Episode 95

Substance use treatment isn’t just about dealing with the substance. That would be like treating a cavity but not dealing with underlying disease. People in long-term recovery know that their mental health is a vital part of their recovery and needs to be addressed. If you listen to recovery stories (here on the podcast or in other  venues) you will hear the thread of pain, sadness, trauma and loss. People will talk about how they had to manage life without the use of substances and the painful and freeing thing that it is to do that. Mental health therapists are needed in the recovery space!  Today we’ll talk about what the role of mental health is in a solid recovery program.


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 95. Today is August 15th. Tomorrow there is a free event that I’m putting on with a colleague of mine. It’s called Braving the Course. 

Braving the Course is about  helping therapists treat trauma and substance use without burnout.  As therapists, we know that burnout is a real concern,  as is compassion fatigue. So when I’m asking people to add substance use to their scope, it might feel like they just can’t add anything else to their plate. Maybe they’re already overwhelmed.  If that sounds familiar, or if you have colleagues that you think would be interested, please share it with them.

 The event is tomorrow at 7:00 PM Eastern 4:00 PM Pacific. We have four speakers, one is Guy McPherson, who is the host of the popular Trauma Therapist Podcast, Dr. Hughes, who was with me on the Roe V Wade episode, Jean McCarthy of the popular podcast, the Bubble Hour and author of the Unpickled series and myself. 

The event is free. You can register at my website at betsybyler.com/braving-the-course and that’s braving dash the dash course. If you can’t attend live, there will be a replay that’s sent out the next morning to those who’ve registered.

Today we’re gonna be talking about aspects of substance use treatment. Treatment in this case is anything that’s being used to intervene in someone’s problematic substance use. Recovery can be for everyone. It doesn’t mean that the problem is over, it means that you’re working on recovery and there’s a lot that goes into that. 

When it comes to substance use recovery, there are a number of things that need to be a part of it. Not just cutting down or abstaining from a substance. So we’re gonna go through these different aspects one at a time. Today, we’re gonna talk about mental health in recovery. 

As I was thinking about this topic for the week, I had to think about how many people over the years have I seen who were using substances and had no mental health problems and no trauma. And the answer is very, very few. Even in those cases I found myself wondering if they were under reporting. 

Substance use is super effective in the short term for managing emotions. People who need to change the channel in their head because it’s uncomfortable or they feel sad all the time or they feel nothing or they feel anxious can use substances and it’s immediate. Whereas when we’re talking about medication like SSRIs, well, that takes time.. In the meantime, what are they supposed to do? 

I’m certain that there are some people who get into a place of using problematically without the co-occurring mental health issues. What I know though is that it’s not a lot. Just based on the recovery stories that I’ve shared here, each one of them has talked about their mental health struggles as being a precursor to their use. 

When someone is getting sober or cutting back, even their mental health issues are going to come up. We know that as we’ve seen that when somebody stops pushing away problems or thoughts, It can start to be overwhelming because once the brain gets the idea that it’s open season for processing, lots of things come rushing forward because they too wanna be processed.

If I have to rank the things in recovery, I would say that their relationship to the substance would be number one in terms of whether they need to abstain from all substances , or whether they need to cut back on substances. The second most important thing behind that would be mental health.

Most of the folks that we see who are going to be using substances problematically didn’t mean to start that way. They didn’t mean to get into a place where they were using that substance to cope. In the beginning, it was maybe wanting to cut loose, maybe wanting to relax, maybe after a hard day. They didn’t mean it to get to the place of being a problem.

 Because of that, when it becomes a problem and they have to cut back or stop using altogether, their problems seem amplified. They don’t have the substance that was helping them manage whatever was happening for them. Whether they’re using stimulants to manage low energy, or whether they’re using a depressant to try to calm down their anxiety or check out from the reality of life. Their distress tolerance is usually pretty low when they first stop using substances like that. 

Without addressing the mental health issues. Recovery is going to be really difficult. It’s going to be a continual struggle to keep putting those issues back in the box. So to speak. This is where we come in. We are hugely important to people’s recovery. A lot of times, I think therapists feel like they don’t have much to do with the recovery community or with the process of recovery from substances.

However, that is not the case. Every person that I have worked with personally has needed mental healthcare in addition to dealing with the substance issues. Perhaps they didn’t have something that was pre existing their substance issue and it developed as a result of. But all the same, it needs to be addressed or recovery really isn’t going to be sustainable. It’s going to be an uphill climb, white knuckling as it’s called, meaning that you’re holding on so tightly that your knuckles are turning. 

When you’re evaluating symptoms for a person who’s been using substances in a problematic way, what we’re gonna be looking for is what existed before the use started. The reason for this is that we wanna find out whether their mental health symptoms are from something before they started using that they’re organic instead of substance induced. 

Substance induced, anxiety, depression, psychosis, all of those things still exist and certainly are in the DSM for us. In my experience, I have found that there are some substance induced disorders. Typically I find that it’s substance induced psychosis rather than substance induced anxiety or depression. Psychosis can be part of a number of different drugs and their side effects. 

One that people wouldn’t expect would be marijuana. Marijuana has a link to increased psychosis. Marijuana itself does not seem to cause the psychosis, but it does push it forward, so to speak. The way I’ve heard it described by a psychiatrist that I worked with was that if the person has let’s call it a pre-disposition even though that’s not quite correct, or a genetic marker, where if it’s flipped on psychosis would be present, that marijuana can push that forward where it wasn’t before.

I remember one of the first times I saw this. It was a young man who I think was 20 and he had been hospitalized because he was having psychosis and his behavior was erratic and he was picked up by the police. He was taken to the local hospital, put into the psychiatric unit and diagnosed  with the beginning stages of developing schizophrenia,

understand why they gave him that diagnosis. His psychosis was pretty intense and even without the drugs, he still had some lingering psychosis. However, I don’t think he was developing schizophrenia, at least not yet. Through more evaluation, it seemed that the psychosis had happened to him before, when he was smoking marijuana on a really consistent basis and multiple times.

When he cut back or switched to alcohol for a while, it started to fade and indeed there were months where he didn’t have any that he was aware of. By the time he got to me, he was on some pretty serious antipsychotic medications and was still experiencing psychosis. I’m not sure if it’s super common knowledge that when someone is smoking marijuana regularly, that for some people it can increase their psychosis.

And so I asked him about that and he answered, yes, he was still smoking. And so I needed to chat with him about what that was potentially doing to him, because if he kept smoking and the psychosis kept going on. What we’ve seen  is that eventually it’s no longer substance induced and can stick around permanently.

It was difficult for him to understand because marijuana is a plant, it’s natural, it’s from the earth. And what I was explaining to him was that it has psychedelic properties. That THC isn’t just a depressant, that there are  of marijuana that have more psychedelic effects than others. People who have smoked marijuana more than a handful of times will be able to tell you that there were different bags that they got or different strains that they got that gave them a different high. 

Some they were more paranoid on, some they were more relaxed on some, they were more hungry on it just sort of depended on the strain. And a lot of times you have no idea what you’re getting for this young man. The psychosis was setting in kind of, and I did my very best to educate him on what was happening and he may find that in the future, if he quit smoking weed, that the psychosis might be there to stay. 

While he was in the program, he was required to be abstinent from all mood altering substances for at least 30 days. That was because he was mandated to be there and had to follow the court recommendations from his probation person. He was able to do that. As expected, the psychosis started to dwindle. He stopped taking the medications, even not that we recommended that, but he did. And no psychosis. He was feeling better, was feeling clear and really happy about not having the paranoia and the voices that he had been hearing. Those were really scary.

Unfortunately, human nature is that we believe that it won’t happen to us. So he started smoking. A little bit here and there believing that he could handle it and wasn’t going to start smoking daily again. He was smoking again, started smoking daily and the psychosis started coming back.

Another drug and honestly, the main one that causes psychosis is methamphetamine. Methamphetamine in the beginning isn’t what it turns into. What we think of as meth addicts who are losing teeth, have sores on their body look like the stereotypical strung out person that is later stage. In the beginning it’s not like that. And you’d be hard pressed to guess because those symptoms just aren’t there. 

One of the things that people who have used meth will talk about is shadow people or people in the walls or looking outside all the time for police or government types. The shadow people are just that. Shadows in the shape of people that appear to them when they’re high and even when they’re not high, because the drug isn’t necessarily out of their system. These are a common occurrence for people who have been using meth.

Another thing that is common is people picking at the carpet. And what I mean is sitting on the floor, picking at the carpet, looking at every piece of lint to see if maybe you dropped some meth. People will spend hours doing this because they believe they dropped meth and they can’t stop until they believe they have found it. 

This can get really obsessive and definitely not the only thing that gets obsessive when people are using meth, there are lots of that. It’s like it kicks something into overdrive where they’re unable to focus on something else and can spend hours focusing on one thing.

In the case of the carpet though, they believe that they dropped. And that they’re looking for it. And they examine every little piece of thing they find. Potentially try smoking that to see if it is meth. And of course it’s not meth. People who are using meth or drugs in general are usually pretty careful not to drop it. That doesn’t matter in that instance though.

The trouble comes when they get sober and they stop using meth. There’s a lot of difficulty coming off meth in general, and we usually end up talking about the dopamine system being totally jacked, but in this case, it’s not that it’s psychosis. 

Psychosis can stick around after meth and in my experience, it’s far more common than people getting psychosis. Then people having psychosis while using marijuana. Psychosis during meth use is pretty much everyone at a certain point. Perhaps not in the beginning, but eventually that is just part of it.

We had clients who had called the cops numerous times to have them around their house because they believed there were people on the walls. We’ve had people destroy their home or their apartment breaking down walls, breaking things looking inside them to see who it was that was listening to them. This is all super, super, real. 

Remembering as well that while they’re on meth, they’re not sleeping. So we now have sleep deprivation on top of it, they are paranoid and their body is firing all their nerves, cuz it’s a stimulant and their brain is moving super fast, but not finishing any real thoughts.

So whenever someone comes in and I’m noticing what sounds like psychosis, whether it be delusions or that they’re hearing or seeing things I always have substance use in the back of my head. I wanna know if they’re smoking marijuana. I also wanna know if they have any experience with meth or other substances. 

Having psychosis is probably the most serious symptom that comes up but not the most common. The most common for us is going to be people using it because of depression, anxiety, or PTSD. What I wanna know is what they were like before they were using. I wanna know if before they started using something happened. If they tell me they started using it 14 or 15, I wanna know. If it didn’t pick up until college, then I wanna talk about that. 

I wanna know if there were mental health symptoms that they were dealing with at that time. Dealing with stress from a parent’s divorce or dealing with increased pressure from school or being ostracized by friends or a breakup with a partner.

If they had depressive or anxious symptoms before they started using, I can bet that those symptoms are going to rise again, once they’re sober or mostly sober from their substance. They didn’t learn before how to manage those emotions without substances. In the intervening time period, they might have grown up, they might have aged, but typically their coping skills have not gotten any better. 

So we may be dealing with someone who’s in their thirties, but doesn’t know how to cope with stress, without drinking, or doesn’t know how to cope with stress without smoking weed. When they try to do that, it’s gonna be really alarming and just feel raw and loud to them.

Part of the reason this matters is that if the depressive or anxious symptoms were there before the substance use, then we can be pretty sure it’s gonna still be there. If it wasn’t before that, then we may need to wait until the person has some sobriety or some time away from substances, whether it’s a break or not to see what is there. And that could take a little while. 

This is totally okay to be talking with your clients really specifically about it. Some clients aren’t ready to talk about total abstinence from a substance. That’s all right. That’s not even necessarily the goal. We don’t know whether people can moderate. There are a lot of people who can and there are some who aren’t so far down the line that they might be able to moderate that they might have more choices about that. 

We can talk with people about potentially taking a break. Letting them know that if they could take a couple month break from their substance, that it would really help the work that we’re doing. Because at that time we’ll be able to see how much of that is from the substance and how much of that is part of their organic makeup. 

That is also going to inform the decisions that they need to make about medication. I have found that when people come to substance use with  mental health symptoms already, the majority of the time they are going to need medication to manage. For those who didn’t have that and developed it while they were using, they may not need it. That is not a medical opinion. It is just something I’ve noticed during my time doing this work. 

Starting medication while someone is still actively using can be risky. Certainly we know that alcohol interferes with a number of medications and can interact poorly. I think sometimes people believe that psychiatrists or doctors overstate the risk. And I don’t know that they do. I just think that people may tend to ignore those warnings, feeling like they’re just being extra cautious or covering their ass. For us though. Those medications are kind of serious and we really don’t want someone drinking heavily or using other substances heavily and being on medications.

People smoking weed, it’s a little different. I find that when people go on an antidepressant and are smoking weed all the time, they won’t notice that the antidepressant is really doing anything.  and that is because the drug is overpowering the effects. When that person cuts back on their marijuana use or quits entirely, they may be able to see that it has been working; they just couldn’t feel it. 

I’m less concerned if someone’s smoking weed and they’re on an SSRI, because while it won’t necessarily show that it’s working, I’m not worried about it having a bad interaction and hurting them somehow, but it’s also not necessarily useful for them to be on medication and smoking weed all the time. 

Let’s move to talking about trauma. Trauma is a bit of a buzzword and I think for the most part, it’s good that it’s getting so much press, I’m sure you have had the experience of having clients come in having filled out paperwork and where there was the, have you been through trauma section they put none. As you’re talking to them. You’re getting a different picture. 

A lot of times, I find that people who grew up in homes, where there was a lot of fighting and a lot of alcohol use, have told me that there was no trauma. Yet when I asked them about certain things, they absolutely experienced a lot of fear when people were drinking. That they often experienced parental neglect and emotional unavailability from their parents. And while those things aren’t necessarily traumatic to everyone, they definitely can leave an imprint for most of those people. 

In our field it seems we have moved towards talking about big T trauma, and little T trauma. Big T trauma being sexual assault, domestic violence, natural disasters, those kinds of things. And little T trauma being things that left an imprint, but weren’t necessarily to a high degree. 

Substance use and trauma almost always coexist, at least in my world. Not everybody who’s had trauma has used substances. A lot of times they’ve used other things to try to cope with their emotions. It could be developing restrictive eating or binging and purging behaviors. It could be some form of self harm.  It could be working themselves into the ground so that they don’t have to be alone with their thoughts. People who have had trauma have to find a way to make it be quiet and they find creative ways to do that.

Over the years, as I have worked with, as I ran the program, either myself or was supervising my staff who were working with those clients, it was extremely rare that we would have someone who had no trauma. And in this case, I’m talking about no big T trauma.

Most of the folks that we had in our substance use programs had big T trauma. Sexual assault, physical assault, or abuse and neglect as a child. I would say probably 75% of the people that we saw had big T trauma from childhood, whereas probably about 25% didn’t have it prior to age 18, but something happened after they were 18 that would be in that category. Of that 75% who had it as a child. Many of them also had it as an adult. 

If you’ve listened to other episodes where I’ve talked about trauma, I will say that it is my belief that time does not heal wounds; that trauma must be dealt with and processed in order for the person to resolve it and move forward. I also don’t require sobriety for someone to do trauma work, but there are levels of substance use where I will not address someone’s trauma. This can feel sort of confusing as some of the things I’ve said are a little contradictory. So I wanna explain. 

If someone is smoking marijuana or using marijuana somehow, and they wanna come and talk to me about their trauma or they wanna do EMDR. I am willing to start the process with them. As I’m doing the first few stages of EMDR, because there are eight stages I am assessing how much they dissociate. I’m trying to figure out what their pattern of use is, what their symptoms are like, how intense they are. What I’m looking for is how much emotional space does this person have to handle dealing with trauma. 

I describe it like that. There’s a basement in this person’s mind where all the boxes are of things from their history. We can’t start going through boxes until we clear a space on the floor in order for us to start working. If the person is using all the time and the space can’t stay clear where they have the boundaries to do that, I’m not gonna start EMDR.  

I had a conversation with a client at one point that I couldn’t start working on trauma while they were drinking the amount that they were drinking. At that time, that person was drinking every single night to go to sleep from the moment they got home from work, until they passed out. They were doing that in order to avoid thinking. On the weekends that person was drinking so often that they were blacking out and driving home.

While this person had significant trauma and needed trauma therapy, that was not something that we could do. Additionally, that person definitely needed medication as these symptoms were  totally preexisting to the substance use, but starting medications when you’re drinking almost every day isn’t something that is a good idea. So that’s an example of when I wouldn’t do trauma therapy, because they already can’t handle what’s happening in their head and inviting their trauma to come out and show itself is not wise. 

There are times when someone’s using marijuana on a daily basis, and it’s not necessarily to forget. It’s just part of their day. They’re no longer getting high. This is just how they do the day. What I want is to know how stressed they feel when they’re not high, whether they’re using it to manage those things. Sometimes they are and sometimes they’re not. 

I have done EMDR work with someone who was using marijuana on a hmm, few times a week basis and all I did was ask them to not smoke before coming to see me for four hours. And I asked them to not smoke for about two hours afterwards, just so that they could be emotionally present before, during and after for a little while. In that sense. I am willing to do EMDR work on a case by case basis, of course, but that’s an example of when I might do EMDR, even if someone is still using substances.

Once people get sober or have their substance use to a place that they feel like is under control, then do we address trauma? And the answer is likely not. Here’s what I mean: the American Society of Addiction Medicine, or ASAM as they’re called, had had in their recommendations and I can’t find it for the life of me, but I’ve known this for a while. I just was trying to find the citation for you that dealing with trauma within the first two years of recovery is not advised.

 The reason they say that is that there’s a lot to be done in early recovery. There is the rebuilding of a life. The person needs to learn to manage symptoms typically doesn’t have the space and the emotional resources, they need to go through trauma. So what I would tend to do is if someone’s trauma was coming up in the form of nightmares or intrusive thoughts, we would work on teaching them how to contain it. We would work on getting their anxiety level down and dealing with triggers. I wouldn’t necessarily take that as a sign to start digging into their trauma. 

The two year mark makes sense to me. If someone had a little less time in recovery and had the emotional resources where I felt that they had the space, I might do it, but early recovery is difficult. Even after the first year, someone can get to a year alcohol free or substance free, and then it’s different and in some ways harder. In the first year, you have to get to the first milestone for everything: first birthday sober, first Christmas, first 4th of July, first boxing day, who knows. But all of the holidays where somebody would usually celebrate, the person has to get through that.

In the second year they’ve already been there and done that. And so in some ways it can be harder because no one’s really celebrating that with you. Once you get through the second year things shift again, I have found for people that it does get a little easier because they’ve navigated things a few times. So the two year mark does make sense to me.

When you’re working with someone who has been using substances to manage their symptoms. Our goal first is triage. How bad are the symptoms? How are they impacting their lives? How do we help minimize their symptoms and increased function? What’s underneath it probably needs to stay there until they have some time where they feel really stable.

Mental health is a cornerstone of recovery and absolutely cannot be ignored. A person who ignores their mental health and all they’re doing is getting sober and getting away from a substance, their recovery isn’t really complete. It’s more like they’re just hanging onto the sobriety. In the AA circles. They call that a dry drunk, meaning that the person got sober and they’re not drinking anymore, but they didn’t change anything else. 

We are fully needed in the recovery space. What we haven’t had is the information that we needed in order to be in that space. We think that we need to refer to other people and as you’ve been hearing, my message of course is no, we don’t. These people, our clients need us.

Tomorrow night when the event happens, we are going to be talking about this very. You’re gonna hear from Jean McCarthy, whose recovery story we heard at the beginning of the month. And she is going to talk about her experience listening to hundreds of people in recovery and the thread of mental health.

I am really hoping that those of you who hear this in time are able to join us, go over to Betsy byler.com/braving the course. And that’s raving dash, the dash course, and register for this free event.  

I hope the discussion today about mental Health’s role in recovery has been helpful. Next week on the podcast, we’re gonna be talking about ACT Acceptance and Commitment Therapy and how those skills can be used to work with substance use.  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.

Helpful Links 



Chapter 2 The Neurobiology of Substance Use, Misuse, and Addiction, The Surgeon General’s Report on Alcohol, Drugs, and Health – chapter-2-neurobiology.pdf

https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112 https://www.asam.org/docs/default-document-library/nccbh-infographic.pdf?sfvrsn=dfe787ab_0