Informed Conversations About Substance Use: Bridging the Gap to Care

In the latest post for a blog titled "In Our Humble Opinion” with content by Family-Based Recovery (FBR) Model Development and Operations (MDO) team members, Amy Joy Myers, LCSW, addresses ways in which providers who are not substance use specialists may approach clinical conversations about substance use behavior. Myers is an assistant clinical professor of social work at Yale Child Study Center (YCSC).

The National Survey on Drug Use and Health (NSDUH) gives us the following statistics, in 2024:

• 48.4 million people aged 12 or older had a substance use disorder (SUD) in the past year, including 27.9 million who had an alcohol use disorder (AUD).
• Among people aged 12 or older who were classified as needing substance use treatment in the past year, about one in five (10.2 million people) received it.

These numbers made me wonder about the gap between needing and accessing treatment. Undoubtedly, there are multiple barriers. One possible bridge to treatment involves increasing conversations between patients/clients and non-addiction specialist providers about substance use behavior.

My first professional experiences with substance use disorders came in the early 2000s when I was a caseworker at a social service agency in New Haven, Connecticut. My job was to assist adults with meeting their basic needs while also managing life with chronic and debilitating illness. I also performed community outreach in various settings including shelters for the unhoused and in community health services. Most of our clients were people with very limited resources and support and layered adversities. Several people on my caseload had substance use disorders. Some were engaged in treatment. Sometimes clients would come to their appointments to meet with me while they were under the influence of drugs and or alcohol.

My employer’s stance was that addiction was part of the reality of our client’s lives and therefore a reality of our jobs, but we had no standard approach to discussing substance use nor any stated policy for clients arriving at the agency while intoxicated. I was told that we were not substance use providers and, therefore, not to address it, but to welcome people in and to be polite and respectful. I felt like I was floundering.

My coworkers and I each approached these instances being led by our idiosyncratic guts, which resulted in well-intended but ineffective combinations of: things learned in school; professional and lived experiences; biases; and personal values. I pieced together a way to soldier through appointments and make conversation with the individual without attending to the task at hand, recognizing that little could be accomplished if the client was under the influence. I would sometimes take the person to the small kitchen in our office to make them a sandwich, or the conference room, if it was empty, where they could sleep for a while, out of the elements. These encounters left me feeling worried and ineffective, and dreading the next time someone showed up high in my office. Our clients were long-term, and many had close relational ties with the agency, so the likelihood of this happening again was significant.

Reflecting back on this experience, I understand that the agency director’s intentions came from a desire to ensure that our clients always felt a sense of belonging at our agency and an effort to minimize shame. We worked with people who were turned away from so many spaces in their communities, we did not want to replicate this harm. The director’s unspoken philosophy was to look the other way when it came to substance use disorders.

Now that I have worked in the substance use field for more than 16 years, I can empathize with the worry of doing harm by talking about someone’s substance use. Professionals who are not specifically trained to treat substance use disorders often fear addressing it. There can be sentiments ranging from “what if this conversation gets bigger than I can handle?” to fear of saying the wrong thing and potentially rupturing a fragile relationship.

One of the things I feared in those days was what my silence conveyed. I worried that my silence left people feeling unseen—possibly thinking, “Wow, she does not know me at all if she doesn’t notice how messed up I am.”—and I was concerned that was I validating a false sense of functionality, leaving them to think, “I knew it! I am really good at masking my use. No one can tell when I have popped a few benzos.” Worse was dread that my intent not to harm was actually harmful, with clients thinking, “Geez. How messed up do I have to be for someone to realize that I need help?”.

By looking the other way, was I validating the hopelessness and unworthiness driven by judgment and stigma? Did my silence convey that the relationship was not valued enough to take a risk?

While the example of turning a blind eye to obvious intoxication may seem extreme, I think the worries about what to say and how to say it are relatable. I often wonder how scary it may be for helping professionals who have not been trained to deal with addiction to talk directly about substance use behavior. What would feel supportive to those with strong desires to be helpful who get stuck or feel like they are floundering?

In FBR MDO, we think a lot about ways to approach conversations about substance use. Certainly, some approaches are specific to the FBR model. Yet other approaches may be generalized to support clinical providers who are not specifically providing substance use treatment. Below are some possibilities to consider.

Ask about substance use

We can ask everyone about substance use behavior even if substance use is not the reason for clinical care. We can normalize that knowing about substance use is a part of understanding wellness and mental health. Including questions about substance use as standard practice can increase our comfort with talking about substances and can build a foundation for future conversations if a concern arises. Questions such as “tell me about your drug and alcohol use” rather than “have you ever had a problem with drugs and alcohol?” allow you to enter an information-gathering mission, with a non-judgmental stance.

Depend on the relationship you have established

It is a standard in mental health care to pay great attention to our relationships with clients; it is commonly agreed upon that the relationship itself is a primary intervention. When clinical relationships are solid it can feel safe to take emotional risks. It can feel like an emotional risk for a therapist to give voice to concerns and observations about someone’s substance use, fearing “What if I am wrong?” or “What if my client gets mad at me?”

Relationships built on consistency, unconditional acceptance, transparency, and predictability can create relationship security. The implicit communication from the provider to the client is: “You are important to me, therefore, when I share an observation with you it comes from a place of care and concern, not of judgement.” In these secure clinical relationships, there is greater chance that if a rupture occurs it can be repaired, that a client may have increased ability to tolerate challenging feedback, and that difficult conversations can be spoken.

Notice things out loud

If we have concerns about a client, we can ensure they are based on objective information and be sure to share the information objectively. If we share observations with clients, we are not stating conclusions or making accusations. We are simply noticing things out loud. Imagine the different response possibilities between stating the conclusion, “I think you are intoxicated right now” versus sharing an observation such as, “I notice your words are slurred and you seem to be having some difficulty walking. I also noticed that your eyes are bloodshot.”

Lead with curiosity

Even if we believe that a client may be misusing substances, we can approach a discussion recognizing that our hypothesis is one hypothesis, and there may be others. Take this example: a mother is in early recovery from fentanyl use. She is also parenting an infant who sleeps two to three hours at a time and is trying to readjust her own sleep schedule. At a session, the therapist sees the mother’s eyes are droopy and makes a call to child protective services to report that the mother “has likely relapsed.”

The outcome may be different if the therapist speaks their observations aloud saying, “I noticed you seem less alert today than you were the last time I saw you. Your eyes are droopy.” And then the therapist is curious rather than certain: “I am curious about this. How is your sleep? How are things going with your recovery? A new baby can be a stressful transition. Can we talk about your sleep and your recovery and anything that may be impacting your presentation?” This curiosity may successfully keep the conversation open and may provide either a clearer understanding of what is happening with the mother or a bridge to needed recovery support.

Express gratitude

Speaking your observations aloud may lead to a longer conversation or it can lead to a rupture. Either outcome is an opportunity for humility, for remembering we (providers) are not all-knowing and are not perfect. One way to express this humility is to thank clients for staying in the conversation with us, for hearing our concerns, and maybe even for letting us know that they are angry. If a rupture has happened, perhaps an expression of gratitude can increase the likelihood of repair.

Have resources ready

If a link to more treatment or services is warranted, we can be ready with information. It is not feasible to know every resource out there, so connecting with colleagues who may have experience with substance misuse, or with a database such as 211, can be a great start. Learning about resources alongside clients can be a powerful and humbling experience, indicating, “I don’t know everything,” as well as expressing to clients that we are dedicated to their needs wholistically.

Keep the door open

As clinical providers, we may not consider ourselves trauma specialists, though we understand its prevalence and impact. Instead, many of us strive to be trauma-responsive and informed. I think of substance use in a similar way. Many providers likely recognize the prevalence and impact of substance misuse but may feel uneasy talking about it. I wonder if a helpful start to being substance use-informed is to find ways to convey to clients that we are interested in knowing about their substance use behavior; we are available to discuss concerns; we are willing to take risks in clinical conversations; and we’ll work to build relationships that can withstand ruptures should they occur.

The FBR MDO blog was launched in February 2025 to provide information and resources for professionals related to the experiences of FBR providers. Approximately quarterly throughout the year, team members share insights learned from their work providing home-based substance use treatment and attachment-based therapy to parents of young children. Visit the FBR MDO webpage to learn more about the model.