OPINION: YOU CAN’T HAVE AN INVERVENTION WITHOUT STORYTELLERS
INSIDE BOOKS: OUT OF THE DOGHOUSE
BY JEAN HAGER, DSW
BY ROBERT WEISS, LCSW, CSAT-S
New Treatments EMDR and Brainspotting Hypnosis for Addiction Treatment for Minority Populations Interview:
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CONTENTS
28
Letter from the Editor
7
CCAPP
8
By Gary Seidler Consulting Executive Editor
Application of EMDR and Brainspotting with Addiction and Mental Health
National Advocacy Update for Addiction Programs and Professionals, Part II By Andrew Kessler, JD
By Denny Cecil-Van Den Heuvel, PhD, LMHC, LMFT, NCC
NACOA
Describes EMDR and brainspotting, provides examples on how they can help clients with addiction and mental health issues, and presents client cases.
The Children’s Program Kit is Back and Better than Ever By Sis Wenger
Cultural Trends
32 The Addictive Dilemma: Clinical Hypnosis for Addicted Clients By LaMarr Edgerson, PsyD, LMFT, NBCCH Provides information on clinical hypnosis, describes how it can help addicted clients, and presents a case study.
Kratom: Truth or Lies?
Opinion
You Can’t Have an Intervention without Storytellers
By Laura Newton, LCSWA, MSW, Anna Pereira, MAADC-II, Alexandra Persinger, MSW, Lindsey Shoemaker, MSW, Sheretta Butler-Barnes, PhD, & David A. Patterson Silver Wolf, PhD
16
By Jean Hager, DSW
From Leo’s Desk
God’s Grace: What is it?
18
By Rev. Leo Booth
The Role of Resiliency in Wellness and Recovery
SUD Treatment among US Minority Populations: Models of Success
13
By Maxim W. Furek, MA, CADC, ICADC
Wellness
37
10
20
By John Newport, PhD
The Integrative Piece A Life Well Lived
22
By Sheri Laine, LAc, Dipl. Ac
Topics in Behavioral Health Care
23
Addressing Substance Use Problems in Medical Systems By Dennis C. Daley, PhD
Presents a literature review of studies on treatment and minority populations and describes cultural considerations that should be addressed. www.counselormagazine.com
3
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Counselor · February 2017
Advertising Sales JAMES MOORHEAD Phone: (949) 706-0702 E-mail: jamesm@counselormedia.com
Conferences & Continuing Education LORRIE KEIP Phone: (800) 851-9100 ext. 220 Fax: (954) 360-0034 E-mail: Lorriek@hcibooks.com Website: www.usjt.com Advisory Board ROBERT J. ACKERMAN, PHD, CHAIRMAN JOAN BORYSENKO, PHD RALPH CARSON, PHD TIAN DAYTON, PHD BOBBY FERGUSON DAVID MEE-LEE. MD DON MEICHENBAUM, PHD PETE NIELSEN, CADC-II CARDWELL C. NUCKOLS, PHD MEL POHL, MD MARK SANDERS, LCSW DAVID E. SMITH, MD
ADVERTORIAL
Healing and Recovery: It’s a Matter of the Heart
“Healing is less about ‘saving’ or ‘fixing’ and more about ‘allowing’ ourselves to ease into the remembering that there’s a wholeness that has been there all along.” –Emmanuel Dagher After years working in the treatment field, we’ve come to believe that clients benefit from a program that helps them “remember that there’s a wholeness that has been there all along.” This means creating a healing environment grounded in respect and empowerment; where clients begin to make their own decisions and choices again, and are encouraged to believe in themselves as whole rather than damaged or defective.
The Healing Environment
The word healing comes from the AngloSaxon word haelen, which means to make whole. A healing environment cannot be created through fear, working from a “one up” or expert position or control and manipulation. It can only be created through respectful practices such as nonjudgment, kindness, compassion, healthy boundaries, and mutual respect. We cannot demand respect, we must earn it. We cannot empower others, we can only create an environment that supports clients to believe in and empower themselves to risk trying something new. We must respect where clients are in terms of their readiness to change, and remember that they are usually afraid, wounded, stuck, sad, and angry. In treatment, clients often act out these emotions and are labeled “resistant,” “noncompliant,” and “not caring.” We don’t want to view clients through this lens and instead see
them as human beings who are suffering, not as addictions, eating disorders or depression. We may suffer from those things, but they do not define what we ARE. Labels tend to inhibit the creation of a healing environment. In contrast, “holding space” (being fully present with others without judgment) for clients invites them to settle in and feel safe enough to let go of these adaptive behaviors. Holding space allows clients to have their own experience without someone else trying to “fix it” or affect a specific outcome, which enables clients to gain confidence in themselves as they work out their struggles themselves with the support of the group community. This provides the foundation for them to begin to believe that they are good enough and can live a great life.
Structure vs. Control
“Fear focuses on what you don’t want; love focuses on what you do want. Fear controls, love structures. Fear judges, and love notices.” –Becky Bailey Author of Easy to Love, Difficult to Discipline Intrinsic motivation does not rely on external pressure like fear, rewards/approval or punishment/disapproval from peers or health professionals. It exists within the individual, and is driven by interest or enjoyment in the task itself. This is the basis of self-determination theory. Contrary to rewards and incentives, research supports the idea that intrinsic motivation is stable and lasting as the individual is making changes based on what is
enjoyable or compatible with their “sense of self,” core values, and life goals. Establishing an environment that supports choice over control and promotes intrinsic motivation has been a cornerstone for us at ILC. People need to feel a sense of choice and responsibility for their actions, to feel capable of achieving their goals and also understood, cared for, and valued by others. Our staff understand this and help guide clients along a path of change of their choice. We offer opportunities for them to learn by living life and being accountable (Real World, Real Life, Real Recovery). They are supported in recovering faith in self instead of looking to others for approval. We do not view the self as a bad thing or something to be avoided or shunned and believe that until we are in alignment with our self we cannot be in alignment in life. What we ARE and what we DO are not the same. What we ARE are human beings; reflections of our creator. What we DO is largely inherited when we are born into this world. By supporting clients in recovering faith in and reclaiming their authentic selves, life (recovery) becomes interesting again and clients become intrinsically motivated for change. Our commitment is to support those who walk through our doors in their journey by providing a healing environment, the highest quality care and holding a space of re spect for them until they can reclaim that for themselves. That’s how we roll. One day at a time. — Holly Cook, executive director & Lee McCormick, CEO 877-334-6958 www.integrativelifecenter.com
CONTENTS Counselor Concerns
“Client” or “Patient”: Does it Make a Difference?
25
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor By Toni Galardi, PhD
Inside Books
Out of the Doghouse: A Step-by-Step RelationshipSaving Guide for Men Caught Cheating
27 64
43 Focus on Family Recovery: An Interview with Sharon Wegscheider-Cruse, MA By William L. White, MA Discusses Sharon Wegscheider-Cruse’s early career, her involvement with NACoA and Onsite, and her work on codependency.
By Robert Weiss, LCSW, CSAT-S Reviewed by Leah Honarbakhsh
ALSO IN THIS ISSUE
Ad Index CE Quiz
59 62
From the Journal of Substance Abuse Treatment
48 A Comprehensive Continuing Care Intervention for Clients with SUDs By James R. McKay, PhD, Cheryl Knepper, MA, Erin Deneke, PhD, Christopher O’Reilly, MA, & Robert L. DuPont, MD Introduces the My First Year of Recovery (MyFYR) intervention and presents the results of a study.
54 Gambling, Relapse, and Recovery: Studying a New Technology By Richard D. Froilán-Dávila, PhD, & William B. Secor, PhD Defines compulsive gambling, presents a study on compulsive gamblers with co-occurring disorders, and identifies triggers for relapse.
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Counselor · February 2017
LETTER FROM THE EDITOR
Change in the New Year A
s we enter a new year, change is absolutely everywhere you look, from a new White House to fresh crops of marijuana on the west coast . . . and just about everything in between. None of us can predict with any kind of certainty what we’ll be seeing on the political, economic, national, and international fronts, or what the costs and benefits of legalized marijuana in a growing number of states will be, so I’ll just stick with a couple of changes that are clearer and closer to home. First, we begin with this issue to bring our readers a new section: U.S. Journal Training Conference Reports, with highlights from our most recent professional training conference (in this case, the 7th Western Conference on Behavioral Health and Addictive Disorders held this past October in Newport Beach, California). This new initiative is designed to merge our Counselor readership with the estimated three thousand professionals who annually attend our eight or more conferences throughout the country. The schedule for this year’s events can be seen on the inside back cover.
William White
This issue of Counselor features one last contribution by William White, who has graced the pages of this magazine with his interviews with dozens of noted leaders in our field for many years. Bill himself will be the subject of an interview with incoming contributor, Dr. Andrea Barthwell, in our April issue. On behalf of all our readers, we thank Bill for being an integral part of Counselor magazine. An emeritus senior research consultant at Chestnut Health Systems/Lighthouse Institute and past chair of the board of Recovery Communities United, Bill has a master’s degree in addiction studies and has worked full-time in the addiction field since 1969 as a streetworker, counselor, clinical director, researcher, and well-traveled trainer and consultant. He has authored or coauthored more than four hundred articles, monographs, research reports, book chapters, and eighteen books. His book Slaying the Dragon: The History of Addiction Treatment and Recovery in America received the McGovern Family Foundation Award for the best book on addiction recovery. Bill’s contributions have been acknowledged by awards from the National Association of Addiction Treatment Providers (NAATP), the National Council on Alcoholism and Drug Dependence (NCADD), NAADAC: The Association of Addiction Professionals, the American Society of Addiction Medicine (ASAM), and the Native American Wellbriety Movement. While we will miss his interviews in Counselor, Bill continues to write about the history of treatment and recovery on his website, www.williamwhitepapers.com. We wish all our readers and U.S. Journal Training conference alumni a blessed and healthy New Year, and, as always, we invite your evaluations, letters, ideas, and even prognostications.
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication
www.counselormagazine.com
7
CCAPP
National Advocacy Update for Addiction Programs and Professionals, Part II Andrew Kessler, JD
I
t’s been close to a decade since the Wellstone/Domenici Mental Health and Addiction Parity Act, yet the spirit of the law has yet to reach its full impact. Federal agencies were slow to issue rules pertaining to the law, and insurance companies and consumers alike fail to grasp the intricacies of the law. The Affordable Care Act (ACA) then required all new small group and individual market plans to cover ten essential health benefit categories, including mental health and substance use disorder services, and to cover them at parity with medical and surgical benefits. The ACA did not identify which benefits should be covered; each state chooses an Essential Health Benefits benchmark plan to determine which addiction benefits must be covered by the ACA plans sold in that state. Parity, like every law, will not be effective unless it is properly implemented and executed. Last spring the White House announced the formation of a parity task force, given the charge to promote compliance with parity best practices; support the development of tools and resources to support parity implementation; and develop additional agency guidance as needed to facilitate the implementation of parity. Its deadline for a report is October 31.
8
Counselor ¡ February 2017
CCAPP When The National Center on Addiction and Substance Abuse at Columbia University reviewed addiction benefits offered in the 2017 Essential Health Benefits benchmark plans, they found more than two-thirds violate the ACA (CASA Columbia, 2016). None of the plans are adequate, the report concluded. People with SUDs are not receiving effective treatment because insurance plans aren’t covering the full range of evidence-based care. For example, the CASA review did not find a single state that covered all of the approved medications used to treat opioid addiction. A study just published in Health Affairs found that insurance financing has not increased for substance use disorder treatment (Mark et al., 2016). Many plans do not cover or restrict access to residential SUD treatment and eating disorder care, even when treating professionals determine a needed length of stay based on clinical criteria, despite covering comparable levels of care for other chronic health conditions. They also do not cover services that help people to manage their disease and maintain wellness, such as mental health and SUD recovery support services. As part of the Coalition for Whole Health, CCAPP has been mindful of these issues. We are part of a coalition that calls for the federal government to issue additional specific guidance to state regulators and plans on how to implement the federal parity law, identify parity violations, and enforce the law in both public and private insurance. We also believe the federal government should issue additional guidance detailing the parity law’s transparency requirements and modeling for issuers the appropriate disclosure of coverage and plan design information. Finally, federal and state regulators should robustly enforce the requirements of the federal mental health and SUD parity law prospectively during plan approval and retrospectively through complaint investigations. Through the work of the Coalition for Whole Health and many of its organizational members, we have seen many critical gaps and restrictions in insurance plan coverage of substance use
disorder and mental health care, even when equitable coverage is required by the federal parity law and consumers are paying for what should be compre-
when insurance plans do cover services, they often impose more burdensome obstacles to obtaining that care, including inappropriate denials based on lack of medical necessity, prior notification or authorization and repeated authorizations, Step therapy, and other medical management. Access to care is further hindered by inadequate provider networks that do not include providers that offer the full range of covered services or specialize in adolescent care. CCAPP will continue to address these gaps and keep its membership appraised of progress. c Acknowledgements: The author would like to thank the Legal Action Center for their assistance. Andrew Kessler, JD, is founder and principal of Slingshot Solutions LLC, a consulting firm that specializes in behavioral health policy and federal policy liaison for IC&RC.
hensive benefits. Studies have documented many problems. These include deficiencies in most states’ benchmark plans that result in the failure of many Essential-Health-Benefit-based insurance plans to cover services, or the coverage of noncomparable and limited services, including intensive outpatient, residential, and recovery support or chronic disease management services, and medications (LAC, 2016). And even
References
CASA Columbia. (2016). Uncovering coverage gaps: A review of addiction benefits in ACA plans. Retrieved from http://www.centeronaddiction.org/ addiction-research/reports/uncovering-coveragegaps-review-of-addiction-benefits-in-aca-plans The Legal Action Center (LAC). (2016). Substance use: Parity and health care access resources. Retrieved from https://lac.org/resources/substance-use-resources/ parity-health-care-access-resources/ Mark, T. L., Yee, T., Levit, K. R., Camacho-Cook, J., Cutler, E., & Carroll, C. D. (2016). Insurance financing for mental health conditions but not for substance use disorders, 1986–2014. Health Affairs, 35(6), 958–65.
CCAPP is unifying the addiction field 2400 Marconi Avenue P.O. Box 214127 Sacramento, CA 95821
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T (916) 338-9460 F (916) 338-9468 www.ccapp.us
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www.counselormagazine.com
9
NACOA
The Children’s Program Kit is Back and Better than Ever Sis Wenger
I
n the early 2000s, Karol L. Kumpfer, PhD, was director of the Center for Substance Abuse Prevention (CSAP) in the Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Kumpfer, a noted researcher and an outstanding evaluator of the state of substance abuse trends and related prevention needs of America’s youth and families, recognized that the prevention programs of those years, including those listed on the National Registry of Effective Programs and Practices (NREPP), did not meet the needs of the one in four children growing up in families with parental addiction. While helpful for the general 10
Counselor · February 2017
population of children and youth, existing prevention programs were inadequate to address the silent suffering of these high-risk children.
At-Risk Kids Become At-Risk Adults Producing At-Risk Kids
Because it is the at-risk population that is most likely to produce the next generation of people with substance use and/or mental health disorders, Dr. Kumpfer sought a practical, flexible program product that could be used in a variety of treatment settings, community organizations, and school-based student assistance programs. This would be a kit that could provide education
and support that could change the life trajectory of the kinds of kids referenced in the quote by Dr. Rob Anda, the CDC’s director of the adverse childhood experiences (ACE) study. Dr. Kumpfer envisioned reaching thousands of children through the organizations and systems where they were already in the community. The remarkable Children’s Program Kit, created by NACoA in 2003, with the guidance and program materials contributed by many leading experts in providing healing support to children of alcoholics, was the result of her vision. Over 150,000 toolkits were distributed to school counselors,
NACOA family program directors in treatment programs, youth organizations, and summer camps. The Children’s Program Kit was reprinted twice, and thirty thousand copies of an American Indian version were distributed to help provide education and support to family service programs for the American Indian population. NACoA developed its training services to strengthen programs being initiated across the country, and American Indian trainers took it to their communities.
Constantly in Demand
Demand for the Kit has never waned in the thirteen years since its introduction to the prevention, treatment, and recovery support field. Professionals who work with children who are struggling to cope with the daily chaos in their homes have steadily relied on this education tool, and can now help support the children of opioid addiction who comprise the latest wave of children in need of help. CSAP commissioned an updated and enhanced Children’s Program Kit last year, and it will be available by Children of Alcoholics (CoA) Awareness Week, February 12–19, 2017. In her Huffington Post blog last January titled “The Invisible Children: It’s CoA Awareness Week, So Listen Up, This Matters,” Tian Dayton, PhD, addressed the importance of speaking up for children trapped in addicted families. She stressed that
“Experiences like growing up with parental addiction, and the chaos and stress that surround it, pop up over and over again as primary causes of toxic stress. But addiction isn’t the only thing we’re looking at here. If children grow up with addiction, that’s probably not the only risk factor in the home. ACEs or adverse childhood experiences tend to cluster; once a home environment is disordered, the risk of witnessing or experiencing emotional, physical or sexual abuse actually rises dramatically” (Anda et al., 2006).
Great strides have been made in bringing the shame of addiction out of the shadows and getting our country and the world to believe recovery can and does happen and is impacting millions to great benefit. However, the biggest little secret remains the countless kids who are being hurt each and every day who don’t get talked about, funded, donated to or brought out of the shadows nearly enough (Dayton, 2016). And, as a result, so many will continue forward with the negative life consequences of mental health problems, relationships that don’t work, diminished physical health, and carry the family trauma into the next generation.
Why Do We Need CoA Awareness Week?
Children who are trapped in homes with addicted parents live in an atmosphere filled with chaos and confusion. They are trying to be normal kids, trying to develop an identity, and trying to make sense of the world, but the deck is stacked against them. Dr. Dayton states, The children’s lives are wrapped up in reacting to and hiding from the fallout of their parents struggling with all of the conflicts germinating from the drinking and drug use of one parent and the fruitless efforts to control it by the other. The distorted thinking, the emotional outbursts, the hiding, the rage, the passing out, the lying, the bravado, and the mortifying behaviors that are part of addiction rain down upon children from above (2016). Participating in an educational support group with peers offers CoAs a safe opportunity to tell their truth and begin their healing. This is where the rules that govern addicted family systems that we learned from years ago by Dr. Claudia Black—“Don’t talk, don’t feel, don’t trust”—are broken with each activity and the seven Cs are embedded in the lessons at each age level.
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11
NACOA A New and Revised Children’s Program Kit
NACoA is immensely proud of this unique and effective Kit that has already helped many thousands of young people in this country starving for clarity, safety, and hope. The new and enhanced Kit, which can benefit family programs within treatment centers, programs in the growing sober living movement, and support programs in schools and community-based youth programs, will include such additions as: n Specific skills to be acquired from participation in each of the program activities n More complete messages for parents and caregivers n New program evaluation forms n Additional activities offering more healing strategies and support specifically designed for tweens and teenagers
Evidence-Based Standards
The Kit was reviewed by two members of NACoA’s board of scientific advisers. While it is a program kit, as Dr. Kumpfer requested—that is, a tool to create and implement a children’s support program in multiple settings to address the needs of this population—it is not a program. The researchers matched it against the NIDA Prevention Principles and concluded that a program which used the Kit’s materials and implemented an educational support program as outlined in the Kit should meet the standards for evidence-based programs. We at NACoA are excited to reintroduce the Children’s Program Kit to the readers of Counselor. We hope you will honor the annual observance of CoA Awareness Week by writing and speaking about the silent suffering of the countless unnamed children who are struggling under the grinding, daily pressure of living with parental addiction. Dr. Dayton reminds us that “they are the forgotten victims of this disease. As we are lifting the secrecy and shame around being an addict, we need to pay equal if not more attention to lifting the shame and secrecy around these innocent 12
Counselor · February 2017
victims who live in its dark orbit” (2016). These children can be part of the healing or part of passing the disease down through another generation. It’s up to us.
Programs
NACoA has developed several customized trainings for various applications for using the Kit to implement a program of support for CoAs in multiple settings including family courts. It has even designed and provided a training to implement a national program in Sweden. The sites for use of the original Kit have primarily been those serving the children of clients in treatment and in school-based student assistance programs. Today it is not only being used in CoA-specific summer and weekend camps, but also in youth camps and churches as additional curriculum to existing activities, as part of an equine therapy program for school-age children, as an ongoing, stand-alone weekly program in several states, and as one- or two-week CoAspecific camps. The Kit provides all that is needed to implement a program of support. It is also not difficult to train staff to use the program materials and to follow its design to manage an effective support program.
From Confusion and Chronic Emotional Pain to Hope and Resilience
During CoA Awareness Week, NACoA follows the healing arrows from silence, confusion, and chronic emotional pain to hope and resilience. We urge you to imagine the millions of children of alcoholic parents (actually 18.5 million in the US alone), who wait for at least one caring adult to speak up and advocate for them and to start by reaching out to advocate and support just one of them. Just follow the arrows. Awareness leads to empathy in a caring adult. Empathy strengthens the ability and the desire to understand children’s silent but desperate realities. Understanding motivates towards action—both to help children directly and to advocate for appropriate educational support programs for the children who need them. Effective action leads
to support that brings hope and healing, making it possible for the children to tap into their own resilience and recovery. And that is why CoA Awareness Week is important, in this country and throughout NACoA’s affiliates in Great Britain, Germany, Slovenia, Poland, and New Zealand. To find more information and resources for CoA Awareness Week, visit NACoA’s new website: www.nacoa.org. c Sis Wenger is NACoA’s President and CEO.
References
Anda, R. F., Felliti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences from childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–86. Dayton, T. (2016). The invisible children: It’s CoA awareness week so listen up, this matters. Retrieved from http://www.huffingtonpost.com/dr-tian-dayton/the-invisible-children-it_b_8970102.html
CULTURAL TRENDS
Kratom: Truth or Lies? Maxim W. Furek, MA, CADC, ICADC
S
A 2014 study in the Journal of Pacific Cancer Prevention even concluded the benefits of the leaves are not limited to analgesic properties, but could be promising antioxidant and anti-cancer compounds. It’s no wonder at least four patents have been filed on the primary constituents of the plant (“American Kratom,” 2016).
ome believe that kratom, a relatively obscure drug, may be a possible weapon against the opioid epidemic that has plagued the US in recent years. But along with with the drug’s growing popularity and easy availability, also comes a looming controversy. In August 2016, the Drug Enforcement Administration (DEA) stated that it was placing kratom in the restrictive Schedule I category. The announcement read, The Drug Enforcement Administration (DEA) today announced its intention to place the active materials in the kratom plant into Schedule I of the Controlled Substances Act in order to avoid an imminent hazard to public safety. Mitragynine and 7-hydroxymitragynine are found in kratom, which is a tropical tree indigenous to Thailand, Malaysia, Myanmar, and other areas of Southeast Asia . . . Kratom is abused for its ability to produce opioid-like effects and is often marketed as a legal alternative to controlled substances. Law enforcement nationwide has seized more kratom in the first half of 2016 than any previous year and easily accounts for millions of dosages intended for the recreational market, according to DEA findings. In addition, kratom has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and has a lack of accepted safety for use under medical supervision. These three factors constitute a Schedule I controlled substance according to the Controlled Substances Act passed by Congress in 1970 (DEA, 2016). Expectedly, the DEA’s announcement triggered an immediate and forceful response. A group of kratom vendors filed a lawsuit against the government to block the move. Others took to social media in protest. Scientists questioned whether they would be able to continue kratom research, as some believe that it
is a promising, safer alternative to traditional opioids.
“Most Hopeful”
According to an article about the most lied-about drugs, “Kratom has the ‘most hopeful’ prospects for medical use, Jeff Lapoint, MD, says” (O’Neill, 2014). Dr. Lapoint is an attending physician in emergency medicine and medical toxicology at Kaiser Permanente in San Diego. The article continued, It mostly hits the kappa-opioid receptors, like traditional opiates. But unlike them, kratom doesn’t cause respiratory depression. So in theory a painkilling drug could be derived from kratom that has all of the positive effects of, say, codeine, but no risk of overdose. Dr. Lapoint also stated, “I think kratom has tremendous potential as a tool to treat the epidemic of opiate addiction in the US” (O’Neill, 2014). According to the American Kratom Association, Many studies have shown kratom to have positive medicinal benefits. A 2015 study in Dove Press Journal concluded kratom merits further study to develop its medical benefits, as a better opioid substitute, with fewer lethal side effects, or as an effective painkiller.
The kratom plant (Mitragyna speciosa) is a relative of the coffee plant and has been used as a stimulant and painkiller. It has a long tradition in Thailand, where laborers have chewed the leaves for centuries, as a means of increasing work output and also as a means of relaxation. When taken orally, kratom causes a mild euphoria effect, along with a mild stimulant effect often likened to a cup of espresso. Kratom has been described as a benign herb that mimics the effects of low-dose opiates without the risk of addiction. Anecdotally, the drug is believed to help alleviate pain and serve as a tapering agent to help get off opioids. According to an article on FoxNews. com, “First described in an 1839 publication by Dutch botanist Pieter Willem Korthals, kratom is used as a traditional medicine to reduce pain, as an anti-diarrheal, and as way of reducing opiate dependence” (Kilham, 2013).
Gray Area
Kratom’s status is murky. The drug remains legal in many countries, including the US, but has been banned in Indiana, Tennessee, Vermont, and Wyoming. The US Army has forbidden its use by soldiers (Join Together, 2016). Kratom bars, selling brewed varieties of the substance, have opened in Colorado, Florida, North Carolina, and New York. Obscurity is one of Kratom’s chief characteristics. While many professionals were quick to recognize K2, Spice, and products known as bath salts, kratom has easily slipped under the radar, known only to Internet, headshop, and gas station convenience store costumers. Legally, it exists in a gray area. Kratom is classified as a www.counselormagazine.com
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CULTURAL TRENDS botanic dietary supplement. The Food and Drug Administration (FDA) cannot restrict its sale unless it is proved unsafe or producers claim that it treats a medical condition. The drug’s effects depend upon the dosage. At low doses, individuals become more talkative, energetic, and sociable. According to a blog post by White Sands Treatment Center, At high doses, kratom acts as a sedative, creating lethargy and euphoria. Some of the adverse effects of kratom use include severe nausea, sweating, itching, edginess, vomiting, constipation, delusions, tremors, psychosis, lethargy, paranoia, hallucinations, and aggressive behavior (Kendall, 2016). An article in The New York Times addressed kratom and described how the American Kratom Association started: Susan Ash of Norfolk, Virginia said she had taken kratom during treatment for dependence of prescription painkillers, and now uses a small amount daily for chronic pain and depression. Last year, she founded the American Kratom Association, a consumer group of more than two thousand members that lobbies against state bills to ban the substance. “We know from all our experiences that kratom has the potential to be a wonderful medicine,” said Ms. Ash, age forty-six, adding that her organization receives little funding from kratom manufacturers. “We’re all experiencing that it’s changing our lives. We do agree that more science is needed to actually prove this potential that we know it has” (Schwarz, 2016). Despite its popularity, many are alarmed about the drug. An article in Behavioral Healthcare states, “According to NPR, fifteen people died of kratom overdoses in a two year period, and fourteen of them had other substances in their system as well” (Miller, 2016). The FoxNews.com article also stated that the DEA considers kratom a “drug of concern” and warned about the substance in a January 2013 publication: Kratom consumption can lead to addiction. In a study of Thai kratom addicts, it was observed that some addicts chewed kratom daily for three to thirty years (mean of 18.6 years). Long-term use of kratom produced anorexia, weight loss, insomnia, skin darkening, dry mouth, frequent urination, and constipation. A withdrawal syndrome was observed, consisting of symptoms of hostility, aggression, emotional lability, wet nose, achy muscles and bones, and jerky movement of the limbs. Furthermore, several cases of kratom psychosis were observed, where kratom addicts exhibited psychotic symptoms that included hallucinations, delusion, and confusion (Kilham, 2013).
Hoped-For Response
The kratom protest has shifted into high gear, forcing the hopedfor response. On October 12, 2016, the DEA halted their efforts to place kratom into the restrictive Schedule I alongside heroin, LSD, and MDMA. Schedule I drugs are recognized to have no currently accepted medical use and a high potential for abuse. 14
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The DEA accepted public comment on the drug until December 1, 2016, and solicited input from the FDA. According to NPR, DEA spokesman Russ Baer says the DEA received more than two thousand phone calls since August, mostly in opposition to the plan to classify kratom as Schedule I. “So in a spirit of transparency, and to open this up to public dialogue, we withdrew our notice to temporarily schedule kratom,” Baer says. “We will then give full consideration to those comments before we move forward with any action” (Silverman, 2016). Over the years there have been several drugs that have straddled the line between perceived drug abuse and potential medical application. Of these, MDMA, salvia divonorum, and psilocybin come to mind. But in the case of kratom, at least the DEA appears willing to review the evidence and then make their determination. Silverman writes, “After the public comment period ends, the DEA could still decide to temporarily ban kratom, permanently place the plant in a scheduled category defined by the Controlled Substances Act or decide to leave kratom unregulated” (2016). Whatever the outcome, the DEA’s official public comment period will review current scientific research and allow individuals to share their experiences using kratom. This common sense approach is good news and is in the best interests of everyone concerned. c Maxim W. Furek, MA, CADC, ICADC, is an avid researcher and lecturer on contemporary drug trends. His rich background includes aspects of psychology, addictions, mental health, and music journalism. His latest book, Sheppton: The Myth, Miracle, & Music, explores the psychological trauma of being trapped underground and is available at shepptonmyth.com.
References “American Kratom Association.” (2016). Retrieved from https://d3n8a8pro7vhmx.cloudfront.net/americankratomassociation/pages/86/attachments/ original/1475527128/AKA_Factsheet_10_03_2016.pdf?1475527128 Drug Enforcement Administration (DEA). (2016). DEA announces intent to schedule kratom: SE Asian drug is imminent hazard to public safety. Retrieved from https://www.dea.gov/divisions/hq/2016/hq083016.shtml Kendall. (2016). The dangers of kratom addiction. Retrieved from https://www. whitesandstreatment.com/2016/01/11/the-dangers-of-kratom-addiction/ Kilham, C. (2013). Kratom: The latest legal plant-based high. Retrieved from http:// www.foxnews.com/health/2013/12/04/kratom-latest-legal-plant-based-high.html Join Together. (2016). Kratom used as alternative to heroin, but can lead to addiction: Experts. Retrieved from http://www.drugfree.org/news-service/kratom-used-alternative-heroin-can-lead-addiction-experts/?utm_source=Stay%20 Informed%20-%20latest%20tips%2C%20resources%20and%20news&utm_ campaign=03ebc938a2-JTWN_KrtmAltrntvtoHrnCnLdtoAddctn1716&u tm_medium=email&utm_term=0_34168a2307-03ebc938a2-223274169 Miller, J. (2016). Kratom research sorely needed for clinical, policy decisions. Behavioral Healthcare. Retrieved from http://www.behavioral.net/ article/policy/kratom-research-sorely-needed-clinical-policy-decisions?utm_ campaign=Enews&utm_source=hs_email&utm_medium=email&utm_content=35865259&_hsenc=p2ANqtz-8UK64pvVO1D8_kTE0Gsh2FcoyDkhfCirAcm9ZnZaYfl3uPMytveX5hcnD6qviGgGzHO9Ts89HyD8HCbgmSiDU_XMIYjA&_hsmi=35865259 O’Neill, T. (2014). Ten of the most lied-about drugs. Retrieved from http://www.alternet.org/drugs/10-most-lied-about-drugs Schwarz, A. (2016). Kratom, an addict’s alternative, is found to be addictive itself. The New York Times. Retrieved from http://www.nytimes.com/2016/01/03/us/kratom-anaddicts-alternative-is-found-to-be-addictive-itself.html?partner=msft_msn&_r=0 Silverman, L. (2016). Kratom gets reprieve from Drug Enforcement Administration. Retrieved from http://www.npr.org/sections/health-shots/2016/10/12/497697627/ kratom-gets-reprieve-from-drug-enforcement-administration
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OPINION
You Can’t Have an Intervention without Storytellers Jean Hager, DSW
W
hen a family contacts me to help a loved one who is suffering from active addiction, and is interested in an intervention, I am confident they are in a desperate situation. They see me, the interventionist, as the last hope for recovery for a family member or friend in physical, emotional, and mental crisis. What they most likely don’t see the first time we meet as a group to prepare for the intervention—a caring, empathic, nonjudgmental, supportive confrontation to interrupt the progression of the fatal disease of addiction—is that the intervention’s success has little to do with my role as the therapist or “healer,” which Cheryl Mattingly refers to in her essay, Broken Narratives (2001). It has more to do with their emergent roles as narrators, and their powerful position of having personal experience with the addict’s destructive behavior and telling the story of the negative impact these interactions have had on them. This unique kinship between an addict and loved ones is why an intervention has any effect on the fragile, but well-defended, chronically ill person. Mattingly writes, “The art of the good story depends upon its capacity to
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OPINION dramatically transform lived experience” (2001, p. 183). The only tool that family members and friends can use to possibly break or put a crack in the addict’s wall of denial (self-deception) and other defense mechanisms—such as rationalization and projection, and a delusional system that causes euphoric recall of events they have blacked out—is sharing explicit, concrete data outlining specific destructive or abusing behavior, a true timeline of the drinking or drug usage’s progression, and, most importantly, that family members personally observed the negative behavior. This collection of incriminating data is then written in letter form, and family members read it to the addict at the intervention. The confrontation letter is thoughtfully written and rehearsed prior to the intervention. The reason to read the letter, and not just direct a stream of verbal assaults at the addict, is because the phenomenological process that occurs for most (if not all) intervention members is powerful. Without the letter, the fear is that the focus would shift or skew, and potentially sabotage the intervention’s success. In an intervention, the story emphatically begins with the ending. The family and friends who make up the intervention team write and tell their stories having firsthand knowledge, or very close to it, of how the addiction started, how it progressed, and what they will do or not do if the addict does not accept treatment. In other words, they give an ultimatum regarding the future of the relationship. The loved ones are overwhelmed by a dichotomy of feelings—fear, anger, resentment, compassion, love, hate—all directed at the addict. But as powerless as they feel, and as helpless as they initially presented in the first session, they emerge as the narrators, the storytellers, and the major keys to the intervention’s success. Their goal is to write a narrative in a way that the addict will receive, as well as accept the reality of the crisis. This means the addict’s defenses are down long enough to see the need for treatment. As Mattingly identifies this process, “The story’s structure exists because the narrator knows where to start, knows what to include and exclude, knows how to weigh and evaluate and connect the events he recounts, all
because he knows where he will stop” (2001, p. 185). My role in the intervention is to choreograph or guide the members of the intervention team, and direct them as if they were actors in a play: where they will sit, who will speak first, and who will follow. I educate them on the disease concept of addiction, and the benefit of
This unique kinship between an addict and loved ones is why an intervention has any effect on the fragile, but well-defended, chronically ill person. an intervention. I also tell them about the downside, and I provide support, encouragement, reassurance, and validation. How I interact with the family members, and how confident they feel in my ability, is crucial because they need to accept and follow my coaching exactly as I outline it to give the intervention a greater chance for success. Mattingly references the importance of the relationship between healer and patient, and in this particular therapeutic setting, I strongly agree: “The capacity
of a healer and audience to create a dramatic moment, a ‘time out of time,’ is often culturally linked to the healer’s perceived efficacy” (2001, p. 206). After the intervention, the family and other members of the intervention team feel a tremendous sense of relief if the addict immediately enters a treatment program. But the intervention’s covert success, resulting from their sharing of stories, is that they, as a group, will interact differently from that moment on. I conclude with one more quote from Mattingly that helps solidify this point: “A narrative form is sketched in action, one with beginning, middle, and end. This is a drama, characterized by suspense, excitement, heightened desire, even a kind of foreshadowing, an elusive gaze into possible futures that live far from this small clinical encounter” (2001, p. 206). c Jean Hager, DSW, has thirty-five years of experience as a clinical social worker in a wide range of issues, particularly alcohol and drug addiction, and co-occurring mental health disorders. Dr. Hager also treats other compulsive disorders, anxiety/mood disorders, grief and loss issues, and posttraumatic stress disorder. At her active private practice in New Jersey, founded in 1989, Dr. Hager offers adult, adolescent, individual, couples, group, and family therapy, as well as assessment and interventions.
References
Mattingly, C. (2001). Emergent narratives. In L. C. Garro & C. Mattingly (Eds.), Narrative and the cultural construction of illness and healing (pp. 181– 211). Oakland, CA: University of California Press.
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FROM LEO’S DESK
God’s Grace:
What is it? Rev. Leo Booth
I
n my last article titled “Prayer: What is it?” I said that I’m a critic of religious statements that sound great but make no sense to me. Anything, if you expect people to believe in it and pass it on, needs to make sense. In the realm of religion this is particularly true because we are talking about ideas concerning God, our relationship with God, and how that relationship has changed over a period of time. Also, remember that all of these ideas are coming from our perspective: what we understand God to want from us, what we think God is saying to us, and particularly, what we think God has done and is doing in this world. I suggested in that article that I did not believe it to be sensible to be asking God to intervene in our lives or events happening in history because it is clearly not happening. Either God is not there (the atheist position), he is not listening or it is not his real nature to “pop in and out” of actual events in history. The truth is that people create war and peace, people hurt lives and save lives, people are responsible for their lives or irresponsible. Do I believe in prayer? Yes. And when I pray I believe that God hears my prayers, but more importantly I hear my prayers and I’m then able to focus on the action needed to make things happen. What is God’s grace? In my book The Happy Heretic I write the following: The theology of God’s grace has a history that involves the idea that mankind is “fallen” and that we are inherently sinful creatures wholly incapable of doing anything good without God’s grace. This teaching was in part the result of Saint Augustine, who famously said, “Give me what you command and command what you will” (2012, p. 29). This has prompted a theological response to life that suggests everything that happens occurs as God’s will. God is in charge; we need forever remain in the passenger seat. I am sober, happy, prosperous, and alive only through God’s grace. We are who we are and where we are only through God’s grace. This theological response to life and the world can also become extremely elitist and arrogant when we consider the following: let’s say we see a blind man or
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FROM LEO’S DESK living of our lives. We are able to live the good life when we know, on a spiritual level, that we make life worth living. Our decisions and choices determine success or tragedy. God doesn’t make anyone happy, sad, successful or loving. That’s our job (2012, p. 21–2).
person with a serious limp and we say to a friend, “There but for the grace of God go I.” Really? Are we seriously saying that we are not blind or having a limp because of God’s grace and sadly those unfortunates did not get the blessing of God’s grace? Or let’s say we are walking down the street and see a pathetic drunk and— because we are in recovery—think to ourselves, “There but for the grace of God go I.” I’ve even heard people who are watching a documentary of India or Africa, where millions are living in poverty, say, “Let’s thank God’s grace that we were not born in such a country.” This is surely not intelligent or spiritual thinking. And what kind of God is this theology revealing to us? Surely not a God that most of us reading this magazine would or could believe in. In The Happy Heretic I wrote the following:
The history of the Reformation in the Western World needs to continue and seriously confront and present a better theology than the above. In past articles I’ve criticized ISIS for wanting to take us back to the seventh century, but we too need to revise some of our theological understandings.
A New Understanding
What if grace is not something that descends upon us but has been given to us at birth? God’s grace becomes akin to our reasoning powers, our ability to think and make choices, and our ability to take responsibility for our lives and what is happening in our world. We utilize God’s grace when we see clearly the many disabilities that affect
I believe that God is involved in everything and, using traditional language, His grace abounds. However, I believe that we play an essential role in the
mankind and we use our brains to figure out ways to prevent sickness. God’s grace is working through doctors and scientists. We see God’s grace in the work of recovering alcoholics throughout the world who make the choice to stop drinking and then stay sober. They begin to clear the wreckage of their past and embrace a spirituality that is both positive and creative. We see God’s grace at work in countries that are slowly working their way out of poverty and developing economic employment for their citizens. God’s grace is never favoritism, rather is it knowing and massaging a gift that has been given to every human being. This understanding of grace makes more sense to me. c Leo Booth, a former Episcopal priest, is today a Unity minister. He is also a recovering alcoholic. For more information about Leo Booth and his speaking engagements, visit www. fatherleo.com or e-mail him at fatherleo@fatherleo.com. You can also connect with him on Facebook: Reverend Leo Booth.
References
Booth, L. (2012). The happy heretic: Seven spiritual insights for healing religious codependency. Deerfield Beach, FL: Health Communications, Inc.
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