Understanding client choices: What substance of choice tells us

Episode 91

Client’s use lots of different things to cope with life. Sometimes those things are good and some things aren’t as adaptive. When people are using drugs or alcohol to cope with life or mental health issues, it gets in the way of the work we are doing with them. We want to teach them new ways to cope that will be more helpful, but nothing can compete with substances. Substances are more effective at making people forget about problems than anything we could offer. It’s not that our skills are bad or don’t work, they just can’t compete.

So what’s behind the client’s choice of substances? Why does one person choose alcohol vs marijuana? Why does one person choose pills instead of cocaine? There are actually specific reasons why people choose one drug or another and it can really be helpful to understand the reason. People tend to like stimulants, depressants or are what I call kitchen sink type people. They either want to be full of energy, be relaxed or they don’t care what they use. As long as it will get them high, they will do it. Today we are going to talk about the reason behind someone’s choice of substances.

Transcript

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 91.

As therapists, there are lots of things that we have in common with each other, in terms of how our sessions go. We’ve had clients that come in and they say that they want help, but they have a lot of trouble letting us help them. We’ve had clients who come in and do all the work that we ask them to do and even some other ones that they think of. We’ve had clients come in, who’ve had a number of other therapists and they struggle with the idea of starting over.

Our experiences as therapists are going to resemble each other’s in one way or another for the most part. Of course, it changes with our niche and with the agency that we work for. For people who have only ever been in private practice, perhaps their experience is gonna be really different. For those of us who have spent any time in community mental health. We are gonna have even more similar experiences

One of the things that we end up doing is teaching people how to cope in a better way. We have a lot of skills. Sometimes though our clients don’t always take to those and they don’t always practice them. Sometimes they’re able to pick some up and find that it really is easier to do it in a more adaptive way. But what happens when our client chooses something like a substance and keeps going back to it.

What is it that makes someone choose their specific substance? We know why people choose substances, right? Because they’re effective. They’re effective at changing the channel in your head. They’re effective at making you think differently about life and typically distracting you in a way that is helpful at the moment.

We’re not talking about when people get to an addiction level where no one is having fun anymore and the substance stopped being fun kind of a long time ago. Right now we’re talking about people who are dabbling in a specific substance. There are really unique reasons why people choose to use, and there are unique reasons why people choose the substances they choose. So what we’re gonna be talking about today is why people would choose a certain substance.

The reason that I wanted to talk about this is that when we are working with someone who is using substances. The “why” they’re using is really important because it’s the why that holds it up the most. Not just what they’re trying to manage or get away from, but specifically what the substance does for them. There are lots of choices in terms of what you wanna use to get high or to check out, but why did they choose the specific one?

So let’s start with some basic categorization. In this case, substances fall into three categories: stimulants, depressants, and hallucinogens. Typically a substance is only going to be in one of those categories. However, there are a couple that fall into other categories as well.

A stimulant is just what it sounds like. It stimulates something and in this case, it stimulates the central nervous system. The whole point of a stimulant is to make things go faster. A lot of us use a stimulant every morning. As I record this, I have a cup of coffee next to me. Caffeine is a stimulant.

There was a time in my life when I was a Diet Coke drinker and every morning would start with a can of Diet Coke on the way to wherever I was going. And another one, right when I got there. I also know that if I don’t have coffee or caffeine within a certain timeframe, when I get up, say a couple hours, I’m gonna get a nasty caffeine headache, because caffeine is an addictive substance and the body starts going through withdrawal after a specific amount of time.

The stimulant that a lot of us tend to use once we reach adulthood is meant to help us wake up. To help our brains get going and to help us get things done when we’re trying to change from sleep mode to awake mode.

For people using stimulants it helps their brain and everything move a little faster and they’re able to perhaps get a few more things done or wake up more quickly than they normally would. For some people they’ve been using caffeine a lot, and it doesn’t seem to do much anymore. They wanna avoid that withdrawal of the caffeine headache and so they keep using it. Of course, there are people who just love coffee in general, and aren’t really thinking about caffeine, but so many tropes and memes are about “don’t talk to me before I have my coffee.”

There are specific reasons why people would choose a substance. Personally. I was never a stimulant kind of girl. I was already somewhat anxious just because there was some chaos going on around me and so the idea of amping my body up more was not attractive at all. In this stimulant category, let’s start with cocaine.

Cocaine is a fine white crystal or a white powder. When someone’s using it, typically they will snort it or some will put it on their finger and rub it on the inside of their mouth. And some do end up smoking it. Cocaine typically gets used in binges where it’s used over and over for a period of time. That period of time could be an evening, or it could be multiple days, but eventually the come down has to happen and there’s a really big drop that happens afterwards.

The effects of cocaine are increased energy, happiness, feeling excited, wide awake, confident and on top of your game. So the thing about cocaine is that it’s not very effective in terms of use as a stimulant in order to get stuff done.

The come down from cocaine is pretty intense and deep, and it’s like a steep drop off in your mood. Like you were fine and everything was great and then all of a sudden, bam, you’re at the bottom of a hole. What it’s used for isn’t just to check out. Cocaine is about a unique experience, a person who is using cocaine, isn’t doing it so they can get things done or wake up, so to speak.

Cocaine tends to get used as a party drug, as a, pick me up as a unique experience. People who try it and end up using it when they’re partying, it is to have a very intense and very unique experience. It pulls them out of the mundane of life and gives them something in bright technicolor.

Some people might wonder, well, what about crack? In my experience, anyone who’s using crack is not using it once in a while. You don’t move to crack until you need something in a way that you kind of don’t care what it is. Crack is cocaine mixed with baking soda and has different properties and lasts way shorter time.

If you want more information, there is an episode I did on cocaine and crack in the podcast. You can head over to the website at betsybyler.com/podcast, and you can find the section for substances or just click on the all episodes button and it’s episode 35.

Next on our list of stimulants is meth. Methamphetamine is kind of the big daddy of all stimulants. There is nothing greater in terms of its effect and its impact on a person than methamphetamine. Meth was first synthesized in the late 1890s into the early 1900s. In the beginning, it was used in pill form to treat narcolepsy. In the 1950s it would be called benzedrine or bennies. This was popular during the war in order to keep troops awake.

In the later fifties, the FDA in the United States required a prescription, which made it kind of fall out of favor. But previously it was available .In the last 20 years or so meth has become a well known drug, probably more well known than almost any other substance besides marijuana.

We can thank Breaking Bad for that as well as anti meth campaigns across the world. With good reason, because meth is destructive. The first time I saw a campaign that was depicting meth in its true form was the Montana Meth Project.

It was showing really disturbing images about meth use that drew a lot of criticism, but those images were accurate. It was saying things like stealing from your family, isn’t normal, but on meth it is, and more distressing type of situations that they described.

I talk about meth far more in depth in three consecutive episodes, starting at episode 40. Talk about in depth, why someone would ever get into meth. Here I’ll tell you very briefly. Meth causes a dopamine spike that is seven times more intense than anything we could create naturally.

The biggest thing that we can do as humans naturally, to feel a spike of dopamine is have sex. That gets us to a dopamine level of about 200. Meth is at 1400. To put that in perspective, even cocaine is about 300 or 400. Nothing can compare with meth. The difference between meth and cocaine here is that people can often start using meth because they wanna get things done.

Meth lasts for hours. It causes some compulsive behavior and a lot of times that shows up as cleaning because there’s always things that can be cleaned. In the beginning when someone’s using meth for a while, they’re gonna be able to sleep normally. They’re gonna be able to eat normally, and there’s gonna be no outward sign that they’re deteriorating from meth.

It’s super attractive. They try it, it’s like no feeling that we could ever recreate, the most euphoria they felt and yet they were able to go to work the next day. Additionally, the small amount that they needed probably didn’t go that much. And so why not?

What I have found is that the people who are using meth began in a recreational way, maybe once or twice, and then they figured out, huh, I could get more done at work, or I could be more focused or I have energy to get my life done today. For a number of people concerned about weight they don’t really feel like eating very much and it’s pretty easy to avoid it. You can see why somebody might start it.

If we have someone who’s using meth, we’re gonna be able to tell kind of quickly if they’re far into the deep end of the pool or not. Because there is a switch somewhere in the early stages where meth no longer is something that they can easily control. The withdrawal from meth when you’ve been using it to the point that there is a withdrawal is intense and painful and gross frankly.

That requires a different level of treatment than what we provide in outpatient therapy, for the most part. What I get concerned about is someone who’s dabbled here and there who’s used meth at a party here and there, and occasionally used it during the week, once in a while. That’s where I get concerned and I’m gonna be looking at what are they trying to accomplish and what is happening for them when they aren’t using meth?

Typically, I find that people who are using in that way have some depression, they’re struggling because they have low energy because they have no real motivation to do things and because nothing seems fun. Well, you drop some meth on that and all of a sudden, all those problems go away.

The majority of people that we see aren’t gonna be using meth. If they’re using stimulants and they’re using it in a substance use type manner, what we’re gonna be talking about are stimulant pills, speed, or ADHD medications.

There are some people who use uppers and are already high functioning people. The recovery story we heard in May from Natalie talked about her use of uppers when she was already a pretty high functioning student. I’m pretty sure that she would say that there was potentially some underlying depression underneath all that, but she came from a pretty high functioning family that expected a lot. And so for her, it meant that she could do all the things and be even more on top of her game if she used uppers.

When I talk about uppers in the sixties, seventies, and eighties, that would’ve been called speed as most stimulants were called speed. So meth during that time as well was often referred to as speed. Basically it was anything to speed things up. For us what we’re talking about with uppers are gonna be pills.

A mild form of these are things like Nodoz, which are caffeine pills. I remember that being one of the first pills I ever tried because well, they were available at the local pharmacy. I had heard that college students would use it during finals in order to have more energy today. It’s not so much caffeine pills as it is energy drinks and above that, even there are pre-workout supplements that people will use to amp up their workout and their energy and give them a rush to keep lifting. \

I did a few episodes on ADHD medications and on the website, those start at episode 44. There are two main types of these pills. They’re basically in the methylphenidate category or in the amphetamine category.

So methylphenidate is the generic name for Ritalin, and that is one type of medications that we use for ADHD. On the amphetamine side. And that’s just what it’s called, it’s not specifically about methamphetamine, are things like Adderall, Dexedrine.

At the end of this category of stimulants, we gotta talk about inhalants. This isn’t super popular, and I don’t think it’s something that’s really gonna come up in your clinical work, but it could. There are people who have used inhalants quite a bit. There are people who have it as their drug of choice, but typically that’s gonna be needing a level of treatment that is kind of outside our scope. Because if someone’s using inhalants on a regular basis, honestly, their brain’s gonna be really, really fried.

It causes some very serious damage to the brain that is almost instantaneous and so that’s not something that someone can really hide. They might be using it on an occasional basis. So an inhalant in this case is something like air duster. The stuff that’s used to clean out computers that is popular as an inhalant, other things like glue or whipped cream cartridges or anything that has like an aerosol to it can be used as an inhalant and abused.

For a lot of people who have used inhalants. It was one of the first drugs they tried because it’s all stuff that’s kind of readily available everywhere you go. From hairspray to air fresheners to household cleaners, like scotch guard. The high from that is super short, like a minute or two. And the dropoff is pretty steep, which causes someone to use it again. It’s really dangerous and can be extremely fatal, kind of at any point, whether they’ve used one time or 50 times. That episode is episode 28. If you wanna know more about inhalants and huffing. Those are the basic stimulants that people use.

Generally when someone is using a stimulant one of the things I am thinking about is underlying depression is probably a thing. Additionally, having a difficult time with kind of the monotony of life and wanting to feel happy or excited about things. Perhaps they’re having trouble getting things done. This is not the kind of drug that you hang out and chill out and just watch TV. This is about action and movement.

So if you’re treating someone that is using a stimulant problematically in order for them to not have that, they’re gonna need to have a way to have natural increase in excitement and sometimes novelty seeking behavior is a thing. They’re gonna need to have something to help replace it. This is a person who wants to feel like things are exciting, at least some of the time and who naturally doesn’t feel that way.

For someone to stop using these kinds of substances they have to feel like there’s stuff to look forward to. The reason typically why it’s a bad idea to use stimulants even once in a while, is that tolerance is a thing, withdrawal and side effects and that progression is a thing in substance use. We progress in how much we use because our body gets used to it. So where a small bump of cocaine would’ve been okay. It starts to take on a life of its own.

In the beginning, it’s pretty difficult because all experiences seem dull and flat and anything natural seems weak. Their definition of what feels fun is something that is only achieved through chemical means. The longer they’re away from a substance, the easier that gets. And so for us, that’s really about distress tolerance and helping them push through those times because the farther they get away from the using the easier it will become to just enjoy normal things.

If somebody has a really strong novelty seeking trait, meaning that they really love new things, that is not something to be ignored or white knuckled through. My experience with people is that it always comes back. It can be quiet for a little while. You can ignore it for a little while, but eventually that person is going to need to have something that they’re pursuing that is new and different.

That could be different sports. It could be skydiving, whatever. These people in their lives are going to continue to want new experiences. Which is not bad. It’s just that substances drive that a lot harder, a lot faster with potentially a lot more danger.

So, what about the people who don’t wanna be amped up? The people who think that that would be terrible. I was a hundred percent in that category when I was using many years ago. The idea of amping myself up and being all jittery was an awful experience and not at all something I wanted. Those people typically go towards depressants.

Depressants slow down the central nervous system. The whole goal is to turn everything down a bit and make it move more slowly. It can be just a little bit, or we can end up moving more like a sloth, either a real sloth or in the movie Zootopia if you saw it. Where the sloths ran the DMV, the Department of Motor Vehicles. It’s a really funny movie if you haven’t seen it.

I have found that the majority of people using depressants often have anxiety. There are some people who use depressants, like alcohol, who are depressed also. In that case, they’re using it to kind of distract from the depression, but sometimes they end up sadder and more upset while they’re drunk, tearful or hopeless, or any of those things.

When we’re talking about why people choose a certain substance, I have seen that depressants usually get chosen by people who have strong anxiety. So when we’re talking about depressants, the major one of course is alcohol. Alcohol slows down the central nervous system. It is effective in the way that it makes people lower their guard.

Lots of people talk about being able to socialize better, being able to talk to people that they would normally never talk to. Being able to let loose that they can’t dance without having alcohol in their system, or they can’t socialize without it, because it does help distract from normal thoughts that go through your head and indeed racing thoughts.

A lot of people use it to help them sleep because when they lay down at night, they just can’t get their brain to shut off. Sometimes people use it to sleep because when they lay, when they lay down at night, they can’t get their brain to shut off and alcohol is effective for that.

I think a lot of people end up using alcohol even if they would prefer a stimulant because it’s readily available and it’s readily available legal and socially acceptable. Alcohol however, has a downside that other depressions don’t. The more alcohol you ingest the less likely you are to be able to function or hide it. And that is not typically what people want.

Alcohol is going to be probably the number one substance that we end up seeing because it is widely advertised, legal, socially acceptable, and part of our cultures. People don’t usually question if someone say having a drink after work or even having mimosas first thing in the morning. Not totally sure why if we mix it with orange juice and it’s champagne, why that’s better, but apparently we as a culture, at least in the US, decided that that’s acceptable in terms of being able to drink in the morning.

It is really easy for someone to justify and to explain why they’re drinking. I find for the most part that people don’t get questioned a lot about that. Think about the mom wine culture. On social media all the time I see posts about how mommy needs wine once the kids go to sleep or moms get together and have wine. It is hugely marketed to women in that way.

For men, stereotypically it’s about sporting events or hanging out. That as dudes, they need alcohol in order to be around each other. It’s also a really social thing. Everyone else is having a drink. It’s starting to help you relax. Things are funnier than they would’ve been

When a client is choosing alcohol in my experience there’s something about their life that is overwhelming and that they need it to relax. A lot of times that’s underlying anxiety. For some it’s also sleep problems. It also tells me that they aren’t drifting into illegal drugs and a lot of times that has to do with wanting to try to contain it and not get addicted basically.

The other big depressant or downer is marijuana. Marijuana slows down the central nervous system. It also easily crosses the blood brain barrier and impacts the brain very quickly. Marijuana is a drug of choice for a number of people. People with depression do use marijuana and a lot of times it’s to distract them from the fact that they’re depressed, but not necessarily to manage the overstimulation that happens with anxiety.

When I have someone who’s using marijuana, typically it is about anxiety. It is about racing thoughts. It is about social stuff. It is about relieving pressure. It is about being able to interact in the world. There are lots of people who choose marijuana because they don’t like alcohol. They don’t like hangovers. They don’t like the taste. They don’t like the sloppiness that comes with being drunk.

Marijuana gives them a similar distraction, but without all those side effects. The trouble with marijuana, I believe, is that people believe that they’re not impaired in any way. They don’t think about slowed reaction time and so driving while they’re high, doesn’t seem like a big deal. It’s also decently hard to tell when someone’s high, unless they are blown out of their mind and have the classic glassy red shot eyes. Most people who are using marijuana on a regular basis though, are gonna be taking care of that. I carried Visine with me every day when I was using marijuana.

A lot of times people will choose it stating that they don’t wanna use alcohol, because alcohol is damaging to your body and marijuana, isn’t in their opinion. Marijuana is less dangerous than pretty much any other mind altering substance. I find that people choose it because they feel like it’s more controllable. They feel like they can conceal it better, especially with edibles.

Edibles are made with THC oil. THC oil is made from the marijuana plant by extracting THC, which is the part of marijuana that gets people high. That THC oil is then put into some kind of food or beverage. Then that food or beverage can be easily concealed. If we’re talking about a gummy bear, no one’s gonna think anything about someone having gummy bears or some other kind of candy and so it’s easily concealable. No longer until you have to have bags of weed that smells a lot, and that people can detect from a mile away. You don’t have to find a place to smoke it. It’s become a lot easier to hide. So a lot of people will choose that.

They’ll talk about it being more natural. They’ll talk about it being something that is going to be legal anyway, or is legal and is just a way to help them. I think that the advent of CBD oil has increased people’s view of marijuana as a supplement. CBD comes from the cannabis plant, just from the hemp variety, although it can come from the marijuana variety too and it’s seen as a supplement for a ton of things. I think that a lot of times people see their marijuana use as a supplement too, sort of the thing that they take to manage their anxiety or other mental health issues.

The issue in therapy is that marijuana has a psychedelic component to it. It separates people from time and space. It’s sort of a little bit like dissociation in a way. Not complete dissociation, just distancing them a step or two from the world and from the outside. Sort of like a buffer, so to speak. When we’re in therapy, we need people to be able to have access to their emotions and not have something interfering with how they feel and how they’re experiencing things.

So for me, I often will ask my clients not to use marijuana in any form within four hours. Four hours is an arbitrary number that I chose based on my experience with people and my own experience, that after four hours, they typically won’t be actively high and they’ll be on the down swing. So that they’ll be more connected.

I have found that when people are choosing marijuana, they are trying to manage their emotions and their anxiety on their own. I have heard a number of people tell me that it’s better than taking some drug with chemicals in it, referring to antidepressants, and that this is natural, et cetera.

There’s a lot of problems with that argument and I find that it’s not worth getting into that with them. But instead setting limits around therapy because that’s the only part of their life that I’m interacting with right now. The problem with marijuana here is that tolerance happens and it happens not immediately, but it happens quicker than people might think where somebody has to increase their use of marijuana. That gets expensive and they start struggling with life without having marijuana on board and that’s also a problem.

I don’t think weed’s the worst thing on the planet. I support legalization with a few caveats. I’m not saying I support use necessarily. I would prefer people not use substances to manage themselves and their emotions. I also don’t believe that it belongs as a schedule, one substance in the United States alongside things like heroin. Those two things are not even remotely the same thing, even though they both fall in the same depressing category.

So moving on from marijuana, we’ll talk about opiates. Opiates are pain pills, and I think we’ve all heard a lot about them. They are depressants. They slow things down. We won’t talk a ton about heroin because heroin is just the next level of opiate. The people that we see are typically not gonna be using heroin. If they are, then you probably need a substance use specialist to help you manage that.

I created a free tool called the Substance use Decision Tree that you can download to help you figure out if your client’s use is appropriate for outpatient therapy or if you need to add a substance use specialist. You can check it out@betsybyler.com/tree.

Because heroin is so much farther down the road, opiates are kind of the focus today. There are a number of different kinds of opiates. They’re synthetic, semisynthetic and natural. When we’re talking about pain pills, we’re talking about anything from Tramadol to Lortab to Oxycontin, to methadone, to fentanyl. Each one has a different level of potency.

What I have found is that people, whose substance of choice are opiates or pain pills, they’re typically trying to manage anxiety and or pain. The reason that opiates help with pain is because of their depressant nature. It’s like putting a blanket over nerves that are firing and angry. It’s soothing them.

For anyone who’s had surgery or some kind of injury, they are a godsend. It’s like a miracle to be in excruciating pain and to feel the wash over your body of the pain receding, it’s hard to even describe. The trouble with it is that the very nature of opiates is that they rewire the brain when it comes to pain.

Abuse of opiates can cause what’s called hyperalgesia and hyperalgesia is an extra sensitivity to pain. So pain pills, long term, can make someone more sensitive to pain. Which is kind of fucked up actually. They are meant for short-term use. They were never good for long-term use.

Now our medical communities didn’t get that information. They were told that it was just fine and honestly that it didn’t have addictive potential, which is part of why we’re in the crisis we’re in now. When someone is using opiates, a lot of times they end up having to switch to heroin when we’re way down the path, because pills are harder to come by.

There are a lot of pressed pills on the market that look just like the pharmaceutical ones, but are indeed just made by drug dealers. And they look identical like pharmacists can’t tell them apart. So in that sense, pills are a little more available, but it’s expensive. It’s not concentrated. It can be really messy to use if someone’s snorting or smoking or shooting or whatever, and so heroin can seem like a better option.

Lastly in the depressant category are other pills. So for our purposes, there’s barbiturates and benzodiazepines and sleeping pills. All of those have downer effects. Their whole point is to slow down the central nervous system. The idea is to relax, to be able to slow down to calm anxiety and indeed we even use benzodiazepines to calm anxiety.

So when we have someone come in, who’s using a substance and it’s a depressant. I automatically am thinking, okay, what kind of anxiety could we be dealing with? What are they trying to numb out? What’s overwhelming them and how can I help address this anxiety? Because in order for someone to stop using these kinds of substances, to manage their anxiety, they have to feel like they have enough tools and that they’re not gonna be left at the mercy of their anxiety.

We all have seen when people develop panic about panic. They now are anxious about getting anxious. In fact, they can even get anxious about not being anxious. Where their brain is like, shouldn’t you be anxious about something? Are you forgetting something? Shouldn’t you be more concerned? Anxiety can be such a bitch.

Getting someone to use good coping skills, adaptive coping skills for anxiety is going to require that they feel confident to be able to manage it. I have found in working with people with anxiety that they need to do that slowly. That just ripping all sorts of things away from them causes panic and this sense of, I can’t do this. This is dumb. I’m gonna stop showing up all sorts of things.

Again, I’m working on a lot of distress tolerance, having them try different things. Practicing them in session and talking with them about what they think is lame and what actually helps them feel better. That repeated sense of being able to calm themselves down is incredibly empowering and totally what we’re after. That is what I focus on when someone comes in and they’re using depressants.

The last category is hallucinogens. So hallucinogens are bigger than you would think. A lot of times someone’s gonna think of shrooms and LSD or acid. And yeah, those are hallucinogens. They fall in the classic hallucinogen category. However, there are a lot of other hallucinogens like DMT, peyote, ketamine, MDMA, or ecstasy, ayahuasca.

All of the things in the hallucinogen category have similar properties of changing someone’s view of time and space. It’s not just interfering with it in the way that weed does, although that is a psychedelic property. It is bigger than that, stronger than that, I rarely find that somebody’s substance of choice is a hallucinogen.

Typically that is because it is hard to recover from that quickly enough to just function in your daily life. It can take a day or two after you’ve been tripping on something to feel normal again. It can also stay with you. There are long term effects from using certain hallucinogens and so typically it’s not someone’s drug of choice.

The exception could be ketamine. Although ketamine is being used for some treatment resistant depression. However, it’s being used at a level and in a way that is not the same as someone who is using it recreationally or to manage their mood. I don’t have any issue with what’s happening with ketamine right now, as long as it’s being done in a way that is scientifically and clinically appropriate.

The whole point of a hallucinogen is to change their viewpoint. We do this in a number of different therapy types. So for instance, EMDR. In EMDR, we are reprocessing memories to try to help people find a different viewpoint so that they can come to a different conclusion.

I had a client who was an incredible dog lover and ended up hitting a dog with her car. It was devastating and awful. Even though the owners acknowledged their fault by not having their dog on a leash, other people around her, the police, everyone told her it wasn’t her fault. But for her, she absolutely could not see around it.

Through EMDR she was able to step back and view what was happening and she came to her own conclusion that it wasn’t her fault. There’s no way she could have seen that dog coming. She was driving at a decent speed for the neighborhood, wasn’t being reckless, was being slow and deliberate and that it was an accident.

The reason that there are trials using things like MDMA or ecstasy for trauma is because it is kind of a shorthand. It pulls you out of your own existence and your body to show you something different. You’re not incapacitated when you’re on those kinds of substances, typically anyway, and you’re able to remember things about your life. It’s just like you stepped outside for a while.

When someone is using hallucinogens, typically it’s gonna be once in a while, it’s for a novel experience and they don’t plan on using it all the time. So when someone is using hallucinogens, I really am trying to find out what it is and how often. They’re kind of self-limiting already and it’s really not common to find someone with that’s their thing.

When someone comes in and they’re using a substance, the first thing you wanna determine is, is it a stimulant, a depressant or a hallucinogen. Then you wanna look for what’s underlying? Is it depression? Is it anxiety? Is it ADHD? Is it trauma? What is it that they’re trying to manage and contain? Whatever that is, is gonna tell you what this person needs to work on in therapy in order to not use these substances as coping.

Using substances as recreation is a human trait. It’s not something that I’m trying to get rid of. What I want is for someone to choose what they do. To not use a substance as a reflex action. I want the same thing for their normal coping skills too. If someone’s coping skill is to check out in their brain and dissociate, I’d like them to choose that rather than having it happen automatically.

We want them to choose, to put their protective measures on whatever that tends to be, rather than doing it and not realizing it’s happening. It’s like you need a winter coat in the winter in the north country here, but you don’t need to keep it on all year. You need to choose if the weather needs it or not. That’s kind of what we’re after here.

Is this person’s use getting to a point where this is their only main coping skill. That when push comes to shove, it’s too overwhelming and they have to drink or they have to smoke weed, or they can’t manage their life in getting things done and so they have to use some kind of upper or a stimulant of some kind.

We wanna help people find freedom from these things so that they can function in a way where. If no one is around and no substances are around that they can still manage. Oftentimes our people feel like their emotions run their life and they feel at the mercy of them. One of the greatest gifts I think we give to people is helping them see that they can manage their emotions internally. That they can have some agency over it and not be at the whim of whatever comes up for them.

It’s a hugely freeing thing and it helps open up other experiences if they’re not being locked down by having to cope in certain ways. So each time someone comes in and they’re using some kind of substance, what we’re doing is dropping a substance use lens. So you’re thinking about it, like being at an optometrist where they’re dropping lenses down in front of your eyes to see what helps you see more clearly.

So we look at it through a trauma lens and through anxiety and depression and all sorts of different things that we’re trying on to see does this fit. Can I see things more clearly if I think about it as this person having anxiety, or what about a medical problem? Substance use is one more lens that we’re looking at things to see how they function and to see how it impacts them.

In order to help people cope better they need to have a repertoire of coping skills that they can count on. My goal is not to rip people’s safety blankets away from them. It is to help them feel like they don’t need them anymore. Each of these substances has unique properties that makes it more attractive to a person than others.

I often like to ask people why that, why not this other thing? If they’re drinking, why not weed? If they’re using weed, why not alcohol? If they’re using pills, why that and not something else.

I know that one of the things I get asked the most is how do I know that this person’s use is something that’s okay for me to talk about? Or when do I need to refer out?

We get really nervous about stepping out of our scope. And the fact is, substance use is in our scope. It’s literally in our manual and we can address it. There are levels, of course, that are outside of what mental health can do. As I mentioned earlier, I developed a free tool that you can use to quickly determine if your client needs a substance use specialist or not. Now it’s based on my opinion and observations, but I do think it’s a handy tool. Go over to betsybyler.com/tree, and you can download it for free.

I firmly believe that we already have the skills that we need to work with substance use, and that it’s just information that we lack. So next week when we meet, I’m gonna be talking about some common skills used in DBT and how they can be repurposed to be used for substance use. I hope you’ll join me for that podcast. 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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