Advances in Addiction & Recovery (Summer 2020) by NAADAC, the Association for Addiction Professionals

Summer 2020 Vol. 8, No. 3

Addiction, Recovery, and

Military Cultural Competence By Duane K.L. France, MA, MBA, LPC

PLUS • Spirituality as a Healing Approach Substance Use Disorders • The Importance of Belongingness • NIAAA Scientists Highlight Alcohol-Related Mortality Increase in the United States

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Showcase your institution, product, or organization in front of NAADAC leadership and constituents from across the country and around the world at the virtual 2020 Annual Conference: Learn l Connect l Succeed, taking place from September 24 - 26, 2020! NAADAC offers various levels of sponsorship to fit your budget, including some of these custom sponsor opportunities: Custom Branded Conference Swag Boxes l Commemorative T-shirt l Virtual Wellness Breaks l Product Theatre l Live Vendor Demos l

Don’t be left out in September! Reserve your space now! For more information, visit naadac.org/ac20-exhibit-sponsor-advertise or contact Irina Vayner at ivayner@naadac.org.

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And so much more!

SUMMER 2020 Vol. 8 No. 3 Advances in Addiction & Recovery, the official publication of NAADAC, is focused on providing useful, innovative, and timely information on trends and best practices in the addiction profession that are beneficial for practitioners. NAADAC, the Association for Addiction Professionals, represents the professional interests of more than 100,000 addiction counselors, educators, and other addictionfocused health care professionals in the United States, Canada, and abroad. NAADAC’s members are addiction counselors, educators, and other addiction-focused health care professionals, who specialize in addiction prevention, treatment, recovery support, and education. Mailing Address 44 Canal Center Plaza, Suite 301 Alexandria, VA 22314 Telephone 703.741.7686 Email naadac@naadac.org Fax 703.741.7698 Managing Editor

■ F EAT UR ES 18 Addiction, Recovery, and Military Cultural Competence By Duane K.L. France, MA, MBA, LPC

Kristin Hamilton, JD

Advisor

Jessica Gleason, JD

Features Editor

Samson Teklemariam, MA, LPC, CPTM

Graphic Designer

Austin Stahl

Editorial Advisory Committee

Kirk Bowden, PhD, MAC, NCC, LPC Rio Salado College EAC Chair

Kansas Cafferty, LMFT, MCA, CATC, NCAAC True North Recovery Services National Certification Commission for Addiction Professionals (NCC AP)

Deann Jepson, MS Advocates for Human Potential, Inc.

24 Spirituality as a Healing Approach Substance Use Disorders

Roy Kammer, EdD, LADC, ADCR-MN, CPPR, LPC (CD), NCC Hazelden Betty Ford Graduate School of Addiction Studies

28 The Importance of Belongingness

James McKenna, MEd, LADC I McKenna Recovery Associates

By Kimberley L. Berlin, LCSW, CSAC, MAC, SAP By Nancy A. Piotrowski, PhD, MAC

31 NIAAA Scientists Highlight Alcohol-Related Mortality Increase in the United States By the National Institute on Alcohol Abuse and Alcoholism (NIAAA)

■ DEPA R T M EN TS 4 President’s Corner: President’s Farewell with Gratitude

By Diane Sevening, EdD, LAC, MAC, NAADAC President

6 From The Executive Director: Becoming a Part of Social Change

By Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, NAADAC Executive Director

Donald P. Osborn, PhD, LCSW, LMFT, LCAC, MAC Indiana Wesleyan University Joseph Rosenfeld, PsyD, CRADC, HS-BCP Elgin Community College Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP NAADAC, the Association for Addiction Professionals Margaret Smith, EdD, MLADC Ottawa University & Keene State University Article Submission Guidelines We are interested in accepting any interesting and topical articles that address issues of interest to addiction-focused professionals. Please submit story ideas and/or articles to Features Editor, Samson Teklemariam at steklemariam@naadac.org. For more information on submitting articles for inclusion in Advances in A ddiction & Recovery, please visit www.naadac.org/advances-in-addiction-recovery.

10 Ethics: Inspiring Transformation: Equity for All

Disclaimer It is expressly understood that articles published in Advances in Addiction & Recovery do not necessarily represent the view of NAADAC. The views expressed and the accuracy of the information on which they are based are the responsibility of the author(s) and represent the wide diversity of thought and opinion within the addiction profession.

12 Advocacy: Social Injustice – How it Affects the Addiction Community

Advertise With Us For more information on advertising, please contact Irina Vayner, NAADAC Marketing Manager, at ivayner@naadac.org.

14 Membership: NAADAC 2020 Annual Conference

Advances in Addiction & Recovery The Official Publication of NAADAC, the Association for Addiction Professionals ISBN: 978-0-9885247-0-5

8 Certification: Announcing a New Needed Step on the Career Ladder By James “Kansas” Cafferty, LMFT, MAC, NCAAC

By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethics Committee Chair By Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, NAADAC Executive Director

32 NAADAC CE Quiz 33 NAADAC Leadership

This publication was prepared by NAADAC, the Association for Addiction Professionals. Reproduction without written permission is prohibited. For more information on ob taining additional copies of this publication, call 703.741.7686 or visit www.naadac.org. Published August 2020

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■ P R ESID ENT ’S CORN E R

President’s Farewell with Gratitude By Diane Sevening, EdD, LAC, MAC, NAADAC President As my Presidency comes to an end, I want to take this opportunity to say thank you! It has been the honor of my life to serve as the NAADAC President and work with such a dynamic and professional team. My experiences with the NAADAC officers, staff, and members are truly humbling and kept me inspired and motivated to keep moving forward in maintaining the mission of NAADAC. The past two years have flown by so quickly with so many exciting achievements by NAADAC and the addiction profession. NAADAC’s advocacy work over the past two years has been significant and exciting. During my time as President, NAADAC hosted two Advocacy in Action Conferences: one in November 2018 with Jim Carroll, Director of the Office of National Drug Control Policy (ONDCP), as the keynote speaker and one in April 2019 with June Sivilli, Associate Director of Public Health, Education and Treatment at the ONDCP, as the keynote speaker. With the support of Polsinelli, NAADAC’s government relations firm, NAADAC is developing an increasing presence on Capitol Hill and proudly continues to advocate for the need for national credentials for the addiction professional, funding for the addiction workforce, maintaining 42 CFR Part 2 for protection of patient confidentiality and access to treatment, and other vital needs of our profession and those we serve. House Resolution 419, Acknowledging the contributions of America’s addiction professionals and their commitment to delivering evidencebased practice to individuals with substance use disorders through recognized standards of education, training, and competencies, was introduced to the House of Representatives on June 3, 2019, to recognize that the House of Representatives supports the delivery of evidence-based care for substance use disorder by acknowledging the contributions of addiction professionals and encourages that recognized credentials reflect the requisite knowledge, training, and competencies for delivering quality, effective substance use disorder counseling.

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A five-year Strategic Plan for NAADAC was developed with the involvement of NAADAC leadership, NCC AP commissioners, NAADAC staff, and NAADAC membership. The plan is based on four pillars, Education and Professional Development, Advocacy and Influence, Membership and Affiliates, and Credentialing and Standards. Implementation of the plan is underway and will continue on. A new association management system was implemented to better accommodate the multifaceted areas of NAADAC and allow for better service to the membership. NAADAC members now have immediate access to their webinar training certificates, membership information, and more.

The National Certification Commission for Addiction Professionals (NCC AP) tests have been updated. The NCC AP commissioners, under the leadership of Jerry Jenkins, rewrote and beta tested test questions for the National Certificated Addiction Counselor Level I (NCAC I), National Certified Addiction Counselor Level II (NCAC II), and Master Addiction Counselor (MAC) tests. The new tests are currently in use both nationally and internationally, and there has been an increase of national and international credentialing boards utilizing the NCC AP resources and tests over the past several years. NAADAC committees are increasingly active and accomplishing their goals and producing new resources to expand NAADAC membership, advocacy, and involvement. Most recently, NAADAC formed a new committee to address critical issues in the Black community. NAADAC sent two professional delegations of addiction professionals to Europe, including one to Kosovo in May 2019 and one to Greece in March 2020. These delegations were a concerted effort between NAADAC, National Council for Behavioral Health, and World Learning. Participants were provided with opportunities to meet with public health leaders and addiction/mental health directors, counselors, and staff, as well as to learn about the progress and advances in addressing addiction and mental health in these countries.

I am confident that NAADAC will continue to move forward with Mita Johnson as the incoming President and Angela Maxwell as the President-Elect. They are both great leaders with a passion for the addiction profession. Whether you are a lifetime member or a new member of NAADAC, a state affiliate board member, or a committee member, please consider running for a leadership position. It is a rewarding experience you will never forget. Thank you for granting me this experience. It has been a pleasure serving you! Diane Sevening, EdD, LAC, MAC, is an Assistant Professor at the University of South Dakota (USD) School of Health Sciences Addiction Counseling and Prevention Department (ACP), has over 35 years of teaching experience, and is a faculty advisor to CASPPA. In addition to serving as NAADAC President, Sevening is also a member of the South Dakota Board of Addiction and Prevention Professionals (BAPP) and Treasurer of the International Coalition for Addiction Studies Education (INCASE). Her clinical experience involves seven years as the Prevention and Treatment Coordinator Student Health Services at USD, Family Therapist at St. Luke’s Addiction Center in Sioux City, IA for one year, and two years as clinical supervisor for the USD Counseling Center. Sevening has been the Regional Vice President for NAADAC North Central Region, the Chair of the Student Committee for NAADAC, an evaluator for the National Addiction Studies Accreditation Commission (NASAC), and currently a member of the NASAC Board of Commissioners.

NAADAC’S FREE CULTURAL HUMILITY WEBINAR SERIES AVAILABLE ON DEMAND: Understanding SUD Disparities Among LGBTQIA People Social Class Bias and the Negative Impact on Treatment Outcomes Do You Know Who You Are and For Whom You Provide Services?

Critical Issues in LGBTQIA Patient Care Substance Use Disorder Treatment for Latinx Communities Why It Matters Now More Than Ever Four Directions of Diversity - Honoring Differences

COMING UP:

Social Responsibility in the Addiction Profession Wednesday, September 9, 2020 @ 3:00-5:00pm ET (2 CT/1 MT/12 PT)

EARN 14.5 CES BY WATCHING THE FULL SERIES!* *NAADAC Members may receive CEs for free, and non-members must pay to receive CEs ($20 for 1.5 CEs or $25 for 2 CEs). Proceeds from this webinar series through the end of the year will be donated to a scholarship fund created in partnership with the Thurgood Marshall College Fund to benefit Black students.

Find the full series at naadac.org/cultural-humility-webinars.

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■ F R O M T H E E X E C U T I VE DI RE C TOR

Becoming a Part of Social Change By Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, NAADAC Executive Director The past months have placed the glaring inequities faced by people of color, particularly Black people, on display in a way that has not been seen in decades. Society is – for the moment, at least – finally paying attention to the wide range of racism that minority individuals face on a daily basis. We, as addiction professionals, have a duty to our clients, our profession, and our communities to be a part of the social change that is occurring. How do we affect this social change? We need to begin with listening to develop understanding and awareness. Listening and learning of the history of oppression, privilege, and the effects on individuals, families and communities allows empathy and understanding to develop. We must also assess our own behaviors and make intentional changes. We must be intentional in both our words and our actions in every aspect of our lives to combat the existing institutional racism and strive to be anti-racist; there is no room for neutrality and there is nothing political about a human life. Lastly, we must constantly evaluate the change. Are our efforts effective? Are they achieving our goals? Are there unintended consequences? What further actions need to be made? Addiction professionals are a community of people who are passionate about the people we serve. It is widely accepted and understood in our profession that individuals with addictive and mental health disorders have experienced prejudices and stigma. Many of our professionals have engaged in advocacy, education and awareness of these diseases and helped systems in our communities to engage in change to become more aware and supportive of people with addictive and mental health disorders.

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People of color, including and perhaps especially Black people, with addictive and mental health disorders face added prejudices and it is vital that we understand the connection between the disparities that continue for the clients that we serve and that we are not yet serving, often due in large part to the disparities in the healthcare system. We are called to be intentional about our voice, our social behaviors, and our actions to be inclusive and take action for social change. Please join NAADAC in doing so by getting involved in the new committee we have formed on critical issues in the Black community, by listening to the new webinars on Cultural Humility, by donating to the Thurgood Marshall College Fund or getting involved in your own community to educate people about addictive disorders and disparities experienced by people of color, and advocate for opportunities, funding, and social justice for our clients and their families. Together – we can – and do – make a difference! Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, is the Executive Director of NAADAC, the Association for Addiction Professionals, and has worked as an addiction professional for over 35 years. She has been a trainer in Domestic Violence/Anger Management and Conflict Resolution for over 25 years as well as an international, national and state trainer in a variety of topics. Moreno Tuohy is also a curriculum writer in addiction screening and evaluation, counseling methods, conflict resolution, co-occurring disorders, and medicated assisted treatment and recovery, and has written articles published in national and other trade magazines. She holds a Bachelor’s degree in Social Work and is certified both nationally and in the State of Washington.

NAADAC Supports Black Lives Matter Across the country, individuals, families, and communities are dealing with trauma and loss that is compounding a history of trauma. We acknowledge that the pain and suffering felt in our communities is real, and, like you, are experiencing renewed and legitimate anger, grief, frustration, and sorrow. We stand against the injustices in our society. NAADAC’s mission is to lead, unify and empower addiction focused professionals to achieve excellence through education, advocacy, knowledge, standards of practice, ethics, professional desvelopment and research. We will never achieve this until there is universal acknowledgment that Black lives matter. The senseless deaths of George Floyd, Ahmaud Arbery, Breonna Taylor, and countless other as a result of systemic, institutional racism provides a stark call to action. Implicit bias and racial disparities are present across the health care spectrum, resulting in disproportionately poorer outcomes for communities of color. These shortcomings needlessly cost Black lives. We must provide better addiction treatment and care of individuals in minority populations. Quality treatment provided by nationally certified counselors must be made available to every person who needs it. We also need to make more room for African Americans within the addiction profession. From workforce development to improved support for those already within our profession, we need to do better. NAADAC has long supported and been involved minority-focused initiatives, such as the Minority Fellowship Program and partnerships with historically Black colleges and universities (HBCU), but this is not enough.

In the days since George Floyd’s murder, we have been listening to what you, our constituents, and the members of our communities, particularly the Black members of our communities, have been saying and thinking about how we can effectuate change. As a first step, we hosted a Virtual Town Hall following our June 10th webinar, Substance Use Disorder in the African American Community, to learn how we can best support our members and constituents in the African American community and provide tools and resources for clinicians to support those they serve. We have formed a new NAADAC committee focused on critical issues in the Black community and are donating all proceeds through the end of the year from our ongoing Cultural Humility Webinar Series to a scholarship fund created in partnership with the Thurgood Marshall College Fund to benefit Black students seeking an addiction-focused degree. We acknowledge that more work is needed. We are committed to doing the work. We are listening.

To learn more, get involved with NAADAC’s efforts, or provide comments on how addiction professionals or NAADAC can best respond to and support our members and their clients during this time, please email naadac@naadac.org. We want to hear from you.

This statement was originally released on June 10, 2020.

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■ CER T IF IC AT I ON

Announcing a New Needed Step on the Career Ladder: The Nationally Certified Addiction Counselor – Associate Level (NCAC-A) By James “Kansas” Cafferty, LMFT, MAC, NCAAC, NCC AP Chair The National Certification Commission for Addiction Professionals (NCC AP) is excited to announce the launch of the Nationally Certified Addiction Counselor – Associate Level (NCAC-A), a new national credential to add a crucial and missing step on the career ladder. People coming into the addiction workforce from a variety of backgrounds are finding it increasingly difficult, due to a variety of factors outside of their control, to get placements and employment needed to accrue the required clinically supervised experiential hours for their state licenses/credentials and national credentials. With an addiction workforce shortage in the United States, NCC AP saw the need to create a step on the career ladder that would allow people to evidence their education and training to enhance their employability and opportunities to continue on their path to become licensed/credentialed addiction professionals. The NCAC-A national credential certifies that a person has taken a minimum of 270 hours of addiction-specific education, including six hours of ethics training and six hours of HIV/Bloodborne Pathogens training, has passed the rigorous National Certified Addiction Counselor Level I (NCAC I) examination, and is bound by the NAADAC/NCC AP Code of Ethics. The intention is that by gaining a NCAC-A national credential and evidencing the required education, knowledge, and ethical standards for a NCAC I national credential, an emerging addiction professional will have an easier time gaining employment to accrue the 6,000 hours of supervised experience as an SUD/Addiction Counselor required to achieve the NCAC I. The new credential will also benefit treatment providers by increasing the quality of the new professionals they hire and allocate limited clinical supervision hours to. The scope of practice of the NCAC-A will mirror that of the NCAC I, but with specific supervision requirements, including an ongoing and documented relationship with a fully credentialed supervisor. The NCACA credentialed counselor will not be able to operate autonomously, but may perform the normal duties of a counselor within the same treatment settings as an NCAC I. More information on the specific details of the supervision requirements will be forthcoming from NCC AP in advance of the credential becoming available to qualified individuals. This new credential is supported by NAADAC’s advocacy efforts with insurance companies to expand acceptance of NCC AP’s national credentials, with Medicaid to add this new level to the scopes of practice for reimbursement, including for 1115 Waiver programs, and with Congress to better explain the role of addiction counselors in the continuum of care and the need for increased funding for education, reimbursements, tuition assistance and more. NCC AP is very excited about the implications of this new credential, which will be launched in January 2021, and to continue the tradition in this profession of placing a great value on training and experience. We

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believe that with the added emphasis on a supervised experience that this credential carries, we have furthered its value and added to the strength of the profession.

Commissioner Recruitment Have you ever considered serving the profession at the level of a thought leader? Serving on the National Certification Commission for Addiction Professionals could be an avenue you might want to consider exploring. We are actively recruiting new Commissioners at this time. In an effort to represent various regions and various levels of credentialing, we are currently especially interested in those who carry a National Certified Peer Recovery Support Specialist credential and Nationally Certified Addiction Counselor Level II, but we are not exclusively interested in these credential holders. If you have the heart and passion to serve, and believe you meet the qualifications to serve, we are interested in hearing from you! Please explore our application here to explore a new lens on your camera as you continue your work to heal the world from substance use disorder.

James “Kansas” Cafferty, LMFT, MAC, NCAAC, serves as the Chair to the National Certification for Addiction Professionals. He has been in the field of substance use disorder treatment since 1997, a year after he entered into recovery himself. He currently serves as the Clinical Director at the Aton Center, a residential treatment center based in the suburbs of San Diego, CA. He has been an active member of NAADAC for 15 years.

NAADAC, the Association for Addiction Professionals, represents the professional interests of more than 100,000 addiction counselors, educators and other addiction-focused health care professionals in the United States, Canada and abroad.

What Can NAADAC Do for Your Organization?

Organizational Membership

NCC AP National Credentials

Join NAADAC as an Organizational Member and help brand National credentials tell third-party payers, government your organization and strengthen its image around the entities, other practitioners, and the public that your country. Organizational Members receive: practitioners are qualified and have met national competency • A listing in NAADAC’s online Organizational Member standards. Employees who are NCC AP certified receive: Directory, available to the public.

• Discounts to advertise in NAADAC’s bi-weekly Addiction & Recovery eNews (sent to 48,000+ addiction professionals) and at NAADAC’s Annual Conference and other events. • $100 discount on NAADAC Approved Education Provider application. • And much more!

• Recognition for having in-depth knowledge, proven work experience, competence, and dedication to the addiction profession. • Increased reimbursement rates. • And much more!

Staff Training & Development

NAADAC can also partner with your organization to provide Individual Memberships for Staff education, training, and professional development to NAADAC Organizational Members receive a $20 discount on enhance your staff’s knowledge level, skill set, and each individual NAADAC Membership purchased for your staff. competencies, and provide continuous education to your credentialed professionals. Training includes: The benefits of NAADAC Individual Memberships include: • Online education through NAADAC’s Free Online • Access to over 145 hours of FREE CEs (worth $2,175) Webinar Series and Specialty Online Trainings, and access through NAADAC’s Online Webinar Series, available on to NAADAC’s online magazine Advances in Addiction & demand 24 hours per day/7 days a week. Recovery. • Reduced rates on all NAADAC publications and • Access to online training and HIPAA-compliant telehealth independent study courses. platforms through NAADAC’s telebehavioral health • Reduced rates for NAADAC sponsored conferences, partnerships. public policy events, regional meetings, and workshops. • And much more! • And much more!

Learn more about NAADAC by visiting www.naadac.org or by calling 703.741.7686!

Be a part of the NAADAC community! www.facebook.com/Naadac/

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■ E T H ICS

Inspiring Transformation: Equity for All By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethics Committee Chair

NAADAC Code of Ethics (2016) I-1: Addictions Professionals understand and accept their responsibility to ensure the safety and welfare of their client, and to act for the good of each client while exercising respect, sensitivity and compassion. Providers shall treat each client with dignity, honor and respect, and act in the best interest of each client. I-20: Addiction Professionals are called to advocate on behalf of clients at the individual, group, institutional and societal levels. Providers have an obligation to speak out regarding barriers and obstacles that impede access to and/or growth and development of clients. III-29: Providers shall be advocates for their clients in those settings where the client is unable to advocate for themselves. III-30: Addiction Professionals are aware of society’s prejudice and stigma towards people with substance use disorders, and willingly engage in the legislative process, educational institutions and public forums to educate people about addictive disorders and advocate for opportunities and choices for our clients. 2020 has been quite a year so far, a year that has caused many of us to critically survey and reflect on our core beliefs, ethics, and professional practices. Emotionallyevocative words are lingering in our conversations – words like equity, social justice, advocacy, racism, diversity, civil rights, and radical change. It does not take much to see that what is transpiring on the societal landscape is immediately affecting and being affected by our clients, colleagues, organizations, and families. Where does that leave us – clinicians, peers, supervisors, staff and allied providers – who work with a highly stigmatized population that does not always experience equity in health care? Do we have a place in this journey? Can we afford to not engage in the movements around us that are fighting for transformative practices and system change? These questions help me to appreciate how Barker (The Social Work Dictionary, 5th ed., 2003) conceptualized “social justice” as a state in which equity, fairness, opportunity, and success for all diverse members of a society are commonplace and expected, in which there is acknowledgement that personal and structural success and struggles in a society are intertwined, and in which inequities of the past are acknowledged and redressed. Practitioners who work with individuals living with addictions and recovery have a key role to play in addressing the social justice challenges inherent in our profession. These challenges can be viewed through four distinct yet interconnected filters on the social justice lens: access, agency, advocacy and action. Access refers to the fact that all clients should have access to viable, evidence-based treatment modalities and recovery programs. Agency refers to the fact that our clients should be empowered to use their voice to assert their rights, share their concerns, and act in ways that create positive change. Advocacy is about using our influence to effect change where needed. Action requires providers to recognize 10

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inequity and act towards equity. Viewed through this lens and these filters, it becomes clear that addiction is a social justice issue and that we, as practitioners, have the ability to make an impact in the quest for true social justice. Addiction is more than just an individualized issue; addiction is a systemic problem affecting families, neighborhoods, communities, and states. If “equity” means equal access to and quality of care for all, members of disadvantaged and marginalized communities do not have the same access to treatment and recovery supports that others of means do. We can advocate here, by identifying and addressing barriers to equitable care. If the concept of “diversity” incorporates acceptance and respect for the full range of human expression in their cultural, socioecological and historical contexts, communities of diversity have not seen the same positive results in treatment and recovery using the current toolbox of evidence-based practices. We can be proactive here by promoting and using tools that have greater individualized success with our client population. ATTC Messenger (https://attcnetwork.org/centers/network-coordinatingoffice/attc-messenger-august-2014-socialjustice-lens-addictions) offers a list of social justice questions all providers ought to consider and act on: A social justice lens for work with individuals/families: • To what degree are our efforts with individuals and families connected to the diverse challenges they face in the real worlds they inhabit? • Are there disparities in who or how treatment need is acknowledged and accessed? • Are such issues as poverty, homelessness, other health challenges, and other human rights concerns intersecting with the need for addictions treatment, and how well do we attend to these challenges? • Do we acknowledge both diversity, and the diversity within diverse groups, in the way that we offer, deliver, and create ongoing recovery supports? • Is the client’s voice and a true sense of empowerment and strengths perspective active, visible, and embedded into the way that services are delivered? How is the client’s voice and authority apparent? • Do we have and value a welcoming and inclusive approach to all people equally? • Are we open to the ideas and opinions of others as equal participants? • Are we promoting the value of multiple perspectives? • Do we demonstrate respect for democratic processes and civil society? • Do we value community and cooperation? • Are we responsive to all – equally?

• Are we encouraging clients to find their own voice? Are we empowering clients? A social justice lens for work with communities: • To what degree do we acknowledge (and participate in addressing) the economic and health disparities across the board that play a role in the communities in which addictions are most apparent? • Does the community in which treatment is being offered have a voice in the design, function, operation, and overall measurement of success of the program? • Are community’s efforts to resolve addiction problems heard, respected, and when possible, partnered with to create networks of possibility rather than contribute to systems fragmentation? • Are we building skills to affect systemic changes, using diverse strategies? • Have we developed an understanding of one’s position and privilege with the community? • Have we developed an awareness of social realities? • Have we developed our analytical abilities? Have we developed an awareness of how to respond where change is needed? • How have we used our voice and agency to enhance the ability to influence outcomes? • How have we empowered the voice of the disenfranchised and minorities? A social justice lens for work with organizations: • To what degree do our treatment organizations challenge themselves to review, consider, and resolve diversity-related disparities in treatment access and outcomes? • Do our organizational missions reflect more than an individualistic notion of addiction and recovery, but also focus on social and social justice levers for action, engagement, and improvement? • Do our treatment organizations create meaningful learning opportunities for treatment practitioners to explore their own biases, stereotypes, and blind spots regarding the causes and progression of addictive behavior, as well as the possibilities of success for recovery among diverse populations? • Do our treatment organizations recruit, hire, and promote diverse staff to reflect the diversity of the communities in which they provide services? • Do our governing structures (Boards of Directors, etc.) have more than tokenistic representation of diverse communities? • Do practitioners understand their right to create change? • Do practitioners and clients understand their abilities to affect their mutual realities? • Are practitioners encouraged to think critically about social problems? • Has the organization developed leadership skills amongst practitioners? A social justice lens for work with policy: • To what degree do we actively participate in efforts to better attend to the policy drivers that limit and/or control access and/or availability of treatment for vulnerable and marginalized communities? (Who gets access to the “cutting edge” treatments and why? How long do people have to wait for the type of treatment that best meets their needs?)

• Do we partner with communities to build better prevention and early intervention opportunities, rather than default to services closely aligned with and/or embedded into juvenile/criminal justice programs as the only service option? • How can we better focus on community wellness as a policy driver for greater economic justice, school success, health, and overall wellbeing indicators for vulnerable populations? • Are practitioners and leaders promoting transformative work for the betterment of others? • Do practitioners and leaders understand that an injury to one is an injury to all? • Do practitioners, leaders and clients value co-operation and coalition-building? • Are practitioners and leaders working across differences to find common ground? • Are practitioners and leaders advocating for broad interconnections and common goal-setting and actions? • Does the practitioner, leader and agency recognize the strength in unity? • Are practitioners, leaders, and clients effective in mediating and resolving conflict to build alliances? • Are practitioners, leaders, and clients encouraging collaboration with the disenfranchised and minorities? • Is the agency nurturing the ability to take action with empathy? As providers who work in the addictions treatment world, we have an ethical obligation to be contributing members of our agencies and communities, working alongside colleagues and clients in a recovery-oriented system of care. We know people cannot recover in a system that has overt and covert oppression and injustice. People heal in relationship – people need people to recovery. Are we using our voices and talents to make differences in our systems so all individuals have access to heal and recover? Systemic change that is meaningful and transformational begins with us; change begins with one person helping one person. Please stand with us against oppression and injustice; please stand with us for equity within a recovery-oriented system of care. NAADAC Code of Ethics III-32: Addiction Professionals shall inform the public of the impact of substance use disorders through active participation in civic affairs and community organizations. Providers shall act to guarantee that all persons, especially the disadvantaged, have access to the opportunities, resources, and services required to treat and manage their disorders. Providers shall educate the public about substance use disorders, while working to dispel negative myths, stereotypes, and misconceptions about substance use disorders and the people who have them. Mita Johnson, EdD, LPC, MAC, SAP, CTHP II, has been practicing in the world of mental health, marriage and family, and addictions counseling for the past 30 years. She has a Doctorate degree in counselor education and supervision and is a core faculty member in the School of Counseling program at Walden University. In addition, Johnson has a thriving private practice where she provides clinical supervision, clinical services to our military, and addictions-related trainings and education around the country. She has been provided telebehavioral health services to individuals and groups for the last three years, and is a certified telehealth practitioner. She is NAADAC’s PresidentElect and Chair of the NAADAC Ethics Committee. She is involved with regulatory and credentialing activities in Colorado; Johnson is very involved in regional workforce recruitment and retention activities. Her areas of specialization include pharmacology, co-occurring disorders, ethics, and clinical supervision.

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■ A D V O C AC Y

Social Injustice and Its Effect on the Addiction Community By Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, NAADAC Executive Director NAADAC is not blind to the social injustices that are reflected in our communities, in our protests and in the discourse currently happening across the United States, and the world. NAADAC was built on the foundation of justice for those suffering from addiction and their families. NAADAC’s Code of Ethics explicitly states, “Addiction Professionals understand and accept their responsibility to ensure the safety and welfare of their client, and to act for the good of each client while exercising respect, sensitivity, and compassion. Providers shall treat each client with dignity, honor, and respect, and act in the best interest of each client.” Each of us is bound to look first to the welfare of the client we are serving or plan to serve, and to not allow our own biases or prejudices to stand in the way. If we find that our biases are affecting our behavior and work, we must either seek assistance to understand and to change, or to make the determination that this is not the career for us. As we are bound to act in the best interest of our clients, we must advocate for measures that will both provide them with appropriate evidence-based care and bolster the workforce that provides that care. It is through advocacy at both the national and local levels that legislation and funding supporting these efforts can be achieved. You are needed now, more than ever, to assist in raising the voice for equal addiction services for all and by persons trained, competent and of the diversity that our clients reflect. Building social justice, equality and parity to make a measurable difference takes commitment, time and focus on these goals. We need to ask ourselves, “What is my part to play in these times?” It may take years to achieve the initiatives we believe to be the rights of those affected by addiction and yet, if not now, when? If not me, who? As addiction professionals, we need to proactively advocate for public policy initiatives that make a difference to those we serve and to the addiction profession. The following are some of the public policy issues NAADAC is addressing: • Continued funding for the Minority Fellowship Program, which provides tuition and other support for aspiring addiction professionals committed to working with underserved populations, including minority populations. We achieved supplemental funding in the CARES Act and plan to continue to grow this important program that we have been involved with over the last eight years. • Funding for advanced education loan forgiveness, which is now a reality due to the CARES Act, and for the first time, funding for education at the Bachelor’s degree level. NAADAC is currently working with the Health Resources and Services Administration (HRSA) on the eligibility requirements of this announcement due out in the summer of 2021. • Equality in pay and benefits for addiction counselors. Many of our addiction counselors and peers across America make a sub-standard

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salary and lack benefits. It is essential to build higher salaries, especially in the publicly funded treatment and peer agencies. NAADAC has been advocating on behalf of this workforce before SAMHSA and Congress. • Infrastructure support for publicly funded treatment and recovery support agencies. The supports given to secure agencies financially have been lacking for decades, and we have seen a continued erosion of treatment and recovery support services due to the closures caused by COVID-19. It is essential to fund to prevent the loss of these vital programs across America, and NAADAC continues to advocate for the inclusion of this funding in spending packages and other legislation. • Substance Abuse Prevention and Treatment Block Grant (SABG) increases to serve the people who are not served by health care, welfare, or other means. This grant needs continued funding and NAADAC continues to advocate for that funding allocation, year after year. • Confidentiality and 42 CFR Part 2. NAADAC is strongly concerned with the known and unintended consequences of the loosening of SUD patient record confidentiality regulations, especially the impact on people’s decisions to seek treatment. As the Administration works to finalize these changes, NAADAC will be closely following implementation to analyze its impact on our clients. • Telehealth counseling, therapy, and recovery support. COVID-19 has required a shift towards telehealth services. NAADAC is working to keep telehealth an option with equal reimbursement of services that are provided in-person and via telehealth. Please visit the advocacy section of NAADAC’s website to learn more about the bills we are supporting, our ongoing discussions, the legislative language we are writing, and the initiatives we support. Watch our free 2020 Advocacy Webinar Series and sign up to participate in our free 2020 Virtual Hill Day on October 6 & 7. Want to get even more involved? Join NAADAC’s Public Policy Committee, Clinical Issues Committee, Critical Issues in the Black Community Committee, Military and Veterans Advisory Committee, or other NAADAC Committees to help shape and guide NAADAC’s advocacy priorities and influence change in and for the addiction profession. Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, is the Executive Director of NAADAC, the Association for Addiction Professionals, and has worked as an addiction professional for over 35 years. She has been a trainer in Domestic Violence/Anger Management and Conflict Resolution for over 25 years as well as an international, national and state trainer in a variety of topics. Moreno Tuohy is also a curriculum writer in addiction screening and evaluation, counseling methods, conflict resolution, co-occurring disorders, and medicated assisted treatment and recovery, and has written articles published in national and other trade magazines. She holds a Bachelor’s degree in Social Work and is certified both nationally and in the State of Washington.

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A Virtual Experience

YOUR VOICE IS NEEDED! Join us for the NAADAC 2020 Virtual Hill Day.

YOUR ADVOCACY IS NEEDED! Speak directly with lawmakers on Capitol Hill about the issues that affect the addiction profession and those it serves!

Earn 2 NAADAC CEs for free! For more information, please visit www.naadac.org/hill-day.

Come Prepared: Watch the NAADAC 2020 Advocacy Webinar Series Learn about grassroots advocacy efforts, federal SUD funding, confidentiality rule changes, and much more! Earn up to 7.5 CEs by watching the full series!* Go to www.naadac.org/advocacy-webinars to learn more. *NAADAC members receive CEs for free; Non-members pay $20 for 1.5 CEs per webinar.

NETWORK AND REVITALIZE AT #NAADAC2020 WITH: Virtual wellness breaks Free conference swag boxes Regional caucus meetings Virtual exhibit hall Product demonstrations Virtual mutual support meetings Fun gamification challenges And so much more!

Join us from the comfort of your home or office on September 24 - 26, for the NAADAC 2020 Annual Conference: Learn l Connect l Succeed. This exciting virtual experience will provide you with the latest information on today’s most relevant topics.

EARN 28 CES! Five interactive keynote sessions, 20 breakout presentations, and an interactive virtual Town Hall will cover:

• Telecounseling and Other Uses of Technology • Trauma-Related Care • Cultural Humility & Social Responsibility • Advanced Addiction Treatment Skills • Peer Recovery Support

Registration includes access to all sessions on demand starting one week after the conference through January 31, 2021! Visit naadac.org/annualconference to learn more. 14

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#NAADAC2020 FEATURED SPEAKERS KEYNOTE SPEAKERS

Carlo C. DiClemente, PhD, ABPP

Marlene M. Maheu, PhD

Professor Emeritus, University of Maryland, Baltimore County (UMBC)

Executive Director, Telebehavioral Health Institute, Inc. (TBHI)

RELAPSE AND RECYCLING REVISITED

TELEHEALTH BEST PRACTICES OUTLINE: COVID CLINICAL ISSUES & DOCUMENTATION

Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP

Executive Director, NAADAC, the Association of Addiction Professionals WELCOME & STATE OF NAADAC Q&A WITH NAADAC & NCC AP LEADERSHIP CLOSING KEYNOTE

Mark Sanders, LCSW, CADC

Diane Sevening, EdD, LAC, MAC President, NAADAC, the Association of Addiction Professionals

Executive Director, Connecticut Community for Addiction Recovery (CCAR)

BREAKING INTERGENERATIONAL PATTERNS OF ADDICTION, TRAUMA, AND DARK SECRETS

WELCOME & STATE OF NAADAC Q&A WITH NAADAC & NCC AP LEADERSHIP CLOSING KEYNOTE

COACHERVISION

International speaker and author Co-Founder, Serenity Academy Chicago

Phil Valentine, RCP

VIRTUAL TOWN HALL PANELISTS

TRAUMA IN 2020: ADDICTION, COVID-19, & SOCIAL INJUSTICE

Miguel E. Gallardo, PsyD

Professor of Psychology and Director of Aliento, The Center for Latina/o Communities, Pepperdine University

Malcolm Horn, PhD, LCSW, MAC, SAP

Director of Mental Health Services, Rimrock NAADAC Northwest Regional Vice President

Janice E. Stevenson, PhD Psychologist

Lisa M. Najavits, PhD

Director, Treatment Innovations Adjunct Professor, University of Massachusetts Medical School

Samson Teklemariam, MA, LPC, CPTM (Moderator)

Director of Training & Professional Development, NAADAC, the Association of Addiction Professionals

Learn more about the featured speakers at naadac.org/ac20-featured-speakers. S U M M E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y â&#x20AC;&#x192;15

#NAADAC2020 VIRTUAL EDUCATION SESSIONS Presentations at the NAADAC 2020 Annual Conference will cover essential and timely content in a format that will allow you to access the information well after the conference has ended! To view the full schedule, please go to naadac.org/ac20-schedule.

TRACK: TELECOUNSELING AND OTHER USES OF TECHNOLOGY

Learn new guidelines, treatment approaches, and counseling techniques that will help counselors leverage technology to improve treatment. KEYNOTE SESSION: Telehealth Best Practices Outline: COVID Clinical Issues & Documentation Marlene M. Maheu, PhD BREAKOUT SESSIONS: Role of Digital Cognitive Behavioral Therapy and MAT to Improve Treatment of Substance Use Disorder Kathleen Carroll, PhD Dialectic Behavioral Therapy: Modifications for Co-occurring Disorders Fredrick Dombrowski, PhD, LMHC, LADC, MAC Digital Technology to Measure, Monitor, and Optimize Mental Health and Support Addiction Recovery Evian Gordon, MD, PhD The Art of the Progress Note: Where Law & Ethics Meet Efficiency Elizabeth Irias, MS, LMFT

TRACK: TRAUMA-RELATED CARE

Review a variety of trauma-related symptoms that impact substance use disorder treatment. KEYNOTE SESSION: Breaking Intergenerational Patterns of Addiction, Trauma, and Dark Secrets Mark Sanders, LCSW, CADC BREAKOUT SESSIONS: Trauma-Integrated Addiction Treatment: What Is It? What Should It Look Like? Michael Barnes, PhD, MAC, LPC Understanding Veterans and Unique Factors Contributing to SUD Capt. Garret Biss, USMC (ret.), MRED A Family Systems Approach to Treating Trauma and Addiction Trish Caldwell, MFT, LPC, CCDP-D, CAADC Let’s Talk Politics: Trauma-Informed Care and Recovery Amid Social Conflict Deborah Kinlaw, LCSW, MAC, SAP VIRTUAL TOWN HALL: Trauma in 2020: Addiction, COVID-19, & Social Injustice Moderated by Samson Teklemariam, MA, LPC, CPTM, with panelists Janice E. Stevenson, PhD, Malcolm Horn, PhD, LCSW, MAC, SAP, Miguel E. Gallardo, PsyD, and Lisa M. Najavits, PhD 16

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TRACK: CULTURAL HUMILITY & SOCIAL RESPONSIBILITY

Understand current racial tensions, the impact on clinical treatment, and what addiction professionals can do to provide culturally sensitive services and advocate for communities impacted. BREAKOUT SESSIONS: The Collective Power of Women: Overcoming Shame and Trauma in Substance Use Disorder Treatment MaryMichael Haley, MA, LAC, CCTP, CSAT Rehabilitating Addiction Treatment: An Anti-Racist Recovery Approach Sarah Buino, LCSW, RDDP, CADC, CDWF, and Sarah Suzuki, LCSW, CADC Culturally Relevant Clinical Work in Addiction Treatment: Moving Beyond Cultural Competence Lorraine Howard, LCSW, LCADC, Natalie Moore-Bembry, EdD, MA, MSW, LSW, and Marla Blunt-Carter, MSW Latino-Informed Therapy Across the SUD and Addiction Continuum of Care Using the SANITY Model Frank Lemus, Sr, PhD, MFT

TRACK: ADVANCED ADDICTION TREATMENT SKILLS

Dive into a focused specialization on evidence based practices and treatment approaches that advance addiction and recovery. KEYNOTE SESSION: Relapse and Recycling Revisited Carlo C. DiClemente, PhD, ABPP BREAKOUT SESSIONS: How Does the Neurobiology of Addiction Guide Choices for Medication Assisted Treatment? Peter Coleman, MD Clinical Application of Pharmacokinetics in Cannabis Use Disorder Eric Geisler, MD, ABAM, ABFP Appearance and Performance Enhancing Drugs: A Hidden Epidemic Tavis Piattoly, MS, RD, LDN Clear the Mind and Cut the Craving: An Evidence-Based Approach to Alcohol Use Disorder John Umhau, MD, MPH, CPE

TRACK: PEER RECOVERY SUPPORT

Discuss critical issues for the peer recovery support specialist. KEYNOTE SESSION: CoacherVision Phil Valentine, RCP BREAKOUT SESSIONS: Meaning in Life, Self-forgiveness, and Locus of Control on Recovery Rev. Livinus, Uba, PhD, LVADC, LICDC, MAC, ICCS Navigating Self-Disclosure Kris Kelly, BS, and Laura Saunders, MSSW Ethical Considerations for Recovery Coaches Stacy Charpentier, RCA, CPRS Demonstrating How to Help Clients Move From Economy Class to Flight Deck Robert Wubbolding, EdD, LPCC, Board Certified Coach, Reality Therapist S U M M E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y â&#x20AC;&#x192;17

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Addiction, Recovery, and Military Cultural Competence By Duane K.L. France, MA, MBA, LPC Director of Veteran Services of The Family Care Center Colorado Springs, CO

sk anyone who has ever served in the military, and they will report that there are unique characteristics of daily existence that are not experienced outside of the armed forces. When someone joins any branch of the military, part of the training and assimilation process is to teach that branchâ&#x20AC;&#x2122;s values, goals, practices, and attitudes, or put more simply, its culture. However, the importance of understanding military culture and its significance in treatment is not well known to those in the addiction field. While addiction and recovery for those affiliated with the military has many similarities to treatment for non-military clients, the unique cultural aspects of service in and life after the military create a dynamic that needs to be understood by those working with this population. Military service and affiliation expose those in it to challenges that increase their risk for a substance use disorder (SUD) and may impact their experience in recovery. This includes societal and contextual risk factors, such as cultural norms of alcohol consumption and availability of alcohol, as well as individual risk factors which include physical injury, psychological trauma, separation from family of origin, and an inherently stressful and dangerous occupation. Substance use disorders are an accepted norm among veterans, and adversely impact their health, personal wellbeing, and occupations (Hawkins et al., 2012). Service in the military can change service members and veterans in ways that they could never foresee. It is vital to understand the psychological impact that military service has on veterans, and addiction treatment professionals must consider clients who have served in the military as any other culturally diverse population and pursue continuing education to understanding their culture.

The Military Affiliated Population One critical aspect to understand about military culture is that it is not monolithic; there is no single type of individual. Those affiliated with the military include those in active duty, those in the reserves, veterans, and even families of service members. When working with clients who are actively serving in the military, it is important to know in which branch of the military they serve: Army, Air Force, Navy, Marine Corps, or Coast Guard. Each branch has its own sub-culture and rank structure, and those who serve have vastly different experiences. Within each branch, there are also additional subcultures based on occupational specialties, and these specialty areas include a variety of additional subcultures that may have connections across branches. For example, an Army Green Beret and a Navy Seal have more in common with each other than with their fellow soldiers or sailors.

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Another critical distinction is that each of these branches has a Reserve Component, which means that their members meet only on a set schedule and are activated to full duty status when necessary. Each state has a National Guard and Air National Guard dedicated to that state. Access to mental health and SUD treatment services are not equal across components, as Reserve and National Guard service members do not have the same resources provided to active duty service members. The term “veteran” is deceptively broad. VA.org (n.d.) quotes Title 38 of the Code of Federal Regulations definition of a veteran as “a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable.” While this may appear clear, an aspect not covered in this description is those who served in the Reserves and National Guard who were never activated. The veteran community is further subdivided into which branch they served in, which era they served in, and whether or not they were in combat. Smith (2019) opines that veterans can be classified as war veteran, combat veteran, retired veteran, and disabled veteran. Four sets of current veterans are typically recognized: the WWII and Korean War veterans, the Vietnam veterans (which has some overlap with Korea and WWII), the Persian Gulf War veterans, and the Post-9/11 or Global War on Terror veterans (which has some overlap with the Vietnam and Persian Gulf combat veterans) (Veterans Law, 2018). A counselor aware of different veteran subcultures will know about specific resources and support groups that are relevant to that subculture, therefore promoting a more individualized treatment experience. Those affiliated with the military also include family members of those who served, but “family member” can be a deceptively broad description. Military spouses and children are those family members who experienced military life with their service member. However, many veterans wait to marry and start a family until after they leave the service, so some spouses

A culturally competent clinician demonstrates deepened awareness beyond cultural sensitivity, wherein a clinician can function effectively and appropriately in settings that include the culturally diverse population.

experience post-military life with their spouse, but might not have a frame of reference around being in the military (France, 2019). The kids may not know how mom and dad were before the military. In addition, some spouses are caregivers for a wounded, ill, or injured veteran, which only compounds the overwhelming and often underprepared challenges of a family member. And finally, with military families, we cannot forget the other members of the family unit: parents, siblings, and in-laws. When a service member joins the military, he or she is removed from his or her family of origin, but parents and siblings still experience the service member’s military duty. This diversity within the military population does not include the other measures of diversity such as “gender, race, ethnicity, age, education, sexual orientation, socio-economic status, ability-status, and religious/ 20

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spiritual orientation,” all of which are present, as discussed by Hudson (2014).” It is important to understand all these factors when working with clients in the military population.

Military Cultural Competence It is necessary for any professional working with veterans to learn about military culture and to understand it as best they can. There may be those clinicians, like myself, who have lived experience in the military, but there are not enough in the field to meet the demands of the clients. One way of looking at cultural competence is to view it as not an either-or situation, but as a continuum from cultural awareness, cultural knowledge, cultural sensitivity, and, finally, cultural competence (Adams, 1995). According to Adams, a culturally competent clinician demonstrates deepened awareness beyond cultural sensitivity, wherein a clinician can function effectively and appropriately in settings that include the culturally diverse population. Recognizing the military population as a separate culture and developing cultural competence is particularly important in light of the fact that we are currently in the nation’s longest continued period of conflict. The Global War on Terror, the official overarching description of military operations in Iraq, Afghanistan, Syria, and locations around the world, is the first major series of conflicts fought by the United States with an entirely all-volunteer force. Clinicians learning to develop cultural competence for the military population was a rapid response to the rising number of current-era combat veterans returning and needing care from a civilian population with little understanding about the military (Atuel & Castro, 2018). To meet the increasing need for military cultural competence, the Military and Government Counseling Association (MGCA) appointed a task force to develop a set of competencies for professional counselors when working with service members, veterans, and their families. The appointed task force developed and presented Competencies for Counseling Military Populations (Prosek et al., 2018), a document to help guide counselors’ clinical practice with military affiliated clients. This document includes a range of considerations and resources for working with the military affiliated populations and is itself a testament to the importance of specialized education and training when working with military affiliated clients.

Psychological Impact of Military Service Having reviewed the diverse population of the military service member, and the need for cultural competence in working with military clients, it is also necessary for clinicians to understand the various psychological and physiological concerns that might be seen in the military affiliated population.

Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) has been described in a number of different ways throughout history, including “soldier’s heart” in the Civil War, “shell shock” in World War I, and “battle fatigue” in World War II and the Korean War. After the Vietnam War, the symptoms that would come to signify PTSD were called “post-Vietnam syndrome” (McDonald, Brandt & Bluhm, 2017). It was not until the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, that PTSD became an official diagnosis. Data from National Center for PTSD show that more than two out of ten Veterans with PTSD have a

SUD. Also, one out of three veterans who seek treatment for a SUD has PTSD (National Center for PTSD, n.d.). There are a number of PTSD diagnostic criteria outlined in the DSM-5, yet the most significant areas to pay attention to are described as re-experiencing, avoidance, negative cognitions of mood, and arousal (APA, 2013). Without assuming that every veteran, or even every combat veteran, “has PTSD,” it is necessary to be familiar with the diagnostic criteria and assess clients individually.

Military Sexual Trauma Military Sexual Trauma (MST) in the U.S. Military is not uncommon and has been increasing. Simply defined, MST includes any sexual activity where one was involved against his or her will (U.S. Department of Veterans Affairs - Make the Connection, n.d.). In the military, the number of sexual assaults from 2016 to 2018 increased by 38% (Kime, 2019), primarily in women ages 17 to 24 (Department of Defense, 2019). Further, a recent study (Schuyler et al., 2020) showed that military personnel who identified as lesbian, gay, bisexual or transgender were more likely to experience sexual harassment, stalking or assault. The U.S. Department of Defense is required to report annually to Congress on sexual assault in the military. While the government is aware and has taken steps to address sexual assault, it is still a major issue in military culture. Potential treatment providers should be aware of the prevalence of sexual assault in the military population, how that can contribute to negative health outcomes, and best practices for treatment.

Traumatic Brain Injury (TBI) Another condition emerging as an important consideration is traumatic brain injury, which is also known as a concussion. Military equipment and medical response have improved significantly over the past 50 years, resulting in greater survivability on the battlefield (Kotwal et al., 2011). Injuries that previously might have been fatal are now being treated quickly and effectively. While this development has reduced the mortality rate in recent conflicts, it has led to an increase in the number and severity of catastrophic injuries. Traumatic brain injuries range from mild to severe, and chronic symptoms can vary widely depending on the nature of the injury. As a provider, screening for TBIs and how symptoms persist is crucial to successful treatment.

Addiction In one study conducted by the Department of Veterans Affairs, it was found that over 11% of those combat veterans who served in Iraq and Afghanistan received a diagnosis of substance use disorder - either alcohol use disorder (AUD), drug use disorder (DUD), or both. Furthermore, a diagnosis of AUD, DUD, or both was between 3-4 times more likely in veterans with PTSD and depression (Seal et al., 2011). Due to the prevalence of use, inconsistently applied alcohol use reduction policies, and the availability of alcohol, alcohol use disorders are the most prominent substance use disorders among service members (Teeters et al., 2017). Generally speaking, in the military, drinking alcohol is normalized and used to relax, to celebrate, to memorialize. Regardless of rank or branch of service, alcohol is acceptable and available. Alcohol becomes problematic, however, when the reason for alcohol use changes from celebration to self-medication or using alcohol to reduce discomfort from psychological stressors.

Recognizing the military population as a separate culture and developing cultural competence is particularly important in light of the fact that we are currently in the nation’s longest continued period of conflict.

While studies show that alcohol is the substance most commonly misused or abused among service members, misuse of prescriptions drugs has also been on the rise among veterans (Bray et al, 2009). Additionally, from 2002 to 2009, cannabis use disorders increased more than 50% among veterans in the VA health care system (Wagner et al, 2007). Given the prevalence of substance use in the military affiliated population, treatment providers should complete a thorough screening for all substances.

Emotional Dysregulation Members of the military-affiliated population may experience difficulty tolerating and managing emotions. While there are certainly emotional components to PTSD, TBI and addiction, it is also possible for emotional challenges to exist apart from substance use, trauma exposure or physical injury. For many service members and veterans, the typical dysregulated emotions are depression, anxiety, and anger. Among the nontraumatic causes for an inability to manage emotions are toxic leadership and systemic harassment. Perceptions of mistreatment can result in psychological consequences such as hostility, anxiety, and depression, and it has been found that there is a correlation between abusive supervision and emotional exhaustion among subordinates (Bhandarker & Rai, 2019). There are many situations like these in the military that could cause anger, anxiety and depression that have nothing to do with exposure to traumatic events. It is necessary to determine whether emotional dysregulation or substance use is the result of traumatic exposure or another cause. These aspects of health concerns are not unique to the military, of course. Combat trauma is not the only cause of PTSD, and any significant blow to the head can cause TBI. Sexual assault and addiction are not just problems for the military population, and emotional concerns such as depression and anxiety are widespread. Although these conditions can be debilitating in and of themselves, there are other factors unique S U M M E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 21

to the military population that can complicate attempts to treat service members, veterans, and their families.

Meaning and Purpose Although service in or affiliation with the military can be difficult, it can also be extremely satisfying. There is a collective effort toward a common goal, a sense of shared culture and community, and a feeling that the work being done is important. This feeling of satisfaction is sometimes a complicating factor when experienced in conjunction with other conditions. Many veterans with PTSD live with profound doubts about the meaning of a life dominated by suffering, guilt, and death. This loss of meaning and purpose has pronounced effects on all areas of psychosocial functioning (Southwick et al., 2006).

Moral Injury Another concept developing over the past 25 years is moral injury. In one of the first articles to fully develop an explanation of moral injury, Brett Litz and colleagues (2009) described moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” There is some disagreement as to whether moral injury is an aspect of PTSD or its own distinct condition. A service member can have a morally injurious event that is not traumatic, and there are several traumatic events that are not morally injurious. Shame, guilt, and a sense of betrayal are specific maladaptive responses to moral injury, and these maladaptive responses have been associated with poorer outcomes in recovery (Stuewig & Trangeny, 2007). Other responses including self-medicating to alleviate painful emotions related to traumatic loss or betrayal, and the use of substances in memorializing or celebrating the memory of those who have been lost. It is beneficial for anyone interested in working with the military population to familiarize themselves with moral injury and to at least explore the concept with these clients.

Needs Fulfillment The military is a highly connected communal society where tasks are divided among its members. When in the military, many basic needs are provided without any effort on behalf of the service member: food, lodging, even social networks. When service members leave the military, those same needs still have to be fulfilled, but it must be done in different ways. This is not to suggest that service members are not capable on their own, but challenges related to employment and housing — the

Over 11% of those combat veterans who served in Iraq and Afghanistan received a diagnosis of substance use disorder – either alcohol use disorder (AUD), drug use disorder (DUD), or both.

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lowest levels of Maslow’s hierarchy of needs — are widely experienced in the veteran population. Certain psychological needs, such as belongingness and esteem, are part of the military framework. The peer group is provided; love them or loathe them, the people one serves with are like family. One’s effort is recognized with rank or reward. Outside of the military, however, service members must learn how to meet these needs in new ways … and for some, that can be difficult.

Relationships The often most under-treated concern among the military affiliated population has to do with relationships. Overall emotional wellness affects interactions with others, and interactions with others affects relational health, social wellness, and belongingness. When military parents fulfill occupational duties during wartime, children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting related to traumatic exposure and subsequent mental health problems (Paley, Lester & Mogil, 2013). When considering how military service impacts relationships and vice versa, it is important to understand that this does not just refer to intimate relationships such as spouses and children, or even parents and siblings. This also includes peer relationships (friends and acquaintances) and work relationships. Understanding how to integrate into a community that has an unfamiliar cultural orientation is difficult. Even if none of the other psychological concerns mentioned in this article are prominent, adapting relationships to a new lifestyle can be challenging. Thus, addiction treatment professionals must learn the relationships that exists in the military population and their family and friends.

Conclusion As with any culturally distinct population, it is necessary to understand how a client’s cultural world view impacts treatment-seeking behavior and adherence to treatment. It is also important that addiction professionals understand the psychological impact of military service as well as how the members of that population can take advantage of evidence-based care. If a provider wants to work with members of the military affiliated population, whether that means those currently serving, veterans, or their family members, further reading and research into these various aspects of military culture and health is recommended. The information provided in this article is simply an introduction to the complicated and multi-faceted impact that affiliation with the military has on the lives of those who serve and those who care for them. As with any culture, the cultural norms of military service are not all-encompassing or monolithic and require specific attention on the part of those who choose to engage with this population. Most importantly, those who choose to serve in the military do so voluntarily. As previously mentioned, the nation is at the end of the second decade of sustained combat operations. To put a finer point on it, this is the longest period of sustained conflict using an all-volunteer force in the history of our nation. As those who have chosen to serve do so willingly, knowing the risks of an inherently dangerous occupation, those who have chosen to serve them have an ethical duty to be prepared to provide post-military life care that they desire and deserve.

REFERENCES Adams, D. L. (1995). Health issues for women of color: A cultural diversity perspective. Sage Publications, Inc. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Atuel, H. R., & Castro, C. A. (2018). Military cultural competence. Clinical Social Work Journal, 46(2), 74-82. Bhandarker, A., & Rai, S. (2019). Toxic leadership: emotional distress and coping strategy. International Journal of Organization Theory & Behavior, 22(1), 65-78. Research Triangle Institute (2009). Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the Defense Lifestyle Assessment Program [Brochure]. https://www.rti.org/brochures/ dod-surveys-health-related-behaviors-among-active-duty-military-personnel Department of Defense. (2019). Department of Defense Annual Report on Sexual Assault in the Military. United States Department of Defense. https://media.defense.gov/2020/ Apr/30/2002291660/-1/-1/1/1_DEPARTMENT_OF_DEFENSE_FISCAL_YEAR_2019_ ANNUAL_REPORT_ON_SEXUAL_ASSAULT_IN_THE_MILITARY.PDF France, D. (2019). From Combat to Counseling: Characteristics of the military affiliated population. Counseling Today. https://ct.counseling.org/2019/08/ from-combat-to-counseling-characteristics-of-the-military-affiliated-population/ Hawkins, E. J., Grossbard, J., Benbow, J., Nacev, V., & Kivlahan, D. R. (2012). Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel. Military medicine, 177(suppl_8), 29-38. Hoggatt KJ, Lehavot K, Krenek M, Schweizer CA, Simpson T. Prevalence of substance misuse among US veterans in the general population. Am J Addict. 2017;26(4):357–365. Hudson Jr, S. W. (2014). Diversity in the Workforce. Journal of Education and Human Development, 3(4), 73-82. Kime, Patricia. “Despite Efforts, Sexual Assaults Up Nearly 40% in US Military.” Military.com, 2 May 2019. Kotwal, R. S., Montgomery, H. R., Kotwal, B. M., Champion, H. R., Butler, F. K., Mabry, R. L., ... & Holcomb, J. B. (2011). Eliminating preventable death on the battlefield. Archives of surgery, 146(12), 1350-1358. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical psychology review, 29(8), 695-706. McDonald, M., Brandt, M., & Bluhm, R. (2017). From shell-shock to PTSD, a century of invisible war trauma. The Conversation. Merriam-Webster. (n.d.). Culture. In Merriam-Webster.com dictionary. Retrieved May 27, 2020, from https://www.merriam-webster.com/dictionary/culture National Center for PTSD. VA.gov | Veterans Affairs. Ptsd.va.gov. Retrieved 27 May 2020, from https://www.ptsd.va.gov/understand/related/substance_abuse_vet.asp. Paley, B., Lester, P., & Mogil, C. (2013). Family systems and ecological perspectives on the impact of deployment on military families. Clinical child and family psychology review, 16(3), 245-265. Prosek, E., Burgin, E., Atkins, K., Wehrman, J., Fenell, D., Carter, C., & Green, L. (2018). Competencies for Counseling Military Populations. Journal of Military and Government Counseling, 87-99. Seal, K. H., Cohen, G., Waldrop, A., Cohen, B. E., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and alcohol dependence, 116(1-3), 93-101. Schuyler, A.C., Klemmer, C., Mamey, M.R., Schrager, S.M., Goldbach, J.T., Holloway, I.W., & Castro, C.A. (2020). Experiences of Sexual Harassment, Stalking, and Sexual Assault During Military Service Among LGBT and Non‐LGBT Service Members. Journal of Traumatic Stress, 33(3), 257-266. https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.22506 Smith, S. (2019). What Is a Veteran? Learn the Service Qualifications for Veteran Status. The Balance Careers. Retrieved 27 May 2020, from https://www.thebalancecareers.com/ what-is-a-veteran-3976315. Southwick, S. M., Gilmartin, R., Mcdonough, P., & Morrissey, P. (2006). Logotherapy as an adjunctive treatment for chronic combat-related PTSD: A meaning-based intervention. American Journal of Psychotherapy, 60(2), 161. Stuewig, J., & Tangney, J. P. (2007). Shame and guilt in antisocial and risky behaviors. The self-conscious emotions: Theory and research, 371-388. Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. E. (2017). Substance use disorders in military veterans: prevalence and treatment challenges. Substance abuse and rehabilitation, 8, 69. U.S. Department of Veterans Affairs - Make the Connection. (n.d.) Effects of Military Sexual Trauma. U.S. Department of Veterans Affairs - Make the Connection. Retrieved July 1, 2020, from https://maketheconnection.net/conditions/military-sexual-trauma VA.org. (n.d.). What is a Veteran? The Legal Definition. VA.org. Retrieved 27 May 2020, from https://va.org/what-is-a-veteran-the-legal-definition/

Wagner TH, Harris KM, Federman B, Dai L, Luna Y, Humphreys K. Prevalence of substance use disorders among veterans and comparable nonveterans from the National Survey on Drug Use and Health. Psychol Serv. 2007;4(3):149. Duane K. L. France, MA, MBA, LPC, is a retired Army Noncommissioned Officer, combat veteran, and clinical mental health counselor practicing in Colorado Springs, Colorado. He is the Director of Veteran Services of The Family Care Center, a private outpatient mental health clinic specializing in supporting wellness in service members, veterans, and their families. He is also the Executive Director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 Nonprofit professionally affiliated with the Family Care Center. He is a member of the Public Policy and Legislation Committee for the American Counseling Association and the Military and Government Counseling Association. He was selected as a member of the inaugural class of the George W. Bush Institute Veteran Leadership program and is active in legislative and public advocacy for both the military population and the counseling profession. In addition to his clinical work, he also writes and speaks about veteran mental health on his blog and podcast, Head Space and Timing, which can be found at www.veteranmentalhealth.com.

Help spread the word! September 20, 2020 Is National Addiction Professionals Day!

ADDICTION PROFESSIONALS ARE AMAZING!

What are you doing to celebrate? Whether you're holding a virtual event or commemorating the day in another way, we want to hear from you! Send information about your event to Caitlin Corbett at ccorbett@naadac.org.

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Spirituality as a Healing Approach for Substance Use Disorders By Kimberley L. Berlin, LCSW, CSAC, MAC, SAP

24â&#x20AC;&#x192;

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he integration of science and spirituality may seem to be diametrically opposed, but the two areas of study are more complimentary today than at any other time in our history. Science is now proving what spirituality has been speaking to all along. Today, the world is awash with profound change due to the COVID-19 pandemic, bringing with it fear, anger, confusion, isolation, anxiety, sadness, and loss – a miasma of conflicting and overwhelming emotions. Prolonged non-human-to-human contact or self-confinement within small dwellings can serve as significant emotional triggers for thousands of people. What is slowly coming to light is a potentially catastrophic psychological toll, especially for those suffering from substance use disorders. This day more than ever, spirituality and science can lead individuals back to well-being, a sense of control, normalcy, centeredness, and calm. A century ago, the medical community approached the treatment of substance use disorders as a moral failing, or a “sickness of the soul,” and used what we would consider today to be barbaric remedies including ice baths, straitjackets, isolation in padded cells, and electric shock. Fortunately, the scientific world has catapulted our understanding of the disease of addiction to a remarkable extent. Technology has advanced to such a degree that we can now see the effects of substances on the brain with fMRI (functional magnetic resonance imaging) and SPECT (single-photon emission computerized tomography) scans and even correct damaged neural activity through advanced chemistry. The neuroscience of addiction opened doors to understanding this condition. Equally important, it has helped to remove much of the crippling stigma that has burdened many from seeking recovery. Eighty-five years ago, Viennese psychologist Dr. Carl Gustav Jung, and Bill Wilson, the co-founder of Alcoholics Anonymous (AA), exchanged letters discussing the then-fledgling society. Jung wrote that the craving for alcohol was a “spiritual thirst of our being for wholeness.” He explained: “You see, ‘alcohol’ in Latin is Spiritus, and you use the same word for the highest religious experience as well as the most depraving poison. The effective formula, therefore, is: “Spiritus Contra Spiritum” (Jung, C., Wilson, B. 1961). The Latin phrase translates to using a spiritual solution to counteract the negative effects of spirits (alcohol). This profound declaration has underwritten the approach to recovery for the 12-Step community for over 80 years. The “spiritual awakening” that is referred to throughout the writings of Alcoholics Anonymous is repeated in stories from recovering persons around the world. One of the obvious questions in any discussion about spirituality is, “What is it?” There is ample confusion between religion and spirituality, which causes

many to avoid pathways of recovery processes due to misunderstanding the difference between the two. There are no prescribed rules or regulations in a spiritual search; while there are many options for direction, there is no “one way” to achieve this goal. It is not necessary to believe in God to hold spiritual beliefs or live a spiritual life. Atheists and agnostics can engage in spiritual practices because, at a fundamental level, spirituality is “religion-less.” There are no do’s and don’ts associated with spirituality other than the invitation to live a life of compassion, kindness, caring, calm, and centeredness. This does not mean that one cannot be religious and spiritual but being spiritual does not require a religious orientation. Spirituality is better thought of as a boundary-less dimension of the human experience: in part, it is taking a moment to be outside of ourselves; in part, it is exercising our muscle of awareness.

There are no do’s and don’ts associated with spirituality other than the invitation to live a life of compassion, kindness, caring, calm, and centeredness. A spiritual awakening is not necessarily required for recovery and many individuals do recover by “sheer will” or other approaches that are employed by mainstream treatment. Further, discussions about a spiritual approach to recovery have become mired in misunderstandings about “the God thing,” which has resulted in arguments that hamper a comprehensive examination of how spirituality can help to heal. However, the advances of neuroscience in the past 20 years shows explicitly how spirituality and its associated practices can alter our brains and begin to repair the damage caused by substance misuse.

Brain Science Our brain, and by extension, our mind, is one of the “last frontiers” of science that humans continue to explore. There are 1.1 trillion cells in the average brain, with over 100 billion neurons receiving 5,000 connections or synapses to each of the neurons. The math is a bit stunning – there are 5 hundred trillion points or links within our skulls (Hanson, 2009). If these were bulbs connected like Christmas lights, they would stretch the distance from Earth to Neptune and back 100,000 times. Each neuron fires between 5 to 50 times per second (Hanson, 2009), transmitting neurochemicals containing information that regulates every process in our being from the movement of a finger to the S U M M E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 2 5

complex computation of Einstein’s formula for the theory of relativity. Each signal is moved through the body by our central nervous system, including complex transmissions that regulate our stress responses. This intricate network can quickly be upended by stress, trauma, anxiety, depression, or other mental health issues. Substances used to offset the adverse effects of these conditions further destroys the delicate balance within the brain. As Daniel Amen, MD, a double board-certified psychiatrist who is regarded as one of the top experts on utilizing brain imaging science to inform clinical psychiatry has noted, “[p]sychiatrists are the only medical specialists that never look at the organ they treat” (Daniel Amen, personal communication, November 9, 2019). Dr. Amen’s “brain bank” consists of over 65,000 SPECT scans reflecting conditions ranging from ADHD, Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD), and Substance Use Disorders. These scans show the effects of substances on the brain and can be accessed on the Amen Clinic’s scan library at https://www.amenclinics.com/spect-gallery/addictions. Notably, Dr. Amen’s use of Four Circles to brain health was one of the first medical approaches to include a spiritual focus in an individuals’ life. This methodology engages clients through their biological, psychological, social and spiritual factors. Genetics, diet, history of brain injury, support and meaning in life, stressors, thinking patterns, and relationships are all targeted for a personalized care plan. (https://www.amenclinics.com/ the-science/amen-clinics-method/ )

response, it would not be until the early 2000s that technology caught up to the teachings of Indus scriptures. As Goleman wrote, “Modern psychology had not known that Eastern systems offer means to transform a person’s very being. When we looked through that alternate Eastern lens, we saw fresh possibilities. By now, mounting empirical studies confirm our early hunches: sustained mind training alters the brain both structurally and functionally, proof of concept for the neural basis of altered traits that practitioners’ texts have described for millennia” (p. 290).

The work of Davidson, Goleman, Newburg, and Waldman, as well as Rick Hanson, Ph.D., Daniel J. Siegel, M.D., and others, in the field of spiritual neuroscience is affording an opportunity to turn to the validity of spiritual healing for states and conditions related to substance use disorders. To date, there is a marked absence of addiction studies with brain scans and the use of spiritual practices. The implied effects for addiction treatment may encourage scientists to turn to this vital area of research. Understanding how and why basic spiritual practices such as meditation, breath exercises (Pranayama), and chanting (Mantra) change critical areas of the brain is the first step in utilizing these techniques with clients to guide them toward a comprehensive approach to recovery. The practices focused here are found in the Yogic tradition; however, all spiritual approaches achieve the same results from a neurological perspective. Spiritual Neuroscience Christian prayer and hymn, Judaic devotion and Zemirot, Islamic prayer, The commonality of ancient scriptures dating approximately 1,500 BCE and Na’at have been included in Newburg and Waldman’s research and and our present-day scientifically oriented world is nothing short of as- shown to have significant results on critical areas of the brain. These intounding. Oral traditions handed down clude changes in EEG readings and resting from cultures originating in the Indus Valley brain metabolism, as well as changes in the Spirituality is better thought of as a brain’s blood flow and brain electrical acoffered insights into the nature of the mind, human behavior, and even the creation of tivity. Critical areas such as the Prefrontal boundary-less dimension of the the cosmos. Not until the development of Cortex (PFC), the Cingulate Gyrus, the human experience. neuroimaging technology were these musThalamus, Hippocampus, and amino acid ings found to be startlingly accurate. neurotransmitters such as GABA (gammaDuring the “mechanistic” era of science, aminobutyric acid) and Norepinephrine are any suggestion outside of its own constraints all shown to be positively affected. was scoffed at and scientists risked their careers if they dared to suggest Newburg (2012), found that individuals who engaged in prayer there might be alternatives to how we viewed the mind or consciousness. (Christian, Judaic, Islamic, Hindu) had significant positive changes in Researchers Mario Beauregard and Denise O’Leary (2008) stepped out- their Cingulate Gyrus (which regulates the process of focus) and the side this prescribed arena and postulated a “Spiritual Brain.” The highly Thalamus (which governs the flow of sensory information). His research regarded neuroscientists demonstrated the effects of spirituality in our also showed that GABA increased during these spiritual practices. The brains with research experiments with Carmelite nuns that showed sig- presence of GABA produces a calming effect, which is linked to reduced nificant brain changes while they were engaged in prayer and personal stress, fear, and anxiety, as well as improved sleep patterns. Newburg’s communion with God. findings indicated that in addition to the other benefits of prayer and Eight years later, neuroscientists Andrew Newberg and Mark Robert spiritual practice, GABA increase subsequently reduces “excitability” in Waldman (2016) took the research further analyzing a broad range of practitioners’ nervous systems. Further, dopamine levels increased sigspiritual activities across several religions and found even more reliable nificantly in individuals who practiced Yoga Nidra, a full-body technique evidence than their predecessors. Newburg and Waldman laid the foun- of progressive muscle relaxation that is directed by a trained teacher for dation for what is now referred to as Spiritual Neuroscience. anywhere between 30 to 90 minutes. Researchers such as Daniel Goleman and Richard Davidson underwent In the Kundalini Yoga tradition, the commitment to a daily disa long journey of research that began in the early 1970s to prove what cipline of practice holds the promise to practitioners for a life-alterwas instinctively known to them after studying in India with Burmese ing experience. Known as Kundalini Awakening, the effects range Indian Vipassana master Satya Narayan Goenka (p. 32-35). While their from awareness of internal energies, intuition, and “inner truth” to 1970s Harvard experiments were groundbreaking using galvanic skin increased compassion, desire to be of service, and a sense of purpose. 26

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The practice includes physical engagement in yoga, prayer (recitation), meditation (contemplation), and chanting (song). Research by GarciaSesnich et al., (2017), found that stress hormone levels of cortisol were “markedly reduced in those participants who practiced Kundalini Yoga regularly for three months” (p. 77).

Breath and Vocalization Known as “Pranayama,” breath exercises have formed the basis of meditation instruction for millennia. The Upanishads (circa 1500 BCE) extol breath as the essence of the body and connection to the self or consciousness. Breathing is the life-supporting nourisher of our beings. Taking conscious breaths automatically engages the Parasympathetic Nervous System (PNS), and augments dopamine production in the brain. Simple techniques include slow intake of breath through the nostrils, holding the breath for a few counts, and then a slow but longer exhalation of the breath via nostrils, repeating for a minimum of ten breaths. Alternate nostril breathing where one nostril is closed by a thumb or forefinger and inhaling through the open nostril is an ancient technique that has a direct impact on the PNS — alternating the right to left nostril balances the brain hemispheres and affects levels of Noradrenaline (NE). This monoamine is part of the body’s “fight or flight” system that increases heart rate and blood pressure. Studies have consistently found that NE levels are lowered when individuals engage in breathing exercises and other mindfulness techniques (Hanson, 2009; Newburg, 2012; Garcia-Sesnich, 2017). The production of musical sounds using the voice has been employed since the dawn of humankind. Vocalization of tribal chants, hymns, incantations, and call and response, to name but a few, have held significance to civilizations past and present. Neuroscientist James Hartzell, Ph.D., (2018), a Sanskrit specialist, researched claims of the efficacy of mantra by studying Thai monks who had entered the monastery in childhood and spent eight to ten hours a day in meditation and mantra practice were recruited. Their recitations were all from memory, including complex stanzas from ancient texts, some of which takes six hours from start to finish. When Hartzell scanned the monks’ brains using MRI, he found that over ten percent of grey matter across both cerebral hemispheres showed substantial cortical thickness compared to controls (2018, para 5). This translates to higher functioning of brain areas and indications of structural changes that result from learned behaviors. The hippocampus, responsible for memory, also showed significant thickness, reflecting the ability for “accurate recitation, precise sound pattern encoding, and reproduction” (2018, para 6).

Techniques in Counseling As counselors, therapists, or coaches, adopting some form of spiritual practice helps to offset the accumulated stressors of our profession. This, in turn, translates to our being of better assistance to our clients. A daily meditation practice of ten minutes, employing breath techniques to regulate our parasympathetic system, or any exercise that connects us to our higher self falls under the rubric of spirituality. Spiritual practices are not solely defined as meditation, prayer, or hymn. Connecting outside of ourselves through walking, cycling, running, journaling, drawing, playing music, or gardening gives rise to the opportunity for much-needed self-care.

Beginning a counseling session with an invitation to take a few moments to focus on the present moment is a first step in offering techniques directly to the client. Sitting together with eyes closed, a therapist can guide the client to breathe in through the nostrils using a count of four, hold the breath for two counts, and exhale through the nose for a count of six, repeating the technique for one to two minutes. This simple Pranayama technique will engage the PNS and increase dopamine production, reduce activity of the Sympathetic Nervous System (SNS) by lowering adrenaline and cortisol output. Teaching clients how to meditate or guiding them to resources where they can learn and engage in daily practice is an important direction to offer individuals who are either in early recovery, struggling with cravings, or seeking a more meaningful experience in their path of recovery. There are countless apps on the market, many for free, that have been created to bring the connection to self. Our world, our country, our communities, and even our own families are undergoing one of the most upending, convulsive changes of any generation. Mass media, social media, and regular conversations are amplifying the dangers that appear in the face of the global COVID-19 pandemic, as millions are affected. More than ever, “control” seems to be lost entirely, and we yearn for normalcy and a return to centeredness and calm. In the words of Thomas Hora, founder of 20th Century Metapsychiatry, “All problems are psychological, but all solutions are spiritual.” (Hora, n.d.) The science of spirituality – like the great scientists who will soon find a vaccine for this pandemic – can serve as our emotional vaccine. REFERENCES Beauregard, M., O’Leary, D. (2007). The Spiritual Brain: A Neuroscientist’s Case for the Existence of the Soul. New York, NY: Harper One - Harper Collins Publishers. Goleman, D., Davidson, R. (2017). Altered States: Science Reveals How Meditation Changes Your Mind, Brain, and Body. New York City, NY: Penguin Publications. Garcia-Senich, J.N., Flores, M.G., Rios, M. H., Aravena, J.G. (2017). Longitudinal and Immediate Effect of Kundalini Yoga on Salivary Levels of Cortisol and Activity of AlphaAmylase and its Effect on Perceived Stress. International Journal of Yoga, 10(2), pp. 73-80. https://doi.org/10.4103/joy.IJOY_45_16 Hanson, R. (2009). Buddha’s Brain: The Practical Neuroscience of Happiness, Love, and Wisdom. Oakland, CA: New Harbinger Publications, Inc. Hartzell, J. (2018). A Neuroscientist Explores the “Sanskrit Effect.” Scientific American: A Division of Springer Nature America, Inc. Jan 2, 2018. Retrieved from https://blogs. scientificamerican.com/observations/a-neuroscientist-explores-the-sanskrit-effect/ Hora, T. (n.d.) The Meta View. Retrieved from https://www.themetaview.com/ dr-thomas-hora-md Jung, C. G., Wilson, B. (1961). “Carl Jung’s Letter to Bill Wilson.” Retrieved from https:// silkworth.net/pages/aahistory/general/carljung_billw013061.php Newburg, A. (2012). Transformation of Brain Structure and Spiritual Experience. In L. J. Miller The Oxford Handbook of Psychology and Spirituality (pp. 489-499). Oxford, England: University of Oxford Press. Newburg, A., Waldman, M.R. (2016). The New Science of Transformation: How Enlightenment Changes Your Brain. New York City, NY: Penguin Random House. Siegel, D.J. (2018). Aware: The Science and Practice of Presence. The Groundbreaking Meditation Practice. New York City, NY: Penguin Random House. Kimberley L. Berlin, LCSW, CSAC, MAC, SAP, is the owner of Compassionate Beginnings, LLC, a private therapy practice in Leesburg, Virginia. Her work focuses primarily on the treatment of addiction and underlying causes and conditions ranging from anxiety and depression to trauma or early childhood abuse. Using Eastern philosophy merged with Western science Kimberley is a trained Level 1 Internal Family Systems (IFS) practitioner. She includes yoga, breath work and meditation with all her clients. Kimberley is also a public speaker and author. She lives in Virginia with her husband and three rescue dogs.

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The Importance of

Belongingness By Nancy A. Piotrowski, PhD, MAC

sense of community, connection with others, a feeling of support and understanding – these are comforts we experience in human groups. But when many of our patients come to us, these feelings can be quite distant. They can feel very isolated, apart, and disconnected due in part to stigma and shame. It is no secret that stigma has a persistent presence in the experience of our patients, their families, and professionals in our field. It also has long been recognized as a barrier to engagement in addictions work. As such, its eradication remains an important task for the field. Strides to destigmatize addiction have been made through the use of strengths-based language, acknowledgement of the full continuum of addiction-related issues, recognition of addiction as a diagnosable condition, and awareness that addiction can affect anyone. But we need to do more. Recent research, in fact, suggests the need to keep chipping away at stigma to bolster engagement by encouraging a sense of belongingness in treatment and recovery communities. Belongingness is simply a way of saying how connected an individual feels towards others. While this may sound simple, it is a vital part of successful treatment, right up there with the value of the therapeutic working 28

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alliance, and it is a growing area of research in clinical, community, and social psychology. As an example, research has demonstrated that belongingness buffers the impact of childhood trauma. Higher belongingness is associated with improved adult mental health outcomes and decreased risky alcohol use (Torgerson, Love, & Vennum, 2018). In essence, belongingness promotes resiliency against alcohol use and other mental health problems in adults with childhood trauma. Evidence from a study of peer-led support groups (e.g., Alcoholics Anonymous (AA)) suggests that having a social identity of belonging in the group is associated with involvement in the group (Taylor, McNamara, & Frings, 2019). Further, Taylor et al. found that social identification with AA is equal to or more important than involvement in the activities of the group. In other words, saying, “I am in the group,” or “that is my group,” is equal to or more important than what one does in the group. Thus, ensuring patients gain the experience of belongingness in these groups is underscored. Similarly, a study by Lund, Argentzell, Leufstadius, Tjörnstrand, and Eklund (2017) revealed that group participation in a mental health lifestyle intervention derived its meaning from the process of joining with others, gaining a sense of belonging, and re-valuing self. The authors also underscored that joining the group is

a unique step in meaning-making and needs more of our attention and effort to help that process be successful. These issues are not limited to face to face groups; they also are important in online activities. Gao, Liu, and Li (2017) demonstrated that social presence online is positively related to sense of belonging. Similarly, Biluc, Doan, and Best (2018) examined online support in sober social networks and found that self-stigma negatively predicted well-being and self-efficacy. Unfortunately for individuals with concealable stigmatized identities, disclosure of these identities is a double-edged sword. From a clinical standpoint, this is not news, but research data confirms this. On one hand, if you reveal a stigmatized identity in the right context, you can gain more social support and increased physical and psychological benefits (Camacho, Reinka, & Quinn, 2020). In more hostile environments or where responses are not supportive, however, disclosure is related to negative outcomes. Further, Tague, Reysen, and Plante (2019) note that identifying with a group was predicted by felt stigma and mediated by the need for belongingness. This leads to the conclusion that both stigma and self-stigma are important considerations. We need to continue working to reduce stigma and self-stigma, through our research and clinical work, to support the experience of a sense of belongingness in the recovery community.

REFERENCES Biluc, A.M., Doan, T.N., & Best, D. (2018). Sober social networks: The role of online support groups in recovery from alcohol addiction. Community & Applied Social Psychology, 29(2), 121-131. Camacho, G., Reinka, M.A., & Quinn, D.M. (2020). Disclosure and concealment of stigmatized identities. Current Opinion in Psychology, 31, 28-32. Gao, W., Liu, Z., & Li, J. (2017). How does social presence influence SNS addiction? A belongingness theory perspective. Computers in Human Behavior, 77, 347-355. Lund, K., Argentzell, E., Leufstadius, C., Tjörnstrand, C., & Eklund, M. (2017). Joining, belonging, and re-valuing: A process of meaning-making through group participation in a mental health lifestyle intervention. Scandinavian Journal of Occupational Therapy, 26(1), 55-68. Tague, A.M., Reysen, S., & Plante, C. (2019). Belongingness as a mediator of the relationship between felt stigma and identification in fans. The Journal of Social Psychology, 160(3), 324-331. Taylor, I., McNamara, N., & Frings, D. (2019). The “doing” or the “being”? Understanding the roles of involvement and social identity in peer-led addiction support groups. Journal of Applied Social Psychology, 50(1), 3-9. Torgerson, C.N., Love, H.A., & Vennum, A. (2018). The buffering effect of belonging on the negative association of childhood trauma with adult mental health and risky alcohol use. Journal of Substance Abuse Treatment, 88, 44-50. Nancy A. Piotrowski, PhD, MAC, is a clinical psychologist with more than 35 years of experience working in addictions. Piotrowski is a past president of the Society of Addiction Psychology and serves as its Federal Advocacy Coordinator in their work with the American Psychological Association (APA). She maintains an active consultancy, teaches for University of California – Berkeley Extension, and serves as Core Faculty at Capella University in the Department of Psychology, where she is Lead Faculty in Addiction Psychology. Piotrowski serves as a Commissioner for the National Certification Commission for Addiction Professionals (NCC AP).

NAADAC’S FREE 2020 ADVOCACY WEBINAR SERIES!

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REMOTE SUPPORT NAADAC has the resources you need to support the clients you serve in today’s world! NAADAC offers members: • Discounted access to a telehealth platform service (members can try the service for free for 30 days AND receive a 15% discount after that!); • Over 145 hours of educational webinars available online and on demand 24 hours a day/7 days a week; • Specialty online trainings that address specific addiction treatmentrelated education needs; • Print publications that can be shipped right to your door; • The ability to take your National Certification Commission for Addiction Professionals (NCC AP) exam from home through distance proctoring; • And so much more! Visit naadac.org/resources for more information.

NIAAA Scientists Highlight Alcohol-Related Mortality Increase in the United States By the National Institute on Alcohol Abuse and Alcoholism (NIAAA)

recent study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) scientists found that nearly 1 million people died from alcohol-related causes between 1999 and 2017. The analysis of yearly death certificate data revealed that the number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017, a year in which alcohol played a role in 2.6 percent of all deaths in the United States. In 2017, liver disease (31 percent; 22,245 deaths) and overdoses on alcohol alone or with other drugs (18 percent; 12,954 deaths) accounted for 35,199 deaths, nearly half of the alcohol-related deaths in that year. People ages 45 to 74 had the highest rates of deaths related to alcohol, but the biggest increases over time were among people ages 25 to 34. “The high rates among middle-aged adults are consistent with previous reports of increases in ‘deaths of despair,’ generally defined as deaths related to overdoses, alcohol-associated liver cirrhosis, and suicides, primarily among non-Hispanic whites,” said first author Aaron White, Ph.D., Senior Scientific Advisor to the NIAAA Director. “However, in

the current study, alcohol-related deaths were increasing among people in almost all age and racial and ethnic groups by the end of the study period.” Rates of death involving alcohol also increased more for women (85 percent increase) than men (35 percent increase) over the study period, further narrowing once-large differences in alcohol use and harms between males and females. “The findings come at a time of growing evidence that even one drink per day of alcohol can contribute to an increase in the risk of breast cancer for women,” said senior author Patricia Powell, Ph.D. “Women also appear to be at a greater risk than men for alcohol-related cardiovascular diseases, liver disease, alcohol use disorder, and other consequences. Our findings underscore that alcohol is a growing women’s health issue.” REFERENCE White, A.; Castle, I-J.P.; Hingson, R.; and Powell, P. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999–2017. Alcoholism: Clinical and Experimental Research 44:178–187, 2020. PMID: 31912524

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Earn 1 CE by Taking an Online Multiple Choice Quiz Earn one Continuing Education hour by taking a multiple choice quiz on this article now at www.naadac.org/magazine-ce-articles. $15 for NAADAC members and non-members.

1. According to the VA, the word “veteran” is defined as: a. A person who served in the active military, naval or air service regardless of discharge status b. A person who served in the active military, naval or air service and who was discharged or released under conditions other than dishonorable c. A person who served in the Navy, Army, Air Force, Marines, or National Guard d. A person who served their country in battle 2. Studies show that this substance is the one most commonly abused by those affiliated with the military? a. Cocaine b. Heroin c. Cannabis d. Alcohol 3. What is meant by the term “moral injury”? a. Perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations b. Survivor’s guilt c. A psychological wound resulting from years of service in the military d. Feeling guilty about actions taken during time in military service 4. Noradrenaline levels have been shown to decrease when engaging in these types of practices? a. Yoga poses b. Breathing exercises c. Sleeping d. Diet 5. Spiritual practices may encompass any of the following, except: a. Prayer b. Walking c. Journaling d. Commuting

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6. When using psychodynamic practices, be judicious in your use of what type of technique? a. Active listening b. Interpretation c. Establishing safety d. Empathizing 7. “Psychodynamic” treatment refers to treatments that are less intensive than the procedure Freud invented (psychoanalysis) yet depend on ideas that derived from his theories. a. True b. False 8. Belongingness can help promote ____________ against alcohol use and other mental health problems in adults with childhood traume. a. A barrier b. Deterrence c. Resiliency d. Alternatives 9. How can group treatment be a double-edged sword for those dealing with the stigma of addiction? a. With the right group, sharing a stigmatized identity can increase physical and psychological benefits; with a more hostile group, sharing a stigmatized identity can result in negative outcomes. b. When sharing in group, some members will support the person and others won’t. c. People with substance use disorders often fail to share in groups and thus don’t reap the benefits of support. d. Stigma does not impact a person with a substance use disorder. 10. _________ is a set of web- based cognitive-behavioral therapy modules developed with NIAAA funding that trains people in seven important skills to help them cut down or quit drinking. a. CBT Web b. Seven Skills to Cut Down c. CBT4CBT d. 12-Step’s 7 Skills

■ NA A DAC L E ADE RS H I P NAADAC EXECUTIVE COMMITTEE President Diane Sevening, EdD, LAC, MAC President-Elect Mita Johnson, EdD, LPC, LAC, MAC, SAP Secretary Susan Coyer, MA, AADC-S, MAC, CCJP Treasurer Gregory J. Bennett, LAT, MAC Immediate Past President Gerard J. “Gerry” Schmidt, MA, MAC, LPC, CAC National Certification Commission for Addiction Professionals (NCC AP) Chair James “Kansas” Cafferty, LMFT, NCAAC Executive Director Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP REGIONAL VICE-PRESIDENTS Mid-Atlantic (Represents Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia and West Virginia)

Ron Pritchard, CSAC, CAS, NCAC II Mid-Central

NAADAC COMMITTEES North Central

STANDING COMMITTEE CHAIRS

(Represents Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota)

Awards Committee Chair Mary Woods, RN-BC, LADC, MSHS

James “JJ” Johnson Jr., BS, LADC, ICS Northeast (Represents Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont)

William Keithcart, MA, LADC, SAP Northwest (Represents Alaska, Idaho, Montana, Oregon, Washington and Wyoming)

Malcolm Horn, PhD, LCSW, MAC, SAP Southeast (Represents Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee)

Marvin M. Sandifer, LCSW, LCAS Southwest

(Represents Arizona, California, Colorado, Hawaii, Nevada, New Mexico and Utah)

Thomas P. Gorham, LMFT, CADC II

Organizational Member Delegate Jim Gamache, MSW, MLADC, IAADC

(Represents Kentucky, Illinois, Indiana, Michigan, Ohio and Wisconsin)

Gisela Berger, PhD, MAC, LPC, NCC

Bylaws Committee Chair Ronald A. Chupp, LCSW, LCAC, NCAC II, ICAC II Clinical Issues Committee Chair Mark Sanders, LCSW, CADC Ethics Committee Chairs Mita Johnson, EdD, LPC, LAC, MAC, SAP Rose Marie, MAC, LCADC, CCS Finance & Audit Committee Chairs Mita Johnson, EdD, LPC, LAC, MAC, SAP Gregory J. Bennett, LAT, MAC Membership Committee Chair John Korkow, PhD, LAC, SAP Military & Veterans Advisory Committee Chair Ron Pritchard, CSAC, CAS, NCAC II Nominations and Elections Chair Gerard J. “Gerry” Schmidt, MA, MAC, LPC, CAC Personnel Committee Chair Diane Sevening, EdD, LAC, MAC Professional Practices and Standards Committee Chair Kirk Bowden, PhD, MAC, NCC, LPC Public Policy Committee Co-Chairs Michael Kemp, ICS, CSAC, CSW Sherri Layton, MBA, LCDC, CCS

Mid-South (Represents Arkansas, Louisiana, Oklahoma and Texas)

Student Committee Chair Jeff Schnoor, MA, LICDC (pending), CCSTA, QMHP-CS, Certified Interventionist

James C. Cates, MA, LCDC

NATIONAL CERTIFICATION COMMISSION FOR ADDICTION PROFESSIONALS (NCC AP)

International Committee Chair Elda Chan, PhD, MAC, Grad. Dip. Family Therapy

AD HOC COMMITTEE CHAIRS Adolescent Specialty Committee Co-Chairs Chris Bowers, CSAC, NCAAC Steven Durkee, NCAAC

James “Kansas” Cafferty, LMFT, NCAAC NCC AP Chair California

PAST PRESIDENTS 1974-1977 Robert Dorris 1977-1979 Col. Mel Schulstad, CCDC, NCAC II (ret’d) 1979-1981 Jack Hamlin 1981-1982 John Brumbaugh, MA, LSW, CADAC IV, NCAC II 1982-1986 Tom Claunch, CAC 1986-1988 Franklin D. Lisnow, MEd, CAC, MAC 1988-1990 Paul Lubben, NCAC II 1990-1992 Kay Mattingly-Langlois, MA, NCAC II, MAC 1992-1994 Larry Osmonson, CAP, CTRT, NCAC II 1994-1996 Cynthia Moreno NCAC I, CCDC II 1996-1998 Roxanne Kibben, MA, NCAC II 1998-2000 T. Mark Gallagher, NCAC II 2000-2002 Bill B. Burnett, LPC, MAC 2002-2004 Roger A. Curtiss, LAC, NCAC II 2004-2006 Mary Ryan Woods, RNC, LADC, MSHS 2006-2007 Sharon Morgillo Freeman, PhD, APRN-CS, MAC 2007-2010 Patricia M. Greer, BA, LCDC, AAC 2010-2012 Donald P. Osborn, PhD (c), LCAC 2012-2014 Robert C. Richards, MA, NCAC II, CADC III 2014-2016 Kirk Bowden, PhD, MAC, NCC, LPC 2016-2018 Gerard J. Schmidt, MA, LPC, MAC

Jerry A. Jenkins, MEd, LADAC, MAC NCC AP Immediate Past Chair California Rose Maire, MAC, LCADC, CCS Secretary New Jersey Kirk Bowden, PhD, MAC, LPC Arizona Gary Ferguson, BS, ND Alaska Nancy A. Piotrowski, PhD, MAC California Michael Kemp, NCAC I Oregon Diane Sevening, EdD, LAC, MAC (ex-officio) South Dakota

NAADAC EDUCATION & RESEARCH FOUNDATION (NERF) NERF President Diane Sevening, EdD, LAC, MAC NERF Events Fundraising Chair Nancy Deming, LCSW, MAC, AADC-S

NAADAC REGIONAL BOARD REPRESENTATIVES NORTHEAST NORTH CENTRAL

MID-CENTRAL

Gloria Nepote, Kansas Amanda Richards, MA, LPCC, LADC, MAC, Minnesota Tom Barr, LIMHP, LADC, Nebraska Megan Busch, LAC, LPCC, North Dakota Mark Young, South Dakota

Renee Lee, MSW, CADC, Illinois Stewart Ball, MAC, LCAC, LMFT, LCSW, Indiana Geoff Wilson, LCSW, LCADC, Kentucky Deborah Garrett, BS, CPRM, CPS, Michigan Raynard Packard, Ohio Daniel Bizjak, MSW, ICS, CSAC, Wisconsin

Susan Campion, LADC, LMFT, Connecticut Ruth A. Johnson, LADC, SAP, CCS, Maine Joe Kelleher, LADC-1, Massachusetts Alexandra Hamel, MLADC, MAC, New Hampshire Christopher Taylor, CASAC, LMHC, MAC, SAP, New York John Mann, LADC, Vermont

NORTHWEST Courtney Donovan, PhD, Alaska Monica Forbes, NCPRSS/CPRC, Idaho Tim Warburton, BS, LAC, Montana Ray Brown, CADC II, Oregon Terri Roper, MS, NCAC II, Washington Frank Craig, Wyoming

SOUTHWEST

MID-ATLANTIC

Yvonne Fortier, MA, LPC, LISAC, Arizona Justin Phillips, LMFT, CATC-IV, California Jonathan DeCarlo, CAC III, Colorado David Marlon, MBA, MS, LADC, CAd, Nevada Brian Serna, New Mexico Shawn McMillen, Utah

Denise D. Cooper, LSATP, CRC, MAC, CSAC, Virginia Heather Sharp-Spinks, West Virginia

SOUTHEAST MID-SOUTH Sherri Layton, LCDC, CCS, Texas Abby Willroth, BA, RDS, ADC, IADC, PR, SAP, MATC, Arkansas

George Towne, AAS, NCAC I, Alabama Bobbie Hayes, LMHC, CAP, Florida Donna Ritter, BT, CAC II, CCS, Georgia Jessica Holton, MSW, LCSW, LCAS, North Carolina James E. Campbell, LPC, CAC II, MAC, South Carolina Terry Kinnaman, LADAC II, MAC, QCS, Tennessee