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st test test test test test test triangulation cirrhosis.

(Break). I didn't mean for the bumper music to be cut off there adisruptpyily. That's kind of interesting.
We're back. Hope you had a good lunch. We're going to go for about 80 minutes, take a ten-minute
break. At 2:20 central, 3:20 eastern, take a ten minute break, come back and go from 2:30 or 3:30 until
3:55 or 4:55, so by shortening the afternoon break we stop 5 minutes early and still meet all the
requirements for CEUs, et cetera. You've been asking really great questions and these are the best
questions I've ever had doing a remote training. Almost as good as being in person. Thank you for doing
that. It means a lot and, again, thank you for our ASL interpreters, for our captioners, Syd, Gwen,
Victoria, all of you.
So we're talking about families we'll talk now about family engagement and treatment. Are interventions
helpful? That's a question I get a lot. In my opinion, especially in how they are portrayed in entertainment
and the media, absolutely not. However, family members with the right support can express their
concerns to a loved one and encourage them to accept help. The person who receives this may not be
aware of the impact their behaviors have on others. I don't think therapy is designed to be entertainment.
So I'm not -- if that's your thing, that's cool. I'm not judging. It's just not my thing.
What is a good approach to this is what's called the CRAFT approach. And the CRAFT approach is
something I'll talk about later. It's actually a more treatment-oriented way to do interventions.
So when working with a family or a couple, the family itself is the client.
We know within family systems that the systems want to try to maintain a state of equilibrium and
balance. In some family systems, the drive toward maintaining the homeostasis may be stronger than
the system's desire for healing. A big part of working with families and couples and even individuals is
understanding and maintaining boundaries. It's also important working with families that we identify
closeed and open systems and how flexible the family is.
And, again, also be aware of some of those rules. So these are broad concepts when it comes to
working with families.
We also want to be aware of triangulation, and triangulation, just like boundaries is applicable in families,
but it's really applicable from any system system. He so with triangulation, two people dealing with a
problem come to a place where they need to discuss a senseitive issue and instead of facing the issue
directly divert their energy to a third member who acts as a scapegoat, as an object of concern or an ally.
But by involving the other person they reduce the emotional tension but prevent the conflict from ever
being brought to light.
So triangulation happens -- it can happen anytime you have three people.
Family therapy is often useed in conjunction with individual therapy. There's also a form of group therapy
called multi-family group therapy which I've taken part in and that's where several families -- adults and
adolescents attend group therapy sessions with other families. When I did drug court, I felt that was the
most useful intervention that we had. It was really, really powerful.
So there are different types of family therapy. I'm going to do a 30,000-foot view of this. I'm not saying
one is better than the other. But I do think that just like with individual therapy, we have to have some

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kind of structure in what we're doing. It's not just a matter of I'm going to the client's house, provide in-
home therapy and we're going to shoot the breeze around the dinner table. There has to be a reason
and direction to what we're doing.
So the structural/strategyic family therapy assumes that the family system's power is greater than the
individual's power and that the family system determines individual behavior to an extent.
Some of the concepts we see with truly/strategyic family therapy are identifying subsystems within the
family, figuring out who handles the primary decision making, where the power is in the family. Because
the power is not always with the adults. Boundaries within and outside the family. Rules, roles, ally
allyiances and triangles, flexibility and what does communication look like.
The treatment aspect after we identify all that works to identify the role that substance use disorder plays
in the family while the counselor guides change in the family structure.
So some of the key interventions include supporting the strengths of the system, relabeling or normalize
normalizing certain behaviors, which is often the case with adolescents, that, yes, I think in an example I
mentioned the other day or earlier today, yes, your kid shaved half their head and dyed their hair purple,
they do wacky things like that. That doesn't mean treatment isn't working.
Tracking problems. Overall stress management skills skills. Sometimes education and how do we do fun
things as a family.
Mutual decision making. We do that in my family here. There are certainly a number of decisions that
Claire and I are going to make and that's it and too bad. But other things that particularly as our boys
have gotten older we engage in mutual decision making and problem solving.
I think that a lot of times role plays can be really important in this and I've useed these particularly with
adolescents and their parents and sometimes what I'll do is have them play each other. And it takes a lot
of coaching because the idea is not to weaponize therapy but a lot of times -- I had found out through
some work with my family that there were times where it sounded like I was yelling. I didn't think I was
yelling but I was yelling and people couldn't hear what I was sailing, they just heard I was yelling. So I got
to stop yelling, that kind of thing.
So the communication piece is really important as well. Bowen family systems is that all family
dysfunctions, including substance use come from ineffective management of the anxiety in the family
system. So the person who uses does so in part to reduce the anxiety temporarily and when the entire
family can focus on the member who use it's drugs it can deflect attention from other sources of anxiety.
It takes only one person to make some changes in the entire system.
So it may start with one person. It does assume that past influences the present. And attempts to reduce
anxiety as people become more differentiateed, more autonomyous, and less enmeshed in the family
emotional system. So maybe only one person in the family wants to engage in therapy.
Multidimensional family therapy is typically used when the identified client is a child or adolescent. And in
this case the therapy is provided in the home home. Not all in-home therapy is necessaryily
multidimensional family therapy. In-home therapy can be provideed for a number of reasons.
With this type of therapy counselors can respond to the home during crisis. Family members are full

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collaborateors with the counselors and the family sets treatment goals so it's very much strength-
strength-based.
And services are designed to meet the individual needs of clients and can change as needed.
And the counselor and other members of the team are responsible for engaging the client and
exerciseing creativity to meet goals.
Multisystemmic therapy views SUD or substance use disorder in the broader context, how it's influenced
by multiple variables.
In this type of therapy the initial goal is to engage family members and if necessary to identify barriers to
engagement and develop strategies for overcomeing those barriers.
This looks to the needs and strengths within each system and the relationship with that identified
problem. And, again, family members and caregivers have a major role in treatment goals.
Interventions which could be in the home or outside the home are designed to promote responsible
behavior by all members. They are present focused and action oriented, country CBT, targeting specific
and well defined problems. They provide developmentally appropriate interventions.
Therapists are seen as responsible for helping the family overcome those barriers. Let me just say as
we've kind of looked at these different types of family therapy, a lot of times people practice things
eclectically.
So you may think, I don't know what the heck I do, and frankly, I'd be with you.
I think my practice is typically more toward the strategyic and structured type of the family. One of the
things I did when I worked with families including in-homework with the drug court, we'd sit down as a
family and do a gene or gene owe genogram. It helped define relationships on the inside and outside of
the family and helped us flesh out some goals.
So, for example, I gave an example of the young man I was working with raised by a single mom. Mom
got in a relationship with another adult and they blended their families. So part of what I needed to do
with the partner was say, listen, I know you mean well, and even though you come off with a tough
exterior, I know you love this kid and his mom. I need you to respectfully back the heck off so that you're
not overwhelming Mom so Mom can parent. And when things get better there, you can come back
alongside as mom's partner. And it actually worked. But it was tough. It was tough to do. Mom's partner
was highly resistant. She really wasn't sure of her own role in the family but I said, again again, your
toughness is based on love, and that's that's -- when she saw that I was saying it like that, I know you're
being tough because you love this kid, when she saw this kid, that was an aha moment and it wasn't
something I planned on saying, it just kind of came out. And sometimes when that happens in counseling
you're like, oh, that was really good. I wish that happened all the time because sometimes it doesn't. But
that was really a buy-in there.
So the last type of therapy is community reinforce reinforcement and family training or CRAFT. I
recommend this approach more than interventions. CRAFT recognizes that the person with SUD in the
family may be unaware of their substance use disorder and its impact on the family. Or they may be
ambivalent about making changes, particularly about deciding to enter treatment.

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So CRAFT utilizes many of the assumptions and practices of motivational interviewing. And the initial
focus is on the family members, not the identified addict.
Even if the person with SUD chooses not to engage in treatment, the changes within the family system
will likely benefit everybody.
So there are different components. We want to raise awareness of the negative consequences caused
by drug use and possible benefits of treatment.
We want to learn specific strategies for preventing dangerous situations.
Congresscy management training to reinforce the IA's nonuseing behaviors and change drug use.
So we might say, hey, -- and this is also with No. 5, planning of activities that interfere -- let's say the dad
or one of the adult males in the family has a problem, alcohol use disorder, but, hey, if we go out and
play mini golf or bowling, perhaps at a bowling alley that doesn't serve alcohol, we can do that instead so
we're basically planning activities that interfere and compete with their use of substances.
Social skills, trying to improve relationship communication and problem-solving skills in the family. Again,
we want to interfere with the potential drug use.
We also want to have it set up so when the person with substance use disorder is ready to engage in
treatment that the family is ready to respond accordingly. And instead of saying to the person with
substance use disorder, you've got to do this now or else, we began to change the system to recognize
what's going on. And if the person then says, I'm ready, we're ready to go as well. We're not forcing them
to do that.
I really like this approach because it's non-shameing and frankly, even if the person -- I've seen this
happen, the person with substance use disorder doesn't change, the education and support around
other people in the family system helps them to be healthier. In many cases they may look and say, I
thought I had a hand in their use. I really don't. And they may change some of their behaviors. Sorry,
pop, I'm not going to buy you alcohol anymore. And we are going to hide the car keys when you've been
drinking because where he don't want you drinking and driving. So small changes in the family system
can yield pretty big results in my opinion.
Working with families is hard. Let's be honest. And a lot of times as therapists it would be easy if we
could just avoid that. I think when you're working with kids you really -- unless the family system is
exceptionally unhealthy or unsafe, I pretty much insist on doing at least some family work when I've
worked with teenageers. There are exceptions, again, but couples work I think is the hardest work of all.
If that's what you do, more power to you.
It's really, really, really difficult whether SUD is involved or not.
I don't do that anymore and frankly I'm good. I'm good.
One of the modealities of therapy that I like most is group therapy. And, unfortunately, it's one of those
things that in my opinion, at least what I've seen in my clinical work, that is no longer effect effectively
taught in higher education. I was lucky enough when I attended Virginia commonwealth university school
of social work, there were giants in those days. There were teachers there who taught group and group
process and it was a really cool thing to be a part of. And then in my first social worker job it was group

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based. So I learned from pros then and then eventually was teaching other people. So I'm a big fan of
groups. Let's talk first about facilitating groups. And then we'll talk about peer groups. The purpose of
group psychotherapy and the reason it's often found in substance use treatment is it can reduce a
patient's sense of isolation and help cope with addiction and other life problems by provideing feedback,
social skills training and practice through peer-to-peer action.
Group therapy can be superior to individual SUD counseling because peers carry credibility. Positive
peer pressure can be helpful and the therapist's role is spread among members. More people can be
treated simultaneously when compared with individual therapy and the culture can extend outside the
group. If you remember the example before lunch when the Richmond mayor came by years ago and I
said it's a jobs program and he said what do you mean? And I said, well, our members learn from each
other where the jobs are and a lot of times people say my job is hireing, can you put in a good word for
me? Sure, I can do that.
That's a positive thing. Group means when structure structured correctly can provide a safe environment.

So there are different modes of group therapy. There's time-limited groups versus ongoing groups and
there are open groups versus closed groups.
So those are modes of therapy, open, closeed, time limited, continueing.
And then I identified or am going to illustrate 5 different types of group therapy.
So psychoeducational groups are educational in nature. They're usually time-limited and there's usually
an open format. They're highly structured and often follow a manual or curriculum and they're typically
useed more toward the beginning and middle of treatment. And they're probably most effective with
clients in a precontemplative or contemplative stage.
You can have 30 people in a group, just an arbitrary number, or a class, but they're psychoeducational
groups. They're he had indicating people. A lot of times run by peers and things like that. In that program
they call them family groups, educateing families on what substance use disorder is as well as what
treatment looks like and all that. Psychoeducational groups are very, very important. We don't want to
assume that since our clients are useing substances that they know about substance use disorder.
Skills development groups are similar to the skills development and cognitive behavioral problem solving
groups. These can be open or closeed. Open mines anybody can come at any time so people are
comeing in and leaving. Closeed are once we have X number of people we close the group until we're
done.
And they're usually smaller than other groups. Maybe 5-7 people. The idea is to cultivate skills people
need to achieve and maintain recovery. And it provides a forum for clients to practice those new skills.
So for a lot of our clients one thing I noticed is that a lot of times clients with substance use disorder
particularly from families with a history of substance use disorder don't know how to be assertive. They
know how to be aggressive and pass passive aggressive or passive but they think being assertive needs
I have to kick somebody's butt. That's not the case. So one of the things that we look at with this is how
do we practice that. So skills can help with that.

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Cognitive behavioral groups or problem solving groups also can be open or closeed and they're also
typically small. They may utilize a treatment manual or educational materials. And goals are made by
each member an the focus of the group is it on the imimmediate problems and helping one another with
their goals and that's one of the big things we see with this type of approach. So it's time limited,
relatively small, a lot of work involved, but it's focused on specific things. So if you want to think about
skills types groups and cognitive behavioral groups, it's one of the things we see with DBT. It's skills. You
learn skills, practice skills. Cognitive behavioral similar to that but from a problem solving standpoint.
Support groups include peer groups, and peer groups have been a part of substance use treatment
longer than anything else. And our peers can be role models so they can role model healthy behaviors
and use their personal experiencings to help others. They're typically open ended and can be open or
closeed. They may be open to certain individuals, closeed to others. And we see this a lot with AA. And
they're usually a lot less directive than other groups. At daily planet we had a lot of process groups. We
had problem solving group and we had support groups. In support groups there were no clinicians, just
certified peer counselors./experts. They ran that. So, again, that was just mainly role model behaviors
and provideing that kind of support. My favorite group is process groups. Process groups, though, should
only be led by trained professionals. I have run process groups with a certified peer recovery specialist
as a partner, as a coleader. That was fine, too.
But process groups really are important and typically have less structure than what we've talked about,
but that means that the clinician is responsible for creating a safe environment and not overcontrolling
the group but allowing the group to function as a whole.
In process groups we tend to delve into major developmental issues, searching for patterns that
contribute to drug use or interfere with recovery. The group becomes a microcosm of the way group
members relate to people in their lives. Leaders monitor how the group is functioning. Leaders must
understand group process and roles.
It's very important that there be training in this. I have sat in on groups, particularly when I started at the
planet I began sitting in on groups my first week. What I was amazeed with was some of the people on
my team was that they thought they were doing group therapy. They were doing individual therapy in a
group setting. They were so focused -- a couple teammates were so focused on a sense of control it
really wasn't group therapy.
So we initiated a lot of deconstruction and training and one of my teammates left because of that. He
didn't want to give up the sense of control.
We talk about the recovery process, that groups go through a process of comeing together and the first
part they do is forming. So members look to the leader for guideance, for safety, and orientation. And the
leader sets the agenda.
But a lot of groups never make it out of the forming stage because the leader doesn't want to give up
that sense of power. We have to recognize that but I've also seen situations where the group can't form
because the leader can't keep the group safe.
So in the beginning of group process, the leader is most active. As it group grows, the leader takes a

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hands-off approach. Forming and storming are difficult. It's amazing.

So storming, there is a lot of competition for power in the group. There are conflicts over what power
looks like and there's a lot of testing and even confrontation of the leader. A lot of times we don't like
that.
So I was at daily planet and one of my teammates was a good therapist but I realizeed after I got there
that she had frankly been bullied by a couple other therapists on the team. So on the first day I said, no,
we ain't doing that. And under the old regime there she had not ever been taught about therapy. I said I
want you to run this new group here. And she comes in my office one day, hair is kind of frazzled
frazzled. Sits down. She says group was horrible. I said what? She said did you hear it? Is it I said yeah,
I heard a lot of noise. Small building. She said it was horrible. I said group is forming and storming. She
said but I don't have any control control. I said let me ask you this: Did anybody get hurt? No. Did you
end with the same number you started with? I said that's even a bonus right there. And I said, this is
storming. This is what happens when you don't overly regiment the group and you're not teaching
kindergarten here and not teaching Sunday school. It's not that. I was like, stick with it.
And a few weeks later she literally comes bouncing in my office door and she's like, I got it. I said what
did you get? She goes, I'm elect them struggle I'm letting them struggle with this right now. It's not about
me. And I'm like yeah. And eventually the group was flowing. It took about 3 months but she got there.
And I was like, you got this. You got this. And part of it was I needed to have faith in her and I needed
her to know that I had faith in her and I needed her to know that you can make mistakes and don't have
to be perfect and you're still good at your job. It was really just kind of doing that.
By the time we reach norming we have cohesion, community building, problem solving, shared
leadership.
Let me give you a couple examples here. So the group I ran, my team mate was Patricia and she was
our case manager and we ran a group on Monday mornings. The way we ran group and I'll talk about
this in a second, Patricia just had a very calm sense about her. She's older than me and just had a very
motherly almost grand motherly way of doing things but also with no nonsense. Just boom.
And she would kind of take the lead in group. And my role was so kind of sit back and I'm observing and
if I'm seeing things I may be saying, Tommy, what do you think about what Rosie just said right there? I
may do that. But I want to let pat Patricia do most of the work. One day she said I have a cool quote from
Michael Angelo and I want the group members to respond to it. I said cool.
So one of the group members had just come to our program, first group. She was like I don't know about
groups. She said, I'm going to sit next to you. I said cool, you don't have to talk. We're glad you're here.
And a guy comes in and sits down and Patricia goes, okay, glad you're here. We'll call him Ed, -- a lot of
times they call her Ms. Patricia because she was older as a sign of respect. He goes, Ms. Patricia, can I
say something? I need to get it off my chest. She said go ahead. This is kind of heavy, so fair warning
here. He said I just came from the medical examiners officeit to identify my daughter's body and you felt
the air, that room got real quiet and it seemed like all the outside noise just went away. And before pa
Trish is that and I can say anything, another member says what do you need right now? He said I don't

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know. She goes, how about a hug? He goes, yeah. And that was the group. And that's a norming,
almost performing group. We're sitting there and basically -- his adult daughter had been murdered
murdered and it was, like, what do you do? This is a parent's worst nightmare. Really powerful group.
The lady who was brand new said damn. And I'm like, yeah. She said, hell, are they all like this? I said,
no. She said this is some shit right here. I said it's not all like that. It's interesting, she did really well in
our program and became a really good leader in groups. And this is somebody who was like group
therapy is stupid.
Performing is rare. When I worked in residential treatment I had the kids in our programs for about 6-12
months, they would rotate in and out. And I was fresh out of grad school. I was young. And there was a
kid in my group, one of the older kids in my groups, Joe and John, we'll call them, they were older in the
group and I had kids 16 down to 13, boys, and I had about 11 kids in my group. Got a call Saturday
night, I worked Sunday through Thursday back then. I got a call Saturday night from the cottage and it
was my teammates and they're like we just got a call from Joe's grandma, his mom was killed in a car
crash. And I'm like crap. And she's going to tell him and thinks it might be a good idea if you were here.
And on that job you had to be on call 24/7. It was a young person's job.
Anyway, so I go in Saturday night and the two staff that were day shift were there, George and and drew.
And Mr. Larry came in at night and Larry was a grandfather figure to the kids, he worked the overnight
and George and Andrew were there. I didn't remember their names until a minute ago. This is pretty
heavy.
So we're all there, and Joe's asleep. I mean John is asleep. We get the call from grandma. I'm really
sorry this happened. She said I need you to bring my baby home. And George said hey, I'll go with you. I
said, okay. We're going to take him home. We had gotten permission from his probation officer.
So I put him on the phone, and we were there when he learned his mom had been killed in a car crash
and he blew up. We just stayed around. And I just said said, if you get your stuff I want to get you home
to your grandma. She raised him and was the matriarch of the family. So we took him home, drove him
toward Northern Virginia I think and came back. It was really quiet.
So I got home about 4:00 in the morning, got a couple hours sleep and got up to go into the cottage and
on Sundays we run group in the morning then they have family visitation. So I'm in the cottage with day
staff and Larry was still hanging out, the overnight guy, just a good guy. He was there for me me. He was
there for me as a staff.
Anyway, I know this isn't about drugs but just trying to illustrate group processing family dynamic stuff.
And so John's friend Joe says where is John? I said I had to take him home. He said is everything okay?
I said no, tell you in group.
So we get in group and I told them what happened. And I remember it got really quiet. Some of the kids
started crying. And I remember Joe looking at me and look at the group and say do you guys know what
this means? It means the words your mama never have a place in this group and this cottage ever
again. Wow.
What was interesting is most of the group went to the funeral. We eventually welcomeed John back. He

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graduated the program. What was really interesting about performing is that -- because I stayed not in
that cottage, I became an administer, but an add minute administrator an an administrator, after all those
kids had gone, the group process had continued to that was how they were performing. It's powerful
stuff.
So thanks for letting me share that. And adjourning is how we terminate.
So there are group member roles, the monopolist, the person who wants all of your attention all the time.
The help rejecting complainer who doesn't matter they'll just reject the help. There's the silent member.
There's a rescueer, the Haupter, helicopterrer, the clown, I'm going to create laughter because I don't
feel safe. There are bullies in the group. The therapist coopter, someone who knows more than you do.
And the professional patient who knows the DSM-5 better than you do and the person that can recite the
symptomatology and self diagnosis.
You know who I'm talking about.
So how do you manage that? As a group facilitateor, you want to manage the environment. You don't
control the group. You want to role model respect and appropriate communication. You want to clarify
communication using I statements. Provide honest praise and validation. If there are differences
between group members I'm going to let them try to work that out as best they can but if I have to
mediate I will.
If others in the group won't confront inappropriate behaviors I will. I try to identify commonalities. He
works in concrete, don't you work in concrete? Okay. Cool.
Identify differences and how to address them with respect.
With expectations I recommend having the fewest number of rules possible to facilitate your group. In my
role with Medicaid in Virginia Medicaid and helping set up new drug treatment programs covered by
Medicaid I got a chance to travel around the state and I remember going to one facility near Roanoke
and meeting with the staff and I look in their group room and there are literally rules everywhere. And I'm
thinking to myself, this is all about rules.
So I want to have the fewest number of rules. So these are the rules I use. If you want more, you can.
But I want the fewest number.
So my No. 1 rule is group starts and ends on time. You will not be admitted to group if more than 5 or 10
minutes late, however you determine that.
Starts on time and ends on time.
I have no problem with you bringing something to drink into group as long as it's not alcohol or any type
of innobody inebrium. Stay awake. If you can't stay awake we need to find another alternative. Nobody
feels more disrespected when they're talking or sharing than when somebody else starts snoreing.
Confidentiality reigns supreme. What is said in this room stays in this room. There are very few
exceptions except for some of the obvious reasons about suicide, things like that.
Allow others to speak. Everyone is entitled to their opinion.
And there is no such thing as a dumb question. Somebody else probably has that question in mind. The
person who is asking the question just had the guts to say it first.

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That's how I do that.

And the other thing I do is talk about respect. And I also -- sometimes people talk about politics. We're
not talking about that. We're not doing that. We're not talking about politics or sports. This is not a bar.
So that's an important thing for me. What do you do if you have a group member that shows up
intoxicated intoxicated? Well, be prepared for this. We're dealing with folks that have substance use
disorder so don't take it personally.
We need to recognize how one person's relapse or lapse or continued use it trigger thoughts and urges
among other people. It's a learning opportunity but I'm not going to use that person as a scapegoat. So if
I have a person who I think is intoxicated, this is one of the benefits of having two people running group. I
say, Alan, can you step out with me and I'm concerned that you've been useing. No, I'm not. Alan, look
at me. I can smell it on your breath. You know, this is what I need to do. I am not going to have you go
back to group today. You're not kicked out. We need to get you home safely, you're not driving. But I
want to meet with you beforehand and let's talk about this. If I run group by myself myself, I tell them,
give me a minute. I'm not going to do that in front of the group, not going to embarrass them. If I come
back in, where is Alan? He's taking the rest of the day off. Let's move forward. I'm not going to do that.
But, again, the big thing is that I want to make sure they get home safe, particularly if they've driven
there, I don't wouldn't to be like go. You know, who can pick you up?
So it may be difficult if you're in a situation where nobody else is around but there may be times where
we have to say, we can't have group today if I have to make sure he doesn't drive or things like that that
may be the case.
One thing I was asked in developing this program is how do you deal with dealers in the group? The fact
is that majority of people in your group have traded traded, sold, given, and received substances from
other people. So the term dealer is really subject subjective.
Most people who use substances have done that. When I think of dealers I'm talking about people who
are selling drugs who don't have drug problems themselves and are doing it to make a profit.
Part of the way we deal with this is to do a thorough assessment ahead of time. What I've found is that
group members will often report those people to the facilitateors given enough time.
But, again, this is why assessing people and do they actually have a drug problem is so important?
And typically, when dealers are trying to do this, they often see the assessment process as intrusive and
a waste of time. They'll often self identify in that way. Why do I have to answer all these questions?
Because this is a treatment process. That kind of thing. That's what you often see with antisocial
personality disorders, they don't like answering a lot of questions. That's part of what we're doing here.
So this is from a book by Inaba and Cohen called up uppers, downers. I would cross out beginning
counselors. This can be by "experienceed counselors" and we can all make mistakes.
So 10 common group treatment errors, failure to have a realistic view of group treatment. Group
treatment requires long term perspective. But it's chaotic, yeah, because this is the first group you've
been a part of. So have a realistic view. Then realize I'm loving the chaos, this is great. And then
eventually the group moved into normalization.

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Self-disclosure issues and the failure to drop the mask of professionalism. Prepare for this in advance. I'll
talk about disclosure this the last section today and I do think disclosure is helpful to some degree, as
long as it's for the right reason reason.
Agency cultures and personal style. You have to be relaxed running groups.
Failure to understand the stages of group formation. Failure to recognize counter-transference issues.
Clarify the group rules. One of the things I do is to say every time we have a new group member I say
who's been in here the longest. I want you to lead the group and share with Andrew here who is new
today what our group expectations are. That's it.
So I want to clarify those group rules.
What you might see in groups that normalize, they'll develop some of their own rules.
Failure to use the entire group effectively by focusing on individual problem solving or engaging in
individual therapy where I'm talking with client A one on one where clients B through F are just listening.
Failure to plan in advance. Have a plan. Don't wing it. But be flexible as in the example with Patricia
comeing in with a plan on what we're going to do that day and then quietly putting that plan aside when
Ed started talking.
Failure to integrate new members into the group. If you feel comfortable sit next to me. She said, okay. I
like you. So I'm going to integrate her in the group.
Failure to understand interactions in the group as a metaphor for drug related issues occurring in the
group member's family origin.
We can't talk about groups without talking about 12 step groups and related peer support groups.
So Alcoholics Anonymous has been around since 1935. The main material in AA is called the big book.
Sometimes called the blue book. It's originally printed as a big book in big lettering, larger lettering
because the leaders of AA thought that people who were going through -- having the shakes would find it
easier to read. So it's still called the big book. The copy I have in my office is a very small pocket-sized
version.
It contains the writings of Bill W. and Dr. Bob, the founders of AA plus the common themes of AA. And
really the book is made up of firsthand accounts of addiction, specifically alcoholism and recovery. Some
of the stories are from the early days of AA, some are from the middle part of AA and some are more
recent.
The key aspect of AA is anonymity.
That when we come into this group we can share hoo we are but only through an minimum -- who we
are but only through anonymity can people be honest about what they're going through.
A key aspect is helping someone else we help ourselves.
When AA was started in the 1930s, it was men who were white and who were more or less from a
Judeo-Christian background.
Bill W. talks about an epiphany, he called it a hot flash he had in a hospital recovering from alcoholism
that it was a spiritual awakeening. So when AA -- people in AA talk about a higher power, they may
reference God, it may not be God. For them it may be the group. The issue is one of humility. And,

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again, a lot of people the issue of spirituality is uncomfortable for them, the issue of God or religion is
very uncomfortable to them. But at the core, if you really understand this, is it it really is about humility.
One of the things addiction does, whether we admit it or not, it makes us into the God of our own
universe, often to the exclusion of hurting other people. So the first step is really about humility more
than anything else.
And I've met people in AA who were agnostic, atheist, and who feel they benefit from it.
I'm not trying to sell it. It works. But it doesn't work for everybody. Again, one size never fits all.
One of the things AA stresses is that just for today I'm not going to drink or use drugs. Really what it
comes together is for this hour that you're there, you're not going to be using. So it's one hour at a time,
perhaps.
Sometimes people call it being in the rooms, they say I'm a friend of Bill. But recover in is a
transformational process and a whole life change that is greater than just not drinking. That's the main
thing. So the 12 steps of AA, we admitted we were powerless over alcohol. Our lives had become
unmanageable. That's humility. People generally work the 12 steps. This one says God, some say
higher power. If you but if you don't believe in God or you've had negative interactions from people who
claim to be agents of God whether pastors, clergy, things like that, you can see how this could be a big
turnoff.
But I do think it's important to understand what the 12 steps are. So what a person would do would be
continue with usually work withously work the steps. People often go back after step 12. A buddy of mine
who runs -- is one of the leaders in a program I do some work with, he he's been in recovery for I think
15 years, he says what I do is I work on -- every month I work on a different step because I'm always
finding ways to improve myself. And I thought that was a really good way of doing it. So really at the core
it's about self improvement.
There is a really other way of looking at that is the secular 12 steps. These are some of the same things.
I admit that I'm an addict and my life had become unmanageable. Through honesty and effort combined
with the help of others I could recover from addiction.
So this author has taken that same thing and said I can make it humanistic, I don't have to put higher
power or God in there. If that works for you, great great.
Many people are familiar with these 12 steps of AA. What's equally important are the 12 traditions.
Dr. Bob died I think in the '60s, I may not be certain about that. At that point Bill was faced with what to
do with AA. They had gotten a grant from Rockefeller, I believe, that had enabled them to have a living,
not to get wealthy. And at that point, as he got up in his later years, Bill had to decide what he was going
to do.
He ultimately decideed to give AA back to itself. And out of that they developed the 12 traditions of AA. A
lot of people are not as familiar with them as the 12 steps. But the 12 steps and 12 traditions are equally
important. And some of the things that you will notice -- and there is some God talk in there, particularly
step 2, but the only requirement for AA is a desire to stop drinking. It's not saying you have to be sober,
it's a desire. Each group should be autonomyous. Notice No. 6, AA should never endorse, finance, or

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lend the AA name to any related facility or outside enterprise. You won't see them endorsing a political
candidate or any program. They're meant to not do that.
Step 11 is what I want. Our public relations policy is based on attraction rather than promotion. We
always maintain personal anonymity at the level of press, radio, and films.
I love that. So I think that with all that these things is that, again, we want to be separate. I think that's a
great way of approaching drug treatment, later we'll talk about working with people who may be different
from you. I want to do everything I can to attract people to treatment. So anything that detracts from that
I want to avoid.
Some other 12 step groups, narcotics anonymous formed in 1953. Med don't anonymous is for people
on methadone but are in recovery from other things.
You can see some of the other ones there. Double trouble is co-occurring disorders. Al-anonis for family
members to understanding the role of codependency. Millati Islami is based on Islam. This is just some.
Some of the strengths of 12 step groups is they create a community and resource for the clients. Peers
give credibility and provide examples that recovery is possible and sustainable.
The groups are free. Groups are usually offered in a variety of settings and at various times.
Some groups are tailored for specific populations like male or female only. LGBTQ+, you know, different
things such as that and that can be important.
Open groups are for anybody, for the most part. You don't have to identify as yes I'm a person in
recovery or a person with substance use disorder. Closeed groups are for people who have committed
to working the program.
Healthy groups encourage you to take what you need and leave the rest. They're not going to say,
you've got to take everything.
But there's a lot of value in that.
Weaknesses of 12 step groups, some groups can be dogmatic about religion,ation I mentioned
yesterday, as I mentioned yesterday, not taking prescriptions to treat mental illness, members can be
discouraged from treating co-occurring mental illnesses. The group setting can trigger trauma reactions
in clients and the possibility of predation exists within groups, we call that 13 stepping. When I say older
even in their 20s or 30s, to me that's still young, but older or slightly older typically male clients might try
to hook up with younger clients who are female or male to the group. So we call that 13th stepping
stepping. A lot of times when you're new to recover recovery you feel lonely. And generally speaking, a
lot of substances suppress sexual drives and so when you get involved in recovery, you realize your sex
drive bounces back. It's easy to replace a drug with something else. We call it 13 stepping. It's not smiled
upon.
Smart we covery was -- recovery was started in 1994. It useed to be called rational recovery. It stands
for self management and recovery training. It utilizes CBT, REBT, and MET to help people change.
Can work as a stand-alone program or in conjunction with other programs. You can do it individually --
and there are group meetings for support. It's based on a 4 point program that can be worked in any
order.

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Building and maintaining motivation, copeing with urges, managing thoughts, feelings, and behaviors,
and living a balanced life.
So here in the greater Richmond area we have the greatest -- I believe the greatest number of 12-step
groups per population than anywhere else in the country.
In any given week I think there are over 50012-step groups but we also have as many but a fair number
of recovery groups.
Some of the recovery specialists said they prefer a mixture of both. That they might go to different AA or
NA meetings and a smart recovery meeting. A lot of them prefer an eclectic approach. So, I'm like,
again, if it works for you do it.
So we're headed toward the last two sections for today and we still have a bunch of slides but that's
okay. A lot of section breakers in what's lying ahead.
I want to break in 20 minutes but I want to dig a little into treatment strategies for special populations
then a heads up, Gwen, take questions before our next break.
So these are treatment strategies for special populations. I want to emphasize that this doesn't mean
that every person fits into every group that I talk about. This is not meant to be exclusion based based.
It's meant to understand that different groups may have some different specific needs that we have I
think a responsibilities to address.
So we're going to start with women.
Historically most research on SUD and SUD treatment focused on men. It's still catching up. In fact, early
treatment approaches were largely ignorant of any needs specific to female clients by imposeing the
same treatment standards and approaches useed on male clients. So women often found themselves
placed in psychiatric institutions as opposed to SUD treatment treatment.
Research from the past three decades has revealed notable differences on how addiction impacts
women and provides implications for treatment. We have to be cognizant of that.
So there are features of the substance use disorder in women compared to men. Women drink
significantly less than males but reach a higher blood alcohol level than men in a shorter time. They
make less of a chemical called ADH that helps break down alcohol.
SUD develops later in life in women. But it progresses more rapidly in women. So women typically
develop SUD later in life but it increases more rapidly in women. We call that telescopeing.
Women are more likely to drink or use alone compared to men. Negative health consequences develop
faster in women than men.
Women have a higher mortality rate. More likely to die from the effects of substance use disorder than
men.
It's more likely if a woman has substance use disorder that their male partner or significant other or
female partner, the significant other has SUD. With men that may not be the case.
Women have a higher rate of comorbid SUD and psychiatric disorders. Women are more likely to make
suicide attempts. Men are more likely to die by suicide. That still hasn't changed.
Women are more likely to have been victims of physical and sexual abuse than men.

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More often date the onset of pathological alcohol or drug use to a specific stressful event. Women are
less likely to seek drug treatment and more likely to initially seek mental health treatment. When I say
there mained to be more doors, maybe a person enters through a mental health door, that's really
important. So that's why mental health providers need to understand what we're talking about.
Some considerations. Psychiatric screening should be considered as part of SUD treatment for comorbid
disorders and that should apply to men and women. Some of this information is a little dated. Trauma
informed care is a must. Providers must pay attention to trauma history and any present horrific of
physical or sexual assault. Clients may need assistance to get away from violent significant others.
And this is where therapists have to be very careful careful. That may take time. That really may take
time for a person -- and this could be a male or a nonbinary person who is in an abusive relationship. It
may take time to extricate oneself from that. So we have to be patient.
Physical examination, particularly accessing health care is exceptionally important, particularly OB-GYN
care.
And case management needs are often important because more often than likely if we're talking about a
female client they're more likely to have custody or primary responsibility for children. And so we have to
make sure those needs are taken care of as best we can.
Not a lot of treatment programs that allow folks to bring their kids with them and that's a shame. And
there are a lot of reasons for that. I'm not faulting the programs. There's a lot of different licensing and
things like that. But programs that allow particularly women since they're more often than men being the
primary caregivers being able to bring children with them are hugely important.
When I worked in mental health in chesterfield county, the director of the substance use program, this
guy could write grants like nobody's business. We actually had child care in the building from about 4:00
to 9:00, we had eating hours.
So if I had -- like I say, I had a teenageer in a single-parent home and they had younger brothers and
sisters and my teenageer and their mom needed to be in group, I could actually sign up the younger two
kids to be in our child development center where they had toys, they got a snack, obviously making sure
they're not going to have any allergies and stuff like that. And they were watched by somebody who was
trained in that. It wasn't just some random person, background checks and all that and she ran a really
good ship. That was free of charge.
And, again, that was createive grant writing. He could really write grants.
Other considerations, we want to include information on SUD in pregnancy, housing that is safe,
parenting education and assistance. A lot of times people living with substance use disorder may not
have had very good parenting skills and may not know how to do certain things.
And really want to pay special attention to the needs of women in traditionally underserved groups like
sexual minority communities and the justice system.
Other considerations in women's drug treatment we want to evaluate and treatment significant others
and kids. We want to have positive FEMA role models models, treatment staff, peer recovery support.
We want to consider women only treatment programs as a big thing. One of the things we saw at daily

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planet right away is our process groups which were a lot of our drug groups, right away some of the
female clients said can we have some that are female only and my first response was yes but I want to
know is this because -- is anybody doing anything for you to feel uncomfortable? No, nobody's done
anything. We just feel better. Okay. Great. Let's make it happen.
Yeah.
We'll hit this section here then go to questions.
So clients who are pregnant and neonate neonatal impact of SUD.
About 20 percent of infants are exposeed to alcohol at some point during gestation. 15 percent of
pregnant clients smoke tobacco. 80 percent of children born with HIV in the U.S. were born to mothers
who contracted the illness through the sexual intercourse with male partners who were injected drugs or
the mothers were injecting drugs. All impact the baby.
After the baby is born many drugs may be in the mother's breast milk. The maximum fetal vulnerability is
the first 12 weeks of gestation and many clients don't know they're pregnant during that time. The baby
is vulnerable at any stage of pregnancy, but most of the drug exposeed babies who receive prenatal and
post natal care along with pediatric services manage after a slow start to catch up developmentally to
nondrug exposed children children.
During the crack epiKim demic in epidemic, we were told these kids will be a drain on the system. I saw
infants that had been born dependent upon crack cocaine. I will never forget the sound they made as
they were in pain going through withdrawal and all the workers could do -- because in this program you
could have your kids there, too, was hold the babies. Hold the babies. And we wondered, deer dear God,
what's going to happen to these kids when they grow up? Most of them turned out just fine. We are
resilient. And despite horrific bills that were passed for these super predator, and this was during the
Clinton administration, none of that really came to pass.
Screening is imperative in all SUD treatment programs should conduct pregnancy screening for
appropriate clients.
When I was at the Ketamine clinic we had a rule that said if you have the capacity to become pregnant
we need to do a pregnancy screen unless they had had a hysterectomy or tubal lyingation. And lying
ligation.
So we had people who were born female but identified as male. Once we explained this is the reason
why, we never got any pushback. So I think it's about treating the medical needs of the individual is really
important. That could be done with respect.
The biggest risk for client is lack of treatment. And many clients are reluctant to seek treatment because
they're afraid of punitive consequences should they disclose that they are pregnant and have an active
SUD.
The new doctor was at the daily planet and was sitting in with me and one of the women in group had
her baby with her. Baby was asleep. Dr. Clark said how old is your baby? She said 2 and a half months.
He said I'm an OB-GYN, is everything okay? Is there anything I can do? Mom said, no, it's good. He said
I'm curious did you get prenatal care? She said no, I didn't. And the doc said was there a reason why?

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And she said I was afraid they were going to take my baby and every woman in the group nodded their
head. Wow, the fear. Some is reel and some is inflated based upon past behaviors. There is this
pervasive fear of if you find I'm useing drugs you'll take my baby.
So let's talk about specific drugs. Alcohol use during pregnancy is the leading cause of intellect
intellectual disability in the U.S. Fetal alcohol syndrome is the third most common birth defect. It
increases the rate of miscarriage, placental separation, when the Mr. Senta separates from sent
placenta separates from the uterine wall prematurely.
Fetal alcohol spectrum disorder, what we see as prenatal exposure that's part of what causes it. There's
slow growth before and after birth. In severe forms it can be facial deformities and central nervous
system involvement.
Stimulants impact the parent and baby's cardiovascular system. Can elevate blood pressure and cause
placental separation.
Irritable baby syndrome, difficult to console. Difficulty sucking. Babies addicted to cocaine it's difficult for
them to engage in the sucking reflex.
Cannabis, benzos, 20 percent use cannabis while pregnant. Can lead to developmental delays, same
with tobacco and caffeine. Caffeine can affect the baby longer than the mom.
Opioids useed to be called neonateal abstinence syndrome, now called neonatal opioid withdrawal
syndrome. Not all children born to a mother useing opioids illicitly or on MAT will develop this. Currently
less than half of nubs of a patient with -- newborns of a patient with OUD may be impacted. A pregnant
mother who stops useing opioids cold turkey has a greater risk of miscarriage. So if they're on opioids
get them on methadone or buprenorphine. Very important.
There is no link between the dose of the MAT and severity of symptoms. But stopping use greatly
increase increases the opportunity for a miscarriage.
So some of the ways that babies show NOWS, the quick breathing, tremors, high-pitched crying,
projectile vomiting, diarrhea. My Myo colonic, jerking.
Babies are typically admitted to a neonatal intense intensive unit with oral morphine useed. Average 17
days as they are weaned off the medication.
Most spend more than -- if they're admitted to neonatal intenseive one to two days with more recent
evidence suggesting 5 days observation being sufficient in many cases. What they do now is a lot of
custodyiling, lot of music therapy, massage is really important.
Breastfeeding should be encouraged unless medically couldn't indicate contraindicated.
Clinicians must gauge the safety of the infant's parents before going home. I've worked with a lot of
clients where becoming pregnant became a primary motivator for them making changes in their life. Let's
look at some quells. We might go into our break and move it back a little bit.
Any questions?
>> Yes, some great questions. A couple questions related to groups with youths. One person is talking
about living in a fairly small community and having trouble getting youths to attend and wonder if it's from
fear of knowing people in the group or stigma and how you might suggest tackling those barriers.

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>> That's a really good question. Pink it's probably going to take time. I think part of it it is they're
wondering what's in it for me? How could group be seen as an alternative to something else? One thing
to look at is what time is it being offered? What is it competing with if anything else else? But it may be
that you're going to be running very low numbers until the word gets out that it's a safe place and it's
helpful. I think with groups with youths or Yutes I think smaller is better. I didn't get into group sizes but
for process groups I wouldn't go more than 9 people but for teenageers much lower than that, to be
honest with you.
>> Okay. Great. And then a similar question on working with youths, a therapist who works with students
in schools and the students receive 3 mandatory counseling sessions, any suggestion on a curriculum to
use in that short of a time period to assist in preventing future use.
>> Mandatory treatment. Wow. There's cannabis youth treatment, CYT, I will talk about that in the next
section. Cannabis youth training is a manual manualized base training you should be able to download
the materials. It's designed to be useed in short situations like that. Short little, brief things like that. You
can adapt it for use of other substances.
>> Okay. Great. Another person asked about a group -- her group has rolling starts. Not everyone
begins or ends on the same date. Can that be harmful to the group process?
>> I think it can be more helpful to the group process because if you get a group that is established and
people are rolling into an established group, you can actually -- it can perpetuate that forward. The
values can continue forward.
And that also means you're not having to start from scratch every time. Most groups I've run have been
kind of rolling forward like that, or opened. Yeah.
>> Okay. Good to know.
And one last question about groups would be on the effectiveness of online groups and the challenges
that might be involved in the group process with virtual groups?
>> Yeah, I'm not a fan of online groups. With the exception of sometimes it's necessary based upon
geographic dispersion. So there are parts of Virginia particularly in the southwest parts of our state
where you might be linearly 20 miles as the crow flyies as we say from somebody, but because of the
terrain it's a 2 and a half hour drive. So if that's the case I do think that the enhanceed use of online
technology has been a good thing.
What I'm against is frankly therapistsuation online therapy because it's of convenience to them. I think --
I'm going to answer the question but this is my soap box, to me if a client asks for in person therapy they
need to be provided with in person therapy. That's it.
I know a lot of the data show that online therapy is just as good as in person therapy. I think we'll find
over time that's not the case. And one of the frustrations I see in my community is I have people that I
know want to do in person therapy and they say all the therapists are online. I've heard horror stories
doing therapy in their car, driving their kids, running errands. I'm like, no, that is inappropriate.
So when it comes to groups just like any other type of situation, we want to make sure that the person
who is participating in the group is in a place where they feel safe, where it's confidential, we want to be

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able to react to them if they are experienceing some type of crisis so that means that I want to know
where you are physicallyr you're physically located. And I think what you'll have to expect in those
situations is that you're going to slow things down. You're also going to work harder to engage people
because you're not going to read body language and things like that. There needs to be an
understanding that if we're going to do this that people have cameras on and be active. When you're not
talking we don't pick up the background noise.
But you're not going to sit there with it off and do something else.
So I think it's more challenging so my recommendation is that unless it is necessary, I don't -- humans
are social creatures which means in order to be social we have to occupy the same generalizeed space
and I don't think a technology is in any way superior to that. In fact I think what we've seen in my state
the unnecessaryily long lock lockdowns and their continueing issues with kids in school, even with really
good teachers and technology how so many kids are fighting to make up that lost time. And so I think the
same goes with therapy. Hope that answers your question and I'm not pontificateing too much.
>> That makes total sense. Okay. There are some other questions not related to that section so maybe
we break now and save those for the end of the day and see how many we can get to.
>> Sounds like a great plan to me. So it's about 3:23 or 2:23 right now. We'll come back at 33 after the
hour. So 3:33 or 2:33, so take ten minutes and we'll be right back.
(Break). So part of this is we're realizeing now that adolescence is a relatively new phenomenon in
human history. Adolescence didn't really occur until the industrial age. Before then when you were old
enough to work and learn a trade and support yourself you left home. When you were old enough to
have a baby, you got married. That's pretty much how it went. There wasn't this time for extended
education. And what we see now is that adolescence doesn't stop at 18. We have a new term we call
transitional age youth or adults and that can be from 19 to 27 and we've kind of formalizeed that here in
America by saying, you can stay on your parents' insurance until 26. In some ways that's a good thing. In
other ways I think you have people who simply delay launching.
I think everyone is different. What we do recognize is that people don't mature at the same rate. Some
people are slower. And that's not necessaryily a bad thing.
But at the same time, what we have to realize is that to provide treatment, adolescence doesn't mean
doing what we do with a kid with an adult. The adolescent brain places oversized emphasis on the value
of rewards with little real recognition of risk. The oversized emphasis on reward if you're a parent of
teenagers, you may understand that there's no greater example of that than teaching your child how to
drive.
So I took my middle son out driving last night and to pick my youngest son up from a basketball game he
had attended with friends. And he's doing really well but he has a hard time negotiating right-hand turns.
He turns too wide. We were turning onto a busy street and he almost caused a head-on collision
collision. I actually had to grab the wheel. And I yelled. So and he was like, I'm sorry. I was like, okay, I
shouldn't have yelled. Part of what had happened is that he was enjoying the driving process and he
forgot about the risk. And he said, that could have been really bad. And I said, yeah, that could have

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been really bad. So my wife and I were talking earlier today, she's home today off work and I said let's
rethink some of the strategy here because I still think Ben is looking at the rewards of driving but still
doesn't really understand the risk. And the same applyies to drugs as well.
So it's estimated that 5-15 percent of clients will meet the formal criteria for SUD during adolescence.
The earlier kids start useing increases the risk and a preexisting behavioral or mental health disorder
increases the risk as well.
Peer factors can be a risk. Youth who associate with peers who use drugs are more likely to use drugs
themselves. But it doesn't mean just because your kid is associating with kids who use drugs that they'll
automatically use.
A bigger factor is children whose parents have substance use disorder are at increased risk to develop
SUD of their own. Increased drug use during adolescence is associated with families that lack closeness
and affection, lack of effective discipline, lack effective supervision, have excessive or weak parental
control or have inconsistent parenting. So that's a big thing.
Also parental antisocial parenting is also.
So adolescence start by useing experimenting with cigarettes, vaping, alcohol or cannabis, usually in
social settings. Associated with higher level of use later as well as violent delinquent behavior.
I want for reiterate that providing treatment to toalityies is -- for a given degree of severity or functionle
impairment, adolescents require more intenseive treatment than adults.
So the ASAM recommends adolescent treatment should be separate from adults. We should use
strategies to engage adolescents, channel their merge, hold their attention and retain them in treatment.
Treatment must address the nuances of the adolescent experience including cognitive, physical,
emotional, development. So both group treatment and adolescent treatment have been shown -- and
individual treatment have been shown to be effective with adolescents.
Group composition is extremely important. So you'll see more acting out and direct opposition from
adolescents than adults.
Parental involvement is almost always directly linked to better treatment outcomes. If you get the parents
involved it will be better.
Treatment times should limit any negative impacts with the school day.
So I don't like having kids be removed from school. Motivational interviewing is pretty universally useed
but I use a modified form. Once rapport has been established and cleaned shows motivation for
treatment, proceed to CBT or something else.
There are keys to working with teens that I think are important. First be respectful. But I'm also going to
expect respect. I want to be authentic. Practice genuineness. I'm not going to talk in ways that are
different than how I talk. I'm not going to act differently. I'm not going to use inauthentic slang, things like
that.
So, yeah, but that doesn't mean as a middle-aged dude that I can't connect with teenageers. But I need
to do so in a way that I'm not acting like I'm trying to connect with them.
If you know something about their world, if you're not sure get them to teach you. I learned about music

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styles, movies, video games I would never know from kids.

You need a genuine interest in youth culture. If you're automatically dismissive, that's not music, in
mayday we -- that's not going to help. I had a kid that wasn't talking very much and I asked what really
interested him. He was into hip-hop. I said pull him up on YouTube. So he pulled them up on YouTube. I
said so why is he flashing all that money? And so it led to a really good conversation about values.
And he said, what do you listen to? I said this is a band called the Ramons, if you disagree, I'll arm
wrestle you. But it began a conversation and I was honestly interested in why he was listening to this
music, what he liked about it, what it said to him and I asked do you listen to Run DMC? He said oh, you
mean old school. I was like, be quiet. But you get the idea. It created an opportunity for rapport and
genuine learning about what was interesting to him.
I want to limit the amount of advice -- approximately 81 percent of college students have consumed
alcohol and 68 percent have been drunk at least once. An estimated 1825 unintentional deaths occur
each year among college students due to binge drinking. Involvement in athletics is associated with risk
for higher rates of drinking and related consequences.
Collegiate based recovery programs being recognized nationwide, a big one here in Virginia
commonwealth. It's a national model called rams in recovery. Really well run. So increasing universities
are offering recovery based housing. Even where my son SAAM Sam is in college, they have it there.
There's a recovery based high school and that's a new thing. For kids in recovery. And it's really being
embraced by the community.
So this is an important thing as well.
Let's look at cultureal issues in treatment now. So culture is a group's shared traditions, customs,
languages, rituals, history, and expectations. Ethnicity is how people are classified based on shared
ancestry and culture and often appearance.
Race is a social construct based on geographic location and physical characteristics. Identity is how we
see ourselves. Norms are behaviors in a culture that may be positive or negative. Cultural humility. As
opposed to cultureal competence is the ability to maintain an interpersonal stance to other people that
respects their cultureal identity and values and this is an ongoing process and not an end state.
Let me give you an example. I had a couple weekends ago breakfast with a young man, he's 42 now.
But when I first met him he was 12 -- he's ten years younger than me. He was 12 and I was 21 so 9
years younger than me. So he's 43 or 44. He's an elementary school teacher. So we both worked at a
summer camp for inner city kids and it was kind of my entryway into social work. I was going to be a
professor of medieval literature before then. I have no idea why. But anyhow, this young man who was
12 at the time basically just asked me one day why I believe what I believe and I realizeed that this kid
who was growing up in the housing projects of Richmond knew a lot more about the world than I did.
And we stayed connected since then. He's a really good guy.
And we were talking, we were at breakfast a couple weeks ago and we were talking about the camp he
useed to work at and he said do you remember -- I don't know if you remember this, he said there was
an old west theme night. And I said I wasn't there but I know what you're talking about. He said one of

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the counselors basically -- we useed a barn and this old livery stable with a bar. And he said one of the
leadership staff fashioned a noose, like an old western setup and they had that there. And he saw it and
said take that down right now. And he was like that is offenseive, that is wrong and I think he's 100
percent right. And we talked about it. I said that's interesting. When I heard about that my first thought
was oh, my God, that is so inappropriate for kids to see because it's an instrument of death, it's an
instrument of suicide. He said, right. What I saw it as as a black man is an instrument of terrorism. So we
were both reflecting on the fact that this was obviously a negative thing and poorly handled and here we
are talking about it 20 years later. But, you know, we were talking about the fact that our lived
experiences where we group up, how grew up, we saw it as bad but bad in different ways. So the fact we
were still talking about it was really powerful.
So what we actually did from that is I convinceed the camp director to say I've been talking about doing
cultureal competencey, we really need to do this training now. So I co-led that with a therapist friend of
mine, Ed, I'm white, Ed's black so we would come together and we began doing that kind of training. And
the first time we did the training, R Rashad soaked it up. We need to be talking about the elephant in the
room.
So one of the ways Ed and I did that was the water waterline of visibility. Sometimes called the iceberg
exercise. I don't recommend it for group therapy. I've used it before in working with work group that are
established. It's where we begin looking at, okay, most-of-what you see about me you can't see, it's
beneath the surface. Some of it is well above the surface. You can see what I look like, that I appear to
be a male, I'm a bald dude, middle aged. I wear glasses, I have light skin. Some other things that you
might see before or after the water and a little below the water but there's a lot about me, my political
views, sexual orientation orientation, sexual identity, gender identity, everything -- you may not know all
of that. So part of it is getting to know people. When we get to know somebody, unless we are antisocial
in nature it is very difficult to hate somebody. We divide ourselves into different groups when we don't
take a chance to sit down and say, what's that like? And so here is this young man who is now nine
years younger than me but we're both about the same age, and we have these great experiences, but
even when he was 12 and I was 22 I can learn from him. So that's really powerful.
Why is this important? Well, most substance use disorder treatment was historically based on older
white middle upper class heterosexual males. Only recently have we begun to examine how SUD
impacts other groups. Even when we examine SUD in the context of these differences we need to
remember one size doesn't fit all. We need to be aware of cultural trends and our country's historical
treatment of these other groups. We have to acknowledge our history. We don't have to be captured by
our history but I am a big believer that we don't need to erase history. I think that's important. We have to
acknowledge the fact that, yes, this is not perfect. But we have to acknowledge that these things
happened because this influences treatment delivery.
So as I said before, we can't fully discuss substance use disorder and treatment without recognizeing
that racism and classism have been an integral part of determineing which substances are acceptable
and which are made illegal. The difference often lies in underlieying societal attitudes and stigma rather

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than science.
So I'm going to talk about some different groups in a little bit but be aware that the following slides are
broad views. Treatment should always be individualizeed. I'm a big believer that just because you have a
person that comes in your office that may have a certain skin tone or certain physical characteristics,
don't make blanket assumptions about them because that is actually racism. Even if you're coming from
a good space. Let's not make those assumptions. Let's treat people as individuals. Let's acknowledge
our differences and our commonalities. Let's not ignore things but let's also not assume if a person looks
or dresses a certain way they must fit nice and neat in this little small group. That's not okay.
So black Americans, African Americans have historic historically had less access to quality treatment.
There are economic discrimination that remains significant in many communities.
I noticed the first day I went to work when I got off the highway I passed 6 convenient stores but I was in
a food desert. Only recently have some grocery stores opened up in that area. If you go to other parts of
town there's one part of town that there are four grocery stores in less than a block distance between
each of them. It's crazy. There's a public, a public Publix, a Kroger, and others all within 500 feet of each
other. Representation among harder drugs may be disproximately higher because of high incarceration
rate.
Alcohol use starts slower then catches up to white Americans especially men. There are lower incidents
of drunk driving, higher incidence of medical problems, particularly hypertension.
Greater spiritual and religious participation, relationships and emotional expression are often higher and
should be incorporated into treatment.
Among or Latino clients and there are different ways -- I've heard Latino, Latina, Latinx, and I've heard
people in the community say we don't like that word, so, again, this is a diverse group. And by the way,
black Americans are a diverse group as are white Americans. It's not one-size-fits-all.
U.S. males are likely to develop alcohol use disorder possibly due to a more permissive cultureal norm
but women are increasing their levels of drinking. Family roles are important as is interdepends of the
family and extended family is very important and these themes need to be incorporated into treatment.
Asian and Pacific Islander Americans, fastest growing group in the U.S., people of Chinese, Japanese,
Korean, Indian, Middle Eastern, Vietnam easy, Hmong, all of them.
Diversity in religion and spiritual expressions with varying views about chemicalses of misuse.
Flushing reaction when alcohol is consumed. Family embarrassment and shame may lead to increased
instances of hiding drug use. Privacy is important.
Our Native American first nationers, there are over 200 Native tribal groups recognizeed in North
America America. There are some that are not recognized by the government.
Alcohol use disorder is recognized as a significant problem in many tribes but patterns vary widely
among tribes. So we don't assume because a client is Native American they have an alcohol problem.
They believe in the unity and sacredness of all nature. Some of the first drug courts were tribal drug
treatment courts.
What do we need to do as clinicians clinicians? Recognize and confront and adjust our own biases.

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Don't make assumptions about a client based on their ethnicity. Conduct a thorough assessment. Avoid
stereotypeing and develop individualizeed treatment plans for each client. If you have a question, ask if
you have a question, ask. And if you make a mistake apologize.
Another group we need to talk about, lesbians, gay, bisexual, transgender and nonbinary populations. A
lot of times the terminology is LGBTQ+ but that acronym can expand and change so we need to be mind
mindful of that.
This is another -- these are other diverse populations that are only now receiving attention in the U.S.
There is a documented higher prevalence of substance use disorder in these communities overall, and
there doesn't seem to be a specific reason for this.
We need to remember that sexual attraction, behavior and identity may coincide for some people but not
for all. For example, there are men who have sex with men who are MSM who don't consider themselves
gay.
Like other minority groups we have discussed, there is limited research regarding substance use and
subpopulations of this diverse group. Research conducted is largely on gay men and lesbian women not
on people who identify as bisexual or transgender. There are few studies on LGBTQ persons and ethnic
minorities.
Our triage clinician asked clients what they want to be called and which pronouns they preferred. I'll call
you whatever you want me to call you. It's imperative that all support and administrative staff be trained
in the variety of clients that present to your clinicsic and recognize and try to extinguish heteronormative
actions that could push clients away from treatment.
Many LGBTQ clients particularly transgender clients have experienceed shame and even abuse from
medical providers.
I remember talking with a nurse practitioner who was kind of developing a specialty of working with
transgender clients and talked about some of the horrific abuse that her clients, particularly clients that
had been born female but were identify identifying as male or maybe in transition to male and how they
were actually really abuseed during GYN examinations and she's like, Paul, it's not uncommon
uncommon. I was like, that's horrible.
We want to be aware of intimate partner violence. Is your client in a safe living environment? We want to
be aware of physical, mental, and emotional abuse by family members.
There is higher levels of suicidal ideaation and suicide attempts in the LGBTQ communities. So we need
to be mindful of that as well.
Treatment. An overall trauma informed approach and motivational interviewing are almost always used
in the initial stages of treatment. It's important to have diversity of providers but I've worked with people
from a variety of groups and things like that that. Some people are perfectly fine talking to somebody that
is not necessaryily a part of the group and to me that's not personal.
For some clients it's important that the clinics not push the client to disclose identity or sexuality. Some
may be in the process of comeing out and we don't want to push that. That is their process that happens
on their timeline.

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Group therapy, especially with members from other LGBTQ+ communities or allyies can be helpful.
There's rainbow 12 step meetings as an example.
Family of origin issues may need to be addressed once the client is engaged in treatment. Family
therapy is usually couldn't indicated if the family is violent or otherwise toxic. Again, people in these
groups are more likely to have been ostracized or rejected or ghosted by their families.
So we need to really respect that.
Continueing looking at different groups, people with disabilities are often not seen by members of a
larger culture. Some disabilities are visible. People using a wheelchair, while others may not be readily
apparent like a person who is deaf or a person with an intellectual disability. This is important. Just
because a person has a disability doesn't make them immune from having a substance use disorder and
may place them at a higher risk of developing a substance use disorder and may have cause difficulty in
getting treatment.
A strengths based approach to treatment is important for people with disabilities because these clients
may be viewed in terms of what they can't do as opposed to what they can.
Clients with cognitive disabilities -- I've been talking a lot today -- people with certain physical or cognitive
disabilities may require a longer interview and rest periods may be needed to be scheduled. Counseling
times should be flexible to sessions can be shortened, lengthened or made more frequent depending on
the individual treatment plan. Discussions should be concrete. Ask basic questions and repeat as
necessary.
This is an example of a client, for example, that I worked with about 10 years ago. We're going to call her
Suzy. Forty-six-year-old African-American female identifies as lesbian. Currently single. Deaf since birth
and fluent in ASL. She's in good physical health. She has lived independently her entire adult life. Holds
a graduate degree from Gallaudet University in Washington, D.C. for people who are deaf.
She enjoys independence and freedom but says very difficult being deaf in a hearing world. She attends
a Pentecostal church. Has major depressive disorder.
She's an alcoholic. She has had numerous periods of sobriety followed by relapses. The relapses
usually end with her being hospitalizeed in a psychiatric unit.
She comes to our agency and states her regular therapist has left on maternity leave and while sober
she fears an oncomeing relapse of her substance use disorder. She tells you she has found a 30 day
inpatient program in Minnesota for people who are deaf and would like to go. Determined that her
insurance will cover the cost of the program but not the air fair. fare fare.
-- air fare.
So this was somebody who was a former coworker of mine who actually ironically Christie helped the
hospital realize they were underserving this population. Suzy wound up being admitted for suicidal
ideation with a plan. But she appointed out that the interpreter services provideed were not sufficient
expertise level to be provideing medical interpretation as well.
So the hospital needed to be shown that and so she actually helped us realize something that we had
not realizeed. She actually -- what I did was I actually connected my friend who was a therapist with a

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friend of mine who ran a nonprofit that would do one one-time anonymous grants and so they put the
word out and got her air fare to and from the treatment program. So that was pretty cool. Again, it takes
a lot of work for people to make this happen. Just because a person has a disability doesn't mean they
don't have SUD. When I was at daily planet our primary purpose for being there was to work with people
who were experienceing homelessness or who were underhoused.
The government's definition of homelessness and locality's definition are different. Some call it going
from couch to couch we call it couch surfing means you're not homeless. Other agencies would say it
means you have a place that's stable. It's more than just physical shelter. It's a social determinant of
health and is essential for individual physical, emotional, and economic well-being.
People experienceing homelessness and SUD, among people of ages 50 and older who were
experienceing homelessness there is basically a high level of substance use. You can see 63 percent
useed illicit substance, alcohol and different things like that. Not all people who are homeless have a
problem with SUD or vice versa but the two are heavily linked. Housing first is the preferred method for
addressing homelessness. Homelessness is not dependent on the client being in treatment or any form
of recovery -- housing not homelessness ^.
I saw this happen at daily planet because when they are homeless, sometimes they develop
communities so if you're talking about housing you're removing somebody from their community so I like
the housing first model provided that the additional services are there. We're not just throwing people in
substandard housing and saying, we're done. So that's why I say ideally a housing first model should be
integrated with programs that address other things.
We want to think of our military personnel, both act active duty and our veterans. Notice that up to 75
percent of our all-volunteer military has been deployed more than once and many had longer
deployments.
High rates of PTSD among active and veteran personnel.
^.
Higher rates of homelessness or unstable housing. Chronic pain is a huge issue.
There is a lack of SUD screening and a lot of communities has a lack of adequate health care including
unfortunately from some VAs.
We also want to be aware of military sexual trauma which sexual assault in some form from 25 to 30
percent. Alcohol use is not uncommon in the military and so that can develop along with PTSD.
Because of a mistrust of VA care providers, clients may seek services from community providers
instead. So we need to understand that they may not want to go to the VA. I'm not disrespecting
anybody in the VA. I know a lot of people who work there and they're great but the paperwork and
bureaucracy is frustrating for clients and staff.
Clinicians should flairize themselves with military culture and be knowledgeable about services for act
active duty and veterans in their area. Understand the impact on families, both the family member away
and when they have to adjust comeing back.
Ongoing suicide screening is imperative given the high incidence of suicide in active duty and veteran

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populations. It's about 17 and a half percent per day.

Clinicians should address the issue of guns as knowledge and likely carrying of firearms are often a part
of the client's work. This is something we need to look at from a suicide prevention aspect.
The last group we'll look at are older adults. People 65 and older are the fastest growing age group in
the U.S. There are a lot of misconceptions about drug use in the elderly. The idea of substance use in
the elder is often not considered by health care providers. About one third of senior drinkers are later
onset drinking and about 17 percent of adults 60 and older misuse drug or alcohol.
Alcohol, prescription opioids and benzodiazepines are the more frequently useed drugs among the
elderly elderly. I'm at a certain age where my dad and stepmom are in memory care right now. So my
brothers and I are very cognizant of what's going on with what it means to age in America right now. We
need to incidentally recognize that the high suicide rate in 2022 was among people 80 and older.
There are different patterns of -- a lot of that included substance use disorder, comorbid.
Onset patterns of use in older adults, early onset group, have had substance use problems throughout
adulthood. Later onset group SUD problems developed after mid life. And intermittent group have
recovered from earlier substance use problem and experienceed a relapse. This is an important part of
taking this history. It's often just dismissed among the elderly.
Medical illnesses expose the elder to more prescription drugs. Physical resiliency declines with age so
drugs have a greater effect on the older useer. And there's often inadequate training of health
professionals on injury I can't tell lick health and SUD.
Substance use can often be a misdiagnosed as dementia and potential for falls. The treatment is helpful
and during a medical assessment the CAGE questionnaire can be useful to identify people who may
struggle with alcohol in particular.
Any form of treatment must address aging related issues such as grief and loss, loneliness, loss of
independence, health concerns.
Be honest with the person in stating that you believe they have a substance use problem.
Group therapy including ones in which SUD is not the central theme but in groups comprised of other
seniors has been shown to be an effective tool.
All right. I know I flew through that but I think a lot of it kind of makes sense and flows into what we were
doing before.
The last section today has a lot of other things in it as well. When we get through this we'll have time for
questions and we'll be done.
So ethical issues. Each of our licensing boards have guidelines or codes of ethics that guide decision
making to protect our clients, our professions and society at large. As I tell my superviseee it's, the board
of social work doesn't exist to support you. It exists to protect the public from you. And that's what they're
there for.
At the same time, varying views of SUD may place practitioners at odds with other providers. I work with
a lot of teams and a lot of mime time as a social worker I have to say this is my role. Particularly in this
new job I have I work under HR and I have to say, this is what with a I can't and what I can and cannot

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do. So we have to do a lot of educateing each other and understanding not only others' roles in practice
expertise but the obligations that other members of our team may have.
For example, a social worker may be legally and ethically required to report a situation to CPS and that a
physician or CPRS has to.
The ASAM has 5 core ethical principles. Autonomy, the client has a right to make decisions for
themselves even if we don't agree with them. Our role is to make sure the client understands the
potential consequences of their actions.
Beneficiarience, there can be limits to that. Northern maleficence Nonmalfeasance, do no harm. Inform
the client of any risks of the treatment provideed. Justice, at a macro level, goods and services should be
distributed fairly. Microlevel, all clients should be treated equally.
Fidelity, tell the truth. Maintain confidentiality as well.
Now, this leads us to a section that people were asking about yesterday, therapist self-disclosure in
substance use disorder treatment. Perhaps the most asked questions of clinicians working with people
with substance use disorder are are you in recovery or did you or do you use drugs? It's a fair question.
But before we answer those, let's look at guidelines for therapeutic self-disclosure.
Understand that some therapist self-disclosure is inevitable. When we interact with others, we inevitably
convey something about ourselves. That makes us human.
So in my office I have younger pictures of my kids. When you walk in you'll probably assume I'm a parent
parent. I wear a wedding ring, it clearly is a wedding band. I have a few pictures of my life in my office
because she's really pretty and I like to see her. So you can assume these are random people this guy
has in his office, that's kind of weird. But I'm discloseing something about myself and I love the Grateful
Dead but I might have a framed poster of one of their shows or something like that.
So you're going to learn something about that. In here you can see behind me, for example, there are a
couple guitars on the wall. They're more for decoration right now. What you can't see is there are 1, 2, 3
basses, there's a fourth one in the closet. This is our music room. I know the light is fading but you get
the idea.
So some self-disclosure is understandable. So whether or not we utilize therapeutic self-disclosure it
should be planned and not an impulseive impulsive decision. Therapist self-disclosure should benefit the
client, not to meet our needs. If I disclose this because I want you to like me then I need to take a look at
that.
Client questions about the therapist's age, training and experience are often intended to inform the
client's prediction about whether the therapist can be helpful. Client questions about the therapist's
personal experiences are generally to inquire whether the therapist can be empathetic.
So are you a person in recovery? One's first reaction might be to respond either yes or no or the much
dreaded, this is about you, into the me.
Danzer wrote a book on self-disclosure, it's not very thick, it's a good source if you're curious. I love his
response. That's a fair question. We acknowledge it. No such thing as a dumb question. I'm going to
answer it but what I want to ask you first, what will my answer mean to you? If I say yes I'm a person in

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recovery what does that mean? What if I say no I'm knot a person in recovery, what does that mean for
you? I think that's important. It creates a conversation. We're not becoming defensive but it mainly --
maybe they say I want to work with somebody who has a lived experience of this. If that offend you that's
your problem knot theirs. It may be that there are no other options, though. I don't know.
Danzer notes therapists need not anguish over whether or not to disclose, because either answering in
the negative or not answering directly is unlike unlikely to be impactful.
It's worth noting that treatment outcomes are generally the same whether the clinician has experience
with SUD or not. That's from William White who aggregate a lot of history about SUD treatment. Don't
worry about it, don't let it stop you from working with people with SUD.
One person told me, if I have a brain tumor I want the best doctor to operate on my brain. I'm not going
to say, doc, unless you've had this brain tumor I need you -- no, I want the best person to operate on me
or my kid or wife.
Confidentiality of clients and client records is the key to effective SUD treatment.
It's not only a legal requirement, it is really imperative.
Informed consent to treatment should be obtained in writing prior to the start of any SUD treatment.
Should be at the start of any mental health treatment for that matter.
I recommend that you review all aspects of the consent to treatment form with the client prior to start of
treatment to ensure the client understands what is expected in treatment and the limits of what the
clinician can and cannot disclose without the client's permission. Informed consent has three
components, knowledge of treatment, options, risks, and alternatives to treatment. Competencey, the
client has the cognitive ability to make rational decisions and understand the treatment and voluntary
acceptance.
That includes court-ordered treatment. So we have to talk about the limits of what that looks like.
There are two primary federal laws regarding confidentiality with regard to substance use. First is HIPAA.
The second is 42 CFR part 2. HIPAA apply applies to covered entertice, most health care providers,
health plans and related business associates. It protects the privacy and security of protected health
information am. It provides certain rights to patients and protects health data integrity, confidentiality, and
accessibility.
It permits disclosures without patient consent for treatment, payments, and health care operations.
The big thing we know about HIPAA is it allows us to carry our health information with us. It also works to
ensure that confidentiality, that privacy. I've heard people use it all the time like people try to apply
HIPAA to noncovered entityies, things like that that.
But the fact is you should know that you're likely covered under HIPAA.
Forty-two CFR part 2 applyies to programs that are federally assisted SUD treatment programs and most
recipients of part 2 records. So it protects privacy and security of records identifying individuals as
seeking SUD treatment, it's to encourage people to remain in SUD treatment. Proposed changes are
being vetted to better support coordinated care. So the treatment records were somewhat separated but
since we're seeing more and more integrated care, how do we protect the SUD treatment information

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vis-a-vis other things?

So one of the questions people ask is is my program a part 2 program? Well, it is if it's federally assisted.
If you receive federal funds, support, assistance or authorization. That includes being granted IRS tax
exempt status or allowing tax detoxes ductions. If you provide SUD services, diagnosis, treatment, or
referral for treatment for SUD. Holds itself out as a program that provides SUD services. Primary function
is to provide SUD treatment. If you're not sure, this is where you need to consult with state agencies to
determine which roles we fall under. It's better to do that.
Some states have laws that provide even greater protection and if you serve clients in most states you
need to follow the more protective law. Remember the legal adage, ignorance of the law does not
provide you with a way to not be held accountable for not following that law.
What do we mean by disclose? That's when we communicate any information identifying a patient a as
being or having been diagnosed with a substance use disorder having or having had substance use,
being referred to treatment.
Patient identifying information means the name, address, Social Security number, fingerprints,
photograph or similar information by which the identity of a patient as defined in this section, can be
determined with reasonable accuracy either directly or by reference to other information.
So some of the 42 CFR I'm going to show you the required elements. So clients when we disclose their
information, clients must consent in writing to the disclosure of their information. They have the right to
revoke any consent to disclosure at any time and if they orally revoke that we have to honor that.
Clients can also need to understand that information may be discloseed to qualified service
organizations but that only the minimum information needed for the QSO to do its job is to be discloseed.

Client information can be discloseed in connection with a medical emergency but the part 2 program
must document the client's record the name and affiliation of the recipient of the information. That's
important as well.
So these are required elements for written disclosure as noted by 42 CFR. Please note these may have
changed even recently so please don't just rely on this because this can change all the time.
So required elements include the name of the patient patient, the names or general designations of the
program, entityies or individuals permitted to make the disclosure.
What can be discloseed, the names of the individuals to whom the disclosure is to be made, listing the
name of the legal entity is permissible. The reason for the disclosure. The disclosure must be limited to
that information which is necessary to carry out the stated purpose. Nothing more.
A statement that the consent is subject to revocation at any time except to the extent that the part 2
program or our lawful holder of the patient identifying information that is permitted to make the disclosure
has already acted in reliance on it. If they say yes, you can disclose and later says, no I don't want you
discloseing anymore. If it's already been disclosed you can't retract that.
The date event or continue upon which the consent will expire if not revoked before. The signature of the
client and when required for a client who is minor or for a patient who is incompetent or decreased the

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signature of an individual authorizeed to sign. I don't provide you with blanket copies of that. You've got
to do that.
Permitted disclosures. Federal rules permit disclosures in the following circumstances. When a patient
signs a conseveral sent form that complies. When disclosure does not identify the patient as an
individual with SUD.
When treatment staff consult among themselves including systems of care. When the disclosure is to a
qualified service organization.
When there is a medical emergency. When the law requires reporting of child abuse or neglect, that
does not -- we have to still record that. When a patient commits a crime at the treatment program or
against staff members, they are not protected by 42 CFR. When the information is for research, audit, or
evaluation purposes and doesn't identify the client. When a court issues a special order authorizeing
disclosure.
What about adolescents? States have different laws regarding the age of consent for treatment. There is
a general consensus around the age of 14 years. Adolescents have the cognitive ability to understand
informed consent. Some states require providers to obtain parental consent while others allow
adolescents to be treated without such consent.
How mature are they? What's the severity of their SUD? What's the living situation, type of treatment, et
cetera.
So just be mindful of all of this. I think it may behoove you to consult with an attorney. It's going to cost
you money who is very familiar with this with the laws and regulations in your area.
A little bit of prevention on the beginning can help save you a lot of trouble in the end.
Impaired practitioners, rules standards of professional conduct and codes of ethics differ in each state
and each profession. Be aware of what your licensing board requires of you should you believe yourself
impaired or a peer is impaired. Some boards state that you must report any suspected impairment in a
peer or face disciplinary action yourself. Remember the ultimate concern is the welfare of our clients.
Trends among clinicians, generally follow the general population with the alcohol being the most
abuseed chemical.
Like the general population SUD usually causes causes problems outside of work before impacting the
client's work. Treatment often includes settings with fellow clinicians to accept the role of being a client.
There are programs in place for professionals or medical providers.
In many cases most providers step away from their work to focus on recovery and reenter their
professional work. I had a physician friend who stepped away to enter recovery. He's an amazing doc
doc, really good guy. He volunteerly told his voluntarily told his board what happened but has been back
to work for a couple years and is a great doc. So it's not the end of the world for folks. And we need to
understand that providers are people, too.
Clients involve the legal system ^ justice involved members with substance use disorder. About 2 million
Americans have opioid use disorder and 1 in 3 are arrested each year. Fifty-six-90 percent of people
who inject drugs have been incarcerated. So the drug using population in justice involved kind of

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alignment here.
Only 1 in 100 jails offer evidence-based treatment. That's amazingly low.
Clients released from incarceration. Clients can readily obtain illicit chemicals and other contraband in
prisons and some jails. There's a substantial increase in the death rates during the first two weeks
following a client's release from long-term incarceration with overdose being the most common cause of
death. Much of this can be attributed to the client's tolerance decreasing while incarcerated and using
the same substance but because their tolerance has drug dropped the drug is more deadly.
SAMHSA's Apic model is away to do that. Assess the individual's clinical and social needs and public
safety risk. Plan for the treatment and services to address their needs both in custody and upon reentry
reentry. We identify required community and correctional programs responsible for post release
supervisors and coordinate that transition.
A lot of problems faced by recently released clients clients. Lack of coordination between correctional
programs and community based programs. People released from incarceration have difficulty obtaining
housing. Getting their driver's license restored, getting financial assistance, housing, insurance, jobs, et
cetera.
So why does this matter? About 4.5 million people are on parole and probation until the U.S. When
incarcerated the jail or prison has a constitutional requirement to provide medical care but this does not
continue when the client is released. When they're released with limited resources many of them face
high mortality rates, wind up in emergency departments and are more likely to be redetained. That leads
to higher costs for care and/or subsequent incarceration and continued trauma with families. We can
change this.
MAT with incarcerated clients. Many prisons and jails started provideing MAT to clients during their stay
or in preparation for release. Clients who want MAT should be matched with the correct medication and
dosage. Care coordination is an important part of this treatment process as well.
Pregnant clients should be given priority for MAT.
In the jails in the countyies around where I live some of our sheriffs are doing -- have been really up on
this here. Sheriff just said we're elected officials. We're responsible for the community members in our
care. Some of the sheriffs in the area have been the most vocal about starting up treatment programs.
Some are nationally recognizeed.
As I mentioned several times, I had the opportunity to be a part of a drug treatment court for a number of
years. They were developed in response to the growing numbers of court cases involving people being
prosecute for drug use or possession. They use a team-based approach to focus the power of the court
on the client's treatment and avoid incarceration. Programs are highly structured, clear expectations for
clients. Positive behavior is recognized and rewarded while program violations are sanctioned. The
judge is the team leader and they rely on a unique team. My judge was awesome, the probation officer
was awesome, they had two different police officers in my time, both excellent excellent, we had a
prosecutor who is now a judge. Three and 2 clinicians and a school specialist with our juveniles,
someone who acted as liaison in the schools. One of the coolest things I ever did.

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Violent defendants are typically excluded from drug treatment courts. Many drug treatment courts when
the person cleats the program may have their charges dropped, their records expungeed or sentences
reduced reduced. Failure to follow the program expectations typically results in incarceration.
So there are thousands of active drug treatment courts around the world and the model is being useed to
address specific problems like mental health dockets, juvenile courts, tribal drug courts, prostitution
courts, all kinds of things. And the idea is that we're utilizing the resources of the court instead of locking
a person up. Let's keep them in a community with a lot of support. Research has shown that drug
treatment courts are effective and they've led to a major decrease particularly of juveniles here.
Part of the title of this talk today was about confronting stigma. Stigma is a social phenomenon where
individuals who deviate from the accepted norm are perceived by society as bad and areunder or
punished accordingly.
Why is this important? Remember what we started with: People matter regardless of what they're going
through. And stigma is the main reason that people with SUD do not seek treatment. Remember that
stigma or bias leads to prejudice and prejudice leads to discrimination. Discrimination I define as the
codification or legalization of that prejudice.
So how does it manifest? There's self stigma which we'll talk about. Family stigma, language which is
really important, stigma in the medical community, stigma within SUD treatment, stigma and race, stigma
in the legal system, workplace, and media.
Self stigma is huge. This is where we get shame, where we negatively Associate with a stigmatizeed
group. It greatly depends on the sources of shame as to whether its possession may become a force or
recovery or a factor that prolongs addiction.
Consider now one example of a specific effect of looping and self stigma. Addictive consumption in
response to shame where the shame turns out to be cyclical and self perpetuating. Individuals with
SUDs consume drugs in order to wipe out the shame they are feeling and perpetuate the very condition
they need to free themselves.
Stigma and the family. Estimates are that for every person with a substance use problem at least one
family member and as many as 5 other individuals are negatively impacted. Given the choice between
the stigma associated with SUD and SUD treatment, many families choose isolation.
I talked about language, I did it on the first slide so we're comeing full circle here. The term abuse has
been useed for shameful and willful commissions since the 14th century with its roots in the world abuse
meaning wicked act or practice, a shameful thing or violation of decentcy. Abuse or abuseer is not a term
we use for any other medical condition.
It's something we need to consider to avoid that.
Stigma in the medical community, there are a lot of factors that worseen clinician's attitudes toward
individuals with SUD. We may have had clinical experiences primaryily with individuals with severe SUD.
We may have lack of exposure to individuals in recovery. We may feel a lack of time and resources.
We've had poor role models and mentorship or may perceive SUD as a moral failing.
So we can improve clinicians' attitudes. Increase awareness of negative attitudes, provide forums to

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discuss common attitudes, continue to increase and improve addiction treatment options and intervene
at all levels of professional development.
Stigma and SUD treatment. The fact that any person with a medical license with prescribe addictive
opioids to treat pain but those who wish to treat people addicted to those opioids with proven medication
therapies require extensive government scrutiny is the clearest sign that stigma is deeply entrenched in
how addiction treatment is delivered in the United States.
In addition to racial inequalityies in terms of economic and institutional barriers there are differences in
the types of treatment available. Buprenorphine patients enrolled in primary care differed
demographically and clinically from those enrolled in methadone clinics. Compared with the patients in
the med don't clinic primary care patients on buprenorphine were more likely to be white, employed,
stably housed, hold at least a bachelor's degree and be new to treatment. Medical Medicalization of
addiction and the increased accessibility of OUD offered by OBOTs, programs that offer Suboxone were
predicted to decrease stigmatize stigmatization but access to this treatment is not evenly distributed or
experienceed experienceed the same way across race, ethnicity and social class.
So what can we doo about stigma? Educate yourself. Stay up to date on the latest information. I hope I
provided you with some here. Educate others. Speak to community and political leaders. Don't yell, talk.
Listen to the experts, our clients. They know a ton ton.
Point out misinformation whenever you can to correct other people's biases.
Do so gently but firmly. Don't yell.
Enough yelling going on.
Take care of ourselves as clinicians and people.
And that brings us to our very last section. How does my work with people with SUD impact me? These
are questions to ask.
What are some ways that I can carry another person's trauma or crisis when I listen to them?
What can I do to avoid burning out?
Well, part of what we need to do is recognize or life balance. What do I control? What do I not control?
I actually think this thing I have here really forms the most basic thing we do as clinicians, helping clients
understand what they do control and what they don't control because quite often we spend so much
energy on things we cannot control that we miss the things we can control.
Remember that doing something -- remember that caring for ourselves is as porno as caring for our
clients.
So exercise. You don't have to run a marathon. If you do, great. Do it. But exercise. Particularly during
the colder weather months where it's harder because it's dark and cold outside.
At least if you're in certain areas.
Develop and maintain healthy relationships outside of work. You are not what you do. Some do
medication, yoga. Artistic expression. I'm a music musician, I write and I garden. I love growing
vegetables. It was a really bad year for that.
Being a part of a spiritual community if that's important to you or being a part of community in general.

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Some journal. Grounding centering, remind reminding ourselves every day why we do what we do.
That's an important question.
I also think peer supervision is really important. Education does not stop once you receive your degree
degree. Quality clinicians are life-long learners. And you've dedicated a fairly big chunk of time to listen
to me run at the mouth for about 13 hours the last couple days, so good for you.
Likewise, same goes for supervision. It doesn't stop just because you earn your license.
I think it's important that we have people that we can talk to. I have people I seek out when I need
supervision. I'm dealing with a particularly difficult situation or sometimes it's just because a crisis has
continued to bother me. So I want to say say, I'm wondering about this.
That is very, very important. Let's go ahead and take some questions Gwen as we kind of follow up here
if you're still there. I know you are?
>> I am still here. Okay. Super. Lots of great information. Lots of happy emojis. I know it's late Friday
afternoon but people are still interested in this content. Thank you so much, Paul Paul.
I'm going to start with the top 3 upvoted questions. The first one being do you believe that
intergenerational trauma can play a role in substance misuses until the individual and can you
elaborate?
>> Yeah, absolutely. That's been shown in studies. Intergenerational trauma people studied -- people
whose parents were survivors of the concentration camps in World War II.It a client whose parents were
in Korea during the occupation of Korea by the Korean Japanese army during World War II and if you
learn your history you learn what happened in Asia, horrific. And they lived through the Korean war.
I think it can absolutely be a part of that. I think part of that is helping people understand that we can
carry that information, that genetic -- intergenerational trauma with us.
So it can be a causeative factor o. How causeative factor. Substance use disorder, it's an awareness
piece. That's a cause causative factor but need to address the substance use disorder addressing the
interJean rational trauma is inter-- intergeneration intergenerational trauma. Only a piece of the puzzle.
How many poppy seeds need to be eaten to test positive?
>> We should do an experiment on that. Generally a lot. Generally more than a bagel. And if you notice
those short -- I've never gotten this question before. Particularly in the immunoassay test it's a short
detection time. You'd have had to have that bagel within a few hours prior to being tested. It would need
to be probably more than one baggal oneel and there's one one -- bagel.
It would be a heck of an experiment though.
>> Right. Okay. And I work with children whose parents are on drugs. What can I say to help them
understand?
>> I think you start by listening. Start by listening listening to what's going on. You start by being safe
and consistent because one of the things that they are going to be useed to is people not being
consistent, not being safe. But they're also -- that is a big thing. A lot of times kids that are growing up in
those situations are often told to be silent and to not be heard, to not interfere.
I can't tell you how many kids were told, do as I say, not as I do which is pretty much never works.

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I think that's the main thing. Be that resilient -- we know resiliency in kids is because at least one adult
believes in them unequivocally. Be that resilient person in their life. Don't assume that because they live
in that environment that that's fog happen to them. -- that that's going to happen to them. Most important,
it's not their fault. They're not causing this.
You will also need to be mindful of whatever the laws are in your area about what you may need to
report in terms of child abuse and neglect. Again, every situation is different but you need to be mindful
of that as well.
Goes without saying?
>> Okay. Now I'm going to hop to some questions that came in later this afternoon. A couple about
cannabis. I'm interested in cannabis rehab. The only model I know is the MET CBT program. What do
you think of this approach and which model might be more beneficial.
>> Can you repeat the first part?
>> Interested in cannabis rehab, the only model I know is the MET CBT program.
>> Yeah, that's just one model. If we say rehab, if we're looking at treatment there are a variety of
different approaches that can be used with cannabis just like with any other substance. It doesn't have to
be MET CBT. You can be psychodynamic. Like I said, we useed Ketamine infusions to treat a person
with cannabis use disorder. So it doesn't have to be limited to one certain thing. It doesn't matter the
substance useed, it can be other approaches that can be useed for that.
>> Along the same lines of marijuana, with it being legalizeed in so many states, how to get through to
kids that it can be a potential problem.
>> Kind of as amentioned with with the adolescent piece, if we preach at them it won't work. Part is
learning what does responsible use look like? Is there such a thing as responsible use? Most people
stopped using cannabis on their own without treatment because life got in the way. So part of what I do
with kids is say, okay, I'm not going to assume you're going to use it but how would you know if your use
gets to be a problem? What would that look like? If we're saying don't use, don't use, that hasn't worked
for a lot of kids.
So I think part of it is how would you know something is a problem? And I would provide information but
don't preach because kids will be like, whatever. And that's the main thing. So my way of doing is it is I
have pretty firm boundaries of what I do and don't do.
I also make it clear, you're going to be responsible for your actions.
>> Okay. Same advice would apply to vaping with teenageers as well?
>> Yeah, I do think, though, with vaping part of the issue there is what I talk to parents about. When I
have parents who say, it's just vaping, it's just this or that, I'm like you're kind of allowing that to happen.
So I'm a big believer in real consequences so I told my kids if I catch you doing that, you're losing. You're
not driving. Sorry. If you're -- there are certain things that are not allowed in our house and if you want to
do that I'm happy to turn your phone off. I'm not trying to be a jerk but this is how life works and we don't
want to raise kids that believe that there's always going to be second chances. There aren't always
second chances and I think that we have to hold them accountable. So part of it is helping parents

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understand you're not going to do that.

My oldest son's high school in his last year before he was -- he was a runner, across-country, and went
to a parent meeting beforehand and the coach was like, here's the deal. If we catch you -- if anyone
catches you vaping in school, you're out. You are benched for 6 weeks. And he said there's no way
around it. That is comeing from Dr. Jackson, the principal. You are benched for 6 weeks. Matter of fact,
the entire offenseive line got caught vaping two weeks ago, they're out for 6 weeks. Going to be a long
season. They stunk that year. Part of it is you have to have consequences. If I choose to drive 100 miles
down the road I may get away with it, but eventually somebody is going to get hurt or I'll get caught.
This one kind of piggybacks on that. It goes into a little bit of potentially harder consequences, what are
your practices on harm reduction in the home. There's an obvious tension that happens between parents
putting up with unacceptable behaviors from their adult child and/or casting their child out to face their
own consequences including death. What is the therapist's role here?
>> I think the therapist's role is to look at what is the overall harm? More than anything else. I think,
again, it's very difficult to start parenting with enyour child is an adult -- when your child is an adult. It's
hard for a remedial parent. It's not blame, it's just reality.
Part of it is that if you're going to bring something in the home that is going to potentially hurt other
people then as a parent I have to look at the overall safety of my home. That's a tough decision to make.
I think that there are times where if I -- and I have had to counsel families on this. Well, I don't want to
throw him out on the street. You don't have to throw them on the street. You can pint them to programs
that are available, I know free programs in my area, you can choose to do that. That's still harm
reduction, but there are things that are not allowed in our home. They're just simply not. It's our values,
this is how we raise people, this is what we do.
So part of it is we have to find those things.Lets not just a simple thing of if I don't let him stay here and
use drugs he's going to be homeless. One thing I ask parents what happens when you die? Because
you are going to die one day. Who is going to take care of him the way you are now? It's probably not
going to be the siblings? How are you harming your children if they're adults now?
>> This one may or may not be quick and it will be the last one of the day. Can paternal use of narcotics
affect the development of the infant.
>> There is some evidence that cocaine can. There are some studies on cocaine hitching a ride on
sperm. That's the only thing we're aware of more than anything else. But I think one of the things is that's
why it pays to keep abreast of what's going on because anybody who says the science is settleed
doesn't understand science. Science is always asking questions, like is that true? So I think that's a fair
thing to look at and it wouldn't surprise any if it is an effect. Another thing more recently is with cocaine.
>> Good to know. Interesting. I think we're going to call it a day. So thank you so much to all of the
participants and for your high level of engagement. It's been very impressive and I know that's made it
more enjoyable for Paul as well. We just appreciate you being a part of this opportunity and thank you
Paul. This was such great information and I know it takes a lot of energy to keep going at this rate for two
full days but we're very appreciatetive.

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>> Thank you all very much. Thank you for taking the time to do this. Thank you toga when, to Victoria,
our ASL interpreters, captioners, thank you very much, and of course Syd. Thanks for the opportunity
and have a good weekend.
>> Thank you, you too. Enjoy everyone. Have a good night.

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