Special Populations in Addiction Treatment
LGBTQ-Specific Twelve Step Meetings Treatment of SUDs in the Military Using the Arts to Help Incarcerated Women Mobilizing Lawyers to Create a Healthier Profession The Official Magazine of the California Consortium of Addiction Programs and Professionals (CCAPP) December 2018 Vol. 19 | No. 6, $6.95
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2019 U.S. Journal
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CONTENTS
3
Letter from the Editor
21
By Gary Seidler Consulting Executive Editor
Inclusive Sobriety: The Need for LGBTQ-Specific Twelve Step Meetings
CCAPP
By Matthew Nordin, MSW, Isabel Steen, MSW, Lisa Murphy, MSW, and David A. Patterson Silver Wolf, PhD
By Lillie W. Singh, Esq.
6
Sober-Living Regulations throughout the Nation, Part II
Provides a literature review and explains how LGBTQ clients can benefit from population-specific Twelve Step meetings.
NACOA
Two Stories, One Compelling Issue
26
8
By Sis Wenger
10
Opinion
Passing the Bar: Mobilizing Lawyers to Create a Healthier Profession
Treatment of SUDs in the US Military By Douglas Crossen, MSW, Gabrielle Touchette, MSW, Joshua Gibson, MSW, and David A. Patterson Silver Wolf, PhD Discusses how substance abuse is treated in the military, explains the roles commanders and supervisors play, and provides treatment recommendations.
31
By Bob Carlson
12
Wellness
The Wisdom of Thich Nhat Hanh By John Newport, PhD
Topics in Behavioral Health Care
15
Lessons Learned from Clients in Co-Occurring Recovery Groups
Using Storytelling, Role Play, and Film with Incarcerated Women
By Dennis C. Daley, PhD
By Nola Veazie, PhD, LPC, CADC-II, Cheryl Burleigh, EdD, and Elizabeth Johnston, EdD
17
Counselor Concerns
Describes a study on using storytelling, role play, and film with women in prison, describes how those methods can help women, and lists themes uncovered by this form of treatment.
Simple Solutions or Real Results
By Gerald Shulman, MA, MAC, FACATA
From the Journal of Substance Abuse Treatment
38
Fitbit as a Physical Activity Intervention: Getting Women in Early Alcohol Recovery Moving By Ana M. Abrantes, PhD, Claire Blevins, PhD, Marie A. Rapoport, BA, Cynthia L. Battle, PhD, Jennifer P. Read, PhD, et al.
Ask the LifeQuake Doctor
20
By Toni Galardi, PhD
Also in this issue:
Ad Index CE Quiz
2 46
CE quiz instructions are on page 4
Presents a study on physical activity and Fitbit use for women with alcohol use disorder and discusses implications. www.counselormagazine.com
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STATEMENT OF OWNERSHIP, MANAGEMENT AND CIRCULATION (AS REQUIRED BY 39 USC 3685, USPS) 1. Publication Title: Counselor: The Magazine for Addiction Professionals 2. Publication Number: 1047-7314 3. Filing Date: 9/26/18 4. Issue Frequency: Bi-Monthly 5. Number of Issues Published Annually: 6 6. Annual Subscription Price: $41.70 7. Complete Mailing Address of Known Office of Publication: 3201 SW 15th Street, Deerfield Beach, FL 33442 8. C omplete Mailing Address of Headquarters of General Business Office of Publisher (Not Printer): 3201 SW 15th Street, Deerfield Beach, FL 33442 Contact Person: Craig Jarvie; Telephone: 954-360-0909 9. Full Names and Complete Mailing Addresses of Publisher, Editor and Managing Editor: Publisher: Peter Vegso, 3201 SW 15th Street, Deerfield Beach, FL 33442 Editor: Gary S. Seidler 3201 SW 15th Street, Deerfield Beach, FL 33442 Editor: Leah Honarbakhsh, 3201 SW 15th Street, Deerfield Beach, FL 33442 10. O wner: Health Communications, Inc., 3201 SW 15th Street, Deerfield Beach, FL 33442 11. Known Bondholders, Mortgages, and Other Security Holders Owning or Holding 1 Percent or More of Total Amount of Bonds, Mortgages or other Securities: None 12. N/A 13. Publication Title: Counselor: The Magazine for Addiction Professionals 14. Issue Date for Circulation Data Below: 08/01/18 15. Extent and Nature of Circulation Avg No. Copies No. Copies of
Each Issue During Single Issue During Preceding Published Nearest 12 Months to Filing Date
a. Total Number of Copies (Net Press Run) 7,372 7,091 b. Paid and/or Requested Circulation 1. Paid/Requested Outside-County 6,234 5,678 2. Paid/Requested In-County 36 38 3. Sales Through Dealers and Carriers, and Counter Sales 0 0 4. Other Classes Mailed Through USPS 72 71 c. Total Paid and/or Requested Circulation 6,342 5,787 d. Free Distribution by Mail 1. Outside County 0 0 2. In-County 0 0 3. Free or Nominal Rate Copies Mailed 0 0 4. Free or Nominal Rate Distribution Outside Mail 813 1,087 e. Total Free or Nominal Rate 813 1,087 f. Total Distribution 7,155 6,874 g. Copies Not Distributed 217 217 h. Total 7,372 7,091 i. Percent Paid and/or Requested Circulation 89.0% 84.0% 16. Statement of Ownership will be published in the December 2017 issue of this publication. 17. Signed by Craig Jarvie, CFO, 9/26/18
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Counselor | December 2018
A Health Communications, Inc. Publication 3201 SW 15th Street n Deerfield Beach, Florida 33442-8190 (954) 360-0909 n (800) 851-9100 n Fax: (954) 360-0034 www.counselormagazine.com n www.hcibooks.com n www.usjt.com Counselor (ISSN 1047-7314) is published bimonthly (six times per year) and copyrighted by Health Communications, Inc., all rights reserved. Permission must be granted by the publisher for any use or reproduction of the magazine or any part thereof. Statements of fact or opinion are the responsibility of the authors alone and do not represent the opinions, policies, or position of Counselor or Health Communications, Inc. Subscription rates in the US are one year $25.95, two years $44.00. Canadian orders add $15 US dollars per year, other international orders add $31 US dollars per year payable with order. Florida residents, add 6% sales tax and applicable surtaxes. Periodical postage rate paid at Deerfield Beach, FL, and additional offices. Postmaster, send address changes to: Counselor, PO Box 15009, North Hollywood, CA 91615 - 5009 © Copyright 2018, Health Communications, Inc. Printed in the USA. President & Publisher
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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
AD INDEX Betrayal Bond...............................................................................................37 CCAPP.............................................................................................................7 HCI Books.....................................................................................................44 Heart Reconnection.....................................................................................43 Journal of Substance Abuse Treatment........................................................9 Loma Linda.................................................................................................. 11 Newport Academy.........................................................................Back Cover Prodependence........................................................................................... 48 Toni Galardi..................................................................................................20 USJT Calendar..............................................................................Inside Front USJT Clearwater............................................................................................5 USJT Las Vegas............................................................................Inside Back
LETTER FROM THE EDITOR
We’ve Seen a Thing or Two
A
s a recovering journalist, publisher, observer, and commentator, I am struck by the enormity of current developments in the world of addiction.
opioid epidemic—a crisis that threatens communities from coast to coast (Itkowitz, 2018). Lawmakers describe the legislation as “. . . a big breakthrough that will boost access to addiction treatment and many other interventions to mitigate the current epidemic, from law enforcement efforts against illicit drugs to combatting over prescription of opioids” (Lopez, 2018). This is a massive undertaking that needs to be supported by ongoing research, education, and prevention.
We can all agree that chemical and behavioral addictions can no longer be swept under the rug. We are now more aware of the elephant in the room. The good news is that the stigma of addiction is slowly but surely lifting. Cannabis With ten states and Washington, DC now legalizing mariLike the insurance ad says, “We know a thing or two juana for recreational use and thirty-three states legalizing because we’ve seen a thing or two.” medical marijuana (Berke, 2018), it is just matter of time before We come to the end of a tumultuous year with a host of critical issues to contemplate. Disease
Most people have come to understand that addiction is a disease—a serious illness that not only befalls 20.1 million people in the US (SAMHSA, 2016), but directly affects millions of families and extended families.
Trauma
We have also come to understand that trauma—most often unresolved childhood trauma—is the underlying cause of adults using substances or behaviors (or both) to seek relief from emotional and/or physical pain. Once we consider the societal causes of addiction, we can better understand where Canadian physician and author Gabor Maté is coming from when he says, “Don’t ask the question ‘why the addiction,’ but ‘why the pain?’” (Shallow, 2014). There have certainly been shifting views, attitudes, and beliefs as well.
the entire country is marijuana friendly like our neighbors to the north. There is just too much money at stake. While some of the population will likely not suffer any serious negative consequences from cannabis use, we can be sure that a significant number of vulnerable young brains will be scrambled in the mix.
Alcoholism
While the airwaves rightly draw constant attention to the opioid epidemic, we tend to forget that alcohol is the most commonly abused substance in the US (NIDA, 2015). Alcoholism affects people from all walks of life and continues to be one of the nation’s most preventable causes of death, ranking third behind tobacco and a poor diet/sedentary lifestyle (NIAAA, 2018). Approximately 88,000 people die from alcohol-related deaths each year, according to 2018 statistics from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Meanwhile, the addiction treatment industry continues to grow amid constant flux and questioning of treatment
Abstinence/Twelve Steps
While most might argue that Alcoholics Anonymous (AA) and its descendants remain the most effective way to achieve long-lasting sobriety, we have come to accept that AA is not the only way forward. A few short years ago, it was sacrilegious to suggest that drugs might be part of addiction treatment, whereas today more and more professionals recognize that medication-assisted therapy often needs to be a critical component of integrative treatment.
Opioids
In October 2018, Congress passed a series of bills to confront the nation’s www.counselormagazine.com
3
LETTER FROM THE EDITOR CE QUIZ INSTRUCTIONS Special Populations in Addiction Treatment Inclusive Sobriety: The Need for LGBTQ-Specific Twelve Step Meetings Page 21 Provides a literature review and explains how LGBTQ clients can benefit from population-specific Twelve Step meetings. a. Analyze what deters people in the LGBTQ community from engaging in treatment or mutual-support groups b. Discuss the prevalence of SUDs among LGBTQ persons c. Explain why traditional Twelve Step meetings may not be welcoming to members of the LGBTQ community d. Present recommendations for treating this population
outcomes. Integrative approaches are au courant and intensive outpatient programs show more promise. Thankfully, bad actors in the industry are being exposed and providers are adopting better ethical standards. These are challenging times for the treatment industry as a whole and winds of change are in the air. Perhaps the best news of all is in the burgeoning recovery movement, which has grown into a sizable army of folks in recovery banding together via social media, online publications, biographies, blogs, film festivals, walks, sober cafes, sober coaching, and more. We are definitely out of the closet and that is a good thing. c
Treatment of SUDs in the US Military Page 26 Discusses how substance abuse is treated in the military, explains the roles commanders and supervisors play, and provides treatment recommendations. a. Describe how substance use in the military is treated b. Explain the role of commanders and supervisors in relation to substance use in armed forces c. Evaluate some of the requirements of military drug use programs d. List psychotherapies that are effective for PTSD and cooccurring SUDs
Incarcerated Women Page 31 Describes a study on using storytelling, role play, and film with women in prison, describes how those methods can help women, and lists themes uncovered by this form of treatment. a. Clarify how storytelling, role play, and film may be used as learning strategies in treatment b. Describe the narrative analysis research method c. Define each of the subthemes in the theme of the study d. Explain some of the issues incarcerated women might be struggling with
CE Course Completion Directions: This continuing education (CE) course consists of reading the three articles listed in the course description and brief outline above. Pass with a grade of 75 percent or above and you will be mailed or e-mailed a certificate of completion for 1.5 nationally certified CE hours. This is an open-book exam. The posttest (i.e., quiz) and evaluation are two separate requirements and must each be completed and returned to receive credit. The evaluation must be completed and returned with the quiz to receive CE credit. Questions are answered on a sliding scale with 1 being strongly disagree and 5 being strongly agree. Send a photocopy of the page along with your payment of $16.95 to 3201 SW 15th St., Deerfield Beach, FL 33442.
To Complete the Quiz: After reading the indicated feature articles, complete the quiz by filling in one of the multiple choice answer bubbles. Be sure to answer all questions and to give only one response per question. Incomplete questions will be marked as incorrect. Be sure to print clearly and fully complete the information section. For those requiring ADA accommodations, please contact our customer service line at 800-851-9100. The quiz can be submitted within five years of publication date and can only be submitted one time per quiz, per person.
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Counselor | December 2018
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication References Berke, J. (2018). Here’s where you can legally consume marijuana in the US in 2018. Retrieved from https://www.businessinsider.com/where-can-you-can-legallysmoke-weed-2018-1 Itkowitz, C. (2018). Senate easily passes sweeping opioids legislation, sending to President Trump. The Washington Post. Retrieved from https://www.washingtonpost. com/politics/2018/10/03/senate-is-poised-send-sweeping-opioids-legislationpresident-trump/?utm_term=.5a6cece70984 Lopez, G. (2018). Congress is on the verge of a bipartisan opioid package, but experts have big concerns. Retrieved from https://www.vox.com/policy-andpolitics/2018/9/12/17847358/ enate-opioid-crisis-response-act National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2018). Alcohol facts and statistics. Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-facts-and-statistics National Institute on Drug Abuse (NIDA). (2015). Nationwide trends: Drug facts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/nationwide-trends Shallow, P. (2014). #14Days: A cry for compassion in treating addiction. Retrieved from https://www.cbsnews.com/news/14-days-compassion-addiction-recovery-gabor-matevicky-dulai/ Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/ sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf
Helen Fisher, PhD
John Briere, PhD
Participating Sponsors:
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Joan Borysenko, PhD
CCAPP
Sober-Living Regulations throughout the Nation, Part II Lillie W. Singh, Esq.
W
hile there have been many challenges to local municipalities’ attempts to regulate or otherwise limit sober-living facilities, there are few reported cases where plaintiffs have challenged the statewide licensure or certifi cation regulations. Judicial opinions discuss challenges to local zoning laws or other measures enacted by cities and municipalities; however, as of the date of this writing, no published cases concern statewide licensing and certifi cation requirements. As a result, it is unclear how courts will respond if sober-living operators attempt to challenge the licensure or certifi cation requirements as a violation of federal and state discrimination laws. Legal Challenges to Local Laws
In the cases involving municipal zoning laws, the plaintiffs often argue that the laws discriminate against a protected class of individuals in violation of the ADA, FHA, and state discrimination laws. Where the zoning, safety, or other local ordinance mentions sober-living facilities specifically, the law will be challenged as facially discriminatory and subject to heightened scrutiny under the FHA. Typically, courts evaluating such a law will require the government entity to show: “(1) that the restriction benefits the protected class; or (2) that it responds to legitimate safety concerns raised by the individuals affected, rather than being based on stereotypes” (Community House, Inc. v. City of Boise Idaho, 2007). Where the government cannot meet this burden, the law will be struck down. For example, in Human Resource Research and Management Group, Inc. v. City of Suffolk (2010), a sober-living operator challenged a city ordinance that required, among other things: 1. Sober-living homes to provide notice to local authorities about where the house was being considered so that a public hearing could be held 2. Sober-living homes to have on-site “certified site managers” at all times 6
Counselor | December 2018
3. A limitation of five residents at a sober-living facility at a time (exclusive of providers) 4. The operator of the sober-living home to apply for a county license and pay a fee for the application (Human Resource Research and Management Group, Inc. v. City of Suffolk, 2010) The court found that none of the challenged requirements were narrowly tailored to support the asserted government interests ((Human Resource Research and Management Group, Inc. v. City of Suffolk, 2010). With respect to local licensure requirements specifically, the court in Human Resource Research rejected the government’s arguments that licenses were necessary to prevent “slum landlords” in the absence of credible evidence from the city that the protected, “affected class of disabled people are so particularly vulnerable as a class to predatory or unscrupulous landlords . . . in a manner that necessitates the application of the registration, background checks, and inspection requirements” ((Human Resource Research and Management Group, Inc. v. City of Suffolk, 2010). Other cases have also rejected municipal licensing requirements for soberliving homes (See Jeffrey O. v. City of Boca Raton, 2007). Existing cases dealing with local licensure attempts do not foreclose other courts from finding there are sufficient bona fide benefits to sober-living residents from state-wide licensure laws to withstand scrutiny under the FHA and other antidiscrimination laws. Indeed, the publicity over the abuses of sober-living operators will support the government’s potential arguments that licensure is required to protect residents from illegal patient brokering, kickbacks, bed vouchers, and other misconduct.
Legal Challenges to State Laws
Case law dealing with statewide licensure requirements is sparse. However, there should be more judicial decisions on mandatory and voluntary licensure and certification programs being enacted by states, as operators face difficulties complying with new laws and regulations. In New Jersey, there was a reported (but unpublished) case called Department of Community Affairs v. Hansen House, LLC (2017), where a sober-living operator appealed from an administrative law finding that it was operating an unlicensed boarding
CCAPP house in violation of state regulations that require licensure for “rooming and boarding houses” from the Department of Community Affairs (DCA; Department of Community Affairs v. Hansen House, LLC, 2017). In Hansen House (2017), the operator of a recovery residence called RSS House argued that the rooming and boarding house regulations violated the FHA and that the DCA was required to make a reasonable accommodation for the facility and exempt it from the regulations. The regulations required, among other things, that the physical structure for RSS House comply with certain building and safety codes and that the operators pay licensure fees to the DCA. RSS House had sought neither an exemption nor a waiver from DCA, but had continued to operate without complying with the regulations (Department of Community Affairs v. Hansen House, LLC, 2017). It was found to be in violation of the regulations, which it then challenged before an administrative law court. The plaintiff failed to present evidence about the financial impact if the facility had to secure a license, and that complying with the licensure requirements would undermine RSS House’s operations or cause the facility to close (Department of Community Affairs v. Hansen House, LLC, 2017). As a result, the court found that RSS House was subject to the licensure laws and regulations, and remanded the matter to DCA for further proceedings concerning whether RSS House should receive “an exception waiving, modifying or postponing the application of any regulation” (Department of Community Affairs v. Hansen House, LLC, 2017). In Utah, a sober-living operator brought a case seeking an injunction against the state laws requiring recovery residences to obtain a state license and be subject to regulatory oversight, but there was no reported or published court decision in the case. This case, Anderson v. Utah (2016), alleged that the existing regulations would require plaintiffs to expend over $120,000 to make home modifications, and an additional $165,000 a year in overhead costs to cover paid on-site supervision, licensed professional staff, and case management. The plaintiff alleged that the regulations violated the FHA and the ADA, and should be enjoined. The court issued a temporary
injunction against the enforcement of the regulations and then the parties worked out a voluntary stay of the litigation. Shortly thereafter, the Utah requirements were revised to be less burdensome for operators. The requirements no longer include such expensive provisions as professionally licensed, live-in staff and as many physical plant requirements. The new licensure requirements are in effect and have not been subject to any published challenges like the Anderson v. Utah (2016) litigation. Cases like Anderson v. Utah (2016), if they proceed and result in published decisions, will be highly informative about whether state licensing regulations aimed at sober-living houses can withstand judicial scrutiny, especially where they are mandatory for all recovery residences as is the case in Utah. In addition, it is possible that the federal government, including the Department of Justice (DOJ) and Department of Housing and Urban Development (HUD) could get involved if either determines that the mandatory licensure requirements violate federal law. Operators of sober-living facilities and legal counsel involved in SUD treatment are eagerly awaiting further clarification on whether both “voluntary” and mandatory licensure requirements will be upheld if they are challenged as violations of federal laws like the ADA and
FHA, and whether government agencies like the DOJ or HUD will intervene. Until then, operators are urged to follow the laws on the books and seek professional advice and counsel in making decisions about how to proceed in light of current requirements. Operators should also consider seeking out optional certification in the states with programs by NARR affiliates and other private accreditation bodies. c About the Author Lillie W. Singh, Esq., received her juris doctor from the Stanford Law School in 2008. She has been named a rising star in health care by Super Lawyers Magazine. She has given talks to lawyers and health care professionals about patient privacy under HIPAA and state laws, and has written articles on many issues facing health care providers, addiction treatment center operators, and sober-living programs. Disclaimer: The information provided in this article is for educational purposes only. It is not intended to provide legal advice. Due to the complexity of the issues involved and the rapidly changing legal landscape, it is advised to consult qualified legal counsel before beginning or continuing operations as a sober-living facility.
References Anderson v. Utah, No. 1:16-cv-00005-PMW (D. Utah 2016) Community House, Inc. v. City of Boise Idaho, 490 F.3d 1041, 1050 (9th Cir. 2007) Department of Community Affairs v. Hansen House, LLC, No. RBHS-018-09/0601-0058 (S.C.N.J. 2017) Human Resource Research and Management Group, Inc. v. City of Suffolk, 687 F. Supp. 2d 237 (E.D.N.Y. 2010) Jeffrey O. v. City of Boca Raton, 511 F. Supp. 2d 1339, 1356 (S.D. Fla. 2007)
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NACOA
Two Stories, One Compelling Issue Sis Wenger
W
hat happens when a parent is discharged from addiction treatment and comes home? Who prepares the children for understanding that sobriety brings a new set of challenges? If these children have not been part of an educational support group for the children of clients in treatment; or referred to a family service agency in the community or a student assistance program at their school; or given at least one session with the parent’s therapist or the agency’s family therapist during or prior to discharge, how can they be expected to be prepared for all the changes?
of the rejections, blaming, and shaming that were hallmarks of their childhoods prior to the parent beginning treatment—they fear that the slightest stressor in the family will trigger the old behaviors and all will be lost again. They have a right to know how addiction and recovery work, that none of what happened before (or in the present) was ever their fault, and that there are people and programs that can help them understand and heal from all the prior hurts. How can we expect them to be part of a new life for the family if they are not equipped with the age-appropriate information, tools, and guidance to understand the changes that are happening and will continue to happen for each of them and the whole family if they hope to heal?
If addiction counselors want to help their clients have more successful outcomes, one session with the family—especially in age-appropriate ways with the children—should be the minimum, as well as referral to a family service agency for ongoing support and understanding when the treatment program does not provide support to the families of clients during treatment and/or after. Children may continue to feel blamed and carry the wounds
Emmy, age eleven, attended a children’s program while her mom was in treatment for alcoholism. Emmy met many children who knew all too well the pain and confusion that envelopes and consumes families when addiction is large and in charge. She learned that it was not her fault and that she could not make things better for her mom. Her parents also participated in the program and all of them learned about the language of recovery
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Counselor | December 2018
“Emmy’s Story” by Jerry Moe
NACOA and communicated with each other in some brand new ways. They talked about how this disease had hurt all of them and made plans, individually and collectively as a family, to move forward with self-care strategies and healing. I would see the family on Wednesday evenings at Kids’ Night, a continuing care process for each of them. After a few months of regular attendance, they fell off the grid and I did not hear from them. The aforementioned children’s program teaches youngsters that they are not alone and that there are safe people and places that can always help. The call came on a Saturday morning at my office. As soon as she heard my voice, Emmy started to cry. “I’m really scared right now. My parents got into a terrible fight this morning and it reminded me about how awful it used to be,” she shared. Emmy poured out all her worries, concerns, and feelings, and all I did was listen. When she let it all out, I asked her if it felt safe to let her parents know about her thoughts and concerns. She quickly said, “No,” but liked the idea of writing her mom a note. She decided she could now handle things much better and thanked me. I would not find out about what Emmy wrote to her mom for a few days, until the next Kids’ Night. She told her mom how proud she was of her for getting help. She offered thanks about how things were getting better at home. Then Emmy wrote clearly and honestly about her fear. She described being scared that addiction was slowly creeping back into the family and made a plea for mom to go back to her meetings. She told her that she did not want to lose her and that she needed and loved her. And then she said, “Please get help.” Later that night, I was told, Emmy’s mom, after returning home from a meeting, hugged and kissed her daughter. Then she held Emmy and thanked her. They both cried. What if there had not been a children’s program for Emmy to attend?
“A Police Officer’s Concern” by Chuck Noerenberg
After a police officer arrested a parent for possessing illegal drugs, the offender was ultimately placed on probation and required to enroll in a treatment program
because of addiction. There was hope that the drug-using parent would overcome the addiction and that the family would live in a heathier and safer home setting. The police officer later learned from the probation officer that the drug-using parent had been kicked out of the treatment program for being “uncooperative” and for noncompliance with program rules.
The officer wanted to know what the responsibility of the discharging treatment program was in such situations, as kicking a client out of a program left the entire family, especially the children, with an addiction problem. Was it now up to law enforcement and child welfare to deal with the addiction? What was to happen next?
A Family Disease
If addiction counselors want to help their clients have more successful outcomes, one session with the family— especially in age-appropriate ways with the children—should be the minimum. The police officer wondered what would happen to that family, fearing a repeating cycle of drug use, an uncertain home setting, and potentially more arrests. After years of answering 911 calls to homes with parents involved with drugs, he wanted to know who was seeing that the children and the spouse at home would be safe. He wondered whether anyone was helping that family understand addiction and how it could control the family and hurt everyone in the house. What support did the family have?
What happens next? Often not much. The child’s frame of reference from “before” is confusion and fear when the addicted parent was either unavailable or railing at them, blaming them for anything that was going awry at the moment, and the other parent was once again too preoccupied to pay attention to the children. How can they know what to think when a returning parent who was absent, irresponsible, or irrational in the recent past suddenly wants to return to the parental role? Who will help them understand that recovery is important for every member of the family, including them; that all have been hurt by this disease; that recovery comes in different stages for each; and that all need help to recover from addiction’s damage? They need to learn how to be kids and to understand it was never their fault and it is not their responsibility after treatment. Continued on page 14
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OPINION
Passing the Bar: Mobilizing Lawyers to Create a Healthier Profession Bob Carlson
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awyers learn stress early. They stress through three years of law school, they stress preparing for and taking the bar exam, and they stress at highly competitive jobs in law firms, corporations, and government. Stress is often part of the legal profession’s culture. So perhaps it is no surprise that studies show a substantial proportion of lawyers and law students suffer from substance use disorders (SUDs), depression, and anxiety at far higher rates than the general public and even other professionals. In 2016, the American Bar Association (ABA) partnered with the Hazelden Betty Ford Foundation on a comprehensive study of the issue to determine the extent of the problem (Krill, Johnson, & Albert, 2016). The survey of nearly thirteen thousand licensed, employed lawyers found that n 21 percent qualify as problem drinkers—that is more than three times the rate for the general population (6 percent) and nearly double the rate for other highly educated professionals (12 percent) n 28 percent struggle with some level of depression n 19 percent demonstrate symptoms of anxiety In part, the ABA-Hazelden study blamed the culture of the legal profession. The study’s lead author, Patrick R. Krill of Hazelden, said the study’s findings are a call to action: “Any way you look at it, this data is very alarming and paints the picture of an unsustainable professional culture that’s harming too many people,” he stated (Hazelden Betty Ford Foundation, 2016). While mental health issues and substance abuse pose significant problems for lawyers and their families, they can have major consequences for clients as well. Last year in Illinois, for example, 29 percent of the 118 lawyers disciplined for misconduct had one or more problems with substance abuse or mental health, according to a report from the Illinois Attorney Registration & Disciplinary Commission. For many lawyers, problem drinking and mental health issues start early. The ABA-Hazelden study found that attorneys in their first decade of practice have the highest frequency of these problems. Additionally, a 2014 survey of students at fifteen American law schools published in the Journal of Legal Education found that 53 percent said they got drunk in the prior thirty days (Organ, Jaffe, & Bender, 2016). Forty-three percent acknowledged binge drinking at least once in the prior two weeks. 10
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Since the ABA-Hazelden study results were released, the ABA has launched a series of initiatives to raise awareness and reduce the incidence of problematic substance use and mental health problems. With the goal of ensuring that every lawyer, judge, and law student has access to support when dealing with substance abuse and mental health issues, in February of 2018 the ABA’s policy-making House of Delegates recognized the magnitude of these issues and urged all law firms, law schools, and bar associations to take specific steps to solve the problem. The ABA also created the National Task Force on Lawyer Well-Being, which issued a report last year calling for widespread changes (Buchanan et al., 2017). The report included forty-four specific recommendations aimed at changing the culture of the legal world. It addressed every institution in the profession, including law schools, law firms, judges, bar associations, regulators, insurers, and lawyer assistance programs. Many recommendations aim to reduce the stigma that prevents so many lawyers from seeking help. For example, the report recommends that n Law schools and law firms deemphasize alcohol at events n Law firms adopt model policies for handling lawyer impairment, including creating procedures for lawyers to seek confidential help and working with lawyer assistance programs to secure services for impaired lawyers n Judges monitor for impaired lawyers and develop policies to help impaired colleagues on the bench n Legal regulators expand continuing education requirements to include well-being topics, and narrow questions related to behavioral health history for bar applicants n Liability carriers collect data on when impairment is a factor in claims and create incentives for desired behaviors in underwriting risks The report concluded, “The budding impairment of many of the future generation of lawyers should be alarming to everyone. Too many face less productive, less satisfying, and more troubled career paths” (Buchanan et al., 2017). To help ensure the report’s recommendations become reality, the ABA has formed a Presidential Working Group. The Group assists legal employers who want to help but do not know where to start. In August of 2018, the ABA Commission on Lawyer Assistance Programs released a one-hundred-page report, titled the “Well-Being Toolkit for Lawyers and Legal Employers,” that offers practical guidance to help attorneys and employers improve well-being (Brafford, 2018).
OPINION The toolkit includes an eight-step action plan for legal employers; guidance on conducting a policy and practice audit to evaluate what factors support and harm well-being; and a list of organizations that focus on lawyer well-being that can assist legal employers in their efforts. Finally, the ABA launched a campaign in September 2018 for legal employers— law firms, corporations, government agencies, and legal aid groups—to sign a pledge to improve lawyer well-being (ABA, 2018). In the first month, twenty-two law firms signed the pledge, including some of the largest firms in the country. We know our friends and colleagues are suffering. Today, through specific actions and policies, the ABA is dedicated to alleviating the addiction and mental illness that plague our profession. We recognize that it will not be easy and it will not be quick, but that it is a challenge we cannot ignore. c About the Author Bob Carlson is a shareholder with the law firm of Corette Black Carlson & Mickelson in Butte, Montana. He is president of the American Bar Association, which has more than 400,000 members nationwide.
References American Bar Association (ABA). (2018). Working group to advance well-being in the legal profession. Retrieved from https://www.americanbar.org/groups/lawyer_ assistance/working-group_to_advance_well-being_ in_legal_profession/ Brafford, A. M. (2018). Well-being toolkit for lawyers and legal employers. Retrieved from https://www. americanbar.org/content/dam/aba/administrative/ lawyer_assistance/ls_colap_well-being_toolkit_for_ lawyers_legal_employers.pdf
Serving the Inland Empire for over 25 years, we provide multi-level care in the following areas:
Buchanan, B., Coyle, J. C., Brafford, A., Camson, J., Gruber, C., Harrell, T., . . . Slease, W. D. (2017). National task force on lawyer well-being: Creating a movement to improve well-being in the legal profession. Retrieved from https://www.americanbar.org/content/ dam/aba/images/abanews/ThePathToLawyerWellBeing ReportRevFINAL.pdf
• Chronic pain and medication dependency • Eating disorders • Chemical dependency services • Adolescent self injury • Mental health services unique to youth, adults and seniors
Hazelden Betty Ford Foundation. (2016). ABA, Hazelden Betty Ford Foundation release first national study on attorney substance abuse, mental health concerns. Retrieved from https://www.hazeldenbettyford.org/ about-us/news-media/press-release/2016-aba-hazeldenrelease-first-study-attorney-substance-use Krill, P. J., Johnson, R., & Albert, L. (2016). The prevalence of substance use and other mental health concerns among American attorneys. Journal of Addiction Medicine, 10(1), 46–52. Organ, J. M., Jaffe, D. B., & Bender, K. M. (2016). Suffering in silence: The survey of law student well-being and the reluctance of law students to seek help for substance use and mental health concerns. Journal of Legal Education, 66(1), 116–56.
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WELLNESS
The Wisdom of Thich Nhat Hanh John Newport, PhD
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his column will attempt to illuminate practical applications of the teachings of my favorite mentor, Thich Nhat Hanh, a Buddhist monk whom in my opinion is the foremost contemporary proponent of application of basic Buddhist precepts in our daily lives. While Thay (as he is known by his followers) is a leading practitioner of Zen Buddhism, his approach to helping us enrich our lives and the lives of those around us is extremely inclusive. Indeed, his followers include countless numbers of people with Judeo-Christian leanings, including my wife and myself. This column will highlight potential applications of his teachings that I believe have particular relevance to people in recovery from addictive disorders, together with their relevance to all of us when we are confronted with severe mental-emotional trauma. The Man
Thich Nhat Hanh was born in Central Vietnam in 1926 and today, at ninety-two years old, remains an extremely prolific and influential author, teacher, and proponent of nonviolent living. During the Vietnam War he was extremely active in promoting a peaceful end to the war, both in his homeland Vietnam and in the United States, where he was a renowned lecturer at several prestigious universities (“Thich Nhat,” 2018). In 1966, he met with Dr. Martin Luther King Jr. and urged him to publically denounce the war. In 1967, Dr. King nominated Thay for the Nobel Peace Prize, stating, “I do not personally know of anyone more worthy of the Nobel Peace Prize than this gentle Buddhist monk from Vietnam. . . . His ideas for peace, if applied, would build a monument to ecumenism, to world brotherhood, to humanity” (King, 1967). Thay’s distinctive approach combines a variety of Buddhist teachings, particularly from the Zen tradition, with offerings of Western psychology to promote mindful breathing and other practical applications of mindfulness. He is a foremost leader in the Engaged Buddhism movement, promoting people’s active roles in creating change (McMahan, 2008). His writings and teachings place a particular emphasis on compassionate selfcare and healing as integral components in leading a compassionate, purpose-driven life.
The Teachings Thich Nhat Hanh in Paris, France, October 2006 Photo | Courtesy of Duc
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I believe that Thay’s core teachings provide extremely practical and compassionate advice for anyone seeking to lead a more peaceful, joyful, and meaningful life.
WELLNESS Many people struggling with alcoholism and drug abuse succumb to addiction in a misguided effort to escape from the seemingly intolerable pain and suffering present in their lives. I believe that Thay’s teachings are extremely complementary to both the spirit and content underlying the various Twelve Step programs. As many people grounded in their recovery are seekers, I am confident that large numbers of struggling alcoholics and addicts have embraced Thay’s teachings on their road to recovery. The following are some salient teachings of this wise master of particular relevance to recovery from addictive disorders.
Embracing Buddhism
Embracing and practicing core precepts of Buddhism in our daily lives includes the following: n Adhering to nonviolence in our thoughts, words, and actions n Extending our heartfelt compassion to all living entities, be they our fellow humans, our brothers and sisters in the animal kingdom, or all plant-life. Thay especially emphasizes the need to extend compassion to ourselves, whomever we encounter, and our beautiful yet fragile living planet. n Recognizing that suffering is inevitable in our lives, and learning to transform our suffering through engaging in thoughts, words, and deeds that promote peace, contentment, and beneficent outcomes for all concerned n Embracing our negative feelings— such as anger, irritability, and despair—and the negative feelings of others with compassion, as a mother would attempt to comfort a frightened child n Accepting that all things in life are impermanent, and avoiding the cultivation of unhealthy cravings that promote greed, violence, and dominance over others n Appreciating that compassion and understanding lie at the core of all true manifestations of love
Transforming Suffering
Thay expounds on the art of transforming suffering in his wonderful book No
Mud, No Lotus: The Art of Transforming Suffering (Hanh, 2014b). Just as manure must unite with soil to produce a beautiful flower, he emphasizes that suffering is ultimately needed to produce joy and happiness. In his words, “Without suffering, there’s no happiness” (Hanh, 2014b). Without suffering, Thay argues, we would be unable to develop compassion, which forms the basis for all true expressions of love.
Thay’s distinctive approach combines a variety of Buddhist teachings, particularly from the Zen tradition, with offerings of Western psychology to promote mindful breathing and other practical applications of mindfulness. He poignantly states that the main affliction of modern civilization is that we do not know how to handle the suffering inside us—we try to cover it up with all kinds of consumption. These include obsessively accumulating wealth and engaging in toxic, addictive behaviors including misuse of alcohol and other drugs, food addictions, and exploitative sexual expression with total disregard for others. He advises us to be truly present with our suffering, stating that the best way to be with our suffering without becoming overwhelmed is to cultivate the quality of mindfulness.
Elaborating on the Quality of Mindfulness
Thay describes mindfulness as the capacity to be totally present in the present moment, to know and fully experience what is happening in the here and now. His teachings place a great deal of emphasis on use of mindful breathing to build a bridge between our minds and our bodies, while anchoring our awareness in the here and now. In the beginning of my favorite book by him, You Are Here: Discovering the Magic of the Present Moment (Hanh, 2010), Thay elaborates on focusing on our breathing
as the gateway to instantly accessing mindfulness. In his words, “There is no need to manipulate the breath . . . What we are doing (in mindful breathing) is simply lighting the lamp of awareness to illuminate our breathing” (Hanh, 2010). To cultivate mindful breathing, as we breathe in he advises us to say to ourselves, “Breathing in, I know that I am breathing in.” Likewise, as we breathe out we silently say, “Breathing out, I know that I am breathing out.” Try this exercise for six breaths, perhaps for as long as a minute. As we conclude this exercise, we may notice that our minds are free from the constant clamor and clutter caused by an endless barrage of intrusive and often unpleasant thoughts. This troublesome state is the default setting of our “monkey mind,” as Buddha’s followers call it. Letting go of these bombarding thoughts, we have entered the true realm of mindful awareness. To fully experience this pleasant state of awareness, we may take a walk in nature, engaging in mindful breathing as we lovingly gaze at a beautiful tree, cacti, or animal we encounter along the path. Many people, myself included, find this simple, mindful breathing exercise to be extremely liberating, particularly in freeing our minds and hearts from the baggage of anger and irritability we all succumb to from time to time. Clearing our minds through consciously focusing on mindful breathing can be extremely empowering in returning ourselves to a grounded, in-control state of mind whenever we find ourselves experiencing severe mental-emotional trauma to the point of overwhelment. To cultivate the ability to apply the quality of mindful detachment in our dayto-day lives, Thay advises us to nourish our awareness of each moment and to sustain ourselves in a pleasant state of mindful awareness by carefully choosing our surroundings and taking care to avoid toxic places, people, and situations whenever possible. This particularly applies to codependents and people struggling with addiction.
Reflections on Love
Thay’s teachings on love emphasize that true love entails gifting our loved ones with our full presence, compassion, www.counselormagazine.com
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WELLNESS and understanding. In his words, “Understanding is love’s other name. If you don’t understand, you can’t love” (Hanh, 2014a). Compassion is the capacity to understand suffering in ourselves and in other people. We must first understand our own suffering before we can help someone else understand theirs. In expounding on the nature of love in a deep relationship, Thay emphasizes that reverence is the nature of true love—true love cannot exist without trust and respect for ourselves and others. The roots of any deep relationship are mindfulness, deep listening, and loving speech. In the interest of promoting ongoing harmony, Thay advises that we practice conscious breathing with our partners. If we do this, mindful breathing will be there to promote harmony when things get rough.
Conclusion
I hope this column has whetted your appetite to learn more about the relevancy of Thich Nhat Hanh’s teachings in learning to transform the suffering we all experience as part of the human condition and, in particular, their potential relevancy in treating people with addictive disorders. In closing, I encourage you to choose and read one or more of his many fine books. Until next time—to your health! c About the Author John Newport, PhD, is an addiction specialist, writer, and speaker living in Tucson, Arizona. He is author of The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. You may visit his website www.wellnessandrecovery.com for information on wellness and recovery trainings, wellness coaching by telephone, and program consultation services that he is available to provide.
References Hanh, T. N. (2014a). How to love. Berkeley, CA: Parallax Press. Hanh, T. N. (2014b). No mud, No lotus: The art of transforming suffering. Berkeley, CA: Parallax Press. Hanh, T. N. (2010). You are here: Discovering the magic of the present moment. Boston, MA: Shambhala Publications. King, M. L. Jr., (1967). Nomination of Thich Nhat Hanh for the Nobel Peace Prize [Letter]. Retrieved from https:// www.mindfulnessdc.org/mlkletter.html McMahan, D. L. (2008). The making of Buddhist modernism. New York, NY: Oxford University Press. “Thich Nhat Hanh.” (2018). Retrieved from https://plumvillage.org/about/thich-nhat-hanh/ Duc. October 22, 2006. Thich Nhat Hanh marche meditative 06 [Photograph]. Retrieved from https://www.flickr.com/photos/bodhi47/39558134451/
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NACOA
From page 9
If children do not benefit from a multisession educational support group or, at the very least, from an individual session with a counselor prior to the parent’s discharge from treatment—whether early discharge for noncompliance or the end of a planned treatment regime— the children are left just as bewildered as when the parent entered treatment. How can the confusion and fear they feel be dispelled when it was so ingrained in their daily experience during the years of the parent’s active addiction without being given the information and guidance needed to understand? When children do not get their reality validated, when they have thought for years that it was their fault that Mom or Dad drank too much or misused drugs, they are going to continue feeling responsible for what they could not fix before the parent went to treatment. Unless they are given accurate and supportive information that can give them clarity and hope, they will be watchful and continue to fear that the other shoe will drop. There has been so much trauma unaddressed in the family. Mom and Dad have now started to change and are often anxious to be talking about how hard they have worked to get clean and sober and want the family to appreciate that. The parent in early recovery wants to recapture their perceived authority in the house and wants respect from their children who have not been helped to understand the rapid changes or that they deserve help to have their own recovery. They do not understand that getting better will be different for each member of the family. They do not know how to communicate their feelings or their confusion, or that it will take a long time for everyone to heal individually and to learn how to be part of a new family struggling with recovery. We say addiction is a “family disease,” and we have known this for over forty years, but we do not do the minimum to help the whole family heal. If we do not work to ensure educational
support programs through our treatment services or, at the very least, provide an individual session with each child of any client leaving treatment, then we need to advocate for student assistance programs in our schools, where thousands of school-age children have recovered in groups—groups that also helped them to have improved behavior and increased academic success. If we believe and say that addiction is a family disease, then we are responsible for acting on that knowledge. If we say that addiction and its accompanying trauma move from generation to generation in families, then only working to help one person in the family where all members have been devastated by it does not suggest a full appreciation for recovery. Inaction to help the children of adults who should be responsible ignores the clear evidence that there is continued developmental damage to the children’s brains from the unending emotional stress that thrives in their confusion and fear. I will leave you with a closing thought: For generations, our country’s leaders have talked about our children being our most precious possessions and our future. In the addiction treatment and recovery world, there is little evidence of that belief being compelling. With few exceptions, the field’s systematic ignoring of the critical issues that surround the children of addicted parents facilitates the continued generational transmission of the addiction disease and its accompanying trauma through countless families, where it might have been different if only actions and programs matched the rhetoric. Your clients and their children deserve better. c Acknowledgements: I would like to thank Jerry Moe, MA, national director of the Hazelden Betty Ford children’s programs, and Chuck Noerenberg, JD, former Minnesota State drug policy coordinator and past president of the National Alliance for Drug-Endangered Children for their contributions to this article.
About the Author Sis Wenger is NACoA’s president and CEO.
TOPICS IN BEHAVIORAL HEALTH CARE
Lessons Learned from Clients in Co-Occurring Recovery Groups Dennis C. Daley, PhD
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or many years I conducted early recovery groups as a guest presenter in multiple inpatient, residential, and/ or ambulatory treatment programs for clients with co-occurring substance use and psychiatric disorders (CODs). I also conducted recovery and/or focus groups at a therapeutic community program in the inner city, and for incarcerated adolescents or adults with CODs. I met regularly with clients to find out what their concerns were related to recovery from CODs, what they found helpful in COD programs, and what else they thought could help their recovery. I continue to be a guest presenter in several intensive outpatient programs (IOPs). This article provides a summary of what I learned from these experiences and the challenges shared by clients with CODs. Focus Groups of COD Clients
Adult and adolescent clients in inpatient or residential settings often expressed the desire for more weekend
groups because they thought they had too much free time on weekends. While they valued group treatments, clients felt strongly that individual sessions were needed. Many felt they did not get enough time in individual sessions with clinical staff. There was variance between programs and staff within a program in terms of how much individual time was given to clients. The importance of a therapeutic alliance with staff members who spent sufficient time with clients in individual sessions to explore their personal recovery issues was clearly articulated. Individual sessions enabled clients to open up, trust, and disclose personal feelings and struggles with their CODs. Clients could tell which staff members they believed were the most approachable, empathic, and willing to give them personal time and attention. My recommendation for all hospital, residential, and/or ambulatory rehabilitation programs that are primarily group-based is to provide regular individual sessions to clients as a way to explore issues and concerns not discussed in groups. Many clients reported how bad they felt when they perceived negative judgement from staff who did not understand what it was like to have both a substance use disorder (SUD) and a psychiatric illness. This was more likely to occur in a mental www.counselormagazine.com
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TOPICS IN BEHAVIORAL HEALTH CARE health treatment system with staff who did not have sufficient knowledge, skills, or comfort level in addressing substance use issues. Mental health practitioners need to expand their clinical capabilities and comfort level to address substance use issues, and addiction practitioners need to expand their capabilities to address mental health issues.
mutual-support programs, medicationassisted treatment (MAT), strong cravings, and/or how to stabilize from a relapse. While not all of these issues are discussed in a single session, following is a summary of key issues often discussed. After my group ends, clients return to their IOP therapy groups and process the issues we discussed.
Inside Recovery Group Discussions
Motivation and Adhering to the Treatment Plan
My recovery groups usually include up to twenty clients and are conducted in an interactive way to actively engage participants. The goals are to educate, raise awareness, give hope, and stimulate interest in active recovery. Most clients have been in multiple psychiatric and/or addiction programs, and a good number have been incarcerated. While all levels of severity of CODs are represented, most have moderate or severe types of disorders. Many also have medical and other psychosocial problems that require help from other providers. I ask members to introduce themselves, state what problems brought them to treatment, and identify one recovery issue they would like to discuss. Group leaders also attend this discussion and one writes the list of issues on the dry-erase board. I walk around the room during the session and ask questions or seek clarification of issues raised; elicit self-disclosure of clients’ struggles in recovery or what helps them cope with the challenges of recovery; share stories of successes of others with CODs; share information based on research; and share insights on what I have learned from others suffering from CODs. I sometimes ask clients to comment to each other about recovery issues or coping strategies that have helped them so they share support and learn from one other. The group ends with clients stating one thing they learned from the discussion that may help them in their ongoing recovery.
Recovery Issues and Challenges Shared by Clients
Most groups identify the following topics for discussion: motivation struggles, causes of the disorders, negative emotions or moods, high-risk people and places, family conflicts, social- and 16
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Group members express various levels of motivation, from low to moderate to high (about one-third in each category). We discuss how showing up for group, other counseling, medication appointments, or mutual-support meetings is one of the best antidotes for periods of low motivation. Clients report they feel much better when they push themselves and adhere to sessions. Some state this helps divert a relapse because they often want to use when they wake. I share insights from research and our experiences with thousands of clients in our programs in that those who adhere to treatment do better in the short and long run. “Drag your body and your mind will follow” is one of the main messages given.
Understanding SUDs
Many clients are perplexed as to why they continue to drink or use drugs since their SUDs have created problems with their health and in their lives. We discuss why they continue to use substances to feel good, escape feelings of depression or emptiness, or prevent withdrawal from physical addiction. We discuss how the brain may adapt to substances, and how they feel they have to use to feel normal. Clients describe memories and stimuli that contribute to cravings that are sometimes overwhelming. We discuss how MAT can help attenuate strong cravings and decrease the desire to use alcohol, opioids, or tobacco. I suggest to clients with alcohol use disorders (AUDs) that they talk with their team about FDA-approved medications available to reduce alcohol cravings or desires. We sometimes discuss the quandary for clients who do not lose control every time alcohol or drugs are used, which raises the question, “Is my SUD that bad?” A message conveyed is that even with an addiction (i.e., a more
severe form of SUD), there may be periods of limited or controlled substance use.
Understanding Mental Illness and Treatment
We discuss categories and severity of mental disorders, how these interact with SUDs, and how each disorder affects recovery or relapse of the other disorder. Multiple causes of mental illness are reviewed since some clients have a simplistic view that taking medications to normalize their brain chemistry is all that is needed to get well. A key theme is that improvement for a mental disorder can occur without total remission—that some clients will continue to experience chronic or persistent symptoms of illness. We discuss the difference between single or recurrent episodes of a disorder. Many clients with recurrent disorders who experience remission stop taking medications when they feel good. I share research that shows stopping medications during periods of remission for recurrent major depression increases the risk of a recurrence of a new episode of depression. A key message is that clients should not make decisions about stopping medication or therapy on their own without discussing this desire with a provider, sponsor, and/or confidante.
Effects of CODs on Self and Families
Clients identify numerous adverse effects of their disorders on their health, functioning, and loved ones. Guilt, shame, fractured family relationships, and many other negative effects are shared. Many report high rates of disorders in their families, which leads to discussing how some individuals are at increased risk to develop a disorder based on family history. I emphasize that continued involvement in treatment and recovery, and involving the family when feasible, are the best ways to gradually reduce these adverse effects. Clients need help determining how and when to address issues with their family, or how to get them involved in treatment or recovery.
Recovery
We discuss the importance of “active involvement” in recovery as a way of managing CODs. We review domains Continued on page 19
COUNSELOR CONCERNS
Simple Solutions or Real Results Gerald Shulman, MA, MAC, FACATA
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n a previous column (April 2018), I wrote about the genesis of the opioid crisis. While possibly informative, it provided little information about potential solutions currently being offered and identifying those whose major effect is more to make people feel good about doing something, whether effective or not. One of the points I made in the column was that the genesis of the current opioid crisis and its solutions are multifactorial. However, we continue to look for simple solutions while about 115 people die from opioid overdoses daily (NIDA, 2018b). Physician Overprescribing
The US has 4.6 percent of the world’s population, but US residents consume 99 percent of all the hydrocodone and 81 percent of all the oxycodone prescribed worldwide (Compton, 2017). One effort to reduce opioid addiction and overdose is to legislate a limit of three days of opioids for acute pain, with a prescriber able to justify up to seven days. The thought is that if we limit the amount
of opioids prescribed, we can reduce overdoses. Let us look a little bit more carefully at this. Since many people begin using opioids originally prescribed for someone else, we can assume that fewer prescription doses available might reduce the availability of prescription opioids to those people for whom it was not prescribed. But the reality is that any effect this might have would be small. We already see what happens when this occurs: when individuals cannot obtain prescription opioids because of increased price and lesser availability, they turn to buying prescription and illicit drugs like heroin (with or without fentanyl) on the street. Fentanyl overdoses now surpass prescription opioids as the most common cause of opioid overdoses in the US (NIDA, 2018a). Prescribing opioids is now limited to the treatment of acute pain, which is described as usually occurring suddenly and with a known cause like an injury, surgery, or infection. For example, pain from a wisdom tooth extraction, an outpatient medical procedure, or a broken arm after a car crash would be classified as known causes. Acute pain normally resolves as the body heals, but chronic pain, on the other hand, can last weeks or months past the normal time of healing (CDC, 2018). www.counselormagazine.com
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COUNSELOR CONCERNS I have spoken with two orthopedic surgeons who claim all the paperwork surrounding these three- and seven-day limits is overwhelming, and when the physicians’ time is already spent with nonproductive activities such as prior authorization and justifying their decisions to payers, the time for justifying the three- or seven-day opioid prescription is untenable. Both surgeons stated that as a result of the extensive surgery they perform, it is unreasonable to assume that none of their patients are likely to require more than a three-day supply of opioids, and some even more than a seven-day prescription. Since opioids are schedule II drugs (DEA, n.d.), no refills are permitted. Should patients actually require opioids beyond the seven days, they would have to return to the physician, receive a hard copy of the prescription, and return to the filling pharmacy. These patients, by the very nature of the short-term pain resulting from their surgery, are least able to do so.
Prescription Drug Monitoring Programs (PDMPs)
Prescription drug monitoring programs (PDMPs) are statewide electronic databases that track all controlled substance prescriptions. Authorized users can access prescription data such as medications dispensed and doses. PDMPs improve patient safety by allowing clinicians to n Identify patients who are obtaining opioids from multiple providers n C alculate the total amount of opioids prescribed per day in morphine milligram equivalents (MME) n I dentify patients who are being prescribed other substances that may increase risk of opioid overdose (e.g., benzodiazepines) However, because PDMPs are statespecific and not all states have PDMPs, it cannot provide information about controlled substances prescribed across state lines. An even greater problem is that they are not universally used by prescribers. In a survey in of emergency room physicians in Florida, on 88 completed surveys—62 percent attendings, 14 percent residents, and 21 percent extenders—it was 18
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found that only half used the PDMP only if they suspected patients would misuse the medication, 21 percent reported they rarely used the system, and only 3 percent reported using it every time they prescribed opioids (Young, Tyndall, & Cottler, 2017). Furthermore, while opioid overprescribing is the target, the majority of opioid overdoses are caused by heroin and fentanyl. While fentanyl is a schedule II drug approved for the treatment of pain, most of the fentanyl involved in overdoses is illicitly manufactured in Mexico and China. Further complicating the situation is that people on long-term opioid treatment for chronic pain—patients who are stable and do not meet the diagnostic criteria for an opioid use disorder, though they likely are physically dependent— will have to undergo nonconsensual tapers since opioid prescribing is now limited to acute pain. These patients tend to be older (72 percent were aged forty-five years of age or older and 29 percent were 65 or older; Gomes, Tadrous, Mamdani, Patterson, & Jurrlink, 2018), but the burden of opioid-related death falls disproportionately on younger adults (Frank et al., 2017). Another strategy is to avoid higher risk formulations, but the data hints that the return on investment by prescribing extended-release or long-acting formulations may be low (Hwang et al., 2018).
Overdose Treatment
There is a drug available that can reverse most opioid overdoses: naloxone. Even though it is an evidence-based practice, there are still groups that do not make it available because of cost or the belief that they will not run into an overdose situation. In my training workshops, I still find addiction treatment providers who do not routinely keep it on hand.
Antiaddiction Drugs
We now have available to us evidencebased drugs that will reduce or eliminate opioid craving in those addicted to opioids and blunt the response to opioids if they use. While methadone was approved in 1947 (IOM, 1995), it was the only antiaddiction drug for the treatment of opioid dependence for many years until the approval of buprenorphine in its two best
known forms, Subutex and Suboxone, the latter of which is buprenorphine plus naloxone. Originally, physicians were restricted to a thirty-patient limit the first year and one-hundred patients the second year. Physicians permitted to prescribe the drug had to go through an eight-hour course. Because of unmet need, the limit has been raised to 275 patients via the Cures Act (Sarpatwari & Kesselheim, 2015) and can also be prescribed by physician’s assistants and nurse practitioners after taking a twenty-four-hour course. There are two interesting phenomena. The first is that of those physicians approved to prescribe (i.e., those who have a buprenorphine waiver), only less than half are actually prescribing (Thomas et al., 2017). This is further complicated by the reality that there are areas of the country, usually rural, where there are no buprenorphine-waivered prescribers. Interestingly, medical providers can prescribe buprenorphine only after completing an eight-hour training course and obtaining a waiver, while those same physicians can prescribe any schedule II drugs, including opioids, which are considered one of the causes of our current opioid crisis, without any special training.
Solutions
So what are the solutions? Each of the “solutions” offered may have some benefit (along with some harm), but none is the answer to the opioid crisis. For the problem of an inadequate number of buprenorphine-waivered physicians, a long-term solution may be better medical school training and a short-term solution may be incentivizing more physicians to become waivered and having those who are waivered actually prescribe. More education should also be provided to the general public, not just headlines about the number of people dying from opioid overdoses. Reconsideration should be given to forced tapers of those patients who are stable on long-term use of opioids and do not meet criteria for an opioid use disorder. For a significant part of the population, I believe that we are looking in the wrong place for solutions. Rather than just restricting availability and use, we
COUNSELOR CONCERNS should be considering the underlying issues that are much of the seedbed for the opioid crisis: unemployment and substandard living conditions including homelessness and lack of transportation and childcare. Should we do this, we will also reduce addiction in general and make a positive contribution to reducing crime. c About the Author Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
References Centers for Disease Control and Prevention (CDC). (2018). Opioids for acute pain – what you need to know. Retrieved from https://www.cdc.gov/drugoverdose/pdf/patients/ Opioids-for-Acute-Pain-a.pdf Compton, W. M. (2017). Research on the use and misuse of fentanyl and other synthetic opioids. Retrieved from https://www.drugabuse.gov/about-nida/legislativeactivities/testimony-to-congress/2017/research-usemisuse-fentanyl-other-synthetic-opioids Drug Enforcement Administration (DEA). (n.d.). Drug scheduling. Retrieved from https://www.dea.gov/ drug-scheduling Frank, J. W., Lovejoy, T. I., Becker, W. C., Morasco, B. J., Koenig, C. J., Hoffecker, L., . . . Krebs, E. E. (2017). Patient outcomes in dose reduction or discontinuation of longterm opioid therapy: A systematic review. Annals of Internal Medicine, 167(3), 181–91. Gomes, T., Tadrous, M., Mamdani, M. M., Patterson, J. M., & Jurrlink, D. N. (2018). The burden of opioid-related mortality in the United States. JAMA Network Open, 1(2), e180217. Hwang, C. S., Kang, E. M., Ding, Y., Ocran-Appiah, J., McAninch, J. K., Staffa, J. A., . . . Meyer, T. E. (2018). Patterns of immediate-release and extended-release opioid analgesic use in the management of chronic pain, 2003–2014. JAMA Network Open, 1(2), e180216. Institute of Medicine (IOM). (1995). Federal regulation of methadone treatment. Washington, DC: National Academies Press. National Institute on Drug Abuse (NIDA). (2018a). Nearly half of opioid-related overdose deaths involve fentanyl. Retrieved from https://www.drugabuse.gov/newsevents/news-releases/2018/05/nearly-half-opioid-relatedoverdose-deaths-involve-fentanyl National Institute on Drug Abuse (NIDA). (2018b). Opioid overdose crisis. Retrieved from https://www.drugabuse. gov/drugs-abuse/opioids/opioid-overdose-crisis Sarpatwari, A., & Kesselheim, A. S. (2015). The 21st Century Cures Act: Opportunities and challenges. Clinical Pharmacology and Therapeutics, 98(6), 575–7. Thomas, C. P., Doyle, E., Kreiner, P. W., Jones, C. M., Dubenitz, J., Horan, A., & Stein, B. D. (2017). Prescribing patterns of buprenorphine-waivered physicians. Drug and Alcohol Dependence, 181, 213–8. Young, H. W., II, Tyndall, J. A., & Cottler, L. B. (2017). Current utilization and perceptions prescription drug monitoring programs among emergency medicine providers in Florida. International Journal of Emergency Medicine, 10(1), 16.
Topics
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of recovery, roadblocks, and what helped clients in the past since many have had episodes of stable recovery from either or both types of disorders. When I ask clients to state Step One of the Twelve Step program, they usually start with the word “I.” I change the focus to “We” to facilitate connecting with peers in recovery rather than taking a solo approach. I emphasize the importance of reducing negative and increasing positive attitudes (e.g., openness to learn), challenging faulty thinking, learning and using basic recovery skills (e.g., managing negative emotions), and gaining knowledge about their disorders, treatment options, and paths to recovery. I share findings from clinical trials and recovery surveys from the US and other countries to show that long-term involvement in recovery is associated with improvements in all areas of life: health and engagement in healthy behaviors, mental health, spiritual health, family relationships, work and employment, financial condition, and community involvement.
Relapse
We discuss the need to take sufficient time to stabilize from a current relapse or recurrence of illness. Then, as time progress, clients can identify early signs of relapse and high-risk factors to address some of these issues during their treatment episode. I find it helpful to share the insights and research summaries of William White from his blogs, articles, and books. His focus on recovery is exceptional, and he offers many tools to aid clients in enhancing their recovery and reducing relapse risk.
Social Support and MutualSupport Programs
We discuss the need for positive social support as a way to avoid or reduce the impact of negative people and/or unhealthy relationships on recovery. We discuss common resistances to reaching out for help and support,
and reasons why so many clients do not participate in community mutual-support programs. I share research on the benefits of active involvement in mutualsupport programs. We discuss different types of mutual-support programs with the caveat that many communities have few or no non-Twelve-Step programs. We also discuss tools such as chat rooms or smartphone applications to aid recovery. Messages conveyed are to find a path to recovery, change it if it does not work, and let others be supportive.
Lessons Learned
Sharing time in group with IOP members is always one of the highlights of my day. I am grateful to have the chance to remain in the trenches helping others fighting for their recovery. What impresses me is that many clients, despite their complex histories of multiple disorders and related psychosocial and medical problems, want to improve their lives. They listen attentively, engage in meaningful discussions, self-disclose their struggles, and show openness to new ideas. I am also impressed by the resilience of clients who make decisions to reengage in treatment after periods of relapse or recurrence because the healthy part of them wants recovery and is willing to take steps to regain it. Since I have been part of this program for decades, I often see clients who have returned for another episode of treatment—some express guilt and shame when they see me, and judge themselves harshly. I tell them I am glad to see them, and that returning to treatment shows they want to get back on track in recovery and improve their lives. Many of these clients need to increase their self-compassion. c About the Author Dennis C. Daley, PhD, served for fourteen years as the chief of addiction medicine services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. Dr. Daley has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.
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