Episode #116

Sometimes we have to make decisions pretty quickly. I remember being floored when I was out of school and had to diagnose in the first session. I had held onto charts because I wasn’t ready to do the diagnosis. I got in “trouble” with the three support staff ladies who had been at the agency longer than I had been alive. I was supposed to return my charts by the end of the day and I was holding up the process! 

Almost 20 years later, I’m much better at diagnosing on the fly but it took a while. When it comes to substance use, it’s new for a lot of folks and it can be hard to know if it’s ok to treat them in outpatient mental health without a lot of time to assess. To that end, I created a quick reference guide to help you determine if someone’s substance use is appropriate for you to work with. Today I’ll walk through it and explain how it works.


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 116. Well, today I wanna introduce you to the Substance Use Decision Tree. The Substance Use Decision tree has been available for about half a year, so, Some of you may have already downloaded it. If you haven’t, you can head over to betsy byler.com/tree and download it for free.

The Decision Tree is a quick reference guide to help you determine how ready your client is to talk about substance use and whether or not you need to refer out to a specialist.

One of the things I often hear when I bring up substance use is I don’t work with substance use. I refer out, I have been told that people refer out for substance use more times than I could possibly count. There are a number of instances where I’m sure that the therapist needed to refer out. That the person’s use did need formalized treatment. However, in my experience, a lot of people can be served in mental health therapy without specialized treatment. Here’s why all of this matters. 

There are folks who are struggling with substance use. It could be overuse. It could be binge use, it could be coping skill use. They need someone to talk about it with them and help them make decisions around their substance of choice. You are capable of doing that. We do it all the time. 

People come to us with all manner  of maladaptive coping skills, and we help them evaluate whether or not those skills are still serving them. Use of substances isn’t really any different. It is true that there is a limit where people’s substance use does get away from them when we’re into the addiction realm, and in those cases, probably someone’s gonna need a specialist. But there is this vast middle ground that is not being served. 

There are people who will hide their substance use from their therapist, and when I ask them why, they’ll tell me, well, they didn’t ask or I didn’t think it was relevant.

I was talking to a colleague of mine the other day who happens to specialize in substance use work and she was telling me that one of her clients didn’t admit to substance use for two years. Even though she had asked, and even though the person knew that that was a specialty. Sometimes it isn’t because we didn’t ask. Sometimes it’s because they don’t wanna talk about it yet. 

But, It is going to get in the way of the work we do and of their lives because tolerance is a thing and they’re going to have to use more to have the same effect. Along with that increases the risk depending on what the substance is. 

So what I did was create this Substance use Decision tree, and the name of it is exactly what it is. It is designed to help you make a couple choices. The very first one is whether or not you can work with this person in outpatient mental health, or  whether you need to include a specialist. If they need a specialist my encouragement is for you to stay alongside.

It is difficult for people to bond with somebody and when they have a bond with you, they’re not gonna wanna leave. But if you feel uncomfortable because you’ve looked at their substance use and feel like it really is out of what you know how to handle, then encourage them that you’re gonna stick by ’em and be their mental health therapist, and that you’re gonna help them find a specialist.

The very first question that you need to know is, are they using daily? That is a yes or no question. Even if it’s short of daily, it’s still no. And why that matters is that they are able to get a few days put together here and there where they’re not using and that is a big deal.

So if the answer is yes, they are using daily the next question is related to what are they using daily? Is it marijuana?  Because if it is marijuana, I’m gonna tell you that yes, you can work with this yourself.

It’s not a zero risk situation, but it is far lower risk than other substances. If it’s not marijuana, then I wanna know what they’re using. If it is something else, you may need to refer. 

Let me talk about the other thing that is most common to be using daily and showing up in outpatient mental health. Alcohol. Alcohol has different risks than some of the other substances. The fact that it’s legal sometimes I think leads people to not ask about it because we have a culture that normalizes drinking. I don’t have any judgment about that. It just is how we are. 

Drinking alcohol daily is dangerous and it’s dangerous in a number of ways, long term. But in the short term, when somebody tries to quit drinking and they stop altogether, that can be very dangerous and deadly. There are two withdrawals that are at the highest risk for mortality  and those withdrawals are from benzodiazepines and from alcohol.

If you have somebody who is using alcohol on a daily basis,  as some of the folks were in the stories that I brought to you last week, they can come off of alcohol without going to detox. They cannot do that without a doctor. You of course, have no control over what they do, but oftentimes people will go off of alcohol by themselves because they don’t wanna go to detox.

There are primary care providers who are willing to work with people on an outpatient basis to give them medications that will help them come down off of alcohol , and reduce the risk of seizures.  

This is the goal that you would have then if somebody decided that they wanted to stop drinking or cut back significantly. You wanna have them talk to their doctor about coming off of it. This, in and of itself can be a difficult thing because they don’t want to admit to anyone that they have been drinking, but the cost of not talking to a doctor is far too high to not push the issue. This is something I would be adamant about if you have a client who is drinking daily.

If that person is using other substances daily, then I would say they need to see a specialist and by specialist let me clarify what I mean. It doesn’t have to be a master’s level person who specializes in substance use. It can be a substance use counselor, whatever that looks like in your state. There are withdrawal issues that need to be managed as well as early recovery issues. And if that person is using daily, it can be very difficult for them to maintain any kind of sobriety without formalized treatment that is supportive in the sense that it occurs more than once a week.

Very often when someone goes to a clinic where chemical dependency is treated, there will be group sessions that happen multiple times a week. This support system is really helpful and has proven to be very effective. You certainly can stay on as an adjunct and having an appointment with you and with their substance use specialists during the week is extremely helpful.

There are folks, of course, that sobriety is not going to be their goal, and that is perfectly fine. Harm reduction is fine. We still wanna pay attention  to the risk of withdrawal when it comes to.  because that is very challenging and there are times that people aren’t aware that their body is gonna go into withdrawal and so this is not something that we wanna mess around with. 

You are qualified to talk about that. We talk about risks for all sorts of things all the time, even though it’s not our specialty. We will talk about a risk of mixing psychotropic medications with substances.  We will talk about risk if they stop their medications suddenly,  and some of the side effects that they might experience. Of course we don’t go into great detail because we’re not medical, but just because it’s in the substance use realm doesn’t make it not something that you can talk about.

All they have to do is search for alcohol and withdrawal. They will get a very good picture of it. But if I was in your place, I would be documenting that I had that conversation. 

Going back to the original question, are they using daily? And if the answer is no, then we wanna clarify, are they using four plus days a week? The reason it’s four plus is that that is the majority of the week. If they are using under four days a week, so three days, two days, and one day, I have different opinions than if  they are using four, five, or six. 

If they’re using four, five, or that means that while they’re not using daily and they are able to pull a couple days together where they’re not using the majority of the days, they are not able to. They are needing the substance to do something.

After I’ve answered that question again, I wanna say, what is it that they’re using? Is it marijuana?  If it is marijuana, great news, you do not need to refer them. Marijuana is not zero risk, but it has a lower risk and therefore you are able to work with it. This is very similar to any other kinds of coping skills that people use that are maladaptive.

Helping them see the pros and cons and experimenting with periods of abstinence, even if it’s moving their smoking marijuana until the evening or going without whatever it is that they want to do. That is something that you are able to help them with. It is the same behavior modification techniques that we use for everything else.

If they are using alcohol again, we’re in the four plus days a week. I definitely want you to have that conversation with them about medically managed withdrawal. I do think that when someone is using alcohol more days than not, they may need some specialized treatment. However, this is a hard sell. 

What people are worried about is being labeled an alcoholic, and a lot of times they are unwilling to go anywhere near a treatment center. If that is the case, you can decide if it’s something that you feel like you can work with them. My suggestion would be to set boundaries about if they aren’t able to make progress, that a referral would be made and  what it is that they want to move towards so that you can make wise choices about whether or not you feel like you can manage.

Very often clients will not follow through with a referral to a substance use counselor if you do not stay involved. I don’t have research on that. I’ve just seen it. Even in-house in the programs where I had both mental health and substance use, it was difficult to get people to follow through. 

Some of that has to do with stigma. Some of that has to do with people not wanting to admit how far down the road they are. And at times it can take quite a while to get them to a place where they are willing to consider that a quote treatment program would help them. When I’m talking about a treatment program, I am not talking about AA or NA.

We are talking counselors who are trained to work with people who struggle with substance use and to help them with their goals around it. These are very often bachelor’s level folks in a lot of states. 

Other substances, of course, have their risks. If someone is using more days than not, generally a specialist is a great idea if they are unwilling to follow through on that, setting boundaries about what progress looks like and what their goals are is really important. If you haven’t had a chance to listen to the stages of change episode you may want to go do that. It is imperative that we pay attention to the stages of change when we’re dealing with substance use. I think it’s important just in general with all sorts of goals that people are working towards. But with substance use, I think it’s especially important. 

We go back to the other answer.  Are they using four plus days a week? If the answer is no, then I would say this is in the outpatient mental health realm. This means that three days or less a week, they are using substances. The question then is, what is it? How much, and are they having any difficulties that are popping up because of it? 

They may only be drinking twice a week, perhaps even on a weekend, but if they’re getting hammered and making poor decisions that they regret, then that still could be a problem. That’s two nights of binge drinking that they end up spending an entire day having to recover. Not to mention emotional, physical, social consequences from whatever the choices were that they made, and they might be well served to think about why they’re making the choice to use the amount that they’re using. 

If the person’s use seems fairly normal and they don’t see a problem with it, you leave it.  In a lot of cases, if people’s use seems even in the middle range and they don’t wanna talk about it, I think it’s something that you can at least bring up and ascertain that they don’t wanna talk about it, and then you can set it aside. I would definitely document that you did bring it up and it was a discussion. 

I think it is worthwhile to check in every so often to see how they’re feeling about it. If you are noticing a pattern of consequences or regrets related to substance use are increasing. It might be worth a check-in to see if they’re more willing to talk about it now.

There are a couple things I want you to note. If someone is using heroin or fentanyl, they should always go to a specialist every time. Heroin and fentanyl can kill you immediately. This is not something that is a low risk. It’s an incredibly high risk. That doesn’t mean you can’t be their mental health therapist, but it does mean that  you need to be making that referral. We are not fucking around with heroin and fentanyl.

When it comes to pain pills that’s a little trickier. A lot of people believe that the pills that they’re getting come from a pharmacy, when in fact the majority of the pills on the street that they’re getting from people aren’t from a pharmacy. They look like it. They look identical. Pharmacists can’t tell the difference because people are able to buy stamps to make certain pills. You can just buy that on the internet. Having one of those stamps is not illegal.  These are called pressed pills. Pressed pills have fentanyl in them almost all the time and I’m not even talking about just opiates.

Fake Adderall, fake sleeping pills. Fentanyl is cheap and a white powder that is easily joined with other powders to make a pill. Physically speaking that is not a challenge. People who make these pills use fentanyl because it’s really cheap and they can add it to it.-

It does give people a more intense high, and the risk is that the dose is unknown. Someone could be taking what they think is a five milligram Lortab, but it’s a pressed Lortab and not a real Lortab, and so there’s fentanyl in it that is unknown. There is a high rate of people using more than one substance at a time. That’s also something that you wanna take into account. 

So in the Substance Use Decision Tree, you will see this same pathway. It is meant to be a quick and easy reference.  And you still need to use your clinical judgment to make the right choices for the client.

If there are multiple substances, go through the decision tree for each one. Make sure you understand what they’re using. If they’re using marijuana daily. and using pills three days a week and using alcohol three days a week. That’s an interesting combination and it suggests that the marijuana isn’t really working for them. This means you need to do a little more investigation to find out why are they using like that? What’s the pattern and what is the point? What is it that it is being used to? 

The second part of the decision tree talks about how ready they are to address their substance use and even to have a conversation about it. This is based on the stages of change, and this is also just a quick guide to try to help you decide where they’re at. 

The very first question is, have they expressed anything negative about their use? Negative can mean a lot of things. It could mean a statement of regret. It could mean a sideways comment about something being bad for them or that they shouldn’t have done a thing. That’s the kind of stuff that you’re looking for. Have they made any of those comments? And if the answer is yes, then you need to determine are they ready to make a change right now? That is something that we are very skilled at listening for. 

What we’re looking for here is change talk. How close are they to getting ready to make a change? Are they ready to make a change in the next six months, or is it something that they’re contemplating, that they’re trying to figure out if it’s a problem or not. 

Most people have a process where they’re in what we call the contemplation stage for kind of a long time. Sometimes they move in and out of contemplation. After a doctor’s appointment a lot of times people have moved into a contemplation and even preparation stage because of something the doctor said to them.

You’ll notice though that people don’t always stick with the things that they said they were gonna do after they left the doctor’s office, and this is super normal. Understanding where your client is in the stages of change is vital.

You can ask questions like, is that something that you want to do differently? If it’s a yes, then you ask them what their thoughts are. What is it that they’d like to have be different, and is that something that they’re willing to do, or were they thinking of something different? They will let you know if you are getting ahead of them.

Pay very close attention to this because it can be easy for us to hear something and to start making plans to bring them to that. It is in our nature to solve problems and to help people make progress in lots of areas of their life. However, if we get ahead of them and try to go to a new spot too soon, they tend to backpedal and it can start putting us in a position of being the one they don’t wanna disappoint or the one that they wanna try to hide that they’ve still been doing a particular behavior.

So make sure that you’re not tempted to step in front of them. I have been guilty of that and I’ve talked about it in a few different episodes. That I got too far ahead of some of my clients out of a place of caring concern, but that it will backfire. So what happens if they have not expressed anything negative about their use?

The first thing I wanna determine is, do they use this substance to manage stress or feelings? If the answer is no, you don’t feel like they use it to manage stress or feelings. The question then is, can they be social without it? If they struggle in social situations without this substance, then that might be something that could be different for them. 

Needing a substance in order to be social is a sign of anxiety or other issues. That gives you a place to look to see what is it that is getting in their way and is it leading to other problems in their life. One of the more common substance use patterns I see are people who are using marijuana on a daily basis  and don’t see any trouble with it. There are a lot of people who fall into that category. 

What you’re listening for isn’t a place to get them or nail them on their use. You’re listening for if it is causing issues. For some people it might not. My opinion and my bias is that it’s not normal to use mood altering substances every day. That being separated from your life and separated from space and time, 24 hours a day isn’t normal and isn’t being present in your daily life. 

There are people who are going to disagree with me, which they are more than welcome to. However, as someone who is in recovery from drug addiction and spent several years high, I can tell you that it’s different, that it does separate you from being present fully in the day. It does affect reflexes response times because it is a depressant and it slows down the central nervous system. it does have an impact.

Especially with the high levels of THC content that we’re talking about now in the type of weed that people are using. This isn’t a judgment call, this is simply a fact. What I would be looking for is what do they do when they are stressed, when they are sad, and when they are overwhelmed. If their immediate response is to go smoke weed I would want them to have different coping skills that they could use that are not weed.

That doesn’t mean that they’re not going to be high. Let’s say they already smoked in the morning, like they did their morning smoke or their midday or whatever, it’s, and then something happens. I’d like them to try to use other skills so that they have more skills than just getting high. There is a limit to how high you can get when you have a high tolerance. For people who are smoking every day that tolerance is going to be a big factor. 

So if someone is using daily and it’s marijuana and they feel like they can be social without it, that is a sign to me that it is not something they’re ready to talk about. I still have a conversation with them that I don’t want them   using weed or THC within four hours of coming to see me. That is the boundary I set with my clients. I do not work with people while they’re actively under the influence.

If the person does use it to manage stress or feelings, do they admit that? If they do admit that, this sounds to me like they’re ready to have a conversation. They likely know that it’s not a great idea to depend on a substance in order to function. This doesn’t mean that they’re ready to do anything else about it at that moment, but it does sound to me like they’re ready to have a conversation.

If they aren’t able to admit that, and it’s just something you’ve noticed, they may not be ready to have that conversation. I would focus instead on negative emotions that cause them to use.  and see if you are able to draw the parallel  that it seems like when they are upset, when they have a bad day at work, that they tend to wanna go use whatever the substance was.

I am very clear with them that I have no moral opinion on what they choose to do around a substance. My job is to be a mirror to help them see what they’re doing and how it’s affecting them, good, bad, or indifferent.

So the main takeaways of this decision tree, daily use of anything other than marijuana, carries a risk because of withdrawal. There are two main substances that I’m most concerned about with withdrawal, and that’s alcohol and benzodiazepines. Other withdrawals are uncomfortable and typically aren’t going to kill someone, but are very difficult to sustain outside of formalized detox settings. Marijuana has a withdrawal syndrome. It’s just that it isn’t that intense. 

The second thing is that  a vast majority of clients that are using and showing up in your office will be doing so at a level that is just fine for outpatient therapy and does not require a specialist.

Because we weren’t trained with substance use the insinuation is that any substance that might be problematic, needs a referral, and that just isn’t true. We can work with those folks as long as you are willing and if you need more information, that’s what I’m here for.  

You can listen to podcasts, you can check out one of my webinars or you can join Charting the Course. Charting the course is the six week program that is designed to give you the information that you need to feel confident and competent in addressing substance use. 

The last thing I wanna mention is that the opiate crisis isn’t just about heroin. There are lots of folks who are addicted to pain pills and their pain is not being managed well enough. There’s no one to blame for this, but it has caused a massive problem and an influx of pills that are called pressed pills. 

Fentanyl is also popping up in places where you wouldn’t expect it, like in THC oil or other substances that aren’t even related to a downer like meth  or pressed pills that are stimulants.

When it comes to the therapy hour these are the three things that I would suggest. One is that you ask the person not to use anything within four hours of coming to see you. This is typically for folks who are smoking marijuana as the other stuff isn’t really something that they’re going to use before they come see you  unless their drinking is pretty intense. 

With a four hour window the person is not actively high, they still have some in their system, so they’re not in a withdrawal state, but they’re not gonna be blown out of their mind so where they can’t really participate with you emotionally in the session. I find that this is an appropriate boundary and it helps introduce the idea perhaps being high all day every day isn’t necessary.

The second thing I would say is that there are times as well that I will ask them to hold off using again for a few hours once we’re done with the session. This is something I will ask if we’ve had a particularly difficult session or if I’m asking them to consider something. 

I know that when they first leave, their instinct might be to smoke up on the way home or eat a gummy or whatever it is that they’re using. But I want them to sit with things sometimes and to use some other coping skills. This is also just introducing them to a bit of distress tolerance. I find that my clients are really open to it. 

The third thing is to listen for change talk. It is super important that we stay in step with our clients as trying to get ahead of them when it comes to substance use, can actually push them to hold on tighter to the things that they’re using. We don’t want that. We want people to have the freedom to move forward. 

If they feel like you are pushing them too fast, watch for them to start backtracking or changing their mind. If that happens internally, back up as well. We are always giving them agency and autonomy in the things that we’re working towards. 

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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