’s anything that they have been thinking about this week that they wanna make sure we talk about. It could be success, a difficulty,  a random thought. Once I’ve established that, I remind them of what we had been talking about and what the overarching goal was, and we talk about how they feel about if that’s the thing they wanna talk about.

Each session of mine follows that trajectory in the beginning. What we do next completely depends on their answers to those questions. Then I talk with them about what is troubling them, what feeling, what behavior, what thing they keep coming back to that they want it to be different. Then we figure out why that thing is happening and if they wanna do anything about that. You can see where this is going. 

These are my sessions even though I have clients  in vastly different places in their emotional work, yet I am taking the same core skills and applying them to a bunch of different situations. You do the same thing. I am willing to bet that your favorite modalities can easily be translated into substance use work.

This is one of the things that we talk about in my main program, Charting the Course. Charting the Course, if you’re not familiar with it, is a six week live taught program with CEUs attached where I go through the curriculum that I created to help give you the information you need to work with substance use and feel confident at it.

You can check out what things are covered over on the website@betsybyler.com slash course, but one of the components is looking at your favorite modality is, and helping you figure out how to translate those into working with substance use.

You don’t need a special set of skills. You literally have what you need. Certainly there are skills that we use all the time that I think are more effective than others.  There’s of course information that I think is important to understand depending on which substance the person is using, how early they started, how often they’re using that kind of thing.

But are you skilled enough to do this work? Well? Are you skilled enough to work with clients that are struggling with suicidal ideation?  Are you skilled enough to work with clients that are struggling with self-harm? How about clients that are struggling with binge eating? How about clients that are struggling with continually dating the same types of people over and over and over? 

The skills that we would use for each of those things are the skills we need to use for substance use. You are skilled enough, you really, really are.

If you are listening to this podcast, You are a therapist. You have developed skills on how to be a therapist and how to work with clients. What you need is another lens. 

So when we look at people through a trauma-informed lens, when we look at people through the lens of their family system, when we look at people through the lens of their community and culture,  those lenses affect how we see people and how we understand their issues.

Substance use is simply another lens. It isn’t another discipline. It isn’t so different that it doesn’t fit in the same realm. The reason it hasn’t been in the same realm has nothing to do with its place. It has to do with politics and the focus of universities and the organization of information. 

In the fifties and sixties when licensing was happening, the MFTs and the LPCs and the MSWs were all doing their own thing. There were numerous organizations for each type of license, not even mentioning the APA and the psychologists. Substance use was still in its infancy coming from the late thirties and forties with Aa. It didn’t get formally recognized as a valid treatment need that was more than just niche until much later. It just has to catch up.

So what if you are skilled enough? Over the last three weeks , I have been talking with you about what it means to do substance use work. I have encouraged you to not avoid the substance use topic with your clients.  I believe that for the majority of therapists that there are clients of theirs that are using substances, but they just don’t know about it.

It’s not because those therapists are being neglectful or anything like that. It’s that people hide substance use and they’re good at it. We’re good at hiding our own shit if we want to. Sometimes even inadvertently. 

I am betting that you have had an experience or will have an experience to find out that a client of yours has been using substances far more than you realized. Sometimes it can really be because we didn’t specifically ask. It might have even been implied, but the client was like, nope, didn’t ask. Not saying.  I’ve encouraged you. Don’t avoid it. Ask outright.

Then we talked about how once you know about it, that treatment isn’t always formal. It’s not capital T. It can be tons of different things put together to meet the client’s needs in a specific way and that treatment is what we make it. That you are absolutely capable of doing substance use treatment. And today, my main purpose is to encourage you that you really do have the skills.

Don’t forget to go sign up for the webinar on May 16th betsybyler.com/skills. Please feel free to share that with colleagues. It is free. There will be a replay and the slides for it will also be available. I would love to see you there. If you can’t and you have specific questions, I’d love to hear from you. I can’t wait to get a chance to see your faces on screen. Again, you can check that out at betsybyler.com/skills.

Next week we’re gonna be talking about one of the final reasons I hear when people aren’t comfortable working with substance use, about risk and liability. I’m gonna be addressing that directly next week so that we can talk through the pieces of substance use work, where risk might lie, if any, and what that means to us.  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.

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