Substance use shows up in many therapy spaces—often quietly, often layered beneath trauma, chronic stress, or attempts to cope. It’s understandable that many therapists feel uncertain about how to respond. Questions like “Is this still within my scope?” or “Should I refer this out?” are common—and valid.
But avoiding these conversations or referring out at the first mention of use can unintentionally create barriers to care. It may reduce their motivation to remain in care, fracture trust, or interrupt treatment that could be safely and effectively delivered in an outpatient setting. Additionally, it can reinforce stigma. Stigma is a clinical barrier, and many clients expect judgment or disconnection when they disclose substance use. Your openness, tone, and willingness to use person-first language help create a space where their full story- including their use- feels welcome and safe to explore.
Engaging clients in discussions about substance use is not only likely within your scope—it’s part of whole-person, trauma-informed care. You don’t need to be an addiction specialist to assess use, support safer behavior, or respond to risk. You just need the right tools, structure, and mindset.
This guide offers a clear, compassionate framework to help you:
- Screen and talk about substance use confidently
- Understand risk, motivation, and readiness
- Know when to refer
- Document with clarity and care
Substance Use Is a Spectrum
Clients use substances for different reasons and in different ways. Not all use is risky, disordered, or incompatible with outpatient care.
| Category | Examples | Why It Matters |
| Alcohol | Beer, wine, liquor | Common and normalized; often linked to depression or suicide risk |
| Cannabis | Marijuana, THC vapes, edibles | Used for sleep/anxiety, but may worsen motivation or dissociation |
| Stimulants | Cocaine, meth, non-prescribed Adderall | Can lead to impulsivity, psychosis, or cardiovascular stress |
| Sedatives | Benzos, sleep aids | Risk of overdose or dangerous withdrawal |
| Opioids | Heroin, fentanyl, oxycodone | High risk of fatal overdose, even at low doses |
| Hallucinogens | LSD, mushrooms, ketamine | May destabilize trauma or mood |
| Inhalants | Whippets, solvents | High neurological and medical risk, often overlooked |
| Nicotine | Vapes, cigarettes | Legal but impacts stress response and relapse patterns |
| Caffeine | Coffee, energy drinks | Excessive use may increase anxiety and sleep disruption |
Reducing Stigma, Increasing Engagement
Motivational Interviewing is an evidence-based approach that helps clients explore their own reasons for change. It’s especially effective for substance use because it honors ambivalence.
You’re likely already using MI skills:
- Open questions: “What do you like about it? What worries you?”
- Reflections: “It sounds like you’re feeling torn.”
- Affirmations: “You’ve thought a lot about how this affects your life.”
- Summaries: “Here’s what I’m hearing—part of you relies on it, and part of you wants to try something different.”
Change Is a Process: Ambivalence and the Stages of Change
Ambivalence is normal—not a sign of resistance. Most clients feel conflicted about their substance use, especially when it helps them cope.
Use the Stages of Change model to guide your approach:
| Stage | What You Might Hear | Therapist Focus |
| Precontemplation | “I don’t think it’s a problem.” | Build trust, validate their experience, explore context |
| Contemplation | “It’s not ideal, but I’m not ready to stop.” | Reflect ambivalence, explore values and impact |
| Preparation | “I want to cut back.” | Set realistic goals, co-create safety strategies |
| Action | “I’ve started making changes.” | Reinforce success, develop coping tools, monitor risk |
| Maintenance | “It’s been months since I used.” | Celebrate growth, support relapse prevention, plan for stressors |
Your role isn’t to move the client forward—it’s to walk with them, wherever they are.
Assessment: Explore the Full Picture
Move beyond “yes/no” answers to understand substance use in context.
| Domain | Explore |
| History | Past use, legal issues, previous treatment |
| Current Use | What, how much, how often, in what setting |
| Impact | How does use affect mood, work, relationships, health, therapy? |
| Motivation | Do they want change? What are they curious about? |
| Risk | DUI, unsafe sex, suicidal thoughts while using, mixing substances, overdose risk, impulsivity |
| Protective Factors | Support system, goals, coping tools, values |
Withdrawal and Medical Risk
Some clients may experience dangerous withdrawal symptoms, especially from alcohol, benzos, and opioids.
| Substance | Risk Level | Withdrawal Symptoms |
| Alcohol | High | Tremors, seizures, hallucinations; can result in death |
| Benzos | High | Panic, insomnia, seizures; can result in death |
| Opioids | Moderate | Nausea, chills, cravings |
| Stimulants | Low | Depression, fatigue |
| Cannabis/Nicotine/Caffeine | Low | Irritability, cravings, sleep issues |
Refer to detox if:
- Client reports withdrawal symptoms (e.g., seizures, hallucinations)
- Daily use of alcohol or benzos
- Client wants to stop but fears stopping alone
Detox is a medical intervention targeting short-term stabilization; it is not therapy. Many clients return to outpatient therapy afterward.
Harm Reduction and Abstinence: Both Are Valid Goals
Not all clients want to stop completely. Many benefit from reducing harm first, by using differently, less often, or with more awareness.
| Harm Reduction | Abstinence |
| Cut back gradually | Cease all use |
| Avoid mixing or using alone | Engage in recovery programs |
| Plan for safer environments | Maintain total sobriety |
| Carry naloxone | Use medication to assist with abstinence or detox programs |
Ask:
- “What feels like a manageable change?”
- “What would safer use look like for you?”
- “What are you not ready to change yet?”
Risk Level and Referral Guidance
| Level | Indicators | Recommended Action |
| Low | Infrequent use, high insight, no impairment | Continue outpatient care and explore relationship to use. Document use and protective factors. |
| Moderate | Regular use, some impairment or risk | In addition to above, consider: Increase support. Explore harm reduction. Safety plan. Consult as needed. |
| High | Daily or binge use, withdrawal symptoms, limited insight, safety concerns | In addition to above, consider: Refer to IOP, PHP, detox, or psychiatry. |
Final Thoughts
Substance use doesn’t disqualify a client from therapy. In fact, therapy may be the one place they feel safe enough to talk about it honestly.
You don’t need to be perfect. You just need to be present, collaborative, and clinically grounded. This work is within your scope—and it matters.
Need support with a high-risk case? Rula’s Patient Safety team is here to help.
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