Episode 102

Substance use is our problem. By “our” I mean mental health therapists. The subfield of substance use isn’t big enough to be its own thing. It’s just a further specialty. Like other specialties such as eating disorders, sex therapy, OCD treatment, trauma treatment. Generalist mental health therapists will (and should) work with those disorders.. We don’t turn people away lightly.  We have to evaluate if the level of issue they are having is something that is severe enough to warrant a specialist or not. The same is true for substance use. We evaluate and determine if we can work with it or not, we don’t just blindly refer out. 

Today’s episode explains why I think substance use wasn’t included in the psychological conversations that formed our field. I don’t think it was on purpose, I think it was simply a victim of circumstance (with a bit of stigma thrown in). 


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 102. Today I wanna talk about a mindset shift. Creating a mindset shift is something we are really good at. We help people with this all the time. We reframe feelings and thoughts and situations to help people see it from a different perspective. 

Today, though, I wanna address a specific mindset that is something that is just part of our field and the mindset is substance use isn’t our problem. Substance use or addiction work belongs in someone else’s wheelhouse, not in mental health. It’s a mindset that I’m not sure if we’re told directly, but that we certainly have. And today I wanna make the case that substance use and addiction work is our problem.

Our clients are experiencing issues with substance use and using problematically. If our clients are struggling with it, it is our problem.  If I were to take a poll of therapists across the United States and ask them whether substance use was in the same house as mental health or in a different house, I have a feeling that I would have,  not quite a unanimous answer, but a strong majority answer that it’s in a different house than us. It’s a different discipline. I wonder why that is? 

In order to shift something a lot of times we need to understand where it came from, understanding how it grew that way is vital to helping dismantle. If a client has a mindset that they shouldn’t show emotion, that men don’t cry in order to help them dismantle that and shift their perspective we have to understand what’s holding it up. 

Is this something that they just got from the culture? Is this something that was family driven? Is this something that was friend driven or neighborhood driven? Who was reinforcing that? Were there actual words that were spoken to them or was it more just in the experience of being in that family and in that place and time?

So I want us to understand why this mindset got to be this way at all. There is no place I can find where it says that mental health and substance use are two distinct things. When we go to the DSM substance use disorders are smack in the center of a bunch of other disorders. In the DSM V substance use disorders are in the chapter between disruptive impulse control disorders like ODD and followed by neurocognitive disorders like dementia and Alzheimer’s. Those are absolutely in our wheelhouse as well. So why is it separate? 

Well, in order to talk about that, we have to back up a little bit. We’ll have to look at what influences our field? Well, I’m gonna say a few things. In the United States, specifically, the DSM is a big deal whereas in the rest of the world, they use the  ICD 10, moving to 11. That’s the International Classification of Diseases, but the DSM is primarily what we use in the United States. Then I’m gonna say educational institutions like universities and colleges that have programs that help people become therapists. And lastly,  the organizations that represent therapists that review research and journals. And those are the places that therapists and psychologists gather. 

For the majority of us still in practice we have always had a DSM of some kind. The first DSM came into being in 1952. Before that there were hints at it. People were trying to figure out how to classify diseases and put them in some sort of book to be used. In 1921 the American Medical Psychological Association became what is now known as the American Psychiatric Association and they developed the American Medical Association’s Standard Classified Nomenclature of Disease. 

This was mainly used to diagnose people who were inpatient. So people with really severe mental health issues. It wasn’t until the DSM I in 1952, that the standards started to include other mental health issues. So we need to think about the fact that the DSM itself is only 70 years old. The DSM II was in 1968. The DSM III was in 1980. DSM IV was released in 1994 and the DSM V came out in 2013.

What existed before that though were educational programs and the American Psychological Association started in 1892 at Clark University. The APA was based on what they called then The New Psychology. It had slow growth up until after World War II where the increase in service men needing psychological services grew exponentially. It was then that things really started moving in our fields. Some of the things that created the growth were the GI Bill,  the new Veterans Administration Clinical Psychology Training Program and the creation of the National institute for Mental Health. It was the golden age of psychology. 

What happens once something gets into academia is that things start to split. There are divisions about this kind of psychology or that kind of psychology. Or these types of problems that are being addressed and those types of problems. And the divisions started occurring within the APA. And these divisions were like special interest groups.

So during this time, the DSM was written and published in 1952. At the same time, there’s a couple other things happening. The NASW National Association of Social Workers also got its start in 1955. So psychologists are gearing up to classified disorders. Social workers are also coming alongside and starting to seek licensure. At the same time there’s marriage and family therapists out there and professional counselors, but they’re not all called that. In fact, it’s kind of the wild west a little bit with there not being a lot of structure anywhere. 

Psychologists were wanting to be recognized to be able to do therapy without a medical degree. And the master’s level folks were saying that they were needed and didn’t need to have a PhD.  All of this is happening at the very same time Alcoholics Anonymous is on the side. So alcoholics have been reaching out to each other for help for quite a while. Pre AA, there were things called mutual aid societies. These are classified as starting before 1935, where it’s basically peer support recovery. Oftentimes these were called temperance societies and there were a number of different ones in the United States. 

It wasn’t until 1935, that AA was founded. This is when Dr. Bob and Bill W had their first conversation and decided to find other people who suffered from alcoholism and get them together. This was not recognized by the psychological associations and in those discussions. This was happening as a grassroots organization. 

So during the forties and fifties, we have all sorts of psychologically related things happening. The APA is starting to write the DSM. The social workers are starting to organize. The marriage and family therapists are also starting to organize. The foundation of the American association of marriage counselors was in 1942. And the counselors that started in 1952, as well as the American Personnel and Guidance Association, which in itself was a merger of about five other organizations.  TheNASW was a formation of seven different social work organizations. 

So during the forties and fifties, all of the things that we now see as being part psychology, therapy, social work were getting their start and it was all in silos. And none of that included AA. There were not big organizations that were working on substance use that was happening in church basements all around the country. Granted it grew, but it was not part of the psychological conversation.

During the time when counselors and social workers and marriage and family therapists were fighting for licensure, AA was still in its infancy. It didn’t even start getting regulated in a lot of states until much later in the eighties, even into the nineties. So the reason that it’s not part of our mindset is mainly just history. There was no internet.  There wasn’t a way to share information on some national scale, unless you had access to TV and news. And that wasn’t for the average person, those people had to have connections and money. 

So we’re getting the DSM. People are starting to decide what constitutes a classification of a disease or not. And those things are changing throughout the years as well. Finally, the social workers and the counselors and the marriage and family therapists found their footing in the same realm as the psychologists and the psychiatrists. Substance use is still trying to get a seat at the table. It’s left out. Yet the DSM started including it in the DSM III. So in 1980, that’s when substance use became part of the DSM as an entire section of mental health disorders. 

However, this wasn’t enough to start changing the schools or the licensing exams. So as we’re thinking about what influences our fields. Remember that we’re talking about the DSM, schools, licensing exams and research. Substance use is something that didn’t get paid attention to until much, much later. And this isn’t because anyone didn’t think it was a problem. I think part of it was stigma because it’s not that anyone was abusing drugs or alcohol less.

It was that they were treating them as criminals and lacking them in asylums to get detoxed in the thirties and forties from alcohol was excruciating and dangerous. Those patients were not being treated as having a disease. They were treated as people who had moral failings. I think in the future, we will look back and see the marriage of mental health and substance use. I think it’s beginning and started of course before my time, but I think it’s going to continue. 

And so our mindset has to shift, to include substance use as part of our field. Substance use is not big enough. The American Society of Addiction Medicine might have also started in the fifties, but they only had a hundred members by 1967 and it was only focused on alcoholism, not other drugs.

The ASAM criteria that we now use today to establish levels of care wasn’t put out the first time until 1991. By 2003, the membership of the American society of addiction medicine was at 3,200. So we have to look at the development of the addiction subfield. No wonder we feel like it’s not part of our space. It’s gaining ground, but it really wasn’t in a lot of our programs for a reason. Not because no one wanted to look at it, but because it just wasn’t on the same radar. The research in the last 20 years has been huge about co-occurring mental health disorders. It’s finally being recognized that people are using substances to cope with their depression, anxiety, and PTSD. 

Each of us, when we went to school, went to a specific school of thought. So it could be that you’re a social worker and it could be that you’re a marriage and family therapist. You could have gone and become a professional counselor like I am, or a PhD. Each of us were taught specific ways to think about things, whether it’s a systemic approach or looking at the community and social justice issues or looking at psychopathology, we have our own lens.

The lens that we don’t have is the substance use lens. It’s sort of an aside. My encouragement is that we need to shift our mindset. Because if we aren’t the ones addressing substance use, who is? So for a given client who is the one who’s asking questions about their use of substances? If substance use of drugs or alcohol is normal for adults, at least some point in their adult lifetime, who is checking on that?

Well, perhaps doctors, but has your doctor asked you about your use of drugs and alcohol? I think I got asked once. Typically we go to the doctor and they ask us what the problems are. It might have been that back in the day when doctors had more time that they were able to ask more in-depth questions, but I don’t know that that’s happening now. So if doctors aren’t asking then who is asking? 

In recent years, there has been a huge push for medical professionals to ask about depression. The PHQ nine or the Patient Health Questionnaire, that is nine questions has been given out a ton. In fact, now they’re giving out the PHQ two, which is a two question test. And if you have positive answers for any of those, then they give you the nine question version to help them quickly screen for possible depression. 

There are some measures that are being suggested to the medical community to help screen for drug and alcohol problems. It’s called SBIRT  the Screening Brief Intervention and Referral to Treatment. This isn’t super widespread though. It’s just something that is being introduced in certain areas of the country. Doctors have so much to do. 

I don’t know if you’ve worked in a medical system, but there are so many measures that are coming out that they are supposed to do.  I have been a part of conversations where we have to add something for diabetes or hypertension, and we have to meet certain goals and guidelines so that patients are having good health outcomes and we can track that. And that is being linked to funding. The doctors have less and less time to ask the questions that they need. And in fact, it’s causing severe burnout for medical professionals. In general. 

What we know from the research is that substance use is on the rise that problematic substance use is on the rise. Substances are easily attainable. You can do them in private and they’re relatively inexpensive. Now it adds up over time, of course, but an entry level drug or alcohol problem does not take that much money. And they’re a hundred percent effective. Like it will a hundred percent take you out of your head and make you forget for a little while. We don’t have medications that are like, If we do, those are the abusable ones. And since we started cracking down on those in the medical community, as we should have, that has led to a lot more  illicit substance use.

So if the mindset in the medical community is that substance use isn’t their problem and if the mindset in the mental health community is substance use, isn’t our problem. Then I would say, whose problem is it? We are the most likely? Why wouldn’t it? It is a behavior that needs to be addressed. Yes. There are certain brain changes that happen with addiction. That is something that has to be overcome, not by medication, but by behavior modification. That is our wheelhouse. We do have the skills for that.

We teach people all sorts of stuff that is useful to treat substance use. We talk about distress tolerance and emotional regulation and interpersonal effectiveness. We talk about sleep hygiene. We talk about responsibilities and values. We talk about managing curve balls that life throws at people; managing death and grief. All the things that would lead a person to use substances. 

My belief is that substance use may not have been a part of our field in the beginning, but that in the future, it absolutely will be part of it. We are the likely candidates to take this on. Because the skills we already have, the skills we use all the time are transferable. We don’t need massive amounts of new techniques. There is nothing new to treat substance use.

Let’s take this one step further and talk about gambling. Gambling is an incredible problem. It has high mortality rates for people who commit suicide after they have gambled away, whatever it is they’ve gambled away. It is a compulsion and it is listed as a technical addiction. Other things that people call addictions like sex addiction or porn addiction those are not technically addictions according to the DSM. Because they lacked the distinct brain changes that happen with substances and gambling. 

Gambling. Isn’t even really included in the substance use world either. It’s like its own little subset on the outside. The majority of substance use programs to teach people who are going for a certification don’t talk about gambling. How asinine is that? Who takes care of gambling then? 

Nobody sat and decided that substance use and gambling didn’t belong together. Just like nobody sat and decided that substance use and mental health didn’t belong together. It just happened. Behavioral problems are mental health issues. Maladaptive patterns of coping is our problem.  The educational institutions, and the licensing exams did not catch up yet. That’s all.

We are the ones who have the time and the expertise. We are the ones who study human behavior and help people make changes. It’s us. So this mindset shift is taking substance use and instead of seeing it as separate, seeing it as part of the whole. We don’t treat the medical, we treat the emotional and substance use is part of that.

We do need the medical community’s help. When people reach a level where they are using to the point where they have withdrawal and medical complications, we do need their help. But the majority of folks who are using aren’t at that level. We get them in mental health and most of those folks in mental health are still at a level that we can treat. We can help them walk back their use. 

Some of them won’t be able to moderate because they’ve already crossed that line. Some of them will. What we do is help them figure out why they’re using, how to cut back, how to manage cravings, all of those kinds of things. We help people do this all the time with other kinds of coping that they do.

It is our problem. It is our area to address. We belong there. Our clients need us to belong there. Our clients are whole people. They don’t separate substance use and mental health. They think we know how to do it. The majority of people I’ve talked to who are non therapists are super shocked to think that their therapist wouldn’t know what to do about substance use. Why wouldn’t they?

Just like you’re probably shocked that a substance use counselor wouldn’t know how to do gambling. They didn’t learn it either. Now, gambling isn’t my specialty. It is something I think that someone else is gonna have to pull into mental health eventually too, because gambling is highly correlated with mental health issues, but I’ve taken on the banner of bringing substance use into our field. Gambling is gonna have to be someone else’s deal. 

This mindset shift is important because in the last couple weeks, I’ve talked about the myth that we need some kind of certification or license because in the United States, we do not.  It is part of the DSM. We don’t need to refer out nearly as often as people might suggest when it comes to substance use. Much of the substance use that’s happening is in our scope. It is at a level that we can handle. We already have the skills. We just need to know what to do with it. 

So this mindset shift is important to help us get our brains around the fact that our clients are whole people and that the substance use that they have is something that we should be aware of and able to address. I am here because I want to spread the news that it is not hard.

It is not difficult to learn to address substance use. It is not unknowable. It is not risky. It is not something that we shouldn’t touch. I believe the risk is overstated. After working with people the last 20 years, I can tell you that we work with suicidal ideation all the time, and that is far riskier than substance use ever is.

 I wanna help you dip your toe into this water and come join me. I want to teach you how to start asking about substance use in a way that is direct and effective and will not alienate your client. To this end. I am putting on a free webinar that is in two weeks. On October 18th, I will be doing this free webinar via zoom.

At 8:00 PM Eastern 5:00 PM Pacific. There will be a replay. If you’re not able to attend live, you can register for this event at betsybyler.com/steps. That’s STEPS. This webinar is designed to help you stop avoiding the substance use talk: the five steps to effectively and confidently ask your client about their use of drugs and alcohol..

I will help you come up with a way to ask them that feels authentic to you, that is effective and will get you the answers you need in order to assess what needs to happen next. I truly believe that you can do this, that you should do this. You can register for this event at betsybyler.com/steps. 

Next week, I’m gonna be addressing a misguided belief. The belief is that you have to have personal experience with drug or alcohol issues in order to do drug and alcohol work. And I’m here to tell you that’s not true. We’re gonna talk about that in the next episode. 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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