The Practice of Therapy

Betsy Byler
Okay, do the blurb. I am Betsy Baylor. And I'm excited to be on the practice of therapy podcast today. And I am a mental health therapist specializing in trauma and substance use and a podcaster and also have been a clinical supervisor. And I'm now in private practice.

Gordon Brewer
Hello, folks, and welcome again to the podcast. And I'm really excited for you to get to know Betsy Beiler. Hi, Betsy, welcome.

Betsy Byler
Thank you so much for having me. Yes, I

Gordon Brewer
was really, really happy when Betsy reached out to me about being on the podcast. And we're, I think we're going to cover a topic today that I don't know that I've covered that much on the podcast. But anyway, as I start with everyone, Betsy, tell folks a little bit more about yourself and how you've landed where you've landed. Well,

Betsy Byler
long ago, I thought I was going to be in youth ministry and worked with an organization called Young Life back in college. And a series of events that should have worked out job wise kind of exploded spectacularly and directed me and I wound up going to grad school, but I actually had thought of being a therapist. Many times as a teenager, I was in a lot of trouble using a lot of drugs, and was very angry, and so was in therapy and saw nine therapists before I found the right one for me. So I'm really passionate about finding the right person. Her name happened to be Betsy. So, and there aren't really a lot of Betsy, us running around in the world. But I even at the time, where I was really kind of a hot mess, and very difficult and oppositional, she had a style that just worked. And it worked immediately, I within probably 15 minutes of meeting her I was like, okay, like, maybe we can do this. And so winding up in grad school was actually kind of the fulfillment of something I decided when I was 17. And I went from there to community mental health and spent most of my career in Community Mental Health until 2019. And I loved that work and loved working with the populations I worked with doing in home therapy, or outpatient substance abuse work. I did do some residential at a time, which I also loved, and most recently in private practice. And so I'm doing that since the fall of 2019. It's really weird to not be in charge of anybody or have budgets to deal with and audits and all the kinds of stuff that goes along with running an agency. I didn't think I thought it would miss it. And I really, really don't. And so entering into this private practice world, it's earlier than I expected in my career, I sort of expected to spend another 15 years or so in agency work, but this just sort of happened. And so now I'm doing private practice and home because of COVID. And love that in a way. I never thought I was really kind of anti video therapy. Because I don't know, I'm really relational person in general. Like, I feel like their relationship with our clients is the most important thing. And I didn't know how that could be done over video. But necessity, of course, about that necessity being pardon.

Gordon Brewer
Sorry about that. My phone, I didn't have an old silent no from

Betsy Byler
necessity being the mother of invention, right is I actually love it. And I do EMDR over video, and that works really well. And I just don't know if I'm going back to in person. So that is kind of how my career got to where we are today.

Gordon Brewer
Wow. Wow. Yeah. And I think I think what you're talking about just just on the whole topic of doing virtual sessions and stuff, I think a lot of folks are finding that, that it's a good fit for them. And I think clients are finding that as well. I know, I've had several clients that kind of got used to doing when we're meeting online. You know, they'll say, Well, can we meet online? Again, it's just easier for me, I don't have to drive into the office. And you know, I can take my lunch hour and do therapy online. And so yeah, so I think it's interesting thing.

Betsy Byler
It is and it's my state finally made all the COVID allowances permanent because that was the question, right, like in Wisconsin, Medicaid wouldn't reimburse for virtual sessions until COVID. And so that was the question of when were they going to make that permanent and they did and So that, especially where I am, it's a really rural area. And lots of folks, I mean, I'm even out in the country I, I'm, you know, on 10 acres in the woods and lots of people are really far out it take them an hour to get to the office. And it's so it's, it's extending therapy services in a way that people don't have to come to town or if they have transportation struggles, and since a lot of the folks I work with do have transportation struggles, that's a huge deal. So yeah, it was such a shock to me. And I am fully admitting that I was completely wrong about video and virtual work. And it's, it's been huge, and I'm really grateful to be able to do it.

Gordon Brewer
Right. Right. Yeah. Yeah, you mentioned and again, I don't want to get us too far off on a tangent here. But, you know, we were, where I live as well, in my practice, we're surrounded by a pretty large rural area, and, and particularly people that are like on Medicaid are people that have, you know, just struggle more socio economically, transportation is a huge, huge problem. You know, that, you know, they've got to have, number one, be able to afford a car. And then there's no public transportation, all of that sort of thing. So,

Betsy Byler
where are you are, you're serving that kind of that corner? Right. And I imagine that there's just not a lot of services. Right, you know, and it's really challenging. And that's kind of where I am, too. You know, my office office is in a, in the city area of where we are, but my whole count is 40,000 people, right? Yeah, it's pretty, it's pretty small.

Gordon Brewer
Yeah, yeah, I get it, I get it. So change gears a little bit. I know, one of the things that you're real passionate about Betsy is just really making sure that therapists those of us in, in the mental health field, are have a better comfort level with dealing with clients or helping clients with substance use issues. And I think, you know, I just kind of, kind of to be transparent here. You know, in my practice, I've made it pretty clear that we're not substance abuse counselors. And so if we get people that are coming to us for that issue, we refer them to someone else. And so, but as you, as you noted, as we were talking ahead of time, it comes up a lot before us, in our session, so give us your thoughts on all of that just kind of where, where you're taking this and the things that you're really passionate about.

Betsy Byler
So there are levels of substance use work. And I've done both, I ran a program that was substance use, and we did medication assisted treatment and and people who were really far down the line in terms of using really heavily involved with legal issues, all of that. And I think that's what people think of when they think of substance use work. And that is true. But a lot of it comes up with people who aren't that far down the line. And yet substances are a big deal. And I think a lot of therapists, at least for me, when I got into the field, even though I'm a person in recovery, I didn't know how to translate my substance use experience into clinical work. And we didn't get training on that most of us didn't. And I can't find any reason why we didn't accept that it's not on a licensing exam. And since it's not on the licensing exam, it's not in the school. And since it's not in the school, it's not in the licensing exam. And yet, people don't often identify substance abuse as their primary problem, unless they have to. When I was running a program, literally 96% of our clients in the substance use program were mandated in some way, by court or legal issues. And so everyone else would go to mental health, they're coming in because they're depressed, or they have anxiety, or they're dealing with PTSD. And I think a lot of therapists, at least the ones I've spoken to, they sometimes will actively avoid it, because they're like, I don't know what to do. I don't want to mess this up. I'm not comfortable with it. It feels really overwhelming. I don't know when to refer out. And so it can be really challenging. And I totally get that. One of the things I did was create a it's a free substance use decision tree to help people look at and say, Alright, where's my client and when should I refer out because there is there is a place there is a moment where really, I do think for the majority of mental health therapists This is above our pay grade we need to or beside our pay grade we need to move it to a specialist area. area, but I think we can still really work with people. And I think follow through is better if they have a mental health therapist and a substance use specialist. That aside, I think there's a lot we can do. And I'm really passionate about the fact that I don't think we need certification. I don't think we need new modalities, I think that our skills already work just fine with substance use, because frankly, there are not specific modalities for substance use, they don't exist. Like it's not a thing that you can go get trained in how to do this modality, maybe motivational interviewing, maybe. But that's really useful elsewhere, too. And so I feel like, we can use DBT or ifs or EFT. I mean, we can use our skills already. with substance use. It's just, we need information, we need to know what to ask what it means, how to apply it. And when is too much for us. Yeah. And so that's kind of what I'm working on is trying to encourage people that substance use truly is in our scope of practice, it is in our statutes, that it's part of people's lives, it's in the DSM, there's no distinction. And the distinction that's there in the field is really arbitrary. It's not based on anything. And this is the part that might sound a little arrogant, that I believe I know what therapists need to know. Like, the basics, like pulling it all together of all the stuff that could learn, because I supervised for 14 years and trained therapists and interns, and I figured out what do they need? What do they need to know? And what don't they need to know? Because there's a lot of stuff that is floating around in my head, because I am like duly licensed, that I don't know that everybody needs to know. It's, that's a little niche like, Yeah, but I think on an average basis, people who are drinking or smoking marijuana or whatever, there's a lot that we can do. And I My goal is for people to feel confident and really competent, that when it comes up, they're not like, oh, I don't know, that they're feeling like, Okay, I think I have the tools for this.

Gordon Brewer
Yes, yes. Yes. Kid that Do you mind giving maybe some case examples? Just as we think about that, because I'm sure people are really, you know, you got me curious about it. I mean, I'd you know, I would say, yeah, that there's so much that, particularly here in where I'm located in the Appalachian region, you know, the opioid use is just is just rampant. And it's, that's no different than it is other places in the country. But there seems to be a kind of a connection between rural communities and opioid use and that sort of thing. So if that comes up, how do we address that with our, with our clients? What are things that we need to keep in mind?

Betsy Byler
Well, I think there's so there's a couple of different things. One is, in some areas of the country, like what you're talking about opioids, opioids have become a giant problem. And part of that is all the stuff that happened in the 90s with the over prescribing, and I don't blame medical professionals for that. They were told outright that this wasn't addictive. And that the risks were overstated. It was a huge thing. But now we have a bunch of people with chronic pain, who have no idea what to do. But I think that when you have that there are ways of, okay, how much are they using? How often? What's the withdrawal? Like? And these are the things I help people know, like, is this something you can work on or not? And if not, most people on opiates are terrified of going off because of the withdrawal. It's not even about not having the drug, so to speak, because it makes them high because it doesn't make them high anymore. It just keeps them from feeling terrible. And nothing is worse than opiate withdrawal in the drug world. There is literally nothing more painful or more difficult than opiate withdrawal. It won't kill them. They want to die often. But that's alcohol and benzodiazepine withdrawal that can kill you not opiate withdrawal. I mean, certainly there are, are cases where someone might have a complication, but generally, it's just so terrible that they can't deal and the other thing that opiates do is causes what's called hyperalgesia. And it actually makes people more sensitive to pain. And so the pain pills actually make their pain worse over time. That can be corrected over with sobriety like they can rewire their brain but it takes a while and it super painful. And so for us, we're talking about, first of all, setting some limits around like the therapy hour. And I'm talking to someone about, alright, how long can you go before, when you take this pill before you go into withdrawal, they will be able to tell you. And that's when I want them to schedule their appointments is just before that's going to happen. So I get them when they're not actively nodding out and falling asleep, and they're not sweating and in a lot of pain. And that's like kind of the first step of like, hey, let's have therapy be a protected time. Right? Same thing with marijuana, I'll say Don't smoke within four hours of coming to see me. I'm not requiring sobriety. I'm not telling you what that has to look like, I'm just telling you, I need you present, emotionally. And then. So let's say they're trying to manage cutting back. Well, let's take DBT, for instance. DBT has lots of skills. And I think almost all of them that can be used very easily with substance use. Because people who are coming off of substances have very little distress tolerance, almost none. And their emotion regulation is also really compromised. The relationships are typically really compromised as well. And they never live in the moment. It's always this future thing. And so if we take a skill, like there's a skill for distress tolerance about tip, and it's temperature, intense exercise paced, breathing, and weird, muscle relaxation, well, those are all really useful in managing a craving cravings lasts like eight to 15 minutes, on average, it's kind of like a panic attack. And so someone in a substance use issue can use that to kind of push themselves through that. So like, there's tons of skills that we have, that can be really useful. And we just have to repackage it sort of, but DBT if we think about borderline personality disorder, the result of that in symptoms is pretty similar to substance use lots of out of control self injurious behavior, right? Poor relationships, struggles with emotions, erratic behavior, I mean, all of that fits really well. And so DBT is a great option. But I think there are other other places too. I mean, there's protocol for use with EMDR to use with addiction. So I mean, there's a lot of what we already have, is going to be really easily translate it. It's just, I think people need permission. I think therapists need permission to say, like, No, you're not going to mess this up. This really is okay. Mm.

Gordon Brewer
Hmm. Yeah. Yeah, I think so somewhere along the way. You know, I think we get kind of a doctor indoctrinated in graduate school is with, like, you were alluding earlier, to, you know, you're supposed to have the training and the certificate certification before you, you do any of this stuff? Well, there's a lot of stuff that we know just kind of intuitively how to do with people that we can do without having to have the credentials or the letters after our names and that sort of thing. And it's usually, usually you have pretty good outcomes with that as well. Because we've got the, you know, here's kind of like, you know, how it works, kind of thing.

Betsy Byler
Yeah, well, and I think, no, we're all afraid, there are a few knows right in our big nose in our field. And one of them is practicing out of scope. Right? We're always running up against that. And so part of what I start with when I work with people is trying to help them see like, alright, let's look at your license. Let's look at the statutes. And let's I'll show you that there's nothing saying this is out of our scope, there is nothing saying that. When you feel like it's out of your scope, there may there are places where I even would say, if someone is using opiates all day, every day, you need a specialist to help, because they're going to need some medication assisted treatment or something like that, to get over this. But I would really encourage people to stick around and stay with the person. Because most of the people we work with, there's underlying trauma. In all the cases that I've worked with, with substance use over the years, I think I've maybe had two that there was literally nothing. And I mean, I looked and I asked but most people they started out and it could have been that it was depression. It could have been something traumatic in their life. It could be whatever. But once they're free of those substances, they're going to have all of that stuff because we know Time doesn't heal wounds. Right? That's not how this works. And so that stuff's their substance use just puts it on pause. And as soon as you're sober, man, it just slams India. But I think the therapists, I think all of us want to do really good work. And we don't want to mess people up. And we don't want to overstep. And I think my message really is, there's a whole bunch of space before you're overstepping. There's a ton of it most of the substance use that shows up in our offices, because they're not mandated to see us for the most part. They're going to be within that scope that is appropriate for outpatient therapy.

Gordon Brewer
Right. Right. And I would say to is, I say to clients all the time, you don't necessarily have to be honest with me, but I want you to be brutally honest with yourself. Right. And I would say that most of the people that are coming to us for the, you know, the the issues you mentioned, you know, anxiety, depression, you know, trauma, all of those kinds of things. They know already that the substance use is a problem. Right? I think I mean, they're just kind of they know that. And so it's my experience has been, you know, if you bring it up and in session, you talk about it, it's almost like a real relief that I can talk about this in a safe place. It is.

Betsy Byler
And part of that is I can't tell you the number of folks who have had substance use issues that they weren't asked about it. And I don't think it's negligent. On the therapist part, I just think it's just that part of our our intake process a lot of times, right, but it was there. And, and so I have a lot of recovery stories that on the first Monday of the month, there was a recovery story. And as people listen to them, they'll be able to hear just this recurring theme that they went in for depression. But you know, they weren't honest about their substance use or or they didn't get asked. And so they figured maybe this wasn't the place to tell somebody, or somebody was like, Oh, that does that sounds pretty normal, when maybe their alcohol use wasn't normal. Right? And so I spend a lot of so the podcast really is about giving people information about a specific thing that they need to know. Yes, right. Yeah, whether it's about assessment or a substance, or whatever the case may be, the course that I'm launching in the fall is a comprehensive group program, that's six weeks, kind of a small group setting, maybe 12 people. And I'm gonna take them through this as assessment, this is how you apply it, this is how you apply your skills based on your theoretical orientation, really trying to make sure when people leave that they are okay, I know what to do. And then there's consultation calls for six months, there's a one each month or six group consultation calls each month if they wish to discuss cases and talk about problems that came up so that they can really implement it. Because as you probably know, when we go to training, if we don't implement what we learn, right, it's gone. Right? You know, because that's how it is we get these tools. But if we can't practice them, it's sort of goes into the background. And it's not that it wasn't valuable. It's just, I don't know, we get going and hit the ground running and just forget those things.

Gordon Brewer
Right. Right. All right. So Betsy, I want to be respectful of your time and know that we could spend all day talking about this, this topic, and I love it. Tell folks how they can get in touch with you, your website, and most importantly, the podcast or Tell, tell folks where to find her.

Betsy Byler
So my website is Betsy beiler.com. And I'm there as the podcast called all things substance, and you can find it on all the podcast platforms. There's 93 episodes now, and you can find it by topic, or by substance or whatever you're looking for. And if anyone had an idea, I've gotten lots of listeners sending me ideas about hey, would you talk about ADHD medication and people who have abused stimulants? Yeah, sure, absolutely. or specific things that show up in their practice? And so they can find me there. And then, so the podcast comes out every Monday. There is an event coming up. I'm not really sure when this will come out. That we're doing with Guy McPherson and a colleague of mine, helping therapists work with trauma and substance use without the burnout and that's going to be on August 16. And people can find the replay there but we're really You, we know that most therapists who are dealing with trauma and heavy issues can feel burnout at times. Sure. And I know that I'm asking everybody to consider adding something more. And that feels like a lot. Sure. And so the message is, how do we help people do this, but also take care of themselves and really treat their burnout and compassion, fatigue, and even prevent it by something more than just a little self care here and there. And so that's, those are kind of the things that are going on. And you can find that on the website. And people can always contact me at Betsy at Betsy beiler.com. You can email me I'd be happy to answer any questions that anyone has.

Gordon Brewer
Awesome. And of course, we'll have links in the show notes in the show summary for all of this so people can find it very easily. Well, Betsy, I really have enjoyed our conversation and I hope we'll be able to reconnect again and talk more about this very needed topic.

Betsy Byler
Thanks so much, Gordon. I appreciate it.