Counselor - June 2017 Issue Preview

OPINION: ETHICS: BE VISIONARY, VISIBLE, AND VOCAL

INSIDE BOOKS: THE TRAUMA HEART

BY LOUISE A. STANGER, EDD, LCSW, CIP, & ROGER PORTER, BA

BY JUDY CRANE

Compassion & Self-Care

Learning to Practice What We Preach Compassion Fatigue Personal Stress and Burnout Interview: Behshad Sheldon

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CONTENTS

7

Letter from the Editor

27

By Gary Seidler Consulting Executive Editor

Congruence as Self-Care: Practicing What We Preach

8

CCAPP

CCAPP Election Sets the Stage for a Productive 2017

By Ryan Thomas Neace, MA, LPC, & Jeffrey A. Kottler, PhD

By Sherry Daley

Presents the personal story of one of the authors, defines congruence as related to counselor self-care, and provides suggestions on making self-care a priority.

NACOA

What’s Missing in the Surgeon General’s Report on Alcohol, Drugs, and Health?

10

By Robert Denniston

Cultural Trends

32 Addiction Counselors in the Compassion Fatigue Cycle

By Kathie T. Erwin, EdD, LMHC, NCC, NCGC Describes compassion fatigue, lists early warning signs, and provides risk factors for counselors.

Carfentanil: The Military’s Secret Chemical Agent

By Maxim W. Furek, MA, CADC, ICADC

Opinion

Ethics: Be Visionary, Visible, and Vocal

From Leo’s Desk

What is God? Part I

17

By Rev. Leo Booth

Wellness

A Phenomenological Study of Stress and Burnout Experienced

by Licensed Alcohol and Drug Counselors

15

By Louise A. Stanger, EdD, LCSW, CDWF, CIP, & Roger Porter, BA

Wellness Pointers for Recovery from Addictive Disorders

36

12

19

By John Newport, PhD

The Integrative Piece If it’s to be

21

By Sheri Laine, LAc, Dipl. Ac

By Derrick Crim, EdD, LADC, CPPR, MAPM Discusses a study on causes of burnout and personal and occupational stress in licensed alcohol and drug counselors, provides in-depth information on those causes, and presents suggestions for stress reduction. www.counselormagazine.com

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CONTENTS Topics in Behavioral Health Care

Well-Being and Healthy Behaviors for Providers

22

By Dennis C. Daley, PhD

Counselor Concerns

About the Term “Substance Dependence”

24

By Gerald Shulman, MA, MAC, FACATA

Ask the LifeQuake Doctor

26

By Toni Galardi, PhD

Inside Books

The Trauma Heart: Stories of Survival, Hope, and Healing

64

42 Championing Pharmaceuticals for Opiate Addiction: An Interview with Behshad Sheldon

By Andrea G. Barthwell, MD, DFASAM, & Megan Crants, BA Describes Behshad Sheldon’s background, her impact on the pharmaceutical world, and her role in Female Opioid-Addiction Research and Clinical Experts (FORCE).

From the Journal of Substance Abuse Treatment

By Judy Crane Reviewed by Leah Honarbakhsh

Transitioning from Detoxification to Addiction Treatment: Facilitators and Barriers

Also in this issue: Ad Index CE Quiz

46

59 62

By Christine Timko, PhD, & Michael A. Cucciare, PhD Presents the findings of a study on patient-, provider-, and system-level barriers and facilitators for patients transitioning from detoxification to addiction treatment, and discusses implications.

53 Provider Self-Care through Conscious, Balanced Relationships

By Elisabeth R. Crim, PhD Discusses the importance of relationships in counselor self-care, describes somatic transference, and examines early childhood factors that contribute to counselor burnout.

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Counselor | June 2017

LETTER FROM THE EDITOR

Compassion

C

ompassion, according to Dictionary. com, is “a feeling of distress and pity for the suffering or misfortune of another, often including the desire to alleviate it” (“Compassion,” 2017).

This issue of Counselor focuses on selfcare issues—which include compassion fatigue (also known as secondary traumatic stress), burnout, and stress—as related to frontline practitioners in the addiction and mental health fields.

In her article “Addiction Counselors in the Compassion Fatigue Cycle” (page 32), Kathie T. Erwin, EdD, points out that compassion fatigue is far more than “burnout,” a somewhat glorified term of yesteryear: Compassion fatigue is not confined to counselors who work on the front lines of a disaster or in other settings with traumatized clients. The nature of vicarious or secondary traumatization is not linked to a place, a situation or any direct proximity to the trauma incident. It can catch counselors by surprise to be catapulted into an almost imperceptible moment of transference when clients’ traumatic experiences cross over into the psyche of counselors.

So what exactly is compassion fatigue?

The American Institute of Stress (AIS) defines compassion fatigue as “the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events” (2017).

Further, AIS states that compassion fatigue “can occur due to exposure on one case or can be due to a ‘cumulative’ level of trauma” (2017).

The Compassion Fatigue Awareness Project (CFAP) explains, Studies confirm that caregivers play host to a high level of compassion fatigue. Day in, day out, workers struggle to function in care-giving environments that constantly present heart wrenching, emotional challenges.

Affecting positive change in society, a mission so vital to those passionate about caring for others, is perceived as elusive, if not impossible. This painful reality, coupled with first-hand knowledge of society’s flagrant

disregard for the safety and well-being of the feeble and frail, takes its toll on everyone from full-time employees to part-time volunteers. Eventually, negative attitudes prevail.

Compassion fatigue symptoms are normal displays of chronic stress resulting from the care giving work we choose to do. . . . a strong identification with helpless, suffering or traumatized people or animals is possibly the motive. It is common for such people to hail from a tradition of . . . otherdirected care giving. Simply put, these are people who were taught at an early age to care for the needs of others before caring for their own needs.

Authentic, ongoing self-care practices are absent from their lives (2017).

Clearly, addiction and mental health professionals are susceptible to suffer from compassion fatigue, particularly when they treat those who have suffered extensive trauma.

Charles R. Figley, editor of Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized, states, There is a cost to caring. Professionals who listen to clients’ stories of fear, pain, and suffering may feel similar fear, pain, and suffering because they care. Sometimes we feel we are losing our sense of self to the clients we serve. . . . Those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion stress (1995).

In another article in this issue (page 36), Derrick Crim, EdD, concludes from his study that organizations share responsibility for counselor stress and burnout.

His findings emphasized how the need for competence and an inability to control demanding roles and expectations caused stress among licensed alcohol and drug counselors. The study found that workloads, family-work conflict, and workplace racism affected counselors’ confidence. Further, it is suggested that positive values and role models within the organization may help counselors

become more proficient and gain new skills and competencies.

In their article “Congruence as SelfCare: Practicing What We Preach” (page 27), Ryan Thomas Neace, MA, and Jeffrey A. Kottler, PhD, point out that, ultimately, self-care is about an attitude, a cherished belief that we can only do our best work taking care of others when we also take care of ourselves.

Elisabeth R. Crim, PhD, sums it up best in her article, “Providing Self-Care through Conscious, Balanced Relationships” (page 53): To be a psychotherapist, counselor, healer, and helper is a rich and wondrous calling. We can continue to enjoy our journey as healers and live vibrant lives throughout our many roles and relationships if we can heal relationally, become more conscious, balance our attunement to others with attunement to ourselves, and learn to live life in a manner that is relationally genuine, fulfilled, vibrant, and free.

References American Institute of Stress (AIS). Definitions. Retrieved from https://www.stress.org/military/for-practitionersleaders/compassion-fatigue/ “Compassion.” (2017). Retrieved from http://www.dictionary.com/browse/compassion?s=t Compassion Fatigue Awareness Project (CFAP). (2017).

What is compassion fatigue? Retrieved from http://www. compassionfatigue.org/pages/compassionfatigue.html Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Routledge.

Gary Seidler

Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication

www.counselormagazine.com

7

CCAPP

CCAPP Election Sets the Stage for a Productive 2017 Sherry Daley

W

ith multiple nominations and tight races for California Consortium of Addiction Programs and Professionals (CCAPP) board of directors positions, CCAPP started 2017 with a full board of motivated professionals. CCAPP conducted elections for board members and district representatives, and made appointments for vacant positions, filling all slots on its board of directors. The newly elected and appointed members will help to shape the CCAPP organization and thereby the profession and industry in California.

“I was extremely pleased with the number of great nominations we had this year,” said CCAPP CEO Pete Nielsen. “This level of interest is indicative of how dedicated and passionate our members are about CCAPP and its role in leading the state and the nation,” he continued.

Topping the CCAPP ticket was Alan Johnson, who now serves as president. Mr. Johnson came with many years of experience in the profession of substance use disorder (SUD) counseling. He managed state contracts at HealthRIGHT 360 and provided aftercare for the criminal justice population.

Johnson has been an active leader in the alcohol and other drug profession, where he helped to develop and refine certification and educational components for CCAPP to ensure that highly competent professionals are performing substance abuse treatment in the state. He took the lead as CCAPP tackled 8

Counselor | June 2017

numerous high profile issues, including the implementation of Proposition 64, the state’s recreational marijuana statute.

“I am optimistic about 2017 and can’t wait to get the ball rolling,” said Johnson. “I predict that we will have a historic year in which the nation will be taking notes,” he added.

Johnson took the helm as the organization sought to shepherd the state toward an “on-demand” addiction treatment system. Johnson and fellow executive committee members drafted a four-bill legislative package entitled the “California Comprehensive Addiction Reform Act,” introduced in January 2017.

“It is challenging work to put all the pieces together, but I am happy to say that we all share a vision where Californians no longer die while waiting for treatment. This inspires us to think beyond what was once impossible to a new future in which addiction treatment is accessible to anyone who asks for it,” said Johnson.

Johnson, an original architect of CCAPP’s nine-point plan and strategic plan, will continue to implement ambitious strategies for addressing the many concerns that are important to programs and providers. Top priorities this year include: n Leading and collaborating on insurance provider benefit assignment laws n Improving Medi-Cal reimbursement under the state’s organized delivery system n Improving professional recognition via licensure and workforce development for counselors n Influencing legislative policy related to the prevention, education, and treatment of marijuana use

CCAPP n Introducing legislation to support certification of small outpatient programs (SOPs) n Solving provider enrollment issues n Professionalizing and leading the peer support movement n Collaborating with the Sober Living Network to pass a bill requiring registration/certification of addiction recovery residences n Actively participating in shaping the six regulatory reform packages the Department of Health Care Services has introduced in 2016 Johnson joined Past President and newly elected Vice President Lori Newman on the board. During Ms. Newman’s time as CCAPP president she oversaw the development of CCAPP’s legislative program, including the introduction CCAPP’s 2016 counselor licensure bill, Senate Bill 1101. She also led the organization through the finalization of the consolidation of the past organizations. CCAPP expressed appreciation of Ms. Newman’s willingness to serve as vice president of the CCAPP board and to lend her more than twenty years of experience as a certified counselor, program manager, executive director, and an oral examiner for individuals taking the TAP 21 examination at its annual meeting in October.

“Lori has been a wonderful partner in this organization, and instrumental in moving CCAPP to the forefront of the profession,” said Nielsen. “I look forward to continuing to work with her on future projects,” he stated.

CCAPP welcomed Jennifer Carvalho as its treasurer. Ms. Carvalho is the CEO of Skyway House, and is very involved in her community of Oroville, having served on the Oroville Area Chamber of Commerce board of directors, the Oroville Recreation Area Advisory committee, and the Oroville Economic Development Corporation board of directors. Ms. Carvalho has also served as a member of the Butte County Behavioral Health Mental Health Services Act advisory committee.

Warren Daniels returned to the executive committee as the secretary for the CCAPP board. His many past achievements include serving as president of

CCAPP and CAADAC, and serving as secretary for IC&RC. He has led the organization’s legislative program for its first two years of existence and was a driving force in building the coalition that pushed for dedicating marijuana tax revenue for addiction treatment.

The 2017 board includes members who are new to the board, as well as some individuals who have been a part of the CCAPP board from the beginning of the organization and who were instrumental in helping to shape CCAPP into the organization that it has now become.

“Their extraordinary representation of the profession in providing the highest credentialing standards; in ensuring representation in the legislature for both programs and professionals; and in fostering innovative ideas to help move the profession forward is unparalleled,” said Nielsen.

Newly elected district board members included Michael Barnes from district four and Shellie Bowman from district one. Newly elected statewide members included Evan Amarni and Cheryl Houk, who serve as program members.

Stephanie Sobka was also reelected to the board as a program member. New CCAPP credentialing board members John Bokanovich and Tabatha Hernandez replaced retiring members Christie Holmes and Glendora Kirkpatrick. Daniel Chagolla and Eric Smith returned, and

Willie Cosgrave was welcomed as new board members to the Education Institute board. The Education Institute board welcomed Rose Wheeler as its chair. Rick Alsop, Joe Aaragon, Jerry Synold, Christie Holmes, and Glendora Kirkpatrick were thanked for their dedication and years of service at the annual meeting in October.

“We owe the early board members of CCAPP a tremendous debt of gratitude,” said Nielsen. “This group of individuals has left a permanent mark on the future of the profession. Their input has been beyond valuable. Their contributions have improved the quality of treatment in California for generations to come,” he concluded.

CCAPP members were excited to be involved with the election process. Every year valid CCAPP voting members are given the opportunity to give input by nominating members to the CCAPP board.

“It is exciting to see CCAPP members come together and participate in this way in the CCAPP organization. As a membership-driven organization, the members are the ones that push CCAPP forward,” said Nielsen. c About the Author Sherry Daley is in charge of external affairs for counselors and marketing for the California Consortium of Addiction Programs and Professionals (CCAPP). She is also a freelance writer from the Sacramento area.

CCAPP is unifying the addiction field 2400 Marconi Avenue P.O. Box 214127 Sacramento, CA 95821

Education “CCAPP is educating addiction counselors by supplying quality options for schools and providers”

Membership “CCAPP is supporting and advocating for programs and professionals in the addiction field.”

Recovery Residences “CCAPP recognizes quality sober living by registering recovery residences.”

T (916) 338-9460 F (916) 338-9468 www.ccapp.us

Credentialing “CCAPP is the largest, most respected SUD counselor and prevention specialist certifying organization in California.”

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9

NACOA

What’s Missing in the Surgeon General’s Report on Alcohol, Drugs, and Health?

Robert Denniston

F

rom time to time the US Surgeon General issues reports that synthesize health research and public policy in a way intended to reach the public and generate support for needed improvements. Having been involved in the development of two such reports—including the paradigm-shifting “Surgeon General’s Workshop on Drunk Driving” several decades ago—and as a member of the NACoA board of directors, I paid close attention to the latest report, issued last fall, titled “Facing Addiction in America: the Surgeon General’s Report on Alcohol, Drugs, and Health.”

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Counselor | June 2017

First of all, this is a splendid report, chock-full of statistics, illustrations, definitions, program profiles, research and practice recommendations, and a perspective that I believe significantly advances our understanding and forthrightly identifies our challenges, yet gives us reason for hope and optimism. In its more than four hundred pages it covers research, prevention, intervention, recovery, and a “vision for the future” that I hope we can all subscribe to. I recommend it highly.

But something important is missing. In its comprehensive coverage of the issue, the report has neglected to include children of addiction. There is no mention of these innocent victims, either in the section on impact of alcohol and drug problems, in the prevention or intervention sections, in statistics, in the report’s compilation of proven and promising programs designed to address the problem or in recommendations for further research and practice.

For example, in the section “Costs and Impact of Substance Use and Misuse,” the consequences on the individual user, on pregnancy, and on the risks of communicable disease are well documented, followed by specific subsections on DWI, overdosing, intimate partner violence, sexual assault, and rape (US Department of Health and Human Services, 2016).

Yet not a word on the one in four children exposed to alcohol addiction in the family, which can create health, social, legal, and economic problems over a lifetime, as well as the more acute problems of child abuse and neglect.

More than twenty-eight million Americans are children of alcoholics; nearly eleven million are under the age of eighteen. Drinking is the primary factor in family conflict and disruption, and the home environment of children of alcoholics is typically characterized by a lack of parenting; poor home management; lack of family communication skills; emotional or physical violence; and increased family stress including work problems, illness, marital strain, and financial problems.

Why is this important? Because unless we break the cycle of addiction—and the many problems associated with substance use disorders—these children will be at high risk of drug and alcohol disorders themselves, as well as many other health issues, from depression to heart disease to cancer. As the body of research known as Adverse Childhood Experiences (ACE) documents, the risks to the array of problems of growing up in a household afflicted by parental substance dependence and addiction is substantial and is transmitted intergenerationally.

Understandably, the current focus on the opioid epidemic—with some seventy-eight people dying each day of overdose and the need to get more people into treatment, with

NACOA only ten percent of those in need of treatment actually receiving it—absorbs our attention and our all-too-meager resources. However, children in the midst of parental dependence and addiction are in harm’s way, and we as a society have for far too long averted our eyes.

While we support expansion of treatment as a means to recovery for individuals as well as reduced risks for children in their care, we must also support children of addiction to help them cope with their conditions and improve the means for recovery of the whole family.

Yet in the Surgeon General’s report, there are no research, practice or policy recommendations related to children of addiction. In the concluding chapter, “Vision for the Future: A Public Health Approach,” there is a section entitled “Specific Suggestions for Key Stakeholders” including individuals and families, health care professionals, professional associations, and health care systems, but readers will find nary a word about children of addiction (US Department of Health and Human Services, 2016).

Early during the report drafting stage, Sis Wenger, the president and CEO of NACoA, and I, along with other constituent groups, met with the Surgeon General, Dr. Vivek H. Murthy, and were impressed with his attentiveness and sincerity as we all made our points about what the report should include. Some of our colleagues pushed hard for inclusion of sometimes controversial yet well-researched interventions such as increased alcohol taxes and regulation of alcohol outlet density, and those measures were thoughtfully included and well documented. That’s brave of Dr. Murthy. Yet looking out for the welfare of young victims of addiction did not make the cut. That’s regrettable.

But does it really matter that children of addiction are left out of this report?

Absolutely, for several reasons. First, reports from the Surgeon General— the chief health official of the federal government—often set priorities for research, funding, and public policy.

To be left out has great potential for harm, as such reports confer status on an issue and often help set an agenda for research and public policy.

But there is another reason for concern; this report was developed with the direct involvement and support of NIAAA, NIDA, SAMHSA, professional societies, addiction researchers, and policy experts across the country. That this group of experts, steeped in research and policies, could miss or plainly avoid the consequences of parental alcohol and drug misuse and addiction on their children is quite troubling.

Compounding the problem is that the Affordable Care Act, including Medicaid expansion, which has provided increased support for treatment, might be replaced by the new administration’s American Health Care Act, so it is likely that there will be a higher priority placed on treatment availability and even less attention to other funding needs.

But we have some good news: we have proven interventions. For example, Celebrating Families! is an evidencebased, skills-building program designed for families who have been affected by addiction. This program uses an intergenerational approach, engaging parents with substance use disorders, their children through age seventeen, and the children’s caregivers. The program’s focus is to prevent children’s future addiction while also improving their mental and physical health. The Celebrating Families! curriculum is coordinated by NACoA and has been implemented in over one hundred jurisdictions.

Further, SAMHSA is reissuing its proven effective Children’s Program Kit, introduced in this column in the February issue of Counselor, and is making it available to education, prevention, and treatment programs as a tool for providing educational support groups for children of addiction.

In his preface, Surgeon General Murthy observes that how we respond to this crisis is a moral test for America.

He asks, “Are we as a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings to care for one another?”

(US Department of Health and Human Services, 2016). Tough questions, and the answer must be yes, but the true test will be whether we will protect the youngest and most vulnerable among us. Who will march for the children who are devastated by their parents’ addiction and do not have the power to march on their own? c About the Author Robert Denniston is the vice chair of NACoA’s board of directors.

References US Department of Health and Human Services. (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. Retrieved from https://addiction.surgeongeneral.gov/surgeongenerals-report.pdf

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CULTURAL TRENDS

Carfentanil: The Military’s Secret Chemical Agent Maxim W. Furek, MA, CADC, ICADC

C

arfentanil, a dangerous adulterant covertly added to batches of illegal street heroin, was examined in the previous issue of Counselor (Furek, 2017).

Carfentanil “is a synthetic opioid that is ten thousand times stronger than morphine and one hundred times more potent than fentanyl, another deadly synthetic opioid” (MacQuarrie, 2016). This drug is wreaking havoc with addiction professionals and law enforcement unprepared for the drug’s extreme potency and overdose potential.

But carfentanil is not new. Nearly two decades ago the drug was at the center of an international controversy, steeped in mystery and intrigue.

On October 23, 2002, “a group of heavily armed Muslim extremists from the Russian province of Chechnya burst into a Moscow theatre during a performance and took more than eight hundred members of the cast and audience hostage,” according to an article from 60 Minutes (Leung, 2003). The attackers claimed allegiance to the Islamic militant separatist movement in Chechnya and demanded the withdrawal of Russian forces from Chechnya and an end to the Second Chechen War (“Moscow theater,” 2015).

Elite Russian special forces, the Spetsnaz, initiated a rescue attempt (“Moscow theater,” 2015). They tunneled under the theater and began to pump a secret gas aerosol into the auditorium, which, unfortunately—along with inadequate medical treatment—killed 120 hostages and all forty of the terrorists.

Secret Chemical Agent

That event triggered an ensuing mystery. The Spetsnaz and the Russian government refused to identify the secret chemical agent, which provoked international speculation (MacKenzie, 2002). Media journalists questioned if the substance was a wartime nerve agent, banned by international law: “In the records of the official investigation, the agent was referred to as a ‘gaseous substance.’ In other cases it was referred to as an ‘unidentified chemical substance’” (“Moscow theater,” 2015).

The identity of the drug, combining military secrecy, confusion, and conjecture, remained unknown.

Several hostages died on the way to hospital or after their arrival, and “physicians in Moscow condemned the refusal to disclose the identity of the gas that prevented them from saving lives” (“Moscow theater,” 2015). Additionally, later reports “said the drug naloxone was successfully used to save some hostages,” suggesting that the gas was an opiate-based compound (“Moscow theater,” 2015).

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Law enforcement specialist William Harry Challans offered his own theory: “The secret weapon is a gas, a sleep agent, and not a nerve gas as initially reported by the media and assumed by the world. It is a derivative of fentanyl, an anesthetic gas. A double-edged sword, it enables an impossible rescue to succeed, but is responsible for the vast amount of innocent fatalities” (2006).

The “unidentified chemical substance” was discovered after the British analysis of clothing and urine from the siege casualties detected the presence of carfentanil and remifentanil on the clothing of rescued British hostages (Riches, Read, Black, Cooper, & Timperley, 2012).

Remifentanil is a potent, short-acting synthetic opioid analgesic drug given to patients during surgery to relieve pain and as an adjunct to an anesthetic. While opiates function similarly with respect to analgesia, the pharmacokinetics of remifentanil allows for quicker postoperative recovery (Riches et al., 2012).

The study published in the Journal of Analytical Toxicology concluded, This study provides evidence from liquid chromatography– tandem mass spectrometry analysis of extracts of clothing from two British survivors, and urine from a third survivor, that the aerosol comprised a mixture of two anesthetics— carfentanil and remifentanil—whose relative proportions this study was unable to identify. Carfentanil and remifentanil were found on a shirt sample and a metabolite called norcarfentanil was found in a urine sample. This metabolite probably originated from carfentanil (Riches et al., 2012).

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CULTURAL TRENDS “Less Lethal Technologies”

The deadly application of carfentanil and remifentanil was a blatant violation of the 1993 Chemical Weapons Convention (CWC), which “bans the use of chemical weapons in war and prohibits all development, production, acquisition, stockpiling or transfer of such weapons” (Schneider, 2013). The CWC entered into effect on April 29, 1997.

The Russian Federation, as a member-state of the CWC, undertook “never under any circumstances” to carry out any activities prohibited to memberstates of the Convention “to develop, produce, otherwise acquire, stockpile or retain chemical weapons, or transfer, directly or indirectly, chemical weapons to anyone” (OPCW, 2005). The Convention obliges the states to fulfill the conditions of toxic chemicals’ use that allow to exclude or considerably reduce the degree of injury and gravity of consequences. However, during the special operation in Dubrovka this provision was disregarded (i.e., neither the type, nor the quantity of the chemical agent helped to attain the set purpose to neutralize the terrorists so as to rescue the hostages). The Convention allows the use of some chemical agents like tear gas for “law enforcement including domestic riot control,” but requires that “riot control agents” have effects that “disappear within a short time following termination of exposure” (OPCW, 2005).

Dubrovka represents a small part of a larger problem. Covert operations shrouded in secrecy and double-speak are being conducted by global agencies.

As a means of circumventing international weapons treaties, numerous countries are clandestinely developing “nonlethal weapons” as articulated through a bizarre and ambiguous terminology.

These operations have been going on for years. According to an article in the Bulletin of the Atomic Scientists, In 1990, the US Army rebranded their Incapacitating Chemical Program, which focused on the weaponization of fentanyl-related opioid chemicals, renaming it the Riot Control Program.

A plan for a new chemical grenade emerged from this work. They called it the “advanced riot control agent 14

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device,” but the fentanyl payload remained the same (Davison, 2009).

After a meeting in April 2007, convened under the title “Community Acceptance Panel: Riot Control Agents,” representatives directed by the National Institute of Justice (NIJ) came together “to consider the issue of ‘nonlethal’ weapons development” (Davison, 2009). Consequently, “Penn State University won a $250,000 contract to conduct further research into new incapacitating chemical weapons . . . for police use in the United States and ‘operationalize’ these weapons” (Davison, 2009).

In the Bulletin of the Atomic Scientists, author Neil Davison observed, To market these weapons as somehow separate from the chemical and biological weapons that are banned by international treaties, they are being given new, confusing names. In this intentional narrative, chemical weapons become “calmatives” or “advanced riot control agents,” promoted as part of a group of so-called “nonlethal” weapons.

Worse yet, the semantic confusions go farther. These weapons aren’t really weapons at all but “capabilities,” “technologies,” and “techniques.”

Similarly, other weapons under this umbrella lose their descriptive edge: laser weapons become “optical distractors,” acoustic weapons become “acoustic hailing devices,” and electrical weapons become “electromuscular incapacitation devices” (2009).

The justification for these new “lesslethal technologies” was explained in a memo from the National Institute of Justice: Police officers sometimes need to control violent, combative people. Their actions under such circumstances are governed by use-of-force protocols.

Less-lethal technologies give police an alternative to using other physical force options that potentially are more dangerous to officers and suspects. The technologies currently in use include conducted-energy devices (such as Tasers), beanbag rounds, pepper spray and stun grenades (2011).

Fentanil-carfentanil, disguised as “nonlethal” tear gas, and used for riot

control, is among these aforementioned “technologies.”

Carfentanil wields a more sinister potential than was previously known.

Recognized as a “nonlethal technology” with law enforcement, it has also been unleashed as a wartime weapon of mass destruction. Unless eradicated, this “secret chemical agent” imported via Mexico and China will continue to flood the illegal drug market and kill countless individuals. c About the Author 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 Amazon.com.

References Challans, W. H. (2006). Moscow theater hostage crisis. Retrieved from http://www.hendonpub.com/ resources/article_archive/results/details?id=3878 Davison, N. (2009). Marketing new chemical weapons. Retrieved from http://thebulletin.org/ marketing-new-chemical-weapons Furek, M. W. (2017). Carfentanil’s impending tsunami of death. Counselor, 18(2), 14–5, 17.

Leung, R. (2003). Terror in Moscow: Video cameras recorded Chechen terrorist attack. Retrieved from http://www.cbsnews.com/news/terror-in-moscow/ MacKenzie, D. (2002). Mystery of Russian gas deepens. New Scientist. Retrieved from https://www. newscientist.com/article/dn2979-mystery-ofrussian-gas-deepens MacQuarrie, B. (2016). Opioid epidemic’s newest killer is ten thousand times stronger than morphine. Boston Globe. Retrieved from https://www. bostonglobe.com/metro/2016/10/16/region-bracesfor-arrival-new-more-powerful-synthetic-opioid/ uLdoivGZdopm468poRzU3J/story.html “Moscow theater hostage crisis.” (2015). Retrieved from http://crimescenedb.com/ moscow-theater-hostage-crisis/ National Institute of Justice (NIJ). (2011). Less lethal technologies. Retrieved from https://nij.gov/topics/ technology/less-lethal/pages/welcome.aspx Organisation for the Prohibition of Chemical Weapons (OPCW). (2005). Convention on the prohibition of the development, production, stockpiling, and use of chemical weapons and on their destruction. Retrieved from https://www.opcw.org/fileadmin/OPCW/CWC/CWC_en.pdf Riches, J. R., Read, R. W., Black, R. M., Cooper, N. J., & Timperley, C. M. (2012). Analysis of clothing and urine from Moscow theatre siege casualties reveals carfentanil and remifentanil use. Journal of Analytical Toxicology, 36(9), 647–56.

Schneider, B. R. (2013). Chemical weapons convention (CWC). Retrieved from https://www.britannica. com/event/Chemical-Weapons-Convention

OPINION

Ethics: Be Visionary, Visible, and Vocal Louise A. Stanger, EdD, LCSW, CDWF, CIP, & Roger Porter, BA

P

lato, perhaps the most famous of ancient philosophers, laid the groundwork for our modern social mores. He believed that ethics were the pillars of good human behavior. Emphasizing thoughtful consideration and wise deliberation in all matters, he wrote that “human well-being is the highest aim of ethical thought and action” (Frede, 2013). The world’s ancient philosophers posited that if life is a series of choices, ethics are the oil that greases our gears and keeps us moving forward with integrity, dignity, and concern. As such, ethical standards have made a home in our daily lives.

That being stated, ethics did not always have a stronghold in the behavioral health care field. In 1935, the American Public Health Association raised strong concerns for the mistreatment of African Americans in Nazi Germany (Birn & Molina, 2005).

The atrocities committed against African Americans during WWII and the subsequent Tuskegee Syphilis Experiment—in which the association conducted clinical studies of untreated syphilis in black men under the guise of “free medical care”— continued past the Civil Rights Movement. It was not until 1966 that Public Health Services established ethical regulations, and in 1979 the Belmont Report was published, summarizing ethical principles and guidelines for research involving human subjects (OHRP, 2016). From there, the issue of bioethics emerged in the 1970s and 1980s, ushering in a new wave of ethical considerations, backed by the public’s weary doubts over public institutions in the wake of the Watergate scandal and unease over the Vietnam War. Finally, in 1996 the code of ethics for public organizations was revised. In essence, as professions grew in behavioral health care, codes of ethics for professionals developed.

Ethics may be defined as the shared written beliefs—individual at the micro level, group at the mezzo level, and organization/societal at the macro level—a group or individual maintains about what constitutes correct and proper behavior.

Think of ethics as standards of conduct that guide the choices behavioral health care experts make moment to moment as they organize and provide care for clients. Standards of care can be seen as licensing bodies that set standards of organizational practices (i.e., JACHO, CARF, and others). Ethics can sometimes blur lines and come into conflict with laws.

The dubious line between ethics and laws often spur public debate, which leads to reshaping our laws. The Civil Rights Movement of the 1960s is a notable example of how ethical concerns spearheaded laws to be changed. www.counselormagazine.com

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OPINION In the caregiving environment, ethical issues take many forms. Greed, malpractice, human error, and misreporting are common. Oftentimes there is not malicious intent when ethical red flags are raised.

For instance, unpredictable or unforeseen events can cause the kind of human error most would commit in similar situations.

As such, it is important for health care institutions to adopt guidelines, protocols of behavior (i.e., a code of ethics), and a mission statement of the organization’s values. A code of ethics is not only useful at the macro organizational level, but also helps individuals as part of a group or organization at the micro level because they can follow standards on a daily basis set forth by the organization’s ethical code.

In trying to tackle this monumental issue, I engaged in an ongoing qualitative research study to shed light on the most important ethical concerns facing our industry. The research took on the form of interviewing movers and shakers in behavioral health care—from CEOs, marketers, clinicians, admissions officers, and interventionists to line workers and web designers. I asked the participants to list their top three ethical concerns. Their responses varied, but some common themes emerged. David Skonezny, CEO of Simple Recovery; Denise Klein, CEO of Milestones Ranch; David Lisconbee, CEO of Twin Town Treatment Centers; Marsha Stone, CEO of BRC; and Paul Alexander, CEO of Northbound, all reported a concern for lack of training and proper credentials for staff, missing accreditation for treatment centers, and concerns of misrepresentation. Scams were also mentioned— whether online, through the insurance companies or any other misrepresentations that cast a negative spell on the behavioral health care industry as a whole.

In total I interviewed over one hundred people and have since heard from seventy-six others. I have also presented on the topic at three major conferences and have blogged about this monumental issue.

Despite an effort at the organizational and individual level to adhere to ethical standards, human flaws can lead to breaking these standards and damaging the treatment center or organization.

There has been much discussion and public outcry that the addiction field has become big business for Wall Street, curious investors, and opportunistic centers 16

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full of empty promises (Kodjak, 2016). Like salmon running downstream, ethical dilemmas are rampant. It feels like every day there is a new article calling out a center.

In recent years, budget restraints and a stubborn economy have led some treatment centers and other facilities to adopt the “heads in beds” approach, whereby leaders of these organizations adopt misleading websites and advertisements, overpromising and underdelivering on services, and fake money-back-guarantees to fill their centers. Moreover, some organizations pressure staff to fill quotas and meet deadlines all at the expense of quality of care.

Despite an effort at the organizational and individual level to adhere to ethical standards, human flaws can lead to breaking these standards and damaging the treatment center or organization.

And with the move to an online presence, misrepresentations on the Internet such as high-definition “doctored” photos, fake positive reviews, and misrepresented facility locations have tricked unsuspecting clients seeking help. When I interviewed Wes Jones, CEO of Incredible Marketing, a digital marketing agency for medical professionals, he articulated how easily the web can be manipulated with false impressions of treatment centers and the services and amenities they offer (L. A. Stanger, personal communication, July 18, 2016). In addition to fraudulent websites, 1-800 help lines have also usurped ethical providers, funneling good providers’ resources to phantom call centers that have nothing to do with them. I recently fell prey to this type of unethical practice, and Five Sisters Ranch in Petaluma did too, amongst similar reports throughout the behavioral health care field.

Kickbacks and referrals are major issues in the overly complicated health care system in this country. A referral occurs when clinicians or professionals refer clients to a behavioral health care facility in which clinicians have a financial

interest. Likewise, kickbacks can occur when someone offers money for patients or when insurance is used in a way that pays for both outpatient and sober living.

I myself have been twice offered, at conferences, substantial funds (promises of $300,000 per year) for referring patients to a specific lab. Also, there are reports of overbilling of lab charges. For example, I recently heard from one family which verified they were charged by the provider $13,500 in one month for three lab tests for alcohol—a typical sobriety test runs at $150.00 per test. And then there are the insurance companies that set fees which can dictate terms of care. In turn, some providers may misrepresent their claims, making it all the more challenging for the providers who are ethical.

As a result of kickbacks and other unethical practices, Congress passed the Stark Law, a series of provisions that ban referrals and kickbacks in the health care field (CMS, 2015). Furthermore, this law has inspired many organizations to examine and enhance their code of ethics to deter individuals and organizations from slipping into these types of ethical dilemmas. When communities come together to bolster our collective social conscience, it challenges everyone to uphold the values we hold dear in our homes and workplaces.

With ethical uncertainties posing a threat to behavioral health, let’s take a moment to investigate an ethical model that is easy to teach and implement and can help shape the way we work in the behavioral health community. Elaine Congress, a professor and social worker, developed the Congress model, which uses an acronym to employ a collection of guideposts for groups and individuals in the behavioral health field to consider when faced with ethical dilemmas: n E - Examine relevant personal, societal, agency, client, and professional values n T - Think about what ethical standard of the National Association of Social Workers (NASW) code of ethics applies, as well as relevant laws and case decisions n H - Hypothesize about possible consequences of different decisions Continued on page 18

FROM LEO’S DESK

What is God? Part I Rev. Leo Booth

I

realize that many people reading this article may be surprised that I have titled it “What is God?” rather than “Who is God?” Well, I have my reasons.

In June 2016 I wrote an article for Counselor titled “A Spiritual Revolution,” and that has been followed by subsequent articles titled “Prayer: What is it?” and “God’s Grace: What is it?” In light of these published articles, I think it is appropriate to ask the $64,000 question: What is God? I have devoted most of my years in recovery to the question, “What is spirituality?” and my views on this exciting topic have changed over the years. Also, my views concerning my relationship and understanding of God have also changed. Who knows what I will be writing in the coming years!

If we look at some of the definitions that have been offered over the years we will find the following: n The Free Dictionary suggests that God is “A being conceived as the perfect, omnipotent, omniscient originator and ruler of the universe” (2017). The Merriam-Webster dictionary says, “The Being perfect in power, wisdom, and goodness who is worshipped as creator and ruler of the universe” (2017).

So, I ask myself, where did they get these theological definitions from? Well, they got them from what traditional religions have said and believed. n Judaism teaches two aspects of God: the unknowable and the revealed God who created everything and interacts with creation. n Christianity agrees with Judaism, but goes on to teach God as the Trinity: Father (Creator), Son (Redeemer), and the Holy Spirit (Sustainer).

n Islam suggests that God is the one and only: He begetteth not, nor is He begotten. n Buddhism is more fluid and suggests that the spiritual life seeks to alleviate any distress. It neither denies nor accepts a creator and goes on to further suggest that questions on the origin of the earth are worthless! n Hinduism is extremely complex and comprehensive, incorporating all the above theories, but is dependent upon the geographical tradition found in the many parts of India.

These are some of the ingredients that make up the “God Cake,” and I can certainly see why people in recovery, depending upon their religious traditions, if any, often think of God as confusing, baffling, and most difficult to understand!

But let us remember there have always been, in history and today, thinkers who dared to question, disagree or object to the aforementioned teachings. They were called “heretics.” For me, the title “heretic” does not mean that they are wrong—on the contrary, they simply dared to think differently. In my book, The Happy Heretic, I quote Pelagius, who said, “That we are able to do good is of God, but that we actually do it is of ourselves. That we are able to make a good use of speech comes from God; but that we do actually make this good use of speech proceeds from ourselves” (2012, p. 51).

Description, Not a Name

It took me a long time to realize that “God” is not a name like “Leo,” “Ann” or “George.” Rather, it is a term and a description that seeks to explain the unexplainable.

Religious or spiritual people seek to know the unknowable. The belief has slowly taken root that in seeking to understand God they begin to understand themselves.

But does it need to be so complicated? And does what is being said concerning God make sense to what we see and how we live our lives? I think not.

Rumi, a Muslim thinker, makes it so much simpler when he says, “God is in me and I am in God. I am in you and you are in me. We all reflect God” (Booth, 2012, p. 29).

The Baggage

With God, for many people, comes the baggage of Hell, Heaven, sin, fear, right, wrong, immortality, devils, angels, grace, prayer, heretic, saint . . . the list could go www.counselormagazine.com

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FROM LEO’S DESK on and on and has tragically damaged so many people.

In my previous articles, I touched on this baggage and offered a solution that makes sense to me.

Concerning Prayer

When I pray, the essential ingredient is that I hear my prayers. For example, if I am praying for a job, I need to search out the necessary qualifications required and fill out the application form!

It took me a long time to realize that “God” is not a name like “Leo,” “Ann” or “George.” Rather it is a term and a description that seeks to explain the unexplainable.

Concerning Grace

I do not believe that grace is something that mysteriously falls upon us, I believe that it 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.

Concerning God

The divine is in creation, beyond creation, in you, and most definitely in me.

This will require my imagination, that poetic aspect of our mind that enables the created to create. God’s kingdom is within. c About the Author 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. The Free Dictionary. (2017). God. Retrieved from http:// www.thefreedictionary.com/god Merriam-Webster. (2017). God. Retrieved from https:// www.merriam-webster.com/dictionary/god

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Opinion

Continued from page 16

n I - Identify who will benefit and who will be harmed in view of social work’s commitment to the most vulnerable n C - Consult with supervisors and colleagues about the most ethical choice As Congress points out in her paper “What Social Workers Should Know about Ethics,” treatment centers, facilities, and others in the field can use the model to turn their values as an organization into a code of ethics for staff and clients to follow. “A social work value,” writes Congress, “has little value unless it can be translated into ethical practice” (2000). This is key: working an organization’s ethics into its culture and daily duties and responsibilities.

Although ethical challenges are the glue that pieces society together, there are opportunities for professionals in behavioral health to advance a code of ethics for their organizations, which permeate into our homes and communities. As such, in accordance with the Congress model and an uncanny fiftyplus years working in behavioral health (believe it or not I was licensed as a clinician in 1973, BBS 4451), I’ve developed a standard of care challenge for individuals and organizations to implement in their behavioral health setting: n Develop a mission statement for your organization n Articulate the organization’s values and obtain appropriate licensure n Develop or revisit your organization’s ethical code of conduct n Let the world know your mission, values, and ethical statement, and put it on your website n Use the back of your business card for your mission statement n Work tirelessly to elevate the behavioral health care field. If you don’t, the field will fail.

Along with these steps, please be sure to:

n Review your individual professional ethics based on your licenses and certifications n Sign the Hayes-Davidson Ethics Pledge n Sign the Fair Practices Act Pledge n Engage in continuing education The challenge is clear and I empower everyone to put it to action.

Remember to be visionary, visible, and vocal in your organizations and to not let greed and malfeasance outweigh the good we as health care professionals can do for others. c About the Authors Louise A. Stanger, EdD, LCSW, CDWF, CIP, received her bachelor’s degree in English literature from the University of Pittsburgh, her master’s in social work from San Diego State College, and her doctorate in educational leadership from the University of San Diego. Her book Falling Up: A Memoir of Renewal is available on Amazon. You can contact Louise at drstanger@allaboutinterventions.com.

Roger Porter, BA, has two bachelor degrees (film and marketing) from the University of Texas at Austin. He works in the entertainment industry, writes screenplays and coverage, and when he’s not doing that he tutors middle and high school students.

You can contact Roger at raporter15@gmail.com.

References Birn, A., & Molina, N. (2005). In the name of public health. American Journal of Public Health, 95(7), 1095–7.

Centers for Medicare and Medicaid Services (CMS).

(2015). Physician self-referral. Retrieved from https:// www.cms.gov/Medicare/Fraud-and-Abuse/ PhysicianSelfReferral/index.html?redirect=/ PhysicianSelfreferral/ Congress, E. P. (2000). What social workers should know about ethics: Understanding and resolving practice dilemmas. Advances in Social Work, 1(1).

Retrieved from https://journals.iupui.edu/index. php/advancesinsocialwork/article/viewFile/124/107 Frede, D. (2013). Plato’s ethics: An overview. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy.

Retrieved from https://plato.stanford.edu/archives/ win2016/entries/plato-ethics/ Kodjak, A. (2016). Investors see big opportunities in opioid addiction treatment. Retrieved from http:// www.npr.org/sections/health-shots/2016/06/10/ 480663056/investors-see-big-opportunities-inopioid-addiction-treatment Office for Human Research Protections (OHRP).

(2016). The Belmont report. Retrieved from https:// www.hhs.gov/ohrp/regulations-and-policy/ belmont-report/