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PESI Significant with Paul Brasler.

November 22, 2024.
855 Type- Significant SUD SUD-Substance Use Disorder with Paul Brasler.
November 22, two.
22, 2024.
8:55-12:50 p.m. EST.
Remote CART Captioning.
Communication access real time translation (CART)
captioning is provided to facilitate communication
accessibility. CART captioning and this realtime
file may not be a totally verbatim record of the
proceedings. Welcome back, everyone. Wow, we covered a lot of ground yesterday, didn't we? I don't
know about you you, but I'm preparing a special place for the notes from this training because I'm sure I'll
refer back to them often.
I hope everything is going well for you as you're learning this material, that you're finding it useful and
you're already thinking of ways to help your clients. Today will be awesome as we focus more on
treatment considerations.
Keep submitting your questions to the Q&A. We'll start with it closeed to give everyone time to settle in
and then we'll open it up. Please remember to upvote questions you're most interested in hearing what
you want to ask.
Reminder that your CE-related questions can be answered in the FAQ in the portal.
Let's get started. Paul, thank you for being here. Take it away?
>> Thank you for having me. Good morning, everybody everybody. Let's get back to where we were
yesterday. Here we are. Good morning, everybody. I want to thank Victoria, Gwen, Syd on the technical
end, I want to thank our ASL interpreters and our captioners for their work in making this go so smooth.
Thank you for being here and coming back.
A couple housekeeping things, we are going to -- there's a lot of information here, let's start with that.
And basically I create more in the packet than probably we're going to use. As you saw yesterday, some
of it we'll go through and I point stuff out, others we'll linger on for illustration purpose it's and things like
that. But this is for you to utilize. Break-wise, we'll do the exact same as yesterday. I'm in the eastern
time zone here in Virginia. Some of you are mountain, central, Pacific, or maybe even beyond that.
So for central time we'll take a break 9:45 to 10:00 10:00. Central time it will be 11:50 to 1:00. We'll take
a break in the afternoon and end at 5 until 4:00 in the central time zone and 5 until 5 on the eastern time
zone. And it's Friday so your weekend starts then but we have to fill the hours to meet the requirements
from the accrediting agencies.
Really cool questions yesterday. Keep them comeing. I like the little emojis. There haven't been any
middle finger emojis or anything like that so if there are please don't do them.
But anyhow, let's get started where we left off yesterday and it's kind of weird that we're talking about

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urine drug screens but why not?

So basically urine drug screens are the cheapest and easiest form of drug testing there is. You don't just
want to do them to do them. There needs to be a testing protocol in your agency, and this is going to
sound gross but good morning. Urine drug screens usually have low validity unless the person is
observed urinating. I know that sounds gross but it doesn't mean you should throw them out without that
as a therapist in a therapist's role that's not something that I'm going to want to do with my clients. But
the fact is that unless the sample is seen coming from the person, you're not 100 percent sure of what is
being tested. That's the main thing thing.
So when we did urine drug screens in the ER they're absolutely useless because you give them a cup,
say go in the bathroom and give me a sample. You don't know what's going to come out. In the prison
system system, we had people on the drug corps team, a male and a female and they actually observed.
It was set up so the officers could swear in court, yes, the sample that tested positive or neglect came
from subject A.
That's not why they went to school and got training but it was part of the job.
Also, if you're going to have a sampling program, I would really do your research on this. But randomized
standpoint is the way to go. Having scheduled sampleing, there's too much time for a person to try to
pick the sample. Ran comeized is come Domized is Randomized is the way to go.
Now, the picture I have here is an immunoassay test. It's cheap, easy, you can buy them at a drugstore,
but there's the higher possibility with the immunoassay for a false positive. In other words they test
positive but they have not actually useed the drug it's saying they tested positive for and also false
negatives.
So in regulations here in Virginia we call those promptive tests. And actually those tests generally
speaking should not be admissible in court. It depends, but there is, again, the idea being that this is kind
of a screening for lack of a better word, kind of a first-round pass. t it's not something that is -- there's too
much variability.
Lab testing is definiteive definiteive or confirmation testing. And the industry testing is gas
chromatography mass spectrometry. So it's sometimes called GCMS or LCMS for liquid chrome to have
chromatography.
So you can say their THC level was 300. Here's what you want to remember. Drug levels can increase
and decrease in testing. Even if a person doesn't use more of that drug. So when I hear probation
officers say their levels are coming down, it doesn't mean the levels go back up that they've useed more
of the substance, it means something else is metabolizeed. So basically the standard practice with drug
screens is the person is either positive or negative. So most cutoffs, for example, on lab testing -- I'll talk
about cuffs in a cutoffs in a second.
So what it tells us is -- these are some of the three letters you see are some of the things they test for.
So AMP is amphetamines. It can also detect most amphetamine. Generally not Barbiturates it's rare to
see anymore.
Benzodiazepines, there's a wide variety of which they'll pick up. Some more readily pick up Xanax but

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not Ativan. So be mindful of that.

Cocaine is fairly reliable. It's generally one of the only things in this list that it's difficult to get a false
positive for but you always want to do confirmation if making decisions based on drug testing.
Methadone tests just for methadone. OPI, most point of care tests are only testing for opiates.
Remember opiates are those chemicals derived directly from opium, so that's your morphine, heroin
heroin, codeine. It's not going to pick up oxycodone or hydromorphone which is Dilaudid.
PCP, dextromethorphan in cough syrup can cause a false positive.
THC picks up delta 9, not CBD.
I mentioned cutoff a second ago, that's the defineed concentration in the assay or the sample which
above that cutoff it's positive, below that cutoff it's negative. So if the accountoff account cutoff is 50PPM,
if the person tests at 300 we'll say it's a positive test. If they test at 40, that's a negative test. You can
say, well, they still have some metabolites in their system. Doesn't matter. That rules out passive
exposure. And passive exposure has never been shown to cause definiteive positive tests. So we would
hear it all in court, I was happeninging out with my friends and they were passing a blunt around and I
didn't smoke but somebody blew it in my face. No, it doesn't happen like that.
There's a researcher named Paul Carry, I don't have him referenced I think he's out of the university of
Iowa or Nebraska and all he talks about is urine drug screens. He's really good and funny, too.
He did an experiment where they put people in a sealed room and tested them ahead of time and they
pumped in copious amounts of marijuana smoke and left them in there for 4 hours. And even when they
they -- something like that, I'm not trying to discount his work; just giving you an example. But even with
that passive smoke they couldn't get any of them to test positive. So, again, some of that is just -- there's
a lot of myths around these things.
But, again, you can't be kind of positive or kind of negative, it's one or the other.
And the detection time is interesting. This is for immunoassay, this is the non-lab test. The detection time
is really short on a lot of the drugs drugs. A lot of people think if you take a hit off one joint or blunt with
cannabis that you'll test positive for 30 days. No you have to be useing pretty heavily., so, again, it's
relatively short detection time.
And there are a lot of things these tests will not detect. The lab test, if you pay more money you can get
it to detect more things. It won't detect caffeine. So people say, I test positive for amphetamines because
I drink a lot of coffee. That's not the case. If that was true my wife would never have found employment
in the medical field, given her love of coffee.
And she's home today so I have to be careful. Just playing.
Opana, Suboxone, the Z hip nottics -- I love the emojis -- and it's not going to test for that. GHB, very
difficult toddes. So, again, it's really very important that we understand that.
It's interesting with MDMA we can ecstasy, that has a lab test, it has false positives. We changed drug
testing when I was working for the hospital system. They started testing for that in the ER and there were
so many false positives but not before, I kid you not, we had this lady come in, 78 years old, and slightly
altered mental status, don't know what's going on family is concerned. They run the labs and the doctor

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is like, aha, this is right before I got to the ER. He said I think we know what the problem is, granny and
she's like, what? And her kids are there and remember grandkids so the doctor shouldn't have done this.
He said you need to tell them that you've been useing ecstasy and she's like what's that? And the kids
are like, oh, my gosh, mom! And the grandkids are high fiveing.
She had not been useing ecstasy. It was a false positive. So the doctor -- I told the doc when I got there,
I said that's probably a false positive. That is a really bad test. And one of the psychiatrists that I work for
was able to talk with the hospital leadership and say, guys, you know, we got to stop this or just discount
it entirely because there were just too many false positives. But granny learned about ecstasy that day
and, yeah.
But she wasn't taking any. Much to her grandchildren's chagrin.
There are a lot of things that can cause false positives. This is just a partial list. Some of these,
Buproprion, am transcript lean, Effexor, Benadryl, a lot of false positives.
Remember the test is testing for metabolites, in other words products that have resulted from the
breakdown of the substance. It's not testing for the actual substance itself. So there are other things that
can cause metabolites to be in the system. We also don't know if the substance was taken
therapeutically. We don't know how much was taken. It doesn't tell us when it was taken. And it really
can't tell us if the person is currently intoxicated because we're testing for metabolites, if you test right
after they useed, they may test negative but in fact be intoxicated. And it doesn't tell us if they have SUD.
Just because they test positive for a substance doesn't mean they meet the criteria for substance use
disorder. It means metabolites are present and what is there.
We need to be aware of how you can pass a UDS while useing. I'm sure PESI will appreciate this. But I
found they have great senses of humor. We're not telling you how to break the law but I'm telling you
what people do.
You can use somebody else's urine or you can use a urine substitute. Synthetic urine is available for
purchase online. If you go to high times.com for example you can purchase that. Again, I'm not
sponsored by them, but when you work in the field it's a good idea to be aware of what is out there.
You can add a substance to the urine. So, for example, one of the things that should happen when you
do a urine drug screen is the person should wash their hands. So we want to wash hands before and
after. After because they just useed the restroom and that's a good idea. But you want them to wash
their hands before because sometimes they'll put a substance under their fingernail. They'll use Dawn
dish detergent and even if it dryies out they dip that into the urine and what happens is the enzymes or
whatever is in there, I'm no expert though I've done a lot of dishes in my life, that enzyme basically
interferes with the drug test. So that's why you have them wash -- I had to do a preemployment drug test
for my new job and they followed the protocol exactly. So be aware of that.
They might attempt to dilute the sample by drinking a lot of water or dipping the sample cup in the toilet.
So most places where you do a sample the toilet water is dyed blue.
They may try to do that or, again, drinking a lot of water. That can be tested for by looking at specific
gravity so we know people are flushing.

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There are a lot of products you can buy online that will help you pass a drug screen. And they're very
expenseive. What nearly all of them get you to do is drink a lot of water. That's the main thing. If you
drink too much water, believe it or not, those of you in the medical field know this, it can hurt you, it can
throw off your electrolytes.
When my wife ran rescue, they had a guy die. It was a hot day and he literally chugged a gallon of water
after cutting the grass and he died. Electrolyte imbalance.
So -- or they take a lot of vitamin B supplements and the urine will appear orange and their skin will often
appear kind of orange, like, hey, how is your liver, that kind of thing.
So there are ways that people can pass a drug screen screen. They can also -- and this is kind of
interesting -- you can basically hide things. So females can sometimes insert something in their vagina
and use that with fake or synthetic urine and use that to give a sample. There are fake penises,
whizonator that mails can use, goes around your wails with a belt and stuff, comes in different colors. I'm
not making this up. But when I was in drug court, our young people were being observed and I
remember I was at the courthouse for some reason where the testing center was, my office was in a
different building, and Brian, who is our police officer, just a really good guy, I could hear him in the test
room and he goes, oh, my gosh. And I'm like, like what the -- and I'm like, what is going on? He said,
you're not going to believe this. He said, so-and-so is wearing a whizonator. We had heard about them.
He goes, yeah, and I said, how do you know? He goes, well, the whizonator is of a different skin color
than he is.
So this guy had literally done that. So he winds up -- we go to court every Thursday and the judge is like,
are you going to fess up? He goes, yeah. He goes how much did you pay for that? He goes 150 bucks.
Tampering was a huge issue for us.
So take a look at what's out there. It's kind of fascinating.
You can also assess for substance use by asking the client some of the questions that I've asked and
also physical exams. Dilated versus pinpoint pupils pupils. Is the heart rate or blood pressure elevated?
Are they acting different? Hyper active, can't sit still. This isn't definitive but it's enough to say something
might be going on.
When I worked with primarily heroin users, can they stay awake in group, are they falling asleep on their
feet? That's a way to assess something might be going on here.
There are other types of drug screens, hair testing. But again, you have to have hair but at the same
time they can test hair anywhere on body hair. The issue there is how far back do we want to go I think it
depends on the person's job. Cannabis is pretty much legal here in Virginia but there are certain jobs
where it's certainly not allowed, public safety. And when I fly on an aircraft, I really don't want the pilots to
have been hitting the gravity bong or something like that, you know, the night before or that morning
before we take off. I'm not cool with that.
Saliva and breath, less invaseive but harder to detect. More susceptible to environmental conditions.
Breathalyzer results are admissible in court but it has to have been calibrated. If it's not, it's inadmissible.

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Sweat, what we do in drug court, if kids were going on vacation, we'd put a patch on them and it would
collect sweat. And we could test the patch when it came back. When the kids and their parents say the
patch didn't stay on. So the judge says, this is what we're going to do. I'm a cycleist, I'll bicycle 100 miles
tomorrow. And the other swimmer, and Mr. Mr. Brassler is a runner. So we'll test and see if it comes off.
And it's going to test positive -- oh, sorry, negative, that would have been been bad. So there are ways to
do that.
All right. So that takes us through drug testing. I hope that's helpful. It's fascinating, but please please,
please, please don't rely on that alone.
Now, we kind of yesterday and just now have talked about the issue. We've talked about co-occurring
disorders, substance use disorder, at length about some of the different substances people use.
From this point forward we're looking at treatment so we're going to start with treatment planning. We
also did assessment yesterday.
So a successful addiction treatment program offers a wide range of evidence-based treatments backed
by rigorous scientific studies without unnecessary legal and institutional barriers without stigma in a
client-centric manner. I really believe in that or I wouldn't be here talking to you today. First we want to
look at prevention. It's part of treatment and seek to deter people from useing drugs in the first place.
Good prevention efforts take the following into consideration. Realize that provideing drug information
alone to a person particularly with substance use disorder doesn't change their behaviors. They
generally know it's bad for them. They generally have experienceed negative events due tother drug use
and part of the illness is you continue using despite that. Scare tactics have been shown to be ineffective
in preventing substance use disorder. The judge I worked for would say regularly, the DARE program,
drug education program does not work. If you happen to be doing a DARE program, I'm not trying to
disrespect what you're doing but the data are very clear.
I remember talking with a client recentry in private practice and she said, you know, when DARE came
around to school when I was, like, 8 or 9, I knew about alcohol because it was in my home and I saw the
effects, but they were talking about heroin and how it numbs you out and that really interested me. And
later in her life she began useing heroin at 16 years old. She was at a very wealthy private school and
where there's money there's often drugs.
Scare tactics don't lead to long-term change and it's not been shown effective. After 20 years of doing
scared straight where you take kids into jails or prisons, it actually made things worse.
Prevention also takes into accounts that the earlier in life a person starts using substances the greater
the hood for SUDhoodlikelihood for SUD to develop.
I mentioned yesterday when I worked for the county back in the 2000s we had a situation where the
county had done a survey of middle schoolers and found that 20 percent of them had useed inhaleants
in the previous yearment.
So what year. So what we did from a prevention standpoint, we're not going to say to them, don't huff
because we'd probably make the problem worse. Instead, let's approach the families, businesses, let's
talk about being the solution in this and secureing these things and educateing ourselves. When they

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repeated the survey the following year it had dropped by more than half, which was great. So that was a
good prevention effort that was well done.
Primary prevention is preventing future drug use, where we talk about education. What would be great
with DARE instead of telling them about all the drugs that are out there, and if you smoke you'll ruin your
life. People say my older brother smokes weed and he's fine and my parents drink and they're fine so
that part I know to not be true it means everything you're saying isn't true. Kids are thinkers before a
certain age, a lot of adults are, too,.
So how do we talk about education and refusal skills skills, to me it's a discussion much in the same way
that sex education is a discussion. It's not a, hey hey, just don't do this.Lets let's talk about this. Let's talk
about what's out there and things like that.
As somebody in drug treatment, I -- my oldest friends when my oldest son was born, they said when did
he get his first drug talk I said at 6 days old. He was sleeping and I started to practice, let's talk about
this.
So I know somebody in college right now where the drugs were rampant, he was exposeed to that. But
he also both my kids who have been in high school or are in high school now, they know it's there and
they're like, it's not I'm not going to do that. It's not a mystery to them.
Secondary prevention, stop drug use after it starts. Intervention, diverse programs, like drug courts
instead of throwing you in prison or jail.
And tertiary prevention is preventing further damage for those with substance use disorder and with
harm reduction and hopefully that will be a bridge to treatment or changes in behavior.
So that's different levels of prevention.
There are different levels of treatment, too. What I want you to remember is people with substance use
disorder may engage and disengage in treatment during their illness. That doesn't mean it's failed failed.
So knowledge gained during treatment often is cumulative. So this pattern of being in and out of
treatment is not treatment failure, it's just simply how it goes.
Recovery in the context of SUD -- and somebody asked yesterday about recovery, this is a great
definition -- recovery in the context of substance use disorder refers to a long term process in which
there is change not only in the use of substances but also in the personal and social aspects of a
person's life. The road to recovery remains anything but linear and smooth and the outcome anything but
reproductble. Domains of change during the recovery process can include physical, psychological,
spiritual, behavioral, interpersonal, sociocultureal, familyial, and/or financial. I love that, not doing it for
them but we work together.
So SAMHSA has guiding principles of recovery. And SAMHSA is really kind of taking the medical model
of substance use and really kind of reinvigorateing it into a recovery mindset. So recovery emerges from
hope, it's person driven, it's holistic, it's driven by many pathways, it's based upon respect but it's really
defineed by the individual. So good question yesterday, if I have a person who stops useing cocaine but
are still drinking but maybe not to excess, are they in recovery? I would say absolutely. Let's say that
they are still drinking to excess, say, I'm in recovery from cocaine, that's still recovery. But generally

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speaking what I've found with clients, they'll say I'm going to stop this first and this other one later. That's
fine. Or sometimes they stop all of it. That's usually the best way, but it depends on the individual.
The most common thing you would see is a client use using illicit substances like heroin, cocaine, or
something like that, stopping that use but continuing to smoke cigarettes. So part of what I'll say is that is
that something you want to look at, too? Yeah, but just not right now. Okay. But some programs are
changing to say quit it all at the same time. It depends on the individual, though.
Treatment obviously involves goals. The big thing with treatment is it shouldn't be time limited. The
longer a person is in treatment the greater opportunity for recovery to occur. It should be focused on
goals but goals should be determined by the client. And goals should be measureable, realistic and
flexible.
So the ASAM identifies specific levels of care. This has recently been updated to what you see here. So
some things have changed, if you're used to the older one.
So level 4.0 is the highest level, most intense level of care, and long-term remission monitoring is kind of
the lowest level of care. And there's a lot of space in between. What the criteria is basedded upon as I
mentioned yesterday, it's not usually one experience or treatment, it's multiple levels and the people go
kind of up and down in them as needed. So ASAM level 4 is hospital-based, medical or psychiatric
stabilization. So 24-hour medical care is at the core of the mill you milieu.
So it's often with ASAM used to apply medical detoxification. As I mentioned yesterday, my friend who is
a registered dietitian who works in the intenseive care unit of a moderately sized hospital, any given day
1 to 3 of my patients are going through DTs, generally because of alcohol, sometimes because of
benzos.
They need that level 4. Absent that level of care there's a good chance they could die. Level 4 stays are
usually very short. It's designed to stabilize ideally the person would then transition to a lower level of
care. However, psychiatric hospitalization for co-occurring disorders is often level 4, but it's not unusual
for people to be discharged from the hospital into a very low level of care if not no care. A lot of times
what I would see from psych hospitals is follow up with a local mental health agency. Well, the mental
health agency in Richmond has a waiting list. Their same-day access is about 6 months. How is that
going to help you? It's not. It's not that the hospitals don't care, it's that quite often the hospitals are not
employing enough social workers to manage discharge outcomes. So the hospital I worked at had 40
beds and 2 and a half social workers. Two full time, one part time. That's simply not enough.
So what we see is people follow up with the local behavioral health authority, but when are you going to
get in? Again, it's not just a lack of resources resources, it's also just for -- from the public sector, a lot of
it is inefficiency, in my upon.
Residential treatment, there are different levels of that. But it's generally a nonhospital-based setting.
The higher residential treatment like 3.7 is medically managed. And some of those places may be
attached or adjacent to a hospital. So 3.7 is medically managed, 3.5 is clinically managed, 24- 24-hour
program but managed by clinicians.
I can't emphasize enough, residential treatment should always be followed by aftercare services within a

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continuum of care. It's not just I went to this program for tul days and went home and that was great.
That rarely works. In fact, meta-analysis found mixed results. For clients with severe co-occurring
disorders, people who are inadequately housed or homeless, required a structured and contained
environment, hospitaltation or partial hospitalization programs were more effective and services were
significantly cheaper.
Medically managed in high intensity outpatient, at least 20 hours per week of listen can go services.
These are often step-downs from residential treatment.
There's one I'm familiar with for people with eating disorders and co-occurring disorders, one of the
disorders is eating disorders and they have a very structured residential and HIOP and very, very
structured. Their outcomes are pretty good as a result of that.
So these are heavily structured groups. And general generally with HIOP they contain all the therapeutic
recreational stuff you'd see in a residential program but the person is living at home. And if home is
stable and supportive, what this means is that these services from a cost perspective can extend for 4-6
weeks and they're getting some of the state your name stuff they were getting residential but for a longer
period of time. And a lot of times they include a family component and in residential it's difficult to
incorporate that.
Then you have intenseive outpatients. Clients live outside the program but generally doing 20 hours or
less per week. This can be a step up from regular outpatient treatment or step down from a higher level
of care. This is the met analysis meta-analysis found as effective as residential treatment for most
clients. Usually the partial hospitalization programs were a shorter duration and longer duration for IOPs
but a lot of times they meet for 3 weeks at a point. They'll be going back to work or school and they can
do it in the evenings or stuff like that.
And then traditional outpatient therapy. Usually 9 hours -- less than 9 hours per week, so less than an
IOP. And, again, this is where you have individual or group therapy, so most of the programs I've worked
at with people with substance use or co-occurring disorders were these types of programs whether it's
the Suboxone clinic that we set up at daily planet health services or the drug court program I worked at
with chester field county. We were provideing this type of outpatient therapy. And it was pretty effective,
in my opinion.
Really this is what most people are going to receive receive. Most of the people don't need the higher
levels of care, and this is also the most prevalent.
There's another level that ASAM added, level 1.0, called long-term remission monitoring. Basically this is
to highlight the fact that people do not necessarily need to stay in treatment, even outpatient treatment
indefinitely. But this is for people who are just doing recovery management checkups. So it's for people
in sustained remission remission. It may be for people on medication for opiate use disorder like
methadone or Suboxone, who have done treatment and are in the maintenance phase phase.
The key reason why ASAM put this in there is we want clients to still be engaged and to be able to have
quick access to higher levels of care if they return to use.
And then there are recovery residences sometimes called recovery houses or sober-living communities.

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These are step-down from residential requireing people to be involved in peer recovery services like AA
or NA or smart recovery and doing treatment. I'm actually -- where I am in lakeside just outside of
Richmond, there's a major drug treatment program a block away. They've been there about the same
amount of time we've been in this neighborhood. And in our neighborhood around us, they own 17
recovery residences residences within our neighborhood. They're good neighbors. It's a good program.
And really what they did in that program was they realizeed that there was a lot of treatment available
but there was not a lot of housing. So when they started that program, how do we create recovery
residences was the thinking and they run it really well. There are plenty of places in town that don't.
There's ample drug use in the home and other types of things. But generally speaking a good one has
these elements, separateness from other programs, community activities, the staff have lived
experiences but access to clinicians. A lot of them -- and I'm a big proponent of this -- is work.
Employment is such an important part of recovery. Years ago when I was writing the program at daily
planet, I'll share this with you, we started the drug treatment program and it just blew up. We went from,
like, 6 people in it when I started there to -- we were at well over 150 within about a year and some
change probably because I really -- I had a good CEO who just kind of let me do my thing and hired
good people and I said, here, do it. And we tried a lot of stuff and we literally were busting at the seems.
The mayor was newly elected to Richmond and I went to meet him because I was always the one trotted
out by our development team because I guess I can talk. And I'm not much of a fan of him because he's
done some things I don't like, but they asked me to speak to him. He was a really nice guy. He's kind of
channeling his -- I think he was channeling President Obama, but he was no President Obama, not
nearly as smooth but he was like, so tell me -- he even had the whole hand thing. Tell me more about
your program. I said it's a jobs program, Mr. Mayor Mr. Mayor. He looks at his aide like, what? I said it's
a jobs program. He said I thought it was drug treatment. I said it is, but 80 percent of clients who come in
the program who don't have a job have a job within a month if they stay engaged in the program and
they find jobs based on what their peers in the program are telling them. He goes, that's interesting. I
said, so here's the thing, Mr. Mayor Mr. Mayor, they start out having to be on public assistance but within
a month they're paying taxes. And he's like, well, everybody can get behind that. I said, yes, Mr. Mayor.
In fact I've got one guy in our program, when he came in we got him hooked up with Medicaid. He's now
on commercial insurance and and, Mr. Mayor, his insurance is better than mine. And he's like, wow. I
said, that's how it's supposed to work. I said, and he is part of a crew that is helping to rebuild -- there
was a lot of construction -- I said he's one of these people that's helping to change the skyline of
Richmond. He's a great guy. But he went from living in his car when he was not in prison to now buying a
house. I said this can work.
I told him, Mr. Mayor, I'm actually a pretty fiscal fiscally conserveative guy. I don't like to see money
thrown away. He said I think everyone can get behind this. But it was cool.
So let's talk about pharm cotherapy or medication medication-assisted therapy. MOUD is kind of the new
thing.
So let's start with myths. No. 1, medications like methadone and buprenorphine replace one addiction

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with another. Remember what I said earlier -- maybe not -- that we have depends and we have addiction
-- dependence and addiction. They are similar but not the same. I was not a proponent at all of
medication-assisted treatment. Working in the ER I had seen how people got hurt by it. I only saw the
bad side.
When I went to work for daily planet and I was told we're going to do this, I was like okay. What changed
my mind was talking with clients. People who had benefited from it and opening my mind. I also
realizeed that because most of my exposure before then had been an abstinence-based treatment
because it was court-ordered in the drug court and I had worked in 12-step programs which I do believe
that I had a very negative view of it. That helped me to see a broader view and my view of drug
treatment is whatever the client wants or needs.
So if you have -- so when I worked at daily planet we set up a Suboxone program, we were one of the
first to do that on a large scale in Virginia, now they're all over the place.
And I remember the doctor I work with saying I know you're doing some work with the healing place,
which is a shelter or treatment program that's abstinence based. He said why do we want to work with
them? I said because they have needs. He said but they're abstinence based. They don't adhere to our
model. I said who says they have to. They're not telling us how to run their program, we're not telling
them how to run theirs. But they're abstinence based. I said that works for those folks folks. Nobody's
forcing them in there. What we do works for our folks. Nobody's forcing them in there there. There has to
be more than one doorway.
So another myth is that clients should tapeer or turn down or get off methadone and buprenorphine at
some point. Most people actually will. Most actually want to. There is a push in some programs that say
you can never get off it. That's not true. But it's really wrong to say you've got X number of months to get
off this. That's not okay. Likewise dosages of methadone and buprenorphine should be limited. There
should abceiling. After a certain amount it has an automatic ceiling. And with methadone we'll see how
much an agency can prescribe or give to a client can be problematic in the age of fentanyl.
Another myth is clients prescribed buprenorphine or methadone must attend counseling. At daily planet
counseling was mandated. I've since come to see that's not always a good idea. I've seen when
counseling is offered but not mandated people more likely engaged in it and make use of it. Whereas
when testifies mandated it created automatic resist resistance.
MOUD is incompatible with 12 step peer recovery programs. Since every group is independent, yes,
there are some groups that would say if you're on methadone or Suboxone you're not really in recovery.
But there are plenty of groups that would say, we accept you.
What I tell my clients is it is nobody else' business what medicines you're taking. So if I go to a meeting --
and I go to them every now and then, and I do not identify as a person living in recovery -- but I go to
meetings because I find it's -- particularly AA -- I find it's very uplifting and I'm supporting people I know
and love that are part of the fellowship.
I go to open meetings, which means anybody can go. But, you know, it is compatible. So what I tell
people is yeah, I'm on this medication. The only person that knows what medications I take and why I

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take them are my doctor and my wife. I think it's a good idea she knows in case I keel over. It's nobody
else' business. So I tell them if you go to a meeting you don't have to tell them that.
Clients should be terminated from MOUD if they use illicit substances. No, no, no, New York City no. If
the client is testing positive, does it mean they need a higher level of care? Yes. But kicking them out for
using using, if you think about it it doesn't make any sense.
Now, what I will say -- we'll talk about termination later -- there are some reasons to terminate somebody
but it's very rare.
So medication for opioid use disorder, methadone and buprenorphine. Methadone was in Germany in
the war. The Nazi regime was collapseing because their territory was shrinking as the allyies closeed in
and they needed a way to create pain medication that's why methadone was developed. It was never
useed much much. It was approved to treat opioid use disorder in 1972. Whereas buprenorphine which
had been around since the 1960s was useed to treat opioid use disorder in 2002.
They're given by licensed providers. This isn't -- particularly with methadone, not everybody can
prescribe it. With buprenorphine it's become much easier now. And behavioral health treatment is
important but should not be forced so the ASAM recommendations are that psychotherapy not be
mandated. These act as agonists. Keep the client from experienceing withdrawal and block effects
should they use other drugs. When useed as prescribed they can both be misuseed because most
things that are helpful have a harmful side. We talked about Ketamine yesterday which I provided -- was
part of practice for 4 years. Can people misuse Ketamine? Absolutely. Does that mean we should throw
it out? No.
Same with methadone and buprenorphine, can people misuse them? Absolutely. At the same time these
are still well regulated medicines. What's key is that both medicines allow the brain to heal from opioid
use and provide opportunities to address the underlying causes.
And part of it is how the receptor activation works and I'll show you another slide in a second. So part of
what happens if you see heroin, that's the red one, it activates the receptor site quickly and that creates
the straight up line. I realize I'm pointing with my finger and you can't see that. But the straight up line
there is the rush that happens. So so there's a rush and then a long period of it kind of wearing off.
Methadone builds more slowly. So we're talking about this top like, it's not a rush but that receptor site is
fully blocked. So in theory if a person were to use more opioids on top of that it's going to keep them
from having an effect.
Buprenorphine takes longer and doesn't have the receptor site fully engaged but it has enough in the
receptor site to block, theoretically, any further use. Though, again, nothing is perfect.
Naltrexone is antagonist, it simply blocks the receptor site. So it looks like this. So the opiate receptors
up there, methadone is a full agonist. It locks in and blocks it. So it's activating the receptor site. It's
keeping the person from getting dope sick or withdrawal. And it's blocking that receptor site. Now, what
we know with fentanyl is that strong enough opioids can overwhelm that. So nothing is foolproof.
Buprenorphine is a partial agonist. It creates enough of a reaction to limit opioid withdrawal symptoms
and partially blocks that from something else coming in. Naltrexone puts a lid on that. It's antagonist,

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puts a lid on the receptor but doesn't activate it. So it serves as a block. But, again, you can overwhelm
that. Fentanyl has changed everything.
So methadone is the strongest evidence base of any opioid addiction treatment. Delivered in liquid or pill
form in opioid treatment programs sometimes called methadone clinics.
It's in a small cup, the client drinks it, and if it's a good clinic the nurse will say give me your name and
date of birth. It's hard to cheek it if you have to talk. The reason we say that is some people try to drink it,
put it in their cheek and then sell it. I know, gross, but one way it's diverted. But they receive a dose
every day. And that lasts throughout the day. And as they've been in the program longer they can get
take-home doses. But they have to be secure and things like that.
If it's the right dose it's not going to cause increased some lens, some you some you lens. Some no If
they sleep a lot it's because the dose is too high or they're taking other medications. Methadone can
cause overdose because it can build up in the system more than other substances. Because it is long-
acting, the withdrawal -- if you were to suddenly stop taking it, the withdrawal from it -- the symptoms are
much, much longer than with heroin.
Interviewees with methadone treatment experience argue that an appropriate methadone dose is critical
to success. Yet over 40 percent of U.S. methadone clinics patients receive too low a dosage with
nonwhite minorityies particularly likely to receive insufficient doses.
Minorityies are typically treated for pain in medical institutions anyway and we see that quite a bit.
There's a lot of institutional work that has to map happen there. Significant evidence exists that
methadone treatment programs should provide a minimum dose of 80 mg a day. The average is 120.
Some need more, some less.
Buprenorphine is an agonist in low doses and antagonist in high doses, often combined with naloxone.
In this formulation should the patient try to inject or snort the drug, instead of taking it orally in a strip that
dissolves under the tongue, the idea when formulated was if they take that strip, melt in water and try to
inject it, the Naloxone, another name for Narcan will cause them to go into withdrawal.
So somebody was talking at a conference, this is foolproof. You can't tamper it. And I'm sitting next to
our judge who was one of the most awesome people I ever met in my life and he's listening and he goes,
that sounds like a challenge. And he looks at me and says, don't you think our clients would find a way
around that? I said yes, sir. He said me too. They're very resourceful, very smart people and I don't think
that company is giving them their due. I thought, wow, that's great.
It does have a ceiling effect, so it can be given by provider not in specializeed treatment programs.
Above 32 mg it doesn't do anything more. So it's very hard to overdose on. However, people have
overdosed on it because they mixed it with other medicines.
There's stop sign sublocade, it's an abdominal injection once a month and it's kind of -- it's about the size
of an almonth under the skin and that slowly dissolves so they don't take it every day. Most people when
they take buprenorphine are taking the dose two or three times a day.
It has a greater affinity for the brain's opioid receptors, it binds more tightly to the receptors. Even though
buprenorphine has greater affinity for the opioid receptor it has less activity to activate the receptor site.

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People should start feeling the effects of opioid withdrawal when they start it. There's a lot of barriers a
lot of concern about aversion and it does happen. A lot of times it's diverted to people who want the
Suboxone without having to go through a lot of the rag ma role that clinics want them to go through like
abstinence, no prove U UDS screens. But same-day access is really important.
What ^ about tapeering? These are the SAMHSA guidelines. Forcing a patient to tapeer off of
medication for nonmedical reasons or because of ongoing substance misuse is generally inappropriate.
Forced tapeering may violate the ADA.
Naltrexone is useed to prevent relapse by limiting cravings. Generally speaking it's started in oral form
and if a person passes what's called the PO, which means oral challenge, they can get Vivitrol which is
an injection that lasts 28 days. This works to stop. So basically if you were to use a substance like an
opiate with nail frequency on, it's naltrexone, it will block the effects. What we see with fentanyl is you
can overwhelm that.
I have clients who took oral naltrexone and it had good effect on their alcohol cravings. A lot of good
effects like that.
Narcan is useed intranasally to rest an opiate overdose. Very short acting.
So I've got my Narcan right here. I got this free. This is a nasal injection. This is a dose that I would -- I
have a bunch of it here. This is the show and tell part of the program, but basically I can use this, one in
each nostril if a person is down and each box comes with two doses. I got this free from the health
department. I have a couple boxes. I usually give it away. But it's good to carry. Really good to have.
Most states have laws that protect you if you use this, and the person doesn't make it. It's called a Good
Samaritan law.
Generally speaking if you deploy this, it buys you time to get them to the emergency room for further
treatment. Some people may need to have more doses. One of the last shifts I worked at the hospital
before I left had a guy come in who had overdosed and was found down on the street maybe a mile from
a hospital. I remember the paramedic comeing in and the guy was conscious, he was breathing on his
own and the paramedic said, well, doc, we got this call, by the time we got there, 4 civilians, regular
people like me and you, had deployed Narcan on him, probably saved his life.
And the doctor, really good doctor, Dr. Z was awesome had a talk with this guy. And they started doing a
bridge clinic, they're more commonplace now where doctors in the ER give people a prescription for 3
days worth of Suboxone and hand them off to an outpatient clinic. Doesn't always work but the idea
being we're not going to let them leave.
This guy wound up leaving anyway despite the best efforts of the doctor. That happens but it doesn't
mean we give up.
Oral naltrexone is not widely useed to treat opioid use disorder. You need someone to stay with the
person. While it blocks opioid receptors -- SAMHSA recommends not discharging MOUD patients if the
benefits outweigh the risk.
As far as other drugs, no medication has been shown to be effective in treating stimulant use disorder
and no medication is approved for treatment of stimulant use disorder at all. We're working on some

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things like that. Some studies are useing Wellbutrin and naltrexone. There are places looking at
replacement therapy like prescribing Adderall but nothing has been decideed on yet.
Disulfiram is useed to treat alcoholism. This is use used less and less now because you have to take the
medicine every day. So if you want to drink just don't take the medicine. The other thing is with the use of
alcohol-based hand sanitizeers, even though it's not ethyl alcohol, your body will still react to it. If you
were to use a hand sanitizeer with it, you'll get really sick. So this is still around, but it's not widely useed.

Nicotine replacement, I'm a big fan of this. There are a lot of things like patches, gum, nasal spray,
lozenges lozenges, things like that. This is a thing to get people to stop smoking or vaping. People may
need to be on these for a very long time. But, you know, again, I'm not going to hurry somebody off
these.
Withdrawal management or detoxification. These are the ASAM goals for withdrawal management. It
useed to be that people were for lack of a better word made to suffer as if somehow going through the
withdrawal process and all of its horribleness that that's what they had to do. So withdrawal management
alone, this is very clear, or detoxification alone is not treatment and rarely suck seeds without follow-on
and multidimensional support.
So we want withdrawal to be safe. We want withdrawal to be humane and dignified and we want to
utilize withdrawal to prepare the person to engage in further treatment.
So inpatient withdrawal management typically what occurs in medical hospitals and some psych
hospitals hospitals. The focus is on stability. So in those cases small amounts of methadone or
buprenorphine may be given to rapidly tapeer the patients withdrawing from opioids. They may use
clonidine, a blood pressure medicine, Zofran for nausea, different things like that to help alleviate
symptoms.
We also see the use of Valium, Ativan, Librium, or barbiturates to tapeer the effects of alcohol. And once
they're stable we transition to a less intense level of care.
Outpatient withdrawal management is typically what you'll see with opioids. Some places may require an
emergency department to declare the patient to see if they handle the withdrawal process and there are
still programs around that simply offer social detox detox, which is into medical support but a supportive
environment. That's what some people utilize.
Again, when we talk about opioid withdrawal, it feels horrible, lasts a long time, it's rarely medically
dangerous. Alcohol and benzodiazepines are a different story because of the risk of seizure and
delirious extremens.
Withdrawal management, CIWA-AR, -- it's public domain domain, you can download it off Google. It's
useed in inpatient and outpatient settings. It helps to guide medication use to manage these symptoms.
So, again, our signs of things that a medical professional can see symptoms are what the patients
report.
You can see some of the symptoms and signs. Is the person reporting nausea or are they vomiting? Are
they reporting anxiety? Are they sweating? Some of the specific questions, tactile disturbances, visual

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disturbances. Have the patient extend their arms and spread their fingers? Do they have tremors? Do
they know who they are, where they are?
What we did in our hospital is initially when I started working there they wouldn't engage with this
protocol until the person was on the psychiatric unit. When Dr. Steven came there about the same time I
did in 2010, he changed it. He said I want this initiateed in the ER. It was better for the patients overall.
The opioid withdrawal management protocol is calls the COWS, unfortunately. There's also something
that can be down outpatient that he was the subject subjective opiate withdrawal scale, called SOWS. It
looks at patient report and observations. So items are scored from 0-4, sometimes 5. It determines the
dosage to be used.
COWS are resting pulse rate, beats per minute, sweat sweating, restlessness, we're observeing. Bone
or joint pain. Pupil size, runny nose, are they tear tearing up? GI upset, tremor, outstretched hands,
again, yawning. Allose a lot of yawning with opiate withdrawal. Goose-flesh skin, hair standing up.
Studies show that most patients with opioid use disorder who undergo medically supervised withdrawal
will start useing opioids again and won't continue in recommended care. That means withdrawal
management alone is not treatment. Here's the thing, if you go through medically supervised withdrawal
and there's no follow-on treatment or MAT, MAT MAT and you return to use use, your threshold has
dropped significantly and the potential for overdose is very, very, very high.
It's also really important for people starting naltrexone which requires 7 days without short acting opioids
and 10 days without long acting opioids. If you treat someone with naltrexone and they have opioids in
their system, they'll be thrown very quickly and uncomfortably to say the least into full-on opioid
withdrawal and that's going to stay that way.
Other withdrawal management, there's no established medications or medical protocols to talk about
opioid -- drugs other than opioids, alcohol, or sedative. We want to help the client feel comfortable and
safe. And we can manage symptoms medically, but at the same time helping people to feel safe, having
structure, and understanding that this is going to take a little bit, but there's no necessaryily medicines
we can give people.
Last word on treatment, and this goes to the splent question yesterday where the person said, what do I
have to have? Do I have to have the experience of living with a substance use disorder to be effective at
what I do? I said, no, you don't. The most consistent predictor of the outcome has been the quality of the
relationship between therapist and client. What may be of polar practical importance to successful
outcome is not who provides what treatment is provideed but who provides it and the manner it's
delivered.
What it comes down to is the connection more than anything else.
I want to pivot. We'll take a break for about half an hour. We're going to talk about behavioral addictions.
This is not a huge section but this is really something to watch because there's a debate about including
behavioral addictions alongside SUD or whether they should be something else. And there's also frankly
a lot of shall we say inventive inventiveness in our field about new addictions.
So I'm going to kind of play it kind of conserveative conserveative here for lack of a better word and stick

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with what we got. So the DSM-5 includes gambling disorder as a primary diagnosis. It does include
internet game gaming disorder in the conditions for further study. It also contains some information
around sexual behaviors and we'll look at that as well.
So alter describes behavioral addictionings as 6 components. Goals that are beyond reach. Irresist
Irresistible and unpredictable positive feedback, in other words if feels really good. A sense of
incremental progress and improvement. Tasks that become slowly more difficult over time. Unresolved
tensions that demand resolution. Social connected connectedness with gambling in particular.
So we'll focus on gambling disorder, compulsive sexual behaviors, and internet gameing disorder. Other
disorders, bing binge eating disorder was defined in the DSM-5, there were terms of defining it as an
eating disorder. It's more of a behavioral addiction than an eating disorder in my clinical opinion.
Compulsive buying disorder. Is that due to something else? Trichotillomania is pulling your hair out,
sometimes eating it.
Exconversation is scratching or diggingEx-- excoreiation is digging in the skin. Cleptomania is stealing.
Very rare. Just lie pyromania, starting fires.
Excessive tanning, useing tanning booths. Intermitt Intermittent explosive disorder. That's considered a
behavioral addiction for some people. For other people, IED is really seen with almost seizure like
activities.
We'll focus on the ones in green.
So here is adage gnostic criteria for gambling disorder. In many ways it follows what we see with
substance use disorder except with substance use disorder you have 11 categories, at least two of
which have to be met for a year to qualify for substance use disorder. For gambling disorder it's 4 or
more, so you can see that here.
Gambling is a big problem are. It's more so than I think -- and it's really invisible and treatment is still
hard to come by. So why do people gamble? There are ways people they gamble. Casino, slot
machines, cards, et cetera. If you've ever been to a casino, it's fascinating. It's dark, there are no clock.
Everything is designed to keep you at the table or slot machine. I've spoken twice at PESI events that
happened to be in casinos and it was just fascinating to watch.
Really interesting.
Lottery is a very common way that people gamble. Sports betting has become huge. In fact, when I listen
to sports radio which I do a lot, a lot of times the talk is on the point spread or this and that. They're
talking about ways to gamble as much as they're talking about other aspects of the game. If I'm following
football or basketball in particularly.
Stock purchases, chasing the stock, day trading. And then games of chance, bingo, internet gambling,
things like that.
Gambling disorder often begins in adolescence or early adulthood and anyone issues with age. Can
cooccur with substance use disorder or replace another addiction. I've lost more in a row so I'm due for a
win. If you take an average person and you have a 6-sided die and you say I've rolled four 6s in a row.
What's the chance that the next one will be in a 6? We'll, you've rolled 4 in a row, you're due for another

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one. You're due for a 1 through 5. The odds actually remain the same. But we don't think of it like that.
We think that -- you hear this about the weather, we've had a lot of mild winters so we're due for a strong
winter. That may be the case, but it's not always the case. Just because it hasn't happened in a while
doesn't mean it's going to happen again.
We're also seeing small wins instead of big losses. When I worked at daily planet there was a
convenience store across the road. I got to know the owner. He came to America from Iraq, studying to
be an accountability but worked at the store. Super nice guy. I remember being in line to get something
to drink and this lady walked out. He said, Paul, let me tell you about that. I said what what? He said that
lady comes in and spends $50 a day on lottery tickets. Six days a week, not on Sundays. So she's
spending $300 a day on lottery tickets. The other day she won $250 and she was so happy. I didn't have
the heart to tell her she spent over $300 to make that 250.
She saw it as a win, it's really a loss. He was blown away by that. But that's true, that's how it works.
And that's -- the house always wins wins, as we like to say, whether it's a casino or whatever, the house
always wins.
How do we screen when assessing for gambling disorder? There's the lie/bet screen. Have you ever had
to lie to people important to you about how much you gamble? Have you ever felt the need to bet more
and more money?
There's also the south observation gambling screen called SOCS, once a proofficial.
ASAM addresses that.
We want to treat co-occurring substance use disorder disorders along with gambling. CBT can help
clients recognize triggers to gamble. Medication, and there are gam builders anonymous 12-step groups.
There are several in my community that are really good.
Compulsive sexual behaviors, various terms are useed to describe this, sex addiction, pornography
addiction is really a big deal. Addictive sexual behavior, hypersexual disorder, sexual impulsivity. Key
themes include frequent hyper sexual urges that the client has a difficult time controlling and, again, a lot
of this is driven by the widespread inexpenseive use of pornography that helps drive this this.
Consistently compulsive sexual behaviors are linked to high risk sexual behaviors. For some people --
not everybody -- multiple partners, unprotected or unsafe sexual practices or engaging in sexual activity
unled the influence of drugs. The consequences could be severe.
It's more common in men, but not necessaryily overwhelmingly so.
Part of what the DSM-5 recognizes is pairphiliasphilia paraphilias, intense and persistent sexual interest
other than sexual interest. Voyeuristic disorder, exhibition exhibitionist, showing off, frotteuristic, sexual
masochism or sexual sadism. If this is happening between consenting partners with safe establishment, I
personally and professionally don't see that as something that I need to treat. In other words, what you
do on your own time and with people if it's a consenting adult, that's your business. He pedophilia, that's
an attraction to people who are underage. People can have those attractions and not act on them. Same
with trans vestic disorder, or fetish disorder, my personal thing is you do you. If that becomes an issue
then we can talk about that that. But that's my personal take on it. I want to be clear, rape, incest,

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pedophileia and sexual abuse are crimes. I want to be very clear about that. I've supervised people who
were like I want to work with a female therapist I'm like, but you are a registered sex offender. And,
again, I'm going to be protective over the people that are on my team, not because they can't take care
of themselves but that's part of my role as supervisor and leader. I'm big on this. I don't like people
utilizeing mental health struggles to justify abuse. I just don't. So to me, I'm very, very firm on that.
So first thing we want to do is rule out the possibility that it's due to a medical or mental health condition.
I have had people really struggling. It's like, let's get you looked at by a interest. Sometimes it was
medical.
Psychological interventions with other addictive disorders can be helpful. I've worked with some
particularly men who had a really difficult time with pornography and it started out innocently, but it
started to consume them and began to affect their relationship with their protect spective partners or
current partners. I usually start with motivational interfereing and move to cognitive behavioral therapy
things like that.
There are varieties of 12 step programs based upon that. Some have different approaches., but, again,
in terms of sex addiction, there is nothing in the DSM-5 that says this is sex addiction.
And I've been frank with clients who have said I'm a sex addict and I have had to tell some I think you're
useing that terminology to justify cheating on your spouse. That doesn't mean that you're a bad person.
You've made mistakes. So part of what we need to do -- in some of those cases, how do we help you
reengage with your spouse? And that's also going to mean that you have to stop the behavior. I mean,
this is something that you may not want to do. And, again, I am so often asked by people as a therapist
to help them be comfortable in things that are hurting them. And, yes, that involves a judgment on my
part, okay. What I tell folks is if you don't like the approach I'm using, I can help you find a different
therapist. But if I have a couple -- and I useed to work with couples -- I would say, well, so-and-so who is
had an affair. And we want to work on our marriage. Has the affair stopped? Because we can't work on
the marriage if you're still having the affair. And so some things like that, they want to find a therapist
that's okay with that, that's great. It's just not going to be me. I'm just very clear on that. Again, it's not a
judgment. It's this is what I'm saying but you don't have to see me.
Internet gameing disorder. This is a really -- this is good. I mean not good, this is a good thing to talk
about. I think it will be in the next DSM-5, something like this, particularly with the MMORPGs, massive
multiplayer online role playing games. They can be consuming. What we're seeing with young and
middle aged people, avoidance, social anxiety, and people that are more imMERSed in their game world
than in life.
So you can see the proposed IGD diagnosis. Very much with withdrawal symptoms, tolerance,
unsuccessful attempts to control participation, loss of interest in everything else. I do think that with kids
in particular it has to be limited.
When we first had kids my wife and I are like, we're not going to have any video game machines in our
house. And our reasoning for that was because Claire and I knew that we would play the games a lot lot,
and she's like, the kids will never be fed, the dog is dehydrated because we knew ourselves, you know?

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As our kids got older, we relented, but it's interesting, there's a game console on the desk that I'm sitting
at right now that my son Ben has, and one in the other room that Eli has, and it's hooked up to the only
TV in the house. But our boys saved money to buy those. And even then, they're limited on what they
can do.
But I can also as a parent see some of that frankly holeier than thousand attitude I had early on.
Sometimes it's like, I don't want my kid watching TV TV. Sometimes as a parent it's nice to have them
watch TV so you can catch a break. It's really tempting.
So we try to manage that. But what we've seen, particularly with my son Ben who as I mentioned
yesterday has a history of a TBI, the transition from cutting off screen, it takes a minute for his brain to
readjust. Because he can just be a jerk. I'm like, dude, take a sec. Get off that.
Even more so with phones. More so with phones now. In fact I really think that probably in the future I
IGD it may be internet gameing disorder but maybe it's also Smartphone addiction as well.
So medication is still being investigated. I like the cravings behavioral intervention. Talking about
cravings with the different games and stuff like that.
There's also this CBT and a motivational enhancement treatment. That's basically what we're looking at
this from kind of a stage of a change approach. Looking at it differently, so contemplation stage, building
rapport and preparation stage and then contracting stage so it's a little different than stages of change
overall, but the idea is that we're going to try to get the person thinking about what they're engaging in.
So, again, while the DSM-5 focused on internet game gaming disorder, the overuse of social media and
hand-held electronic devices bears watching as well. Could you live without your phone? If so, for how
long? How often do you accession social media? How often do you check your email? I don't do social
media. Even when I started working with PESI, they're like, have a social media presence. I don't like it
and I don't do it. But I check my phone all the time. It's the first thing I look at in the morning because I
want to see what's going on, who won the game last night. It's one of the last things I do at night. I'm very
cognizant of that.
So what does it mean to take vacations from that? It's a huge thing. I mentioned John than Heidt's book
yesterday, I don't know him, seems like a cool guy, but he talks about how the use of smartphones has
really damaged our kids and he's advocated having them not in school at all, not just putting them away
but not having them.
So the governor of Virginia who I actually like basically told school systems lazyish based upon the
evidence you need to have something to do about those. And a lot of parents have been upset. My kid
should have access to a cell phone. But in the county I live in they said no cell phones in school now.
My kids are doing better in school. And so my friends' kids are doing better in school. No distractions,
less distractions, things like that. Again, Heidt talks about that kids really should not receive a
Smartphone until they're in high school and they should not be given access to social media until they're
16 and older. So they've had a chance to do other things first. I like that idea.
When our old errest sonest -- eldest son went to middle school, it was time to get him a phone. I said
let's just get a flip phone. They were either not available or they were more expenseive than the iPhones

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that we use. So we're just very mindful of that. My wife has done this thing recently because she'd see
me check my phone during dinner and she'd so no more phones during dining. I said okay. I struggle
with it, too.
Tell you what, do we -- we have any questions we want to go to since we're at a good place to do that
that?
>> Hi, Paul. Thank you, we sure can. There are so many questions.
>> Okay.
>> We won't possibly be able to get to all of them, sorry, everybody, but please keep adding questions
and upvoting when you can. I'm going to start with one not at the top of the list. There are a couple in
there about urine drug screens. Thank you for your review of this. Looks like what you taught has helped
many of us to think about these differently. Given that they're uncomfortable for clients.
How can you tell if a sample has been tampered with specifically when other substances have been
added to the sample do those substances come up in the results?
>> So with the immunoassay you're not going to detect that. Most lab tests test for the not for the
presence of metabolites but they'll notice some of the inconsistentcyies measureing specific gravity and
things like that. Really the best way to test and easiest way is a temperature strip. So there needs to be
a temperature strip on the cup. If not, it's really useless. I have had people give me mountain dew and
say it was urine. It's fizzing. Maybe there are more problems here than drug use, I don't know.
But a temperature strip is the best thing to start with. It should be between 90 and 100 degrees. If that
strip comes out and it's 120 degrees, there's a lot of problems here. This is a definite medical
emergency. If it's below 90 and they just provideed a sample something is wrong there. So temperature
strip is a good way to rule out quite a bit. That's what the data says?
>> I don't know if it's an answerable follow-up question but under what circumstances would you
recommend urine drug screens be useed?
>> I think anytime that you're dealing with really issues more related to court issues more than anything
else, criminal justice. Obviously if you have a person that's going to be in a position to where they're
responsible for other people. So different jobs, first responders, bus drivers, things like that. That's the
main thing. I think in terms of treatment I really -- the main reason we did drug screens at our clinic,
frankly, was not necessaryily to test for the presence of other drugs. We were testing to make sure they
were taking their buprenorphine and they weren't taking the medicine they were being prescribed and
selling it on the street. That have the biggest thing. It wasn't a lot but if you're not going to take the
medicine, we're not going to prescribe it to you. We would do the lab tests to make sure they were taking
the medicine. Even then we found ways that people could submit a screen that indicated it was in their
body and still -- I mean, there are ways people can get around it. It's not foolproof.
Where we tire ourselves out is trying to make things foolproof. At the end of the day people are going to
do what they're going to do and I can't live their lives for them. I'm not going to tear my hair out trying to
catch everything. I'm just not.
But that's the main thing. But that's why we use drug screens.

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>> And there's a risk in depending too much on them if you use them, it sounds like.
>> It becomes punitive. It's too easy to become punitive. And in some situations there has to be a
punitive nature. I don't want the pilot of my aircraft high. I really don't. I don't want a police officer out
there that could be involved in a high-speed chase or deploying lethal force high. I don't want the bus
driver that drives my kids to school high.
As I worked with first responders as we set up this new program, I've directed that everybody in our
behavioral health program is tested at the same rate as fire, EMS, and police because I want us to be on
the same page. Not that I'm concerned about my team like that but I want to follow the same rules they
have to follow. That's great. Thank you, Paul. The most upvoted question at this point, might not be the
best timeing but I'll put it out there, if a person is in recover recovery how long do we continue to use a
diagnosis?
>> Well, that's a really good question. If you look in the DSM, what it says is that if they're in recovery up
to I think it's a year or two years, I've got to look, so pardon me for my ignorance, they're in early
recovery. Or sometimes called partial recovery. If it's after a certain amount of time it's considered
sustained where he covery. recovery.
What I do is if the person -- let's say I'm dealing with somebody who's 38 years old and it was 15 years
ago, that's an arbitrary number, that they were treated for alcohol use disorder but haven't had a drink in
12 years, I'm not going to put that down, particularly if it's they're not seeking treatment from me for that.
So I usually look at beyond 5 years but, again, it depends how severe a problem it was that impacted
more than anything else.
That's a good question.
>> Yeah. There's some subjectivity in diagnosis, isn't there?
>> As there should be, absolutely.
>> Okay. So here is a question, to what extent do you consider crisis a potential leverage point for
change and patient readiness?
>> Depends on the type of crisis. We're going to look at change next in the next session so that's a nice
segue. It depends on the crisis.
I think a lot of times it is a precipitating factor. So like when I worked in community mental health, if you
notice one of the questions I would ask is why are you seeking treatment now? And it was often
precipitated by crisis. This had happened and this is what I want to do. And I think that that can be a
precipitant factor but unless we help them engage in treatment it's not generally going to be a long- long-
term factor more than anything else.
But it can be an opportunity and that's one of the reasons why we have bridge clinics set up with ERs so
when you have people who have overdosed who were essentially going to die without medical
intervention we can say, hey, this happened. Now here is an opportunity for you to get help immediately
as opposed to saying we'll follow-up next week. We don't have that kind of time.
So those bridge clinics have been shown to be very, very successful. So I think crisis can be an splent
opportunity to do that, but we've got to really deploy those resources immediately and not just say, well,

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hope it works for you next week.

>> Yeah. Yeah. The availability of care and access issues unfortunately often end up being dictators of
what we're able to give patients.
>> That's right. And a lot of times it's because of outdated models of care. One thing I hate hearing is
that's not how we do it. Then change it. Time for one more question.
>> Next top voted one, professionally and personally what do you see as a long-term impact of
legalizeing marijuana?
>> I think it's still too soon to tell. I think if you look at states that legalized it first like Colorado, they are
spending a lot more on mental health than before. I know that when I was on the road teaching for PESI
I had an inordinate number of directors -- when I say inordinate I don't mean thousands -- but I had a
number of directors of college mental health clinics attending my trainings and talking about how
rampant marijuana use had overwhelmed their resources. And other things, too. But I think it bears
watching. I think what you'll see in some states particularly Oregon that legalize legalized a lot of things,
they're rolling that back because they're realizing realizeing it's not exactly a great thing. As I said
yesterday, it's not a harmless drug. It's wrong to say that it's as harmful as fentanyl or
methamphetamine, that's not true, but to say it's as safe as coffee as I had someone tell me who was
part of the marijuana lobby, that is simply wrong. And so I think it really bears watching. I think what
you're seeing in some communities is an increase in car accidents. And I do think -- we nuance so poorly
here in the U.S. We go from one stream to the other extreme to the other. Is it right to put somebody in
jail for a substance that really isn't going to kill anybody? No. But is it also right to say it's okay as we've
done here in Virginia to smoke cannabis so when I go through certain neighborhoods or certain parts of
town and it reeks of cannabis, that's wrong.
So I think there's a balance.
I think it's still too soon more than anything else. So that may seem like a copout answer. I don't think it
is. We're beginning to see in some of the states where it was legalizeed that it's causing a lot of
problems more than anything else.
>> Thank you.
>> Cool. Guys it's about 10:47 right now. So I'll come back in 15 minutes. It will be 2 after the hour. See
you then.
(Break). At the time I was working in residential with kids and we had moved away from that. We would
do group process and the person could call an informal, which meant informal group at any time, school,
cottage, anytime and address an issue. That was not meant to be punitive. So I found out about
motivational interviewing when I went to work in outpatient adolescent substance use and I really liked it.
But I also found some limitations to it. The way it was originally taught to me in 2003 is that you don't ask
any closeed questions. You ask open-ended questions. As I told the person doing the training I don't
think that's necessarily going to work with kids. Adolescents need a combination of closeed and open-
ended questions. It was a good discussion. I wasn't trying to challenge the instructor or give him a hard
time but I thought that was a difference. The big difference with motivational interviewing is expecting

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resistance. So instead of meeting resistance with resistance, we roll with it as a way to engage the client.
If she say, how are you supposed to help me? Sounds like you're concerned about how I'm qualified to
help you you. That's all right. I'm glad you're getting some help.
I think when you roll with resistance you have to be genuine. Some of the -- one of the ways I struggled
in the training for motivational interviewing is some of the responses seemed really canned to me and
that's why I said I don't think this is going to work as well with adolescents because it just seemed too
much canned. But one of the things I liked about it -- and you have to understand if you had worked in
substance use treatment -- again, my main exposure had been as an intern -- it was really a game
changeer. It was the beginning of a significant game changer because it really took the expertise out of
the hands of the provider, the professional, and it made the client the expert. And it really kind of put the
responsibility back on the therapist to connect with the client as opposed to the client having to connect
with the therapist. It also addressed the issue of ambivalence and how common ambivalence is when it
comes to our behaviors. Quite often, again, they feel we need to make changes but we may be
ambivalent about making them. Instead of seeing that as a negative, accepted that as a normal part of
human behavior. So it really has been a game changeer. And if you've come up in the field or been
exposed to the field in the last 25 years, you've probably learned this. You probably learned it in your
formal education. But what I'm trying to point out to you is that it almost seems rote or just -- we're just so
useed to it now it's like, okay, it is what it is. I just have to tell you that if you were doing things before
this, it represented a major shift, and not all programs have adapted to it. But there are still programs that
are very confrontational. I just don't think that's helpful. Which is not to say that you should never
confront, it's just how you do it. I think confrontation is important but it's done from a position of within an
existing relationship and it's never done in a way that minimizes or demon issues the individual
diminishes the individual.
The other is summaryizing. If you've watched recordings of people doing motivational interviewing
interviewing, the therapist is talking a whole lot. I adapted to my own personal style and I really
encourage you to do that with anything to a degree. While it's still adhering to the model.
I'm okay with silence. I'm all right with it. I have found that, again, I use a combination of open and closed
ended questions with younger people. Some questions like on the suicide assessment yesterday, it's
kind of a yes or no question. The person could say maybe a little bit of both, are you thinking about
suicide? It's okay for them to say, yes, at times, no at other times. There can be some ambivalence
there, that's normal. But I really want to have an idea so it's more of a closeed-ended question.
Affirmations are important but they have to be genuine. And if we affirm people for every single thing
they do it diminishes the power of the affirmation. And I'm a big believer so if I give an affirmation, I'm
really going to mean it. So that's an important thing. One thing I struggled with MI is reflective listening. I
want to reflect it back but some of the recordings I've seen there is in my opinion too much reflective, too
much summaryizing, not enough pushing the client. That's my style a little bit.
The more I've seen people become frustrated with therapists is they'll say to me later on, I feel all they're
doing is reflecting back to me what I'm saying. What that said to me, if you're reflecting too much to

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them, the client knows you're hearing them. It's time to dial that way back.
Now, I also have to explain to clients we're doing that but our job is not to tell you what to do.
So there's a balance in that. Same with summarizing summarizing. I don't want to overly summaryize.
What I've seen when I've observed both in recordings and even live situations is clients getting really
really -- you're summarizing the same thing.
When a client does that what I'm looking at is, okay okay, are they ready to move into something else?
We want to use motivational interviewing when the client is ambivalent. When the client is no longer
ambivalent for the most part we can still use some of the techniques of MI but it's time to more into more
treatment-focused approaches which will be the next two sections.
That's the key thing. It's kind of like you think about motivational interviewing as selling. So years ago I
started doing this exercise group, it was based on the Navy seals, it was run by a normer Navy seal. A
buddy of mine had been doing it for a long time so I'm going to join it. So Ben, my mid middle son was
about year and a half old so I'm holding him and Sam was 4 years old so I'm walking with him. So we go
to into the store and I'm ready to sign up. The own you are comes out, nice guy, and he starts doing the
sales pitch and I literally had to say, you don't have to sell me anything. I'm good. I want to do this. He
kept with the sales pitch. And I'm like, I got this 1 and a half-year-old who was a who is. He was Hoss.
He was a big boy. My wife has never lost an argument for that reason because she didn't use meds. So
even when absolutely wrong she still wins. I'm like, I got kids here, let's go. And he was continuing
continuing the sales pitch after I said I want to buy. So I think that's the thing to be aware of with
motivational interviewing.
If the client is ready to move past ambivalence, that's when you move into CBT or one of the
psychodynamic approaches or something like that.
Motivational interviewing is really for those that just aren't sure what they want to do and that's where we
allow them to meet halfway. That's where we use change talk, optimism, believing that good things can
happen. Normalizeing behaviors is also really important.
I was working with a kid in drug court years ago and I did a session -- a family session and I wanted to
meet with Mom first. So I brought her back and she just looked worn out. I said, are you okay? She goes,
I came home today and my kid shaved half her head and dyeed the rest of her hair purple. I have had it.
And I said, -- you know, this is on top of the kid's previous drug use which was in criminal charges.
And I said, let's back up for a second here. When you were 16 or 15, what are some things you did? And
she's like dyeed my hair, got my nose pierced. I said, right. So what your daughter is doing, shaving half
her head, dying the of it purple, that's what they do to express themselves. I don't see that as part of the
drug useing behavior or criminal behavior. So I had to normalize it. She said you're right. I said I can
think about the stupid things I did when I was 16. I had a poeto mullet, -- proto mullet. And my kids can't
get their heads wrapped around shoulder pads.
So we normalize it.
Columbo approach, he was a detective who would solve crimes by playing dumb, not in a disrespectful
way but he would play dumb and literally in every case he gets the perp operator to solve the case for

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him.
Supporting self confidence. Readiness to change we'll talk about in a sec. Developing discretion is like,
you know, it's interesting you told me that you really want to stop drinking yet you said that last week but
then you also just told me that over the weekend you twice went to bars. How is that going to work for
you if you're going to a place whose purpose is to sell alcohol.
So we're looking at that.
And then therapeutic paradox, what if you kept doing what you are doing? I think that can -- you've got to
adapt this for your own style. One of the things I like about DBT which we'll talk about later is there is this
sense of utilizeing some of that -- letting ourselves be rough around the edges when done with
compassion. So I think there's a lot of room to let your personality shine through.
So MI is based on on the stages of change model. I don't believe things follow a linear progression even
though the slide here is clearly linear. I couldn't find a way and I frankly didn't want to take the time to
create a way for the arrows to go all over the place. With the stages of change it's presented in a linear
manner but I don't think people follow a linear model. I think they go all over the place.
So I want to be careful about that.
And the reason I say this, a lot of people think of models like this, you go from precontemplation to
contemplation, blah, blah, blah, you also think about stages of grief, well, you're in denial and then you'll
be angry and then depression and then acceptance. It doesn't work like that. If you've ever grieve
something, a dream or a person, you know know, a person you loved, you know you bounce all over the
place. And this whole idea that we have to achieve closure is really a myth. I mean, my mom died -- it
will be 5 years about two weeks from now. We were pretty close. And it was in many ways a good death
in that we had the chance to say goodbye, she wasn't in a lot of pain, things like that. I did her funeral
and all of this other stuff. But the fact is is that -- so there wasn't any denial about what happened but
there were days where I'm like, it's good and there are days now like I really miss Mom, particularly times
like my son's high school graduation and him saying, he called her baga baga, baga would really like to
be here. Yeah, she would. So that's a normal thing and I think we have to help people realize life is not
linear.
So precontemplation with this model is the person is unaware. Problem? What problem? They're
generally going to resist being told what to do. Most people do. They may rationalize why they don't
need to change. They may feel hopelessen changing. I was running a group on the inpatient psychiatric
urinate when I worked for the hospital and I had about a half dozen people in the group. And people just
going around introduceing themselves. I was doing some psychoeducation and this one guy said, you're
talking about THC delta 9. He knew a lot about it. I said you know a lot about cannabis, reflecting. He
said I've been using it daily for 30 years. He goes it's never caused a problem for me. So he's to my
right. To my left is is lady who reminded me of the comedian Wanda Sykes and she goes wait a minute,
we're in a psych unit. And he said but I'm not here because of cannabis. And the other patient said, why
are you here? For depression. About what? I filed for bankruptcy for the 3rd time, I'm estranged from my
kids, my second marriage is falling apart. I'm like, so is that related to your cannabis use? Oh, no, none

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of it is related. And the other wind was looking like aren't you going to jump all over him? No. She's like,
well then I will. I was like like, hold on.
But the thing is is that this guy -- again, not all of it was probably due to his cannabis use but quite a bit
of it was. And I remember talking with his psychiatrist, a good friend of mine, who -- very dry sense of
humor, he said if there's something before precontemplation, this guy is in it. He said all we can do is
present the information and provide him with a direction. He's going to take that. But the Wanda Sykes
client said, hey, we're in a psych ward. And I appreciated her honesty and I think she really wanted to
help the guy.
After that is contemplation. They recognize there is a problem but are ambivalent about making any
changes. People collect information in this stage and weigh the pros and cons of changing or not
changing. Just because a person has an interest in change doesn't mean they're ready for it.
A lot of times we use this tool here and it's basically a decision balance. What are the bros of making a
change and cons of making a change other the good reasons for making a change for not making a
change?
I will sometimes just write this on a piece of paper and ask people just to keep it with them. As you think
of things, put it down. And this can be applied to a lot of different things. Do I change jobs? Do we look at
moving into a different house? You can utilize this in a lot of ways. But this is how we look at
contemplation. I have had things add to it or cross out.Al preparation is the person has accepted the idea
of making changes and begins to look at ways to make the changes. I've seen this with people in
relationships. They're like I know I need to get out of this relationship and I'm think thinking about ways to
make it happen. Sometimes practiceing could be an important part of that action is the definiteive step.
Maintenance, acknowledging lapses occur and developing strategies to address potential lapses.
But that's where we get into relapses or return to use.
Somebody asked this yesterday, do you differentiate between a laps and relapse? Yes, I do. A relapse is
return to regular use after a period of sobriety or recovery. That's a relapse, sorry. A lapse is a sing the
period of use without a return to regular use.
I don't want to assume they're going to occur but I don't want to assume that they're not going to occur
occur. I'm not going to judge a client for that, but after a lapse or relapse I want to make sure everything
is okay, escalate a level of care, and a lot of what I want to do with treatment is help clients recognize
triggers. And there are some very helpful acronyms that can help with that. HALT is my favorite, people
often relapse when hungry, angry angry, lonely, tired R. or RIID, restless, irritable irritable, isolated,
discontent. BAAD, bored, anxious, angry, depressed.
We want to talk about those things. If you're trying to save money or eat right, it's never a good idea to
go into a supermarket when you're hungry. I can attest to that.
So, again, we're looking at environmental cues. So in AA we often hear the words be aware of people,
places, and things. They're talking about triggers and that's an important thing.
The different things we associate with useing. Because in our meso limbic system, the midbrain, the
amygdala has tied those environmental cues to the strong positive memories of useing and both those

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are tied to the pleasure center. So they can quickly put the person on automatic pilot. So what are some
relapse prevention strategies? We want to help clients understand relapse is a process and event and
identify warning signs. One of the things we often say in drug treatment is the relapse doesn't begin
when you take the drug. It began a long time before that. Help clients identify their high-risk situations
and help develop effective cognitive and behavioral copeing. This is where you have to help them dig
into things. They'll say, I'm going to avoid people, places and things. Let me help you unpack that which
people, places and things? Is that a viable option?
How can we do that? We need to dig into that. Help clients enhance their communication skills and
interpersonal relationships. So what interpersonal relationships do they have that can support their
recovery? Rewant to help them reduce, identify, and manage negative emotional states, lonely, tired,
angry, can precede a relapse. And help them manage cravings and particularly help them -- sometimes
we call that riding the craving wave realizeing it's not going to last forever. How can you manage that 15-
15-25 minutes where the craving is strongest? I'm going to take a walk. What if it's raining? I'm going to
listen to music. What kind of music? What do you like? I want to get as specific as possible to begin
changing that.
This is where a lot of our work comes in. Terminating clients. I mentioned this a few minutes ago. There's
no other major health problem for which one is admitted for care and then discharged for becoming
symptomatic. Further health care problems, symptoms show up it's a confirmation or diagnosis that other
methods are needed.
There are a couple reasons why I would terminate clients from your care. I would not abandon them.
You may need to send them someplace else. But continued use of substance is not a reason to
terminate treatment. It may mean that they need a higher level of care in which case you need to help
serve as a bridge to that higher level of care. But in my opinion there are only a few reasons to terminate
a client. First is violence, threatened violence, and that would include verbal violence particularly racially
inappropriate language, sexual sexually inappropriate language, and things like that.
When I was running the program at daily planet, over the course of my time there I think we served
about 250 people in our drug treatment program. I had to terminate two. One because not at the
program but he beat up another participant. Can't have that. Another because they were distributing
substances on property. That's a liability issue. But that's a pretty good track record and it's really not
unusual in other programs. It's not something that's going to happen all the time.
I would give people opportunities, you know, I had one guy who was very rude to our nurse and I don't
put up with that. So I walked up to him in the room and I said, are you Mr. So-and-so? He said yeah. I
said can you walk with me? Nobody else was around that way. I said I'm walking you out. He said why? I
said because you were rude to Michelle and I don't have that. And he I said, I want you to come back
tomorrow and we can have you come back and I'll go over the consent to treat which has the
expectations expectations. He said what if I refuse too leave. I said I'll call the police and have you
arrested and you'll be banned from our property or we can take a break and do it like this. And he came
back, not happy, and I really wasn't happy with him either either, but before he met with me he went to

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our nurse and said I was really out of line yesterday. I am very sorry. It won't happen again.
I said that's what I wanted to hear. Once that was out of the way I said what was going on? He said I was
having a really, really, really bad day. And he actually became a good participant in there. But I meant
what I said. If you refuse to leave I will call the police and have you banned. I'm not going to play around
with it.
So, again, because I want my teammates to feel safe and I want to feel safe.
Harm reduction, we talked about this yesterday. Does not view abstinence as the only measure of
success. There are some harm reduction approaches when I've met people who work in harm reduction
sects that are almost -- not antitreatment but very suspicious of treatment. Good harm reduction knows
that clients can be linked to treatment. But good harm reduction also means that the clients don't want
treatment it shouldn't be an expectation on them. Success means any reduction in sustains related harm.
The goal is to meet clients where they are, sometimes it means physically.
Abstinence can be viewed as an ideal end goal but it may not be there. Includes a variety of strategies
that it be effective for many clients.
Here are some successes. We've limited transmission of help C and B, HIV, in our clinic we had
condoms everywhere, female, male condoms, different sizes shapes, colors. Things like that.
And they kind of flew off the shelves. We're trying to limit harm.
Naloxone distribution, I mentioned that I have it right here as a show and tell thing. We have those here.
Medication assisted therapy shows that it decreases criminal behavior and crime.
It also be can -- somebody asked about what about safe injection sites? I'm a huge proponent of that.
People are going to be doing this anyway. What we've seen in places like New York is overwhelming use
of those and people in those positions getting into treatment. Again, I can't help somebody if they're
dead.
And, again, this whole notion of if we have safe injection sites it's just going to encourage people to use.
Nobody reasonable person will look at that and say I guess I can use heroin now.
So we've seen success.
One of the things we have here in Richmond is an organization that does needle exchange. And it's
mobile. What we've seen is a decrease in fatal overdoses. They can also treat help hep C in the
community. Test for HIV, prep which is prophylactic for HIV and treating people who have been testing
positive for HIV. The idea is to keep people alive. When the person is alive there's opportunity for
change. They may choose not to change. People can choose not to change. They have to deal with the
consequences of that but that can happen. I'm a big proponent of that.
It's like when I was growing up in the '80s, there was debate in Kentucky about condoms and kids and
it's kind of like, okay, you're right, some kids are not going to have sex. That's great. And I may think that
pretty not a good idea for teenageers to be doing that just for a loot of reasons lot -- a lot of reasons, but
if you have a proportion that's going to be doing that let's talk about limiting unplanned pregnancy. Let's
talk about limiting the spread of sexually transmitted diseases. I never knew someone like, there's
condoms there, now me and my girlfriend can go have sex. It's happening regardless. Same idea with

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drugs.
Where you see issues related to this is where a lot of the stigma rears its ugly head. There is still a part
of our society that says we'll just let them use and die. I just don't think that that's good. Sorry, I think
that's a horrible value because it's reel easy to say when you're saying it's them. When you realize it's
we. That changes everything.
Contingency management, it's a behavioral approach, well studied, rewards positive or desired
behaviors with nominal rewards that can increase in value the longer a person continues the desired
behavior. Abstinence from chemical use -- like Breathalyzer, it can be useed in that way. Sometimes
we're like, we're paying people to not use drugs. With contingency management you're not usually
useing money, it's other he are wards -- rewards.
So at our program we utilizeed a contingency management program put together by my team mate
Adam Adam. Clients could draw from a prize box if they were on time to their appointment, if they took
their subobservation own as prescribed and tested negative for illicit chemicals. This is our way of saying
we're not going to kick you out if you're using but we want to reward the people who are not useing illicit
things. So if you choose to do that, this may be an incentive to consider not doing that.
So half the prizes from the box were inspirational quotes. 40 percent were $5 or less gift cards. Ten
percent had values of 25. So Wes prize cabinet. He had written a grant and gotten it. There were things
$25 or less. Sometimes it was a hygiene kit. Nobody wants a hygiene kit. We put stuff in there that has
value to folks.
So that really worked really well.
CM is shown to work better with people with stimulant use disorder like methamphetamine and other
drugs. It works about half the time. Half the people really get into it, half don't. That's a pretty good track
record. In drug court we used used it where basically if you had a good week, you had negative drug
screens, and they had to be negative if you went to court, if you worked or whatever, you put your name
in a box and then the team member would draw a name out of the prize box and that person could then
pick something from -- they could then draw a prize from the prize box and it could be things like you get
an extra hour on curfew. Big deal for our clients. You get to leave court early. Don't have to stay for the
whole docket. One was lunch with the judge. I remember one of my kids in my program won that. He
was like, oh, great. And the judge is like, it's your choice where we go. And other people on the team that
the kid knew more like the police officer or whoever went with them. And he comes to group and the
other guys are like, how was lunch with the judge? He's like, the judge is a really cool guy. And we just
had a really conversation. I really like him. He's a really cool guy.
And that's why our kids loved our judge. And I think it was because -- the last thing I'll say about that is --
well, I'll talk more about it in drug court, he treated them with with respect. I remember one kid saying
judge H is the only person or authority that has treated my mom with respect. Everybody else has
blamed her. He's like, I'm here because of what I did. Not what she did. She's working two jobs on her
own trying to do best for me and my brothers and sisters. And he treats her with absolute respect. I said,
well, he means it.

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Care coordination/case management. Very important.

Care coordination, coordinated approach to delivery of health and other services. Linking people to
services.
Why is it so important? Well, retention in treatment is associated with better outcomes and a principal
goal of care coordination is to keep clients engaged in treatment and moving toward recovery. Treatment
is more likely to succeed when a client's other problems are addressed concurrently with substance use.
This helps clients move to different levels of care.
Some of the principles of care coordination is it offers the client a single point of contact and it's client
driven. Care coordinators should be advocacy advocacy. They should know exactly what's in the
community and it should be pragmatic. Entering treatment should not be as much of a priority as finding
shelter. It anticipates challenges and has to be flexible. The primary goal is to help clients connect with
services and enhance their recovery. And we start care coordination by understanding the clients'
recovery capital. What I mean by that is what does the client bring that could be helpful to them?
So personal recovery capital would include the client's physical health, emotional supports and things
that support recovery. Do they have housing? Do they have a source of income? In some areas do they
have medical insurance that could pay for services? Do they have food? Are they safe? That's personal
recovery capital.
So a person with lower personal recovery capital we need to help them with housing, income, things like
that.
Family or social capital, do they have emotional support, financial help with child care? That's a huge
thing, child care and transportation. Do you have somebody that's going to help watch your children
that's safe while you're engaged in treatment?
It's a big challenge because a lot of treatment programs don't offer that.
And community recovery, what's available? If we're talking about clients living in rural communities that
encompasses large parts of our country, there are generally speaking less resources there, less
transportation, things like that.
Access to health care. So personal, family, and community recovery capital are things that case
management should look to evaluate at the very beginning of care.
Other care coordination needs, medical appointments, obtaining health insurance if possible, dental care
is huge, transportation, child care, job search, immigration needs, food, clothing, things like that. All of
that is very important.
Finally I wanted to talk about peer recovery supports. As one client told me, you need a mixture of
architects and builders. People who are formally trained in building and people with experience lay laying
stone. I'm a huge proponent of peer recovery specialists and I have run groups with peer recovery
specialists and they have been some of the best groups that I've been a part of, because I don't know
what taking Suboxone is like. I don't know what heroin is like. My body doesn't react very well to opiates
the few times I had to have them for medical reasons.
So having a peer in there, particularly a peer like when I worked in our clinic who was themselves on

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Suboxone and could advise, not just advise clients but advise us was huge so certified peer recovery
specialists emerge in many settings, treatment centers, emergency departments, correctional facilities,
mental health clinics, we use them in the ER, people living with mental illness. We use them among our
first responders in my new job. So part of my team's role is going to be advising the peers. So we have a
peer group in fire EMS, we have a peer group in police, peer group in emergency communications, we
believe in that. And because part of it is if we have -- having worked with the police before is a mental
health advisor and hostage negotiation and training at the academy, there are some things that a police
officer is only going to tell another police officer or a firefighter is only going to tell another firefighter.
That's their fires line. I don't know what it means to wear a badge and have a gun and have people's
safety and my own safety responsibility. If a building is on fire I'm going to run out. Firefighters run in.
So it's very important. I don't think peer recovery replaces clinicians but I think in the same way clinicians
don't replace peer recovery as well. But the lived experience is really big. Here in Virginia peer recovery
specialist is a career path. If you become a certified PRS we can bill Medicaid for your services. It's
actually been increased to a very decent rate which means that programs are really making use of them.

All right. I want to take just a 90-second break real quick right here and then we'll get into psychodynamic
approaches. Give me just 90 seconds. Stand by. More like 60 seconds.
Okay. So psychodynamic approaches. We're moving away from the motivational interviewing approach
of getting people engaged in treatment and some of the ancillary yet absolutely necessary things like
case management and we're now moving into actually kind of more directed treatment. I tend to use a a
psychodynamic approach more than other things but like most clinicians I have a very eclectic approach
approach. They are a number of theories based on interplay of drives and forces within the person. The
contemporary approach emphasizes the process of change and incorporates the interpersonal
relationship of therapist and client.
Typically it's useed in individual therapy but can be useed alongside other types of therapy.
The basic goal of psychodynamic approaches is to determine kind of some of the underlying reasons
why the person uses drugs and what we can change that may result in this understanding.
It also posits that substances or behaviors are useed to replace something missing in the individual's life
or as a reaction to the damaged ego or something missing.
So major themes of psychodynamic approaches is that the past profoundly affects the present. So it's
psychodynamic approaches are well grounded in psychoanalysis and Sigmund Freud. I know when I
was in school in the '90s Freud are really fallen out of favor and I still don't subdescribe to all of his stuff,
some of it is really wacky to me. But we have to understand that his idea that what happens to us when
we were younger can affect us as adults, that was ground breaking. And I think that when we look at --
we wouldn't have trauma-informed care if we didn't have that basic understanding.
So say what you will about a lot of his other stuff, you know, it is what it is. Freud by the way loved
cocaine. That's neither here nor there. Loved it. At least early on in his career he did.
But we can't dismiss him entirely. People are driven by unconscious phenomena that remains out of our

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aAaron, he called it the Id, ego, and super ego. But he also focused on the therapeutic relationship,
including transfers and counter transference.
Transference is displacement or projection onto the counsel and the idea is to work through them. But
we want to recognize counter transference, our unconscious reactions to the patient. Sometimes if we're
aware of our own sense of counter transference transference, that can add insight for us into more what
the client's doing. If I find myself reacting to what a client is saying, it's my responsibility to take a step
back and say, why am I reacting like that? I wonder what's going on there? And what is it telling me
about myself, yeah, but more important what is it telling me about the client? That's an important piece.
So some types of psychodynamic therapy useed in SUD treatment, and I'm going to give a 30,000-foot
view of these approaches, is ego psychology, object relations, around ern family systems therapy.
IFS is not wholly psychodynamic but grounded in a lot of that.
So psychodynamic therapy overall, confrontation is useed but only when a therapeutic relationship is
established and always done respectfully.
Relapse or feelings of wanting to relapse are opportunities to learn more about what led to use in the first
place. Understanding the family of origin is important, especially the role the person played in their
family. We have to remember that patients can become dependent on us in place of a drug. So if this
causes an intractable problem, a new counselor may be needed but we need to be aware of that with
any of our clients that we are not foster fostering depends.
I mentioned earlier not being happy about some counselors in our community, and a lot of times it's
because it's about meeting the counselor's need not the client's. I don't like that.
So ego psychology, some of the major ideas. The ego functions are the way we interact with the outside
world. So one of the things we believe with ego psychology is people are born with the capacity to adapt
to their environments and this capacity to adapt develops through learning and through maturity maturity.

And therefore the social influences on our psychological functioning are significant. Many of these are
transmitted through the family unit whether of blood or choice.
Each of us wants to have feelings of mastery and competence in important areas of our lives. When we
don't feel that, it can lead to distress.
It recognizes the problems in social functioning can occur at any stage of development due to person in
environment as well as internal conflicts. One of the key things about ego psychology is that our ego
protects itself against with defense mechanisms.
We use these unconsciously when faced with strong feelings of anxiety, doubt, guilt, and shame. So
some of the more common defense mechanisms are denial. Again, not just with substance use but
anything. We refuse to accept reality. We repress these strong feelings. We push them in our
unconsciousness, push them down.
We place our feelings on others. So we place our feelings on others or with displacement we direct our
feelings into behaviors of others. We might do things through sublimation where we take unacceptable
behaviors with socially acceptable ones and replace them. A person might replace substance use with

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running. That's sublimation. It's not a bad thing.

I've seen people having problems with aggression channeling that into learning how to box.
Regression, retreat to an earlier stage of development. Or rationalize things, make up logical solutions
for why things have happened.
So as a therapistist if I'm using a psychodynamic approach I want to recognize and identify these
mechanisms and identify them to the client but do it in a really respectful way.
So when I did the internship early on I remember being in group one time and this person said I'm going
to confront you. You're in such denial. Do you know what it stands for? Don't even know I am lying. I was
like, okay. N for know but okay.
It sounded like cool but it bounced off the person it was directed to. You're just in denial. That's not
helpful.
Object relations theory is derived from ego psychology and focuses on our internalizeed attitudes toward
others and ourselves. Objects are people or parts of an individual's personality and our feelings can be
displaced onto these objects. So while ego psychology focuses on drives, object relations looks at
relationships. This is where we get attachment theory. Shares many aspects of object relations theory.
So some additional concepts of substance use disorder that you find in ego psychology and object
relations theory are called narcissistic crises substances are useed because of the collapse of the grans
yes, sir self so it gives them a grandiose self.
Hidden pain as the source of stress. Also the need for control and substance use gives individuals a
false sense of control.
Finally, internal family systems. It takes elements from psychodynamic theory and combines them with
systems theory to posit that a person's psyche or ego is composed of many parts that interact with each
other and shape how the person interacts with the external world. Some parts called managers are
critical and can be shameing. But the manager is there to keep our ego in check.
Other parts sometimes calls firefighters use costly behaviors like substance use disorder to distract and
help us avoid pain. So in IFS, substance use is viewed in the context of what purpose does it serve for
this system?
It's a really fascinating approach and I know PESI has trainings on it. It's a really fascinating approach.
When I say -- I'm -- IFS seek to identify and engage different parts. So I useed IFS is lot in Ketamine
treatment or people in the Ketamine nonordered specific consciousness to talk to their different parts.
Sometimes talk with your younger self. But they found it easier to do that because their ego defenses
weren't saying, this is stupid. I don't have a firefighter in my psyche. It would help them do that.
So the therapist partners with the client.
That's kind of a 30,000-foot view of psychodynamic approaches.
There are less -- they're less concrete than other approaches, and I think that -- I happen to have really
good teachers in my former education that taught me a lot about it. And I had a good clinical supervisor
who taught me about that. I don't think it's as common anymore and I think that part of it is that people
want to stick to concrete things. But I do think it's helpful and, again, I tend to use those approaches

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more. As we move into CBT I use that as well. Now, I've met people who are strict cognitive therapists
and I'm like, rock on, we need everybody. It depends on the situation. I use a lot of CBT. But I'm not a
strict adherent to it.
It depends on the individual. There are times where I stick really closely to the model that we'll talk about
in a minute. Other times I kind of am more eclectic which I think is how most people practice.
So cognitive behavioral therapy is based on the ABC model. The A is the activating event. Something
happens. B is our beliefs. The activating event causes us to -- not just our clients, we do this, too -- to
have a belief, whether rational or irrational.
Leads to consequences. So the rational beliefs lead to healthier consequences, irrational beliefs lead to
unhealthier consequences.
The ABC model holds that events don't cause our emotions but our beliefs and interpretersings of those
events do.
CBT challenges clients to examine, interpret, and reevaluate their believes and change their behaviors.
Because it's more concrete than psychodynamic, it's more widely useed. I think it's also easier taught.
And you see a lot of this in substance use disorder. I think when people are too rigid it can become an
issue. So I think this is where we have to really be aware of that.
Closely related to CBT is rational emotive behavior therapy. It's an early form pioneered by Albert Ellis.
It's kind of related to that. I know people who prefer in approach as opposed to CBT. How we think
influences how we feel which influences how we act.
And so I really respect the work of Dr. Ellis, but just kind of pointing out where this lies on the spectrum
of this approach but I'm really going to stick with CBT.
So there are 5 foundations of practice with CBT, whether substance use disorder treatment or anything.
First is collaboration, mutual collaboration between client and therapist.
Second is case conceptualize or put together a conceptualization of each person individually.
It's highly structured.
Education is a big part of it. It's not the only part but a big part. And we really want to teach people to use
cognitive behavioral techniques. We want them to become their own cognitive behavioral therapist.
When it comes to substance use disorder, CBT sees substitute disorder as a learned behavior which
could be modified by changing the cognitive process by managing cravings, avoiding high-risk situations,
case management, mood regulation, and lifestyle change.
So Aaron Beck is one of the major proponents of CBT, he says cognitive therapy is based on a unique
cognitive conceptualization of each patient. The strong therapeutic aligns is essential. And not every
therapist will be able to create a strong therapeutic alliance with every patient. No one person can do it
all. ^.
The client -- the cognitive therapy is goal oriented oriented. It's the initial focus on the present and is time
senseitive. It's not meant to last indefinitely.
Therapy sessions are structured with active participation expected.
Patients are taught to identify and respond to dysfunctional thoughts. And when it comes to substance

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use disorder psychoeducation and relapse prevention are key.

I'm going to break each of those down now.
Cognitive therapy is based on unique conceptual conceptualization. We're going to analyze the current
problems, thoughts, and reactions. Look for the automatic thoughts, I am useless.
Identify the copeing patterns, positive and negative.
Connect thoughts to actions.
CBT does not ignore the past. It just doesn't bring it into the forefront as quickly as predominantly as
psychodynamic therapy.
But it really kind of focuses on the issue itself of substance use disorder.
So the essential elements or components of case conceptualization are the following.
Core beliefs are sometimes called schemas, negative beliefs, I am unloveable. I'm always going to screw
up. So really identifying those automatic thoughts and really when I use more strictly CBT approaches
for clients struggling with substance use disorder we've really kind of dialed in on those automatic
thoughts because they're often such a ber vaseive vase pervasive part of the person's ongoing struggle
with substance use disorder. But the case conceptualization is important and begins right away.
One of the things I actually do with my supervisor supervisorree superviseees, I don't do a lot of
supervision anymore, but when I was working on licensure, one of the things I pushed for was I need you
to do a case conceptualization succinctly. I want you to be able to present that to the group. It's important
because it helps us as clinicians to really hone in own what the individual needs right now and it helps
the client know you're hearing them.
Strong therapeutic alliance is essential. We explain what we're doing and why we're doing it. We try to
limit activating the client's negative -- core negative beliefs. So we're going to pay attention to body
language. But we're shared collaborateors. It's not you're the client, I'm the expert. We work together.
Goal directed. Goals are set in the first session and revisited regularly. Objectives are smaller mini goals
that help them meet the main goals. We provide honest feedback as therapistses. If they're struggling
with goals we question them. Do you really want to meet this goal or do we change it? We're working
towards something specific.
The initial focus is on the present. Again, we're going to start here. We're going to look at some of the
past stuff but initially we're going to start what's going on right here.
And this is where role play may come in. A lot of times role play is a big part of this.
Problem solving, anticipating. So you're going to your cousins wedding this weekend, you know there will
be a lot of drinking, let's talk about that. Let's talk about how to manage that. One option is not to go but
that's going to hurt your cousin's feelings. So let's problem solve. What are some ways to minimize the
opportunity that you're going to hit that open bar?
Again, the focus on the past is different from psychodynamic.
Cognitive therapy is time senseitive. I like to use the phrase begin with the end in mind. It's actually one
of Steve cubby's habits of highly effective people.
How do things look in your life once you've accomplished your goals? If we can visualize the end stage

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it's easier to get there. Cognitive therapy requires usually weekly sessions.
And sessions are decreased in frequent as the client begins using the tools. There's an open-door policy
at the end.
Sessions are structured. And this is typically how a structured session goes. How are you feeling today?
Discuss any recent substance use, how much, frequency. Explore the client's progress including how
they felt about coming to treatment today.
We set an agenda, what are we going to cover today? I'd write that down.
Counselor bridges to the previous session, this is what we talked about last time, how did it go this
week?
Homework is a very important part of CBT.
Problem solve as needed. And kind of look at wrap wrapping wrapping that part up.
Homework is assigned for the following week. Summaryizing throughout to ensure the client
understands. At the end the counselor asks, how do you think today's session went? That's going to
work in developing trust because, again, we want to acknowledge that most of us want people to like us.
We have to be honest about that. When I hear people say, I don't care what people think about me, yes,
you do. Of course we want people to like us. So with therapy, part of it is understanding that. So I want
the clients to be able to say, I felt it was a little bit off. What do you mean? You seem kind of distant.
Maybe I was, maybe I wasn't. But I ask for feedback.
I'm showing an openness and willingness to hear challenging things for myself.
That's kind of a way the structure works.
Patients are taught to identify and respond to dysfunctional thoughts.
We emphasize the cognitive model. Our thoughts influence how we feel and behave.
And we look at automatic thoughts and we kind of break them down if needed.
So help your client -- some of the steps in cognitive therapy, help your client identify their automatic
thoughts. What am I thinking right now? Help them recognize that these automatic thoughts are not
automatically valid. Is what I'm thinking true?
If I'm thinking right now I'm really just a lousy person. Let's take a step back. Is that true? Are you really a
lousy person?
So I want to help clients see themselves more realistically, maybe challenge some of that.
Sometimes I've seen folks use reminder cards and I've useed these. When I feel sad or angry at myself
or that I'm a fileature I will do this instead of that. I will go on a walk, listen to music, read instead of
useing.
And, again, those were -- when I first heard of it I thought it was silly but they work.
We want to look at developing new habits to replace the old ones. If this happens I'll go for a walk. What
if it's raining? Listen to music. Push that, what kind of music.
And finally cognitive therapy emphasizes psychoeducation and relapse prevention. So the goal is to
maximize the client's learning. Both counselor and client take notes as needed. Therapist often serves
as a teacher. And our goal is to make the client their own best cognitive therapist.

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And that's why role plays are often useed. A do a lot of role plays anyway, that's what I like about it. So
let's try to see what that situation is like like.
It's really good. And I love useing role plays in family therapy which we'll talk about next. Let the kid role
play being a parent and vice versa and it can be powerful if you've got it so the room is safe safe.
So this is the cognitive model of substance use. It doesn't mean it's written in stone. It's just how
substance use is viewed through the cognitive lens of.
There is activated stimuli -- I'll give examples in a second -- beliefs are activate by activating stimuli
which lead to automatic thoughts, urges and crisis, focus on action and continue or relapse.
For example, a person has a fight with the significant other that's the activating event. That begins the
belief of I could use a drink right now. It will help me feel better. That's beliefs activated. The automatic
thought is do it, you deserve it.
Urns and cravings are physiological but they can lead to facilitating beliefs. This will be the last one. I'll
kick tomorrow. That leads to thoughts and actions. Purchase alcohol.
So that's how the model works. What we want to do with cognitive therapy is this model. There are many
ways we can do this.
So we break it down. So you have an activating stimuli, a fight with the significant other. I am vulnerable
when I'm angry.
So I need to be mindful of that. And the thing is that what's anticipateed in these approaches is that it's
going to take a lot of attempts. It's going to take a lot of trial, a lot of repetition, a lot of trial and error,
failures are not a bad thing.
Next thing is thoughts of drinking, like the beliefs. Use a decisional balance there. What happens when I
drink? What happens when I don't drink? What are the pros and cons of each.
Find ways to recognize and challenge automatic thoughts. Use the card prompts I just talked about.
When a person realizes cravings and urges, go back in the psychoeducation. Cravings and urges
generally last about 20 minutes. What can I do for 20 minutes that doesn't involve using or being in the
process of being able to use?
Challenge facilitating beliefs? How do we distract ourselves or do something different? Care out that
plan. And have multiple plans to do in case, well, I'll go for a walk again. What if it's cold and raining? Are
you really going to want to go walk not guilty that kind of thing.
Let's have options.
And, again, repetition. Let's see what works. That didn't work, let's try something repetition, trial and
error. It's like learning to walk. When little kids are learning how to walk, they fall a lot. But the idea is that
as you practice, practice, practice then you're going to fall less and less. But we can't learn to walk until
we do some falling.
Our goal with all of this is that the falls don't stay down.
One thing that is really heavily connected to CBT is DBT. I'm a big fan of DBT. When I was in grad
school I was told by a professor of a clinical class class, he was talking about people with borderline
personality disorder and he said if you have a borderline, we weren't useing person-centered language

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back then, the best thing you can do is get them off your caseload. Refer out.
I remember sitting there thinking, if everybody is doing that, where are these folks going to go?
Borderline personality disorder became what I call the garbage can diagnosis. It's where you threw the
people you didn't like. You threw the people who were "treatment resistant" or just "plain crazy." I like
DBT because it helps us reconceptualize borderline personality disorder.
Now, since that time in 1998 and 1999, most clinicians came to realize it's a manifestation of trauma,
especially when it happened in early child childhood.
So I think we're less willing to necessaryily dismiss people with BPD.
DBT works. There are DBT certification you can pursue through PESI, and whatnot. I think it's one of the
best things that a drug treatment can integrate into what they do. I think even if you have clients that
don't have bodyier line personality disorder it's still a very effective way.
I'm doing some volunteer work with a large-ish treatment program on the south side here in Richmond
and they're integrateing integrating integrating DBT skills into their drug treatment throwing.
So dielectics, a means of understanding or synthesizeing apparent contradictions. Learn to live with
thoughts or feelings that may seem contradictory but yet we hold them at the same time.
Clients are encouraged to accept reality that painful emotions will occur while at the same time working
to previous unnecessary emotional suffering. So we accept some things but we're also like I don't have
to accept -- I have to accept the reality but I can still accept that I can change as well.
So the compromise between acceptance and change is really a synthesis to become more acceptance
based. It's really quite powerful. He love these patient assumptions. Patients are doing the best they can.
Patients want to improve even if they can't conceptualize that.
Patients need to do better, try harder, and be more motivated to change.
You are suffering because of the choices and the actions of your parents. But now you've got these
problems here so it's not about sitting there saying saying, well, my horrible parents did this. Yes, they
did, that was horrible and unacceptable. But the fact is, here we are now.
Patients must learn new behaviors.
I also like the therapy assumptions because patients can't fail DBT but the therapy or therapist can fail
the patient. That's different.
Helping patients work toward their ultimate goals in life is the most caring thing a therapist can do. I like
that.
Therapists need support and therapist support is a mainly part of DBT. And the therapeutic relationship
is a relationship of two equals. Not I and you but we.
DBT and substance use disorder together assumes the patients agree to work toward recovery. There's
a hierarchy of approaches. We want to reduce life- life-threatening and self-injurious behaviors. That
includes dangerous drug use. We want to reduce that and reduce suicidal ideaation and behaviors and
self- self-injurious behaviors. We then want to reduce treatment-interfering behaviors. We want to reduce
quality of life interfering behaviors. All of that is kind of our hierarchy. So we start life threat threatening
and we move down that.

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Patients typically commit to DBT treatment for at least a year. And I know there are variations of DB DBT
and this isn't a DBT training, but in the main D DBT model you have skills training classes each week
and individual therapy. And the content of the skills training classes falls under the mindfulness, distress
tolerance, emotion regulation, and interpersonal effectiveness.
Next is the counselors consultation. Those are integral to the DBT approach.
I mentioned seeking safety yesterday, this is the Na Najavits approach. There are key principles of
seeking safety include safety, that's the goal. Integrateive treatment we treat both disorders at the same
time. And the focus on ideals to counter counteract the loss of ideals in both PTSD arranged SUD it
looks at four content areas, cognitive, behavioral, interpersonal, and case management. It's a manual
manualized treatment. I know that Lisa has a newer project now whose name escapes me. I talked with
her back in August and one of the most approachable, well-known professionals I've ever met. Just
really like her.
I found out about it because one of my teammates started using seeking safety in our outpatient clinic
and just reported really good results so I was happy to share that with her and said this made a lot of
difference in our clients and I think it made her day.
You can see the difference.
So the topics are there, it's flexible. You can do them in any order. You can do them in a group or
individual therapy. I like the idea that it says we're going to start looking at both of these together. So you
can see all the content there. It's really just good stuff.
l right. I'm checking the time here. We have a little less than a half hour before lunch. I want to make
some progress into substance use disorder and the family but I will leave time for questions before the
break like we did last time.
Okay. Cool.
So something to think about, how do we define family family? How has our definition of family changed
over time? More importantly, how might these different examples of family be impacted by substance
use disorders? I think about people from in different countries, cultures, even ethnic groups groups, how
do we define family? How do they define family? How has that changed?
And it's just really a fascinating thing to look at.
So substance use disorders is frequently called the family disease because one person's use can have
negative impacts among everybody. And often more than one person is using or engaging in addictive
behaviors.
Consequences to the family can include deterioration of family values, health issues, adverse childhood
experiences on children in the home, disability, violence, and legal system entanglement.
One of the things about families that are image impacted by substance use disorder is that they more
often than families without -- that are not directly impacted by substance use disorder create certain roles
that can be fairly rigid.
So we're going to look at the roles and rules that we see in families impacted by SUD.
Since it impacts the entire family, these roles are sustained and protected in these families. And there

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are also rules that protect the family. And if a person breaks out of a role arbreaks a rule, they can be
shamed or expelled from the family.
So one of the roles that we see in families impacted by SUD is what we call the identified addict.
This is the person who has -- I'm going to use the Simpson's here, the person has substance use
disorder and/or behavioral addictions. It's often an adult but it may be an adolescent. But in many
families it's typically one of the principle monetary or financial providers of the family.
They surround themselves with denial and the family helps perpetuate that.
The family's various roles are there to protect the identified addict.
But the identified addict may not be the only person in the family system with SUD or engaged in
behavioral addiction.
The Simpson have been around forever, and I'm useing these screenshots of that. If you are of a certain
age like me in the late '80s, early '90s when the Simpsons came on, for the first few years the principal
character on the show was Bart, the son of Homer and Marge. In the later sentence, the focus is on
Homer which is interesting because he's an alcoholic. He loves Duff beer. He's not a bad guy. He does
dumb things, that's part of the nature of the show but in the end he really does love his family but he gets
into trouble because of his buffoonery and things like that.
So codepends is the overinvolvement with others that enables addiction to continue and undermines the
well-being of the person helping. So you can have a supportive enableer who rescues others from the
consequences of addictive behavior and a hostile enableer. Both enable behaviors. Some people
mistake enableing for helping. When we help people we help them do things they can't do for
themselves. Some people believe if you help a person with substance use disorder you are enableing. I
don't see driving somebody to treatment or helping them engage in treatment as enabling behavior.
Enabling is when we do things for people that they should and can do for themselves. So, again, if I'm
doing case management, I'm not going to do all the things for my client. I'll say here are the resources
how can I help you with this? They may need that initial help with making those first calls or first reaches,
but I'm not going to do everything for the client. That's not my job.
The client needs to be able to take some of that responsibility on themselves. That's part of treatment.
So enabling is when we're doing things for people they can and should do for themselves. Helping is
things for people they can't do for themselves.
One of my buddyies, really good guy, they have a bunch of sons like I do and we were running one
morning and I'm like, he stops and I'm like, what are you doing? He said I'm calling to wake my kid up.
He's going to miss soccer practice. I said so what? He said he needs to -- and I wasn't trying to be a jerk
but I might have been, but I was like, why can't he get himself up? He said, well, because I need to wake
him up. I'm thinking to myself, you know, if you want to play soccer you got to get up. I'm not going to do
that for you.
Again, because you're old enough to play soccer and drive, you have a car or access to a car, you need
to go. If you miss practice and you're not going to start, okay, brother, that's on you.
It's also like when I went to college, I remember this because when my son went to college at the end of

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the summer our kids know how to do the laundry. They've known that since they were 10 or 11. You do
your own laundry and you take it, you put it away, stuff like that.
Sometimes they actually fold it which is amazing but usually they don't because they're boys.
But I remember in college one of my suite mates, he was -- I remember going in the laundry room and
he was like this stuff is not drying. I was like what? He goes the stuff in the drier. It was a front-end drier.
He had stuffed literally 6 loads into the drier. It was like a brick. In talking with him I realizeed that he had
never done laundry. His family had a maid and he had never done laundry.
So he had just assumed, I'm going to throw 6 loads of laundry in there. He's like, it's been two hours
hours. I was like that stuff is baking. It's not going to work.
That would be a good life skill to have.
So helping somebody get to treatment, helping somebody engage in treatment, that's not enableing.
Giving someone with substance use disorder money and saying here go do it. That's different.
So the supportive enableer would be always an adult because they have access to some means. It's
often the spouse or the partner of the person with SUD.
Essentially they do what they should do for themselves. Protect them from the consequences of the SUD
and call the boss and say they can't come in today.
Also keeps the people in their roles in line. At times they may become so comfortable in their role that
they will sabotage the IA's recovery work because they are so useed to the client's continued use and
ordered their life around the behaviors.
They get so useed to the recovery, the spouse says I liked you better when you were drinking and part of
it is because they're useed to the way things were. One couple I talked to, it was a heterosexual couple
and the male said, yeah, I really like being in recovery, and she's like, he wants to spend all this time with
me. He wants to reinitiate sex. Ugh. And there's a lot of anger there. You weren't interested in that for 20
years and now you are. So part of it was working with both of them, particularly the identified addict for
lack of a better word saying you've got a lot of repair work to do here.
But also the enableer to say, this is not a bad thing but eventually they wound up splitting up because it
was just too much of a change.
The resident expert or hosteling enableer. My team mate and I developed this idea of the resident expert
when working in adolescent drug court because I had one young man on my caseload, single mom, but
had gotten -- it was a blended family now so she met her partner and her partner's idea was just saying,
let me kick his ass. I'm like, you're not going to kick anybody's ass because the 16-year-old is like, yeah,
try. Nobody's ass is getting kicked. Therapeutic ass kicking is not on the agenda for toad.
We called a resident expert because the person's partner knew everything about everything but it was
interesting beneath all of that there was a lot of care for this young person, a lot of care for this young
man's mom, but they were enableing because this pattern kept them in the role of savior.
So in the Simpsons we've got Marge's sisters in their quest to be helpful. They want to continue to be
hostile and quite often passive aggressive.
The hero is useed useed usually the oldest child. This is Lisa, she's second oldest. They assume a lot of

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the support of enableers' responsibilities because the enableer is so busy taking care of the client. They
Excel in school, sports, they do everything they can in an effort to get attention from the identified addict
enableers. But while they receive some positive attention it's all in vain and leads to chronic emptyiness.
And guess what diagnosis has feelings of chronic emptiness as a clear diagnostic criteria? Borderline
personality disorder. Correlation, yes. Not necessaryily causeality but there are a lot of connections with
that.
The scapegoat. Second oldest usually. In this case the oldest. Mirror to the hero. The scapegoat
provides a focus for the family's blame, shame, negative energy. You are the reason daddy drinks. And
they'll frequently act out to receive this negative attention because it's the only attention they get.
As they get older they will often develop SUD themselves.
The lost child is frequently the third child. Again, people can change these roles. They fly under the
radar. They can even be forgotten by the rest of the family and they may be cared for by the hero but go
out of their way to avoid getting any attention. They are pathologically shy and anxious and avoidant.
Not all families have the mascot but some do. They draw most of the family's positive energy. They're
typically cute, often precocious, often object noxious in my opinion, and they're there for the family to
point out and say, look at that. We're normal. Everything is okay.
^.
In addition to those roles, and again people with move in those roles. As they get older they may move
from the hero to the scapegoat. But one of the things you see in families impacted is these roles often
emerge. So when I did psychodynamic and psychoeducational groups and talked about this, I had one
person say have you been looking inside the windows in my house? And I said, no, that's creepy and
illegal. But she said, you described our family family. And I was like, well, cool.
So there are also family rules. Don't talk, don't have problems. Denial is the family rule. Because if other
people in the family have problems it may reveal the identified addict.
Don't trust other people.
Don't feel. Feelings just bring pain.
Don't act differently than you are acting now because it will upset the balance of the family.
Don't blame substance use disorder. Do what the identified addict wants.
Do better, be more responsible. Compensate, but even then you'll never be good enough.
Don't have fun because fun only happens from drinking or using drugs. There's no other bay to have fun.

Family members are so busy keeping the family system in balance that there's no time for fun.
All right. Let's go ahead and take some questions as we near lunch. So Victoria or Gwen, whoever is
there, if you want to -- I know we have had a lot of questions pop up. Let's go for it.
>> Okay. Absolutely. And, yes, thank you, everybody, for the questions that you're submitting. They are
wonderful. Regrettably we won't get to all of them but keep upvoting so we know where to focus.
I'm going to jump and and try to focus on more of the treatment material that you were just reviewing
since the last time we paused for questions?

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>> Okay.
>> So here is one. What does research evidence show about peer recovery usefulness?
>> Research is generally very positive. The meta-analysis shows that it's very effective.
>> Are you aware of any recovery groups not based in religion?
>> Yeah, we'll talk about some of them later. Smart recovery is a big one. Smart recovery is really big
big. And to be clear, I'll talk about 12 step programs in the next section. There are also secular 12 step
groups as well.
>> Awesome. More to come. Thank you. Can you give us an example of what homework would look like
in substance use disorder treatment? Do you assign homework to clients? How do you get them to buy
into any homework you assign?
>> Yeah, so a client I was work being recently had been in recovery for about 9 months, was originally
useing heroin and then will be recovered from benzodiazepines which is really tough because you just
feel foggy. A lot of what we focused in on were identifying her automatic thoughts. So her homework was
to note when those automatic thoughts came up and just kind of make note of it.
She was able to determine that the automatic thoughts occurred mainly in certain social situations and
interactions with her mom. So when we were able to determine when they came up, we were able to
really kind of go back and fully identify them and begin to kind of deconstruct them.
So that's what I had her do.
I don't assign homework all the time. I don't. If I'm useing more of a cognitive behavioral approach, yeah,
I will. If people don't do their homework we look at why that is the case. What happened this week? So
one time she came in and I said let's talk about the homework. She was like I didn't do my homework
this week. What's going on? Her cat had been really, really sick. That's a chance for empathy. I'm not
going to say, well, you're in denial. No, her cat was really sick and so it was a lot of stress in terms of
making decisions there but also not just facing the loss of a beloved animal but also the financial
stressors of I think the cat needed surgery or something. It was horrific.
>> I get the sense that you're not a rigid rule follower.
>> Well, yeah, that's true. Yeah, I don't -- I'm not. Except with my kids.
[Laughter]
>> Bring them in.
>> No, they're in school where they should be.
>> Good. There is a question that I'll sort of make a comment on, it seems like maybe there might be
some concern that useing psychodynamic or insight therapy could lead to more relapse. Is that the
case? Is there some timeing in the course of treatment that's best to use that type of approach?
>> Yeah, that's a good point. It's a really good -- the person who asked the question makes a really good
point. I think that approach I would use when there's a lot more motivation more than anything else. If
there's ambiguity it could lead to some of that for sure, so it just really kind of depends. I really think that
there has to be more of a commitment or even demonstration to sustain recovery before I would deploy
some of the psychodynamic stuff, absolutely.

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>> Thank you. And related to timing or other factors that might impact the appropriateness of an
intervention, what are your thoughts about DBT and SUD services being combined because they both
could be rather intenseive, or do you recommend one first then the other?
>> I recommend combined. I think, again, what you can do though is you can start with DBT skills and
not necessaryily just do the skills and then utilize the individual therapy or group therapy tore other
things. I think teaching even the most basic skills the program I'm working with now that is implementing
it it's a residential program based upon 12 steps, but they're implementing DBT skills to a certain point in
their program to help clients clients -- because clients asked for it, to deal with their emotional volatileity
and it aligns nicely with what they're doing. It's not a true DBT model that Marsha linehan would be like,
that's DBT straight up. But because the clients asked for it. The clients said we're getting all this about
substance use but how do I deal with the emotions coming up? What the clients were saying to the staff
is it's not all about drugs. And I was like, they got a point, guys. So they're beginning to integrate that
now. And it's really cool.
>> Can you comment on -- I don't know if timing is the right word but I know there's been debate in the
field about timing of trauma treatment and SUD treatment, the worry being that if I work on trauma first
that creates a vulnerability or a risk that my client's use will increase. And also if I don't address the
trauma early I'm not sort of working on some of the reasons that the use exists in the first plates. What --
how would you comment on what clinicians should do when dealing with these issues?
>> It's up to clients to decide when they want to deal with trauma. My issue -- I'm glad we recognize
trauma as a common causative factor for substance use disorder. Good trauma treatment does not push
clients to address their trauma until they're ready. One of the complaints I have about the wide spread
use of EMDR right now, and I believe EMDR is a very effective tool just like I like psychedelic therapy,
it's what I did, is that oftentimes what I hear from clients is that their therapist, even though they mean
well, pushed them to start dealing with their trauma before they were ready. I think that as EMDR training
has become more wide spread and in some ways easier, people are going to that tool first and not
allowing their client to dictate when they're ready to begin dealing with their trauma but instead the
therapist is pushing it too quickly. I've said that in other PESI trainings. I've been really up front about
that because PESI is a major trainer of EMDR. It's a powerful tool, should be treated with with respect
and shouldn't be the only toolbox you have.
In my toolbox in the shed, I have a powerful hammer drill. I don't use that when I need to hang a picture.
Sometimes because we know it's effective people are returning to that very powerful tool. Just like I have
people coming to our clinic wanting to use Ketamine, it's a powerful tool. They weren't ready for that yet.
It could do more harm than good good. So when it comes to trauma we don't move into dealing with the
trauma until the client indicates they're ready and when it comes to substance use disorder there has to
be an issue of safety.
So in my opinion that means there has to be at least some stability, maybe not complete abstinence,
maybe not complete cessation of it, but there has to be a degree of stability before we move into that
and we move slowly and we emphasize to the client that if we have to pull back, retract, go back to

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grounding and safety, that is not a failure. That's a big thing. I cannot emphasize that enough. But, again,
the powerful trauma tools if you look at the models as they're designed make it very clear. We don't
begin to address trauma until the person is ready, and we take breaks as needed. I'm very emphatic
about that. That may tick some people off. I'm sorry. I've seen people who have been hurt by the tools
that were meant to help, and I probably in my career in an effort to do the right thing, I know I've hurt
people because I went too quickly because I was inpatient or I had the wrong motivation. This is where
we've got to be humble as therapists and you've got to listen to your client and nothing else can replace
that. Sorry, didn't mean to interrupt you. I get worked up?
>> I was just going to thank you for sharing that because I think we all agree and we're taught I feel like
in our training programs on day one meet the client where they're at.
>> Yes.
>> Right? And the enthusiasm to offer them something based on things that we've learned can override
that sometimes and it's so helpful to hear you share with us that you've met people who have not
benefited from some of those powerful tools. So thank you for sharing that.
>> To be clear, I've met more people who have benefited than didn't, but I'm really -- I get really -- yeah,
just pretty upset punish not upset. Any other questions?
>> Sure. And I didn't hear you knocking the EMDR. I heard you talking about readiness.
>> All right.
>> I'll talk about the one most voted right now, I think it's more pertinent to earlier content but -- harm
reduction typically focuses on opioids. This person is trying to create a harm reduction group at a
treatment center but the main drugs used are cannabis, cocaine and alcohol. Do you know of any
evidence-based options to do this?
>> Yeah, harm reduction is not always based on opioids. It can be based on other things as well. I think
probably the more visible things are based on yep I'd because of the fentanyl epidemic but if you're
looking at harm reduction with alcohol, for example, one of the most effective harm we duction things
and we don't call it that was mothers against drunk driverses, MADD is harm reduction. Designated
drivers are harm reduction. So start with that. Cocaine since a lot of it is possibly tainted with fentanyl,
start with provideing fentanyl test strips. Things like that.
So cannabis same thing. How do you know what you're utilizing is safe to use? Where are you useing?
So even looking at people utilizeing in places that are safe are not going to use harm to other people,
that's still harm reduction. And people forget that MADD -- by bringing, it was formed by mothers who
had lost kids to drunk drivers, made a huge impact on the amount of drunk driving. They had laws
passed, raised awareness. It became something that was ha ha this is funny, believe it or not there was
a time when that was kind of funny, the whole idea of a loveable lush, they were like, no, this is not funny
and that radically changed our society's use of intoxicated drivers.
And that's one of the biggest examples of harm reduction more than anything else. And we don't think
about it like that. So you can totally do that.
>> I feel like I'd love a list of all of the -- well well, not all but some common harm reduction strategies.

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Maybe you'll get to that, too.

>> Maybe I will. I don't know. Why don't we do this, we're at a break time for lunch and we'll come back,
talk about family therapy, then talk about groups, and we'll talk about some moral stuff after that. But I'll
see you at either 1:00 central or 2:00 eastern. Take care.
(Break).

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