Finding a substance-friendly therapist?

February 28, 2014 12:54 PM

I'm looking to establish a therapeutical relationship for standard-ish reasons (ideally, a cognitive behavioral approach to some interpersonal issues) and need to find someone with a nuanced-to-permissive view of substance use. I'm not talking about narcotics, but occasionally I enjoy cannabis and often drink alcohol--neither, I believe, is excessive and certainly never cause health or legal* problems in my life.

Additionally, my partner and I will carve out an afternoon, every few months, to use a psychedelic substance that we both feel enhances our experiences in this life and our relationship with each other. Any psychedelic we do is well researched, verified, measured, etc. and I see no reason to discontinue this.

But I just returned from an initial appoinment with a therapist who acted appalled that I will drink half a bottle (about 12 oz) of wine in one night. My partner has had bouts of addiction in the past, but avoids AA and NA in favor of a belief in his own agency and a more moderate view towards substance use in general. I, too, want to avoid an all-or-nothing life, but I also want to keep a watchful eye on his past habits.

I'd like to find a therapist who won't be so quick to yell "twelve steps!" And who might even be encouraging of thoughtful, deliberate psychedelic use in a therapeutic way. Is this impossible to find? Are mental health practitioners obligated to tsk-tsk any instance of non-sobriety? And what are some questions I might ask a potential therapist in order to suss out where they stand before I spend an hour + a copay?


*though I do live in a state where pot isn't legal yet, so that may be an obstacle to finding a therapist?

posted by anonymous to Health & Fitness (16 answers total)

The Harm Reduction Therapy Center in San Francisco has a list of resources that might be helpful. I know the founders, and they are excellent people.
posted by rtha at 1:01 PM on February 28, 2014 [3 favorites]

I think it's pretty common for your first few meetings with potential therapists to be a dud. You have to think of it like an interview process for someone you want to hire, because that's what it is. Ask them to schedule some time to talk about this stuff briefly before setting up an in-person appointment.
posted by bleep at 1:09 PM on February 28, 2014 [1 favorite]

Harm reduction is the way to go. But I'm a tad biased as I work in harm reduction. As a professional I would investigate it further but it isn't an 12 step approach and is based off your goals and desires.
posted by AlexiaSky at 1:33 PM on February 28, 2014

This isn't going to be something you can find out from asking the receptionist over the phone. It's the same as any other issue in therapy; finding the right provider involves a ton of trial and error and unfortunately it's something you really only can do in the office.

I recently had to dump my psychiatrist because he got religion. There was nothing about it on his professional web site. I told him I was an atheist in our initial consultation and he said that he respected that, and that religion was a personal matter. There were no problems, we made a lot of progress, and then all of a sudden every problem I had was because I wasn't getting back to my (religious) roots and I was finding Chick tracts tucked into my envelope of prescriptions.

Therapy is like dating. There's no Big Book of Doctors You Will Like. You have to get out there and meet them.
posted by The Underpants Monster at 1:34 PM on February 28, 2014 [3 favorites]

Just keep looking, like The Underpants Monster said. I definitely wouldn't assume that most therapists or even many therapists would be judgy about this stuff. Their job is to help you, after all, and judgment doesn't fit in to that mission. In fact your therapist who acted appalled about 1/2 bottle of wine seems like an outlier - not just because 1/2 bottle of wine for many people is not a huge deal, but also because acting appalled = doesn't know how to therapist. I've known of people to have quite constructive relationships with their therapists while being very open about recreational drug use, both legal and not-necessarily-so. In my case I had to endure a string of costly disappointments before finding a therapist that a) wasn't a complete dunce and b) was a good fit for me. You need to accept that expense; it'll be worth it when you find the right therapist. Hang in there.
posted by univac at 3:20 PM on February 28, 2014 [2 favorites]

Harm reduction can be quite successful for some people but I sense you were going to therapy for interpersonal issues and hoping for a CBT approach not modifying your substance use. Speaking as a (retired) therapist it is quite reasonable for any therapist to ask you to moderate your substance use, at least initially, while in treatment. Personally I would ask that you limit alcohol consumption to two units a day for at least 2-6 weeks and no psychedelics until we mutually agree. It is rather important to look at baseline behaviors before proceeding with treatment. If a client refused to agree I might proceed, with modest expectations, and explain you might well be wasting your time and money. Generally I would take a refusal to agree as either indicative of a relatively limited motivation to change or some level of substance abuse rather than use. I am not sure how you find this out before a session except by asking the question at the first session and hoping for a candid discussion. I applaud you for being honest--it makes it much easier for all parties. If someone recommends a therapist who appeared unconcerned/uninterested in the their patients substance use I would be skeptical. If you go to a physician and say "i am having trouble sleeping" and BTW I use xxx substances. It is perfectly reasonable for the physician to suggest monitoring and/or modifying the substances being used while making an appropriate DX and TX plan. It is virtually impossible to unwind the interaction and inter-dependence of behavior and substance use without negotiating, and complying with, some baseline behaviors. I wish you the best.
posted by rmhsinc at 3:23 PM on February 28, 2014 [3 favorites]

On reviewing some of the other comments, I have to respectfully disagree about looking for Harm Reduction specialists. From my reading of the OP's situation, the substances themselves don't seem to be a major factor - they just want a therapist who doesn't freak out about what is a pretty common ("normal") pattern of substance use.
posted by univac at 3:24 PM on February 28, 2014 [1 favorite]

The harm reduction folks who founded the center I linked to are explicit in saying that if your substance issues are not something you feel the need to be in therapy about, but there *are* other issues you want to tangle with, they can and will help with those without making you talk about something you don't think is actually a problem, like your substance use.

Ideally, even non harm reduction-specialist therapists would do the same, but the OP hasn't found one yet.
posted by rtha at 3:34 PM on February 28, 2014 [1 favorite]

Part of any good therapeutic relationship is honesty. Hell, this is pretty much an essential part of any relationship. I've spoke to practitioners, though not via treatment, that are both for and against substance use, and it really is just a case of being open with people about it.

The confidentiality agreement you'll have signed means you can be happy that what's said in the room stays in the room, and if the person you're speaking to doesn't agree with your viewpoint, you'll just have to try elsewhere. Unfortunately, it might not be as easy as finding a register of people due to the legality, however, so it could literally be trial and error. Most people I know UK side are extremely open-minded, so I'll keep my fingers crossed for you that it's more trial and less error. Good luck!
posted by Howisstifflucky at 4:32 PM on February 28, 2014

I think a regular therapist would be cool about occasional substance use. I was seeing a therapist and going through the process of breaking up with my live in girlfriend and I told him with the expectations of the "twelve step" talk how I was downing a couple whiskeys to knock me out and put me to sleep early and avoid a long, stressful night. He didn't even blink and never brought the subject up again. In fact, we didn't even discuss my drunky avoidance plan, just that it was time for the relationship to come to a conclusion.
posted by Che boludo! at 4:38 PM on February 28, 2014 [1 favorite]

I didn't mean find a therapist who only does motivational interviewing in respect to harm reduction, just a therapist who knows it well enough to use it when need-be. (And, I know very few people in therapy who actually solely use one approach so I rarely even think about it that way. Sorry if I was being misleading) In terms of looking for a therapist, it is a good term for google and to quickly ask the therapist.

I do agree with rmhsinc 100%.
posted by AlexiaSky at 5:07 PM on February 28, 2014

my old therapist actually ENCOURAGED me to smoke pot, so....

it's good you told the therapist about your wine (half bottle? no big). and that you got an honest reaction. now you can move on to find a new therapist.

if the drinking and pot that you use are not causing problems in your life then they should not be problems for your therapist. you just might have to vet a few more to find a good one.

one thought might be if you are in a big city to go to one of the "alternative" clinics. i find they are generally more open to things.
posted by misanthropicsarah at 5:08 PM on February 28, 2014

As others have already stated, the level of comfort your therapist has with substances can really only be found out after a session or two. It really is like dating. Of course there's nothing that would prevent you from asking via phone - simply ask whether substance use is something they are comfortable with allowing in their patients. I'd probably prepare for negative responses and/or refusal to answer the question (via phone) at all.

The most recent therapist I saw was completely fine with my somewhat regular use of substances (all plant-related) but likely would've not tolerated hard drug use or excessive alcohol consumption (I don't really drink but FWIW, 6 oz of wine daily doesn't seem like a whole lot to me..). The therapist I had seen before her did not approve of the substance use at all (his method of therapy was repeated, word-for-word, from a book - a book I had already read). Prior to that (many, many years ago) I had a anti-substance-use therapist stop seeing me because I "knew precisely what [I] wanted" and she felt there was nothing she could do to change me (it was later discovered she just wasn't comfortable with my sexual orientation).

So yeah, nthing 'shopping around' and not being afraid to simply ask the therapist what their views are on substance use are via phone/email first.
posted by stubbehtail at 5:22 PM on February 28, 2014

In my opinion, you get to choose what you share with your therapist. It's your therapy.
posted by ClaudiaCenter at 9:02 PM on February 28, 2014

I don't think you are ever going to find a (good) therapist who is going to give blanket approval of your substance use. A good therapist will identify behaviors that may be interfering with your goals, and it is his/her job to have you honestly reflect on your behaviors. It may be that 12 oz/wine a night is fine for you, but if you are having issues like anxiety, depression, or insomnia - or may just benefit from expanding your activities beyond drinking at night - then it would be entirely reasonable for a therapist to reflect on this behavior with you. Likewise a good therapist would want to talk about this usage in context with your partner's "bouts of addiction" and see what that all meant. A good therapist would not conclude instantly that you are an addict or need AA or clutch their pearls at the fact that you shroom every so often. But a good therapist would never just dismiss an entire subject out of hand, although you are within your rights not to talk about it.
posted by yarly at 5:39 AM on March 1, 2014 [1 favorite]

I would screen progressive therapists in the gay / lesbian / queer / bi / trans / poly communities. I would think (just speculating) that your chance for finding a tolerant attitude would be higher, as surely the behavior you describe must come up in their practices while working on other issues.
posted by crazycanuck at 9:21 AM on March 1, 2014