Episode 141

Want to treat trauma and substance use with confidence? We’ve got you covered!  Hi, we’re Betsy Byler and Jenny Hughes and between us, we have 30+ years of treating trauma and substance use under our belts! Today we’re joining together in this episode to talk about the intersection between substance use and trauma. We are so excited to bring our live event Braving the Course to you this August. The next four episodes of the podcast will be part of the lead up to the event where will give you the tangible skills to thrive while working with trauma and substance use. 

Whether you join us LIVE or catch the replay, you will:

  •  Discover how to thrive while treating trauma and substance use
  •  Strengthen your skills in asking clients how they use substances to cope with trauma
  •  Walk away with tangible and actionable skills!

You don’t have to do this work alone. Join us in addressing substance use and trauma while energizing and inspiring yourself.

-Betsy and Jenny


 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.

So this week we have something a little different. I’m joined by my friend and colleague Jenny Hughes, who is out of Texas, and you might remember that we did a couple of events last summer. We talked about the Roe versus Wade overturning in July, and then we came together again for Braving the Course in August.

Braving the Course is where we put together what I work on, which is helping therapists learn to work with substance use and what Jenny works on, which is supporting trauma therapists in a Collective and helping to work to prevent burnout and increase resilience in our careers. So this summer we’re doing Braving the Course again, and that’s gonna happen on August 28th in the evening, and we will be putting out much more information.

So what Jenny and I have been talking about is this intersection of substance use and trauma. We are both trauma therapists. We have been doing this work for a long time. Jenny has talked at length  in her channels about working in a trauma center and dealing with gunshot victims and all sorts of difficulty that comes from the work that we do.

I have been doing trauma work with kids and adults for quite a while. I prefer EMDR these days, although that was a surprise that I’d ever love it. But I do. And of course, substance use work, and those are my two specialties. So what we know is that in our work as trauma therapists, we’ve come across lots of ways that people cope.

One of the really common ways is by using substances,  it’s because they’re really effective. So I think we’ll start by talking a little bit about what we notice in our clients about substance use and  how it’s used to help people manage their trauma. Jenny, do you wanna start and just talk about what you’ve noticed in your clients?

Yeah, so for me as a trauma therapist who, and we’ll talk more about this, but I don’t treat substance use alongside trauma, even though I actually do have some training in that in grad school. And I understand how important it can be for some people to be treating those things side by side.

But that doesn’t mean I don’t. Talk about it and provide psychoeducation around this stuff. Because what I often see in my practice is not people who are using to excess, in that they aren’t drinking all day every day or anything like that, but they are using drugs and or alcohol to take the edge off.

And I tell them like, yeah, that makes sense. Drugs and alcohol are a great way to cope with shit until they become a problem in and of themselves. That is where, for me, my expertise, my interventions kind of end, is when they become a problem in and of themselves. And it’s interesting because  I don’t have a problem talking to people about the substances that they’re using when they share that with me.

But I think like a lot of other therapists who are doing trauma work, but they don’t have that substance use background or specialty, I don’t really know how to ask or when to ask, or I choose not to ask if it’s not just straight up told to me,  and I think a lot of people figure that if it’s a problem, somehow it’ll get brought up.

I will say, even bringing it up sometimes isn’t a guarantee that someone will tell you. It’s the same way that when we go to the doctor and they wanna know about eating habits, it’s the same way that we maybe don’t talk about all that and we minimize things. It’s not about lying per se, it’s about wanting to protect the thing that we’re leaning on.

That we feel like we’re doing hard enough stuff anyway. And so we don’t wanna have to give up this other thing.  I remember in grad school the substance use class I took our assignment was to give up a substance and I. Because I’m like, are you fucking serious? I already quit smoking, gave up drugs and drinking, and now I have to give up a substance for an assignment and document it.

So my choices were chocolate or Diet Coke,  I’m no longer a Diet Coke drinker. But at the time I was like a five can day four or five can a day Diet Coke drinker as many diet Coke drinkers are right. So I’m like, all right, I’m gonna give up Diet Coke because at the time, giving up chocolate was super dumb and there was no way that I was willing to do that.

And it was something I was really bitter about. ’cause I was like, I already did hard things. Why do I have to do more hard things? Getting past the caffeine headaches, of course. But it was challenging because there were times where I just wanted what I wanted. And I just was upset that I couldn’t have it.

So when people come to see me one of the things I find with folks is that even acknowledging that they have trauma is difficult. It’s better than it was. People talk about it more readily than they did 10 years ago. I’ll get on my intake form., I ask what types of trauma have you experienced?

And it’s very brief, but sometimes people will say none. Okay. And so then as we’re talking and they’re telling me about family, and they’re like well, my dad was a raging alcoholic, and I’m thinking, Okay. It’s entirely possible that their parent, who was a raging alcoholic, protected the family from their use. It is possible, but not likely.  But usually that’s because people’s view of trauma is that it has to be like you’re a combat vet or you’ve been severely assaulted. As opposed to all of these other ways. And so having that discussion is something I think we get used to delving into. What was this like? How did you experience this? 

When it comes to substance use? The reason I think it goes together so closely with trauma is that a lot of trauma happens in childhood. Pre 18. Yeah. If we look at the next age range, I’m gonna say young adult, 18 to 25. And so during that time, there’s normal experimentation of substances because using substances is super normal.

People and humans have been using substances since humans began. Age of first use nationally is about 11 or 12 right now. When I was in high school, it was closer to 14 I think, and that would’ve been in the mid nineties. around the time that people are starting to experiment, trauma may have already happened. Or is going to happen. And so there’s all this access to substances, specifically alcohol and weed. And the thing about those is that, they are immediately effective. If you don’t wanna feel, you don’t need to feel. That’s certainly how my use started and I’m a person in long-term recovery, but that’s certainly how my use started.

And it was a very conscious decision of, this is some bullshit. I don’t like how I feel. I’m gonna get high and I’m gonna stay high. And it works.  Until it doesn’t, of course, but nobody knows and or caress about that at that point because it works so well. And I think at that time in people’s lives too, it becomes part of connection with their peers, right?

It is typically, especially in those early stages done together, I think, I don’t know, you tell me, I am not the expert here, but I think for most kids and teens when they first start using, they’re using with someone else or another group of friends, and it becomes, it’s like a social thing.

And I know that’s how it was for me anyway. And so there’s this other layer of not only does it numb things out and make me feel better, but then I’m surrounded by other people who get me, who understand, who are like doing the same things. And that’s super important for teenagers.

If you put a teenager in a new school, You want them to make friends, there’s a group that will always take them.  All you have to do is be willing to use with them. Maybe provide a little money here and there, and not narc on them. Not tell on them. And they’ll take you.

Yep. And that isn’t true of most groups in high school. Yeah. Where they’ll just have a new person and be like, oh, you wanna smoke with us? You’re my best friend now. And so I think it is about connection.  As someone’s dealing with whatever their trauma is, they can numb out and use it to get through.

The trouble is when we start seeing them as adults. Some of those folks may have moved into full blown addiction certainly. The majority of them won’t.  Statistically speaking, they typically don’t. Because we grew out of a lot of that stuff, but it doesn’t mean that their use isn’t problematic or has moved past normal.

Because there’s a really wide range between normal recreational alcohol or marijuana use and addiction.  What I’m encouraging therapists is to work with that middle if they’re in an addiction and they’ve crossed that line and it is difficult at times to know where the line is, and we can certainly talk about that.

But if they’re there, then my suggestion is they probably need a specialist, someone who is specifically chosen to specialize in substance use and do that work. But in that middle ground, I think that we as therapists can take care of that in our office. We have the skills already. It’s just a lot of therapists will tell me that they don’t know where the line is and if they’re overstepping, and so they’re not really sure.

And then I think there’s also therapists like me who don’t really want to ask anyway. Just put that out there. Why do you think they don’t wanna ask? I can speak for myself  and I think that there may be a lot of people that would connect with this, but so for me, there are personal reasons.

My dad was an addict and it had an incredibly negative impact on our lives growing up and into adulthood as well. And. I’ve done a lot of work around my dad. I think that probably, there’s always gonna be unfinished business there. And  it is an intentional choice that I make to not do substance use work because it still just feels too close.

Like I don’t feel like I can truly be objective if I was like full on treating that substance use. That’s why I like, I’m fine talking about it and like psychoed and stuff like that, but like actually then treating it brings up a lot of feels for me, and I can hear that really critical internal voice saying things that are not necessarily true, but like those things of you’re never gonna stop. You’re never gonna actually get better things like that , And that has nothing to do with my client. It is just this, these internal things that continue to be unfinished business for me. Then there also is like knowing again, my background and things like that, but also which is part of this next thing.

There also is just the fear of the weight of it and honestly burning out. Right now in my career, I’m not as worried about like the risk or the liability or things like that because I’ve been practicing long enough that I feel I know how to handle risk. But for me it’s just the burnout of that is just too much shit. I don’t know how to also then do that work while I’m doing trauma work and take care of myself. 

I wanna say that when, and you and I have had this discussion, but for the benefit of everyone listening and watching when you know a thing about yourself that you can’t be objective.

I do think that it is our professional moral obligation to step back.  Part of that is there are people who I can’t see because I have opinions. Where I live is a pretty rural area and lots of people are related. And I know a story about somebody, or I had experience with their sibling or wherever it is. And I already have opinions. And that person deserves competent, unbiased care and concern. And if I feel like I can’t do that, Certainly there’s a little voice that’s you should be more professional than that. And yes,  maybe I should. And I still know that I am me and if it’s gonna feel like a struggle that’s not my style and so I’ll back out.

But there are certain issues where I realize, oh, , nope, I have a really strong reaction to that and I don’t know that I’m gonna be able to, I. To touch that one. So I always want people to trust their intuition about whether or not they can handle whatever the topic is. So if someone’s using and they’re pregnant and that’s gonna really mess you up, then you need to refer. Right.

Where I’m not suggesting that people should use while they’re pregnant, but that doesn’t push buttons for me. And where it would be for someone else. But there might be other things. And so I always wanna say anyone who’s in that boat, those are not the people that I am encouraging to incorporate this into their scope of practice. 

For people who are worried about the weight of it, one of the misconceptions that people have is that our goal is no use, and the goal is not no use. It could be if the person wants that to be the goal. I think there are places where they may have to go that route. But not in the beginning usually. And if they do, because we’re at an addiction standpoint, that’s a different topic. Right. But if we’re talking problematic use, I think the wiser choice is to go with, more of a harm reduction model. Harm reduction and abstinence in my world and the substance use world can often seem like opposites, and they get presented that way, and I really believe that we have to have both.

That there are folks who cannot use safely. I am one of those people, so I don’t, and there are people who had problematic use, who have been able to moderate and are able to do so in a way that. Doesn’t interfere with their life. The person in front of you may be using alcohol or marijuana to manage stress, to manage trauma, to help be the shell  around them. Like a turtle shell. 

Brene Brown talks about that idea of if you take away the shell, which would be the substances; she was talking about her argument with her therapist that she needed a new shell and her therapist’s idea was perhaps we should get you out of the Briar patch. And she was really upset about it, ’cause she was feeling super vulnerable and super raw and everything’s prickly. And her therapist was like, how about don’t live someplace till prickly? And the shell . Is a hard thing for people to give up. And what I have found is that pushing someone to get rid of it totally is unwise.

And even in cases where they think that’s what they need to do because they need to get rid of all the things and do all the health things and make all the changes, I am often like, let’s slow the roll here a little bit. Let’s pick a thing. Let’s change one thing at a time and then let’s see how it goes.

That’s the focus I want for people when they hear about substance use and they’re willing to talk about it, I want them to think about what would toning this down 10% look like? If we toned their use back 10%, what would that look like? And if they can tolerate 10%, Maybe we could try another 10%, but if they can’t, then we need to talk about what is holding up that, what we can do to help hold that up. Because if that’s load-bearing substance use, so to speak.  We can’t just take it out. Because at this level it’s not gonna kill them most likely there’s always an outlier, but we need to prepare them for having that shell removed. And I think it’s unsafe to just rip it away and be like, sucks to suck.

Yeah. Now you get to feel all of this for no point. And so I wanna just encourage people, even as a person in recovery, in an abstinence-based recovery that my advice is not to shoot for sobriety. There’s nothing inherently wrong with having a shell. I. So we need to have defense mechanisms. Our brain has created that as a way to help us manage all of the things that we come across in our lives. And just like with the substance use, when we overdo it, they can become problematic. That shell can become too heavy, it can become too cumbersome, or it can close us off too much.

And actually, even just hearing you talk about it. And I don’t even really know like exactly the steps of doing a harm reduction approach, but it’s something that’s always spoken to me like I, I think oh, that sounds good, but even just us talking here it feels already like naturally aligned with some of the things that I think I do anyway.

Does that make sense? Sense? 

And that’s the part about substance use work that I try to let people know is that, Taking the skills you already use about behaviors, about changes, we’re just shifting it , a little bit to talk about substances, but it’s all the same work because there is not a single modality that is straight up just for substance use.

There isn’t a DBT for substance use or an EMDR or whatever. It doesn’t exist. And so what substance use counselors are doing is CBT parts of DBT. ACT, they’re already picking and from these different schools, and so likely whatever skills ,  they’re gonna work. 

What we’re looking at is what is secondary gain here, because that to me is the most important piece, and by that The substance use might be causing problems like they spend a day or two having to get over a hangover every weekend, and they hate that. Or they wake up feeling like they’re not rested because they’re drinking to go to sleep, and it means they’re not getting enough repairative sleep so they’re not feeling as refreshed. If we don’t fix the fact that they can’t sleep, They’re not gonna stop drinking. And it’s not wise, in my opinion, to ask someone to not sleep, to just not drink. Could we cut that back a little bit? Could you talk to your doctor about, would it be okay to do melatonin or would it be okay to, valerian root or magnesium, or whatever the it might be, so they feel like we are gonna address the problem. It doesn’t have to be alcohol ’cause there’s a bunch of side effects to it that aren’t great.

Yeah. But I think having a more gentle approach is much more palatable for people and more in line with how we roll anyway as therapists. Our job is not to come in and push them to do what we want. Yeah. Yeah. Exactly. And I think that is another thing that for me anyway, feels tricky with substance use work isn’t.

It almost feels like to me, like it is me pushing my own sort of like opinions or beliefs about what’s good and bad on the person, right? Oh, you’re using alcohol in unhealthy ways. That is bad and we need to fix it. It feels like this like force like punishment almost, and. That does not feel good as a therapist, just like you said.

That is not how I practice, nor do I ever want my clients to feel like that.

For me, I think the thing I’d want to tell therapists is that the chance that your person who has trauma has used substances   is extremely high. Whether they are currently or not, I don’t know, but they certainly probably have. The goal would be are they doing that now? Because if they are doing that now, It depends on the level, but it really is gonna get in the way. Some, at some point it’s gonna get in the way because it’s a secret and secrets are not great long term, at least  in terms of ourselves. Like we don’t want our people hiding things from themselves and or us if we can help it. 

Because I can tell you that as someone who had problematic using, there’s lots of secrets. And it’s so much better to not have them, it is so powerful to not be afraid to have people know stuff. Yeah. 

The one thing I would say is that when it comes to talking about their substance use, you’re coming at it from a point of, I just wanna see what the situation is, and then you can tell me how you feel about it.

If you think it’s fine and you don’t wanna touch it, then we won’t touch it. If there are potential things I’m seeing, I might mention it, but if they don’t wanna talk about it and they don’t wanna change that  it’s not my job to make them change it. My job is to help hold up a mirror if there are things that are problematic and that I think this might get in the way.

For those folks who are not using in dangerous ways, letting them be in the driver’s seat, right? Yeah, absolutely. If there’s a real risk, I might mention something.  Even in my line of work where I work with addiction, I don’t badger them, I don’t push them,  I talk about risk and tell them my concerns. I do make sure they’re not coming to session high even on weed. We need to be emotionally present and then otherwise we let that go. I just find that trying to move people through the stages of change faster than they’re ready is pointless. Absolutely pointless. And so for our trauma therapists and people who are working in that area, I would encourage them to find out just the parameters of it, how much, how often. Is it ever difficult? Do they ever feel like it’s causing a problem for them? Once they know that, they can find out if the person wants to change anything about it.

And then you just pick one small area. Like I had said before,  10%.  If they want to, how do we turn this down 10%? Lots of people can handle that rather than how do we turn this off? And That’s the piece that I think if therapists were willing to just tiptoe into this arena, knowing that we’re looking for small changes and we’re looking to see how it affects their day to day, and if it works well, then we see if they wanna move forward another 10% or not. And if not, that’s cool. We just stay. 

There is no marker for sobriety or not. This is all about what the person is able and willing to do, and I want them to have compassion on themselves and there’s no shame to be had here. And what we do to cope with trauma, it is creative and it is built to keep us alive and to survive. What I would prefer is that people get to use their coping skills by choice. Yeah. Rather than reflex. That’s always the goal and substance use. If they continue they’re gonna keep, drinking every now and then or smoking weeded or whatever, I just want them to choose it rather than I feel pain I have to use.

That’s the piece that if we could uncouple those, that feels a whole hell of a lot like freedom to me. And I think it is easier said than done, which is why we were doing braving the Course. And especially just taking, for the therapist, taking the edge off those questions of even learning about, how much, when, why, things like that. That’s a huge thing that we’re going to be sharing during Braving the course this year. 

I think it’s important for the concrete tools and you’re really good at that, at giving people techniques and concrete tools and I want to be able to share with people the main questions that are really useful, that if they only have a couple questions ask, these are the ones that I recommend and why. And so I’m excited to share that with them. Yeah, me too. So I think for today, we’re gonna wrap up here. And we’ll see you all next week for the next installment as we get ready for Braving the course on August 28th. If you haven’t registered yet, head over to betsy byer.com/braving the course, and you can register there.

Thanks so much. 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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