Episode 160 (re-post of episode 97)
Love of others, the law, nor the hope of a good future are enough to keep someone sober long term. Great way to start us off right? I know it sounds like a real downer, but I promise if you stick around it’ll get better. People start working on reducing their substance use or quitting entirely for a variety of reasons. Sometimes it’s a court or legal issues, sometimes it’s a loved one and sometimes its something internal. These reasons are unique to each person and vary wildly. The thing these people have in common is that the original reason that got them on this path won’t hold up forever. The reason to get sober isn’t going to be the reason to stay sober. That, is something else entirely.
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 97. It’s hard to believe that for those of us in the Northern hemisphere, that summer is almost over. For those of us in the United States that means back to school. While I don’t have kids in school anymore. I do pay a lot of attention to the school year. Mainly that’s because I see teenagers and adults and the school year really affects everyone.
My teenagers are getting ready to go back to school and the parents that I see are getting ready for that to happen as well. Each of them has a different energy about it. For the most part. It’s one of excitement, even the kids who don’t wanna go back to school, they’re pretty much bored out of their skulls by the time August rolls around and are at least ready for something new.
I remember this time being exciting in terms of getting school clothes and getting notebooks and pens and binders and all sorts of stuff. I can remember feeling like I’m gonna start better this year. I’m gonna get better grades. I’m gonna do my homework, that kind of thing. Usually the honeymoon period lasts a few weeks into the year.
As therapists we see the summer slump and about a couple weeks after school starts, calls start coming in. Because low and behold, a new school year wasn’t quite enough to keep everyone as motivated as they maybe wanted to be.
So why does that happen? Why is it that people are excited when something new begins like school and then after a few weeks, it fizzles out. A lot of folks will say motivation, that that’s the primary culprit or perhaps, maybe it was harder than they thought, and that other things popped up and got in the way, or maybe they lost focus or maybe it’s all of it.
How this was relevant to today’s conversation is that we’re gonna be talking about what gets a client sober isn’t going to be enough to keep them sober. Before we get into the heart of it, let’s start by defining sober. Sober can mean a number of different things to a number of different people.
Sober in the AA community, that’s Alcoholics Anonymous, usually means abstaining from all mood altering chemicals. In the recovery spaces, though, there are a number of definitions of sober. It’s very dependent on the person. For me, sober does mean no mood altering chemicals, drugs, or alcohol. For some people they might even add medication to that. That certainly doesn’t fit for me, but there are people whose sobriety includes that.
For others, their sobriety includes no use of alcohol or no use of marijuana or using it only recreationally. All of those ways of being “sober” are valid for the person that’s defining them. So when we talk about what gets your client sober, we mean whatever it is that they’ve defined
So why does that happen? Why is it that it fizzles out? We know it’s not just sobriety that this happens to. This is the entirety of diet culture. What starts people down the road to wanting to lose weight or to maintain a certain weight, isn’t going to keep them going long term. At least for most people it doesn’t.
Growing up in the eighties and nineties was the height of diet culture. There were ads for every kind of diet under the sun. I can think of Deal-a-Meal with Richard Simmons, I can think of Nutrisystem or Jenny Craig or Weight Watchers, not to mention that it seemed like every hospital came up with their own weight management programs. Not that that’s that much different today. We have other things that are out there and all of it is built to try to help people have a system to follow, to meet a goal.
Sobriety is no different. We talked about last week, that all the things we do in therapy are applicable to people using substances. And that’s really true when it comes to this as well. So something that’s true about all of us is that we want our clients to make progress. We really want people to get better and to see success.
Yesterday, I got an email from a client and they sent me an approval letter that they got. For something they had applied for. They had been denied and we worked on an appeal and I ended up writing an extremely long email in support of my client. Getting that email from my client yesterday was the highlight of my day.
I got to hear through her words how happy she was. And I got to feel like I had a part in it. That this really big deal, a thing that was gonna make a very real difference in her life that I got to have a small part. That felt really, really good.
For the most part, being a therapist isn’t about getting wins every single day. It’s not about how many people make progress or don’t, it’s about meeting people each day, each visit and helping them get a little more insight and a little more peace. At least that’s what it’s like for me.
When I see a client make a positive change, I want them to be able to maintain it. I want them to be able to keep going, because I remember what it was like just a few weeks ago when they were despairing about this very thing. I wish I could bottle that feeling for them so that when the behavior started to crop up again, I could help them feel what it was like to try to help them keep going.
When we think about the number of people that we know personally, or professionally that keep going with the thing that they decided to change, the number isn’t as high as we would like. That can be especially true when it comes to substance use relapse or relapse is normal. For a lot of folks, when they hear me say relapse is a part of recovery, they will feel like I’m setting people up to fail or giving them permission to use again,
I’m not, I’m being realistic about the fact that we all slip up. Sometimes we take steps backward. That when life happens, we can end up making old choices. Our old patterns of coping are very accessible, even if we’ve been away from them for a while. I know for myself, it can be really hard when a client comes in and tells me that they’ve been doing this old behavior.
So let’s talk about why this happens with substance use. What I mean, when I say what gets them sober, isn’t going to keep them sober and what to do about it. I can’t quantify the number of people that I’ve seen over my career. I’ve tried to sit down and think of how many clients do I see on an average basis? How many did I see when I worked at this job or that job? And does that include the clients that I’ve spent consulting on or supervising.
I spent probably 10 hours a week, every week in supervision or staff meetings with clinicians, talking with them about their clients, about successes and about struggles. More often than not it’s struggles that tend to come up as the staff are looking for some direction, perhaps some advice.
And as I reflect back and I think about all of the stories that I have heard about people who were using and their quest for freedom from it, even if that’s not how they viewed it at the time, I have found a few universal truths.
The reason that people say when they come in about why they want to work on their substance use varies greatly, and isn’t enough to sustain them in the long term. I’ve mentioned before that in a true chemical dependency program, 90 to 95% of the folks there are going to be mandated by the court somehow. In some way, they’ve had the floor brought up to them, the bottom, so to speak.
Now I’ve talked before and we’ll talk again that there doesn’t have to be a bottom for everyone, but for a lot of folks, there can be one. For the people who come in and they’ve been mandated, the floor was brought up artificially. They were picked up while drinking and driving. They had a drunken disorderly got into a bar, fight, public drunkenness, whatever the case maybe. And now there’s an authority person involved who has a vested interest in making sure that they toe the line so to speak.
When those people come in and you ask them why they’re there the majority of the time, they will say because I have to be. Because probation’s making me, because my lawyer said, it’s a good idea so that I get an easier sentence, because the court said I have to, because I wanna get my license back or because my job says I have to.
In the beginning, many of them believe that that’s the reason they’re there and that that’s the reason they’re going to stay. It works for a little while. Sort of like our school example where in the beginning, the teenagers I work with are working hard, doing homework, showing up for class, even getting there on time. And then it starts to slip. And the same thing happens in treatment.
Even though these people are mandated to be there, they start missing, showing up late, perhaps talking about having drank on a weekend. Or driving their car to treatment, even though it’s illegal for them to do so. The person may have even been really zealous at the beginning, really committed. And yet things fade.
What about the person who shows up because they have a partner or a loved one who has begged them to go to treatment? Maybe they even had an intervention. The loved ones in their family sat around and told them all of the hurtful things that have been said or done and begged them to go to treatment. In that moment, shame or guilt, or both may be driving that bus, sending the person to treatment.
In the beginning it’s enough. But I have found that within days that motivation is gone. What then about the person who comes in because they wanna be there? Well, they came in because they got sick and tired of something. My friend, Jean, who told me her recovery story at the beginning of this month, talked about how she had this sense that she needed to save her own life.
She had a feeling that if she kept drinking the way she was, that something bad was going to happen and that it was going to wreck her life and, or take her life. She was not wrong. as things progress when people are using all the time. That is the thing that started her on her journey.
It wasn’t the thing that kept her on it. In the beginning, it was “I need to save my life” and as she was writing her blog from day one, it became, “these other people are counting on me”. In other places. I’ve heard her tell that the potential shame about relapse was so powerful that that is what kept her from drinking.
She will tell you that that’s not recovery though. It’s sobriety as being sober for her means not having any mood altering chemicals, but that after two years she was simmering with anger. And if you’ve heard Jean talk it is absolutely unfathomable to think about her simmering with anger. I’ve rarely met someone who was so genuinely kind. But when someone is holding on by sheer will, that’s not what we’re after with recovery.
In the beginning, people are really clear a lot of times about what it is. That’s bringing them to a place of needing to work on their substance use. As time moves forward they are less clear about that.
So let’s use a weight loss example. Somebody goes to the doctor and they have to get on a scale and the scale says more than they’ve ever weighed before in their life. Even if it’s only five pounds, that’s usually pretty shocking for folks and even while they’re waiting for the doctor, they start making plans to do things differently. Then perhaps they get some blood tests back and find out that some of the numbers are off. Okay. They double down on that. They’re gonna make changes. How often do those changes stick ?
In the diet culture during the eighties and nineties I’m not sure you could have a commercial break without seeing some sort of ad about diet food, or diet programs. And as always, there’s a little asterisk and the phrase results are not typical. Even in the show, The Biggest Loser the contestants have now come out and the research has come out that they can’t sustain the weight loss. This is not because they don’t care. This is not because they decided that they didn’t feel good being at a smaller size. This is because things shift.
Now for the biggest loser. There were a lot of other metabolic problems that added to that, and it made it super easy for them to gain weight back. And what was motivating them at the time was Bob and Jillian, competing against each other was motivating them, winning a prize was motivating them and certainly feeling better and feeling stronger in their body was motivating them. As the motivations changed. And as things fell away, it got harder and harder. This is human nature, not a character flaw. So when I say that relapse is part of sobriety, that’s what I mean,
I want you to think of someone in long term recovery, hopefully each of you know somebody who has that, if not, then you could think of any of the guests that I’ve had on the recovery stories. You could even think about me. What got us sober in the beginning was one thing. And then it changed. And what got us sober later and what keeps us sober today is a far cry from where we started.
A couple weeks ago we talked about the idea that people choose their substance over their loved ones. And my assertion is that that’s a myth. That isn’t what’s happening. Love just isn’t enough, regardless of what tons of songs say. It’s not enough, not in the long term. We have moments where the love we have for people is so overwhelming that it feels like we would do anything, but that’s not at that height every day.
It’s there in the background and it can be kind of amped up so to speak, but it’s not a long term solution. So the person who comes in because their partner said they’re going to leave them. That might be what got them in the door. But I have found that over a few weeks, the person’s motivation is waning, their resentment is growing and they’re starting to find ways to do what they want anyway. That’s not about being selfish. That’s about the reasoning.
All of this is about long term goals needing to shift. The long term goal that somebody sets today might be admirable, might even be a great idea, but long term goals don’t really work. They work some of the time. And for some people who are super dedicated, they work probably most of the time. But for average people, long term goals are not effective.
Diets aren’t effective because what somebody eats today, when they’re out with a friend, seems extremely distant from the goal they have of losing weight. They believe they can make up for it later. They make some sort of calculation in their head that they can work out more or cut back here or there. Eventually those things start to go by the wayside.
There are all sorts of suggestions that people have of keeping someone on track. People are told to put up signs all over the house so that they remember. To have something on their person to help them remember why it matters. To say their goal to themselves a certain number of times a day. And I think some of that might work for a little while, but what things are like at the beginning are going to change.
As therapists when we see this happening, it can feel bewildering. Somebody who was making excellent progress and feeling really great and then they start to slip. Let’s use a non substance example.
I have worked with women who have an uncanny ability to find the same dude over and over. Every man that they have dated is a nightmare of a human. How they find them. I have no fucking idea, but it’s almost supernatural, how quickly they find these dudes or these dudes find them whichever way it is. I have worked with women in these situations to help them get out of said nightmare relationship.
They get out, they have a few weeks of feeling great, of seeing all the red flags and all of the things that they should have done differently or could have done differently. They’re feeling excellent and ready to make sure that that doesn’t happen again. The motivation is to protect themselves. The motivation is to keep themselves happy, to have a good, healthy relationship with a partner.
So why then, more times than not, does that start fading? Does the person value themselves less? Do they want different things now that they forget all of those lessons? I don’t think so. I think what happens is that the motivation has to shift with them. So let’s go to a substance based issue.
Let’s say that you have a client who, every time they go out, they drink too much and feel like a fool. And they have to spend the next day asking everyone who was there for reassurance, that they didn’t act like a moron out with their friends. They also have to nurse a killer hangover and they have decided that this sucks and they don’t wanna do it.
And so the next Friday night or Saturday, or whatever comes around and they go out and they have success, right? Their goal is clearly in mind not to feel like shit and not to have to worry about what happened on the weekend. And maybe they have several of those and it feels really great. They’re moderating effectively. And then they start playing around with drinking more. And we know the story, they wind up doing the same things before slipping back into old habits.
People do this with lots of coping skills. People who have successfully gotten away from cutting and ended up sliding backwards or struggling with skin picking ends, ended up getting back to a place where they were doing that. Now, some of this is compulsion and again, a story for a different day, but why do we go back?
Well, there are many things that are happening in each person’s life. So we can’t generalize to everyone for every situation. What we can do is see a thread. The reason that they made the change is either no longer there at all and has been eliminated or doesn’t seem compelling. They’re not thinking about what their future self is gonna be feeling about them today.
And here’s an example, I have struggled with my addict self with working out my entire adult life. I would work out religiously for weeks at a time. I would be busting my ass a certain number of times a week for a certain amount of time and would not be half-assing it. During that time, I was ready to roll, not being begrudging about going to workout, feeling great.
And what tends to happen for me and happens for a lot of people is I got sick. I got injured, something happened. I had to be on a business trip and the hotel had a crappy workout facility, or it was just too busy and I didn’t get a workout in. What do you suppose happened next?
I stopped working out. Like from a hundred to zero overnight. I distinctly remember this in college, I had worked out and was putting stickers on a calendar. And I had like two full months of stickers in rows on the same day, every day. And then I missed today and I don’t remember why, but my roommates were trying to convince me to just put a sticker there anyway because I was upset that there wasn’t going to be a sticker.
So one of them went and picked up a sticker and started to put it there. And I’m like, I know it’s a lie. It doesn’t matter. And I literally stopped working out. Over my adult life that had happened over and over and over. Why was it that I miss one day and it’s all fucked. Because my motivation was different because what I did that day was super removed from what the goal was long term. So it didn’t matter if I worked out. I missed a day and the world didn’t fall apart. And so fuck it. Nothing matters.
Why are we, as humans, built like that? And especially those of us who struggle with addiction, we are absolutely built like that. We’re a hundred percent go or totally stopped. I always joke that I am an object at rest. I love leisure. I love laying around watching something on what counts for TV these days? I love laying in one spot. I swear if there are previous lives, I was a big old, chunky cat, just lazing in the sun.
Something shifted though, about six, seven years ago. I have maintained an exercise routine for the most part since then every week. There might have been a week or two where I was sick, or I might have gotten injured because of wearing stupid Adidas flip flops and not picking up my foot high enough to get onto the sidewalk. But I still work out and I work out generally a similar number of times a week, and generally a similar amount of time each one of those days. So what changed?
I’m the same person. My addict thinking is still very much intact, but it’s really different. And what changed is the motivation. So I don’t work out for any kind of long term benefit. It’s true that it’ll be there. It’s true that after years of practicing yoga and years of working out, that I’m stronger, that my body is more flexible, that I feel better in my body, but that’s not why I do it. It’s a side benefit.
I do it because it makes me feel good today, this week. That it makes me feel more in control of my life. Stronger, more powerful. The motivation stays with me. It’s current. It’s not some long term goal that I don’t give a fuck about today. When it comes to our people, the motivation needs to be inside. It needs to be intrinsic to them. It has to matter, actually matter to them, making people proud does not last. The love of family or friends does not matter either. The love of self doesn’t matter because sometimes my brain tells me the most loving thing to do is to sit on my ass and. I don’t know on occasion, that might be it, but it’s very rarely that.
So here’s what happens with teenagers in school. High school feels like a whole lot of bullshit a lot of times there are some subset of people, a percentage that love high school loved being there loved all the activities were involved, had great friends.
With teenagers It begins before I even start seeing them drop backwards. When they tell me about success and they got assignments in or did well on a test or something like that, I ask them to tell me how it feels. I ask them to sit for a minute reimagine that they have had that moment, the moment of getting their assignment back or of getting an answer right.
I want them to remember that feeling, but not just that feeling. I want them to remember laying in bed that night. I want them to remember getting up to go to school in the morning. That the choices that they made led to those very moments. Not to the grade on the report card, but to the feeling, the lack of anxiety related to having your homework done, the feeling of excitement that if a teacher called on you, you would know what to do. Those are the things I start to reinforce because I know that eventually we’re gonna need to call on it.
When I start seeing some of the things slip, I check in to make sure that what I’m viewing is right. And I’ll say something like, so a couple weeks ago you were doing homework and things were getting on time.
What I just heard you say is that you’re a little behind on some assignments and they’ll be like, yeah. And I’ll say, No shame. I have no opinion on that. I’m just checking in because I know that when you’ve been behind, before it really weighs on you and they’re like, yeah, it does. Okay. So talk to me about what’s happening right now.
And so I will talk with them about what’s getting in the way about how it feels to be behind. A lot of times I’m trying to catch it before we’re in a full slide so that I can say, is this what you want? cuz it’s fine. If you just wanna say like, fuck this and don’t worry about it for now. I get it. When you feel like dealing with it, we’ll deal with it. And I wanna check in and just point out that this is what I’m seeing.
Rather than watching a slip, listening to them tell me why it’s not a slip. And watching them crash and burn into whatever hole they didn’t wanna get into. And it’s the same way with substance use.
So imagine that again, this person didn’t wanna get drunk out with friends and worry about it the whole weekend. So when I hear them say, so I had a little extra to drink and had a little bit of a hangover, but it’s no big deal. I’m not gonna go back to the old way. Okay. If that happens once I might leave it, but my guess is it’s gonna happen the next time.
And so I’m gonna say, okay, I don’t have any opinion about how much you drink. You choose what you wanna choose. I’m here to be a mirror and help reflect to you what it is I’m seeing. So tell me what was different about those two nights. That made you feel like you wanted to drink more. We’ll go through it pretty in detail because something changed.
Were they feeling extra anxious? Were people giving them a hard time about only having one or two? Did someone offer to be the designated driver? Were they having a particularly hard day and repeating the narrative that they quote deserve it so to speak. We have to then talk about what it is that they want their decision to be around alcohol and whether or not that motivation still fits.
In the beginning it was “don’t feel like shit” when they’ve accomplished that even for a little while the motivation’s different now. Because they haven’t felt like shit in a couple weeks. So now it’s time to revisit it and to say your motivation was this. What’s a different reason why you don’t wanna over drink on a Friday night. What did you not love about the way you felt the next day? Emotionally, physically, whatever.
More at times than that, there’s some feeling there and they didn’t love that because they had made a choice to do something differently. So they either need to change their decision about alcohol, or they need to decide how to do that differently. Revisiting the reason and making sure it’s honed in each time they’re gonna face one of those situations is really important and extremely helpful.
When someone is making a change, like getting sober, whatever that is, be very aware of the reason, helping them see the reason, showing them a mirror, no judgment about that if they wanna change it, but giving them an awareness that they are changing it. That if they said one thing and then they come back the next week and change their mind that we don’t necessarily go along with the illusion. Of, oh yeah. Oh, that’s fine. Oh, everyone does that. We’re just pointing it out.
Our job as a mirror for folks is to help shine a light on areas that might trip them up. All we are looking for here is to help people have an honest relationship with themselves and what they’re doing. When it comes to sobriety, like any other change, what gets them sober today is gonna be different. And maybe tomorrow it’s the same. And maybe it’s the same for a couple weeks. Maybe it’s the same for a couple months. But if you ask anyone in long term recovery, why they started getting sober to begin with and what keeps them sober today? The answer will be very, very different.
Working with substance use freaks a lot of therapists out. It feels overwhelming and mysterious and insurmountable. They feel like there must be a key that they are missing. I don’t know if you have felt like that, but I wanna tell you, there is no key. You have the skills to do this work. What you need is a way to apply it. Some pieces of information and perhaps a little guidance.
I created a program for therapists like you who know that there is substance use in their client’s lives and who want to do a more effective job addressing it without having to go back and specialize. I know because I have been there.
I didn’t start out planning to become a substance use counselor. I started out as a mental health therapist who was like, oh shit, I don’t know what I’m doing. And I need to know what I’m doing because no one else is coming into my session to rescue me and my clients are super resistant to going to see someone else.
You don’t need to specialize. I created the program, Charting the Course to help you gain the information you need to add substance use to your scope of practice. This is not about specializing. This is about adding it to the stuff that you talk about. It’s one more thing that you address when you notice it. It’s one more thing you assess for. And it is a facet of almost every adult’s life. Every adult isn’t using problematically, but nearly every adult is using or has used substances at one time or another.
There is no reason we didn’t learn it. It just isn’t. It’s not there, there wasn’t time. There wasn’t a focus on it. My program Charting the Course is to take the mystery out of working with substance use and to help you navigate it with your clients in a way that will feel authentic to you and does not require you to get a bunch of certification or even spend days and days and days in training.
You can read all about charting the course on my email@example.com slash course.
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.