SUD Treatment in Jail Imprisoned Adult Opiate Use Interviewing the Psychopath How Digital Tools Can Help Patients The OfďŹ cial Magazine of the California Consortium of Addiction Programs and Professionals (CCAPP) August 2018 Vol. 19 | No. 4, $6.95
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Letter from the Editor
By William L. White, MA
Substance Use Treatment in Jails: Current Issues and Recommendations
New Bills in the House Address SUDs and the Opioid Epidemic By Andrew Kessler, JD
By Sarah Phillips, MSW, MPH, Jacob Eikenberry, MSW, Sara Beeler-Stinn, LCSW, MPA, and David A. Patterson Silver Wolf, PhD
Discusses the scope of SUDs in jails, lists barriers to treatment, and provides recommendations.
New Movement Ignites Interest and Hope By Sis Wenger
28 Opiate Use: The Tip of the Iceberg for Adults in Jail
Schadenfreude: Celebrating the Misfortune of Others
By Maxim W. Furek, MA, CADC, ICADC
By Albert M. Kopak, PhD, Elizabeth M. Combs, BA, Kaitlin A. Guston, BA, & Norman G. Hoffmann, PhD
Describes the CAAPE-5 assessment, presents the demographic results, and explains clinical and policy implications.
By Michael G. Pipich, MS, LMFT
Laying the Groundwork for a Medication Conversation
Slow Down, Youâ€™re Going Too Fast, Part I
By John Newport, PhD
Topics in Behavioral Health Care
Interviewing the Psychopath, Part I
The Bermuda Triangle of Care Coordination: Medical, Psychiatric, and Substance Use Disorders
By Norman E. Hoffman, PhD, EdD, LMHC, LMFT, Wendy L. Rippon, PhD, LMHC, & Valerie Watt, PhD, LCSW
By Dennis C. Daley, PhD, and Ann Giazzoni, LCSW, MBA
Defines psychopathy in relation to antisocial personality disorder and sociopathy, and explains key characteristics of psychopathy.
High Medical Service Utilizers
From the Journal of Substance Abuse Treatment
Discovering How Digital Tools Can Support Patients
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
By Toni Galardi, PhD
Also in this issue:
By Joseph E. Glass, PhD, MSW, James R. McKay, PhD, David H. Gustafson, PhD, Rachel Kornfield, MA, Paul J. Rathouz, PhD, et al.
Explains the methods and results of a randomized controlled trial of the A-CHESS app on patients with alcohol dependence.
CE Quiz instructions are on page 4
GERARD ARMOND POWELL
MY STORY OF ADDICTION My name is Gerard Armond Powell, I was 41 years old, I just sold my latest company for more than $89 million dollars. I had five houses, two airplanes, 23 cars, a boat, a race horse and everything else a human could possibly imagine. And yet, I couldn't figure out why I wanted to commit suicide. I could manifest anything… and yet every new thing that I manifested ultimately made me feel worse about myself. I was using alcohol, drugs, sex and anything else imaginable to mask my pain. I was a miserable human being, a bad father and an even worse husband. After moving to California for a fresh start, I failed again and got divorced. I was miserable and near the end. I undertook thousands of hours of counseling and it simply wouldn't work. And then, I was introduced to Reverend Michael Bernard Beckwith and started going to AGAPE, and for the first time in my life began to have hope. Reverend Beckwith assigned me the most amazing Reverend, Kathleen McNamara, to assist me. And although I saw improvements I was still plagued by unhappiness. I was so far gone that even though the teachings were perfect, and I could understand them, I still could not feel the joy of being alive. I noticed that if I went to mass on Sunday, by the time Wednesday rolled around I was in trouble again. I still wasn't happy. On a vacation in the Philippines I visited with a friend who was a shaman - she had a colleague with similar problems to me and he found a solution. She told me about a plant medicine that was being served in Costa Rica and how it cured her friend. I was honestly near the end of my rope again, so I said what the heck I'll go down and give it a try. So I went to Costa Rica and tried plant medicine. It was a night that changed my life. I spent the evening with God who reaﬃrmed the metaphysical lessons I learned.
One man’s miraculous, mystical journey from a life of addiction and pain to lasting peace, happiness, and prosperity
ON SALE JANUARY 30, 2018
I got to see ﬁrsthand that love was holding the universe together, that we were all connected, and witnessed other universal truths directly from source. The next morning, I was a diﬀerent person. A miracle occurred in my life. I swore that day that I would do the right thing with my wealth and share the secret with as many people as I could. I realized that it wasn't the plant medicine alone but it was the combination of healthy food, metaphysical teachings, colonic cleanses, breathwork, meditation, yoga and plant medicine that brought around this miraculous change in my life.
So I teamed up with my friend Reverend Michael Beckwith, yoga teacher Shiva Rea, and raw food sensation Meg Pearson to start the world's ﬁrst medically licensed naturopathic spiritual center and everything-included wellness resort that uses ceremonial plant medicines for therapeutic beneﬁt. I purchased a gorgeous luxury resort in beautiful Costa Rica where we collectively designed programs that produce miracles in people's life. Complete life transformations happen every day. Never has there been an establishment like this, where a person can check in and within a week has a new life. I was then joined by the ﬁrst of many in my co-creative team, Dr. Jeﬀrey McNairy and Brandee Alessandra. Dr. Jeﬀ was one of my counselors for the six years during my deep struggle and could not believe the change in me. He was so impressed he dropped his lucrative California practice to move to Costa Rica and help bring this project to life. Brandee, the love of my life, and now wife, joined to help bring the vision to reality. It was our goal to provide all of the things that were used to evoke my awakening in one all-inclusive experience. Meaning, you have access to all the things that took me years to ﬁnd available to you in one week, in one location. We further guaranteed that we would provide these services for one low price. You check in and have no additional charges everything would be covered; spa visits, massage, plant medicine, doctor consultations, counseling, metaphysical classes, farm-to-table organic food, yoga, colonics and more. Visitors never have to spend an additional dollar, not one red cent. Now miracles are happening every single day. More than 90% of the people who check out of the resort cry because they've had a true miracle in their life. Many are booking their next trip before they even leave the resort. Come and visit me, I'm here every day, living my own dream and teaching a class called About Your Miracle, including an introduction to our plant medicine program to ensure your success. If you’re unable to join me, you can learn more about my story and ﬁnd tips on accessing your miracle through our Rythmic Breath Work in my ﬁrst book, Sh*t the Moon Said.
...AND A MIRACLE CURE E
HEAL ING M O D
A & HEAL TH
As the Chief Medical Oﬃcer of Rythmia Life Advancement Center, located in Guanacaste, Costa Rica, Jeﬀ has committed himself to bridging ancient modalities with western psychology to heal guests.
Through Dr. McNairy’s intense experience with the most desperate patient populations (addition, acute mental health, and trauma), he has seen that the only real healing can come from within.
How does the plant medicine help your clients? Having worked at Rythmia since its inception, I have witnessed plant medicine successfully treat many health concerns including trauma, anxiety, and depression. It has eﬀects on mood and thoughtfulness, and activates the frontal and paralimbic regions of the brain. Another interesting component is that it leads to better impulse control and increases long-term planning abilities.
He has worked in a variety of medical environments and has seen the struggle individuals have experienced when actually trying to heal. The current Western system of heath care is deﬁcient in healing the population. It is more concerned with managing symptoms and using external sources for “change.”
What do you do to ensure safety for guests? During the resort booking process, we conduct a thorough medical questionnaire that addresses medication issues, health concerns, and chronic conditions. Once cleared to attend the Rythmia program, upon admission in Costa Rica, the medical team conducts a full evaluation to ensure that each guest is appropriate to participate in the plant medicine sessions. Every plant medicine session is medically supervised to guarantee safety and clinical appropriateness.
The Western medical model struggles to eﬀectively heal people in relation to addiction, trauma, physical, and mental health conditions. Symptom management is not the answer to health. Finding the root cause of your unhappiness, health concern, and discontent, then resolving it is the only way to truly ﬁnd peace. I often say, “One plant medicine session conducted in a safe environment that is clinically appropriate can be as eﬀective as 10 years of psychotherapy.” Dr. Jeﬀ McNairy, Psy.D., M.P.H. has been working in the health care ﬁeld for 25 years.
How is plant medicine diﬀerent than the Western model for healing clients?
Plant Medicine Questions & Answers with Dr. Jeff McNairy, Psy.D., M.P.H.
How do you help guests once they leave the resort? We have an optional after-care program available to our guests so they may continue to be connected to the Rythmia community and our many oﬀerings throughout the week. Further, I host a highly interactive webinar twice a month where former guests can share their experiences and ask questions about how to cope with their new-found clarity.
RYTHMIA, an everything-included, medically licensed luxury resort and wellness retreat in beautiful Costa Rica.
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For further information or to make a reservation please call
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HEALING TOUCH PRACTITIONERS • LIFE COACHING • YOGA • SPA • MASSAGE VOLCANIC MUD BATHS • MEDITATION • FARM-TO-TABLE ORGANIC FOOD • JUICE BAR
*Pricing does not include resort surcharge, pricing is per night per person
CE QUIZ INSTRUCTIONS A Health Communications, Inc. Publication
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Substance Use Treatment in Jails: Current Issues and Recommendations Page 22 Discusses the scope of SUDs in jails, lists barriers to treatment, and provides recommendations. a. Discuss the scope of SUD problems in United States jails b. List various barriers to treatment in jail c. Explain the benefits of cultural competence and continuity of care for incarcerated populations d. Analyze the effectiveness of current SUD treatment practices in jails
Opiate Use: The Tip of the Iceberg for Adults in Jail Page 28 Describes the CAAPE-5 assessment, presents the demographic results, and explains clinical and policy implications. a. Describe the research project and the CAAPE-5 assessment tool b. Summarize the statistics the project uncovered c. List the many unmet mental health needs of incarcerated populations d. Define the ways jails can better meet the needs of inmates with mental health and/or substance use issues
Interviewing the Psychopath, Part I Page 33 Defines psychopathy in relation to antisocial personality disorder and sociopathy, and explains key characteristics of psychopathy. a. Define psychopathy and why it is different from antisocial personality disorder and sociopathy b. Compare and contrast primary and secondary psychopaths c. List characteristics of psychopathy d. Clarify the ways that clinicians can elicit more information from psychopaths during assessment
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CE Quiz Directions: This continuing education (CE) course consists of reading the three articles listed in the course description and brief outline above. Once you have read the articles, complete the quiz and evaluation. Mail the quiz along with your payment of $16.95 to 3201 SW 15th St., Deerfield Beach, FL 33442. Please allow up to five business days upon arrival at the USJT mailing address for the certificate to be mailed. If you pass with a grade of 75 percent or above, you will be mailed or e-mailed a certificate of completion for 1.5 nationally certified CE hours.
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Counselor | August 2018
AD INDEX CCAPP.............................................................................................................6 Foundations in Recovery..............................................................................9 Joan Borysenko.............................................................................................7 Journal of Substance Abuse Treatment........................................................8 HCI Books.....................................................................................................44 Heart Reconnection..................................................................................... 12 Loma Linda.................................................................................................. 13 Newport Academy.........................................................................Back Cover Prodependence........................................................................................... 48 Rythmia..........................................................................................................2 Toni Galardi..................................................................................................21 USJT Calendar..............................................................................Inside Front USJT Newport..............................................................................Inside Back USJT Scottsdale...........................................................................................19
LETTER FROM THE EDITOR
Recovery Porn: A Story of Healers and Hustlers William L. White, MA I am pleased to turn over this space to reprint a recent blog post from recovery historian William L. White, MA, a long-time contributor to this magazine. – Gary Seidler, Consulting Executive Editor
he fi eld of addiction treatment is facing a growing cultural backlash that threatens its future as a viable social institution. Cultural ownership of an intractable problem vacillates over time. Vague but passionate promises of a new approach always garner more hope than the known limitations of William L. White, MA current efforts. And any industry that has attracted substantial financial capital will draw a subset of individuals and organizations who will sacrifice public health and safety for personal and corporate profit. When such limitations and abuses are exposed, there exists the risk that a social institution’s probationary status will be revoked and their functions transferred to other institutions within their operating environment. Aware of such risks, most fields develop standards of organizational and professional practice that maximize effectiveness and elevate ethical decision-making. Such protective devices help assure that exposés of industry shortcomings are viewed as the misconduct of particular organizations and individuals and not a reflection on the industry as a whole. Since its inception in the mid-1800s, there have been regular exposés of incompetence and profiteering within the addiction treatment industry. In recent decades, professional and regulatory standards, professional education and training programs, and clinical research studies have been developed to improve the legitimacy and quality of addiction treatment. In spite of such efforts, the frequency and intensity of criticisms of addiction treatment are presently in sharp ascendance. A week does not go by that one cannot read or view an indictment of addiction treatment as a whole or of one of its providers. These charges include allegations of financial exploitation and fraud, allegations that the dominant models of addiction are inherently flawed and scientifically indefensible, exposure of claimed treatment success rates as nothing more than marketing hype, reports of sexual exploitation with addiction treatment and recovery mutual-aid organizations, headlines reporting staff members of addiction treatment organizations dying of a drug overdose or being arrested for drug trafficking, and media reports of legal suits related to patients dying during addiction treatment. There
are days it feels like the whole industry is under attack. And from a historical perspective, it is. The confluence of rising moral panic over ever-surging opioid deaths and rising cultural pessimism about the effectiveness of addiction treatment poses a significant threat to the future of addiction treatment as a social institution. When such a confluence occurred in the late nineteenth and early twentieth centuries, Americans embarked on a bold new experiment: let those currently addicted die from benign neglect and prevent a new generation of addicts by legally prohibiting alcohol and aggressively controlling the manufacture and distribution of opium, morphine, heroin, cocaine, and newly arriving sedatives. It was in the wake of such changes that America’s first network of inebriate asylums, inebriate homes, and private addiction cure institutes collapsed. To avoid modern replication of such a fate, it is imperative that the treatment industry embarks on a fearless moral inventory (i.e., state of the field review) and shares the results of that inventory with service providers, service recipients, policymakers, and the public. At least one aspect of that inventory should be the clear delineation of the ethical standards of clinical practices that delineate the “healers” and “hustlers” within the field. The latter are most notably marked by aggressively marketed products and services that lack evidence of their effectiveness and that serve a singular goal: financial profit. My long-time mentor, Dr. Ernie Kurtz, used to collectively castigate such products and services as “recovery porn.”
Any industry that has attracted substantial fi nancial capital will draw a subset of individuals and organizations who will sacrifi ce public health and safety for personal and corporate profi t. Reputable providers of effective addiction treatment have been far too silent in confronting professional incompetence and unethical business and clinical practices within the field. As a result, the field is vulnerable to being cast in whole as little more than modern snake oil salesmen. While damage to the field’s reputation among the policymakers, funders, the public, and allied professions would constitute a severe wound, even more tragic would be disillusionment about treatment among communities of recovery who might then increasingly see themselves not as a complement to professional treatment, but as a preferable alternative to such treatment. Continued on page 20
New Bills in the House Address SUDs and the Opioid Epidemic Andrew Kessler, JD
n April 2018, both the House Energy and Commerce Committee and the Senate Committee on Health, Education, Labor, and Pensions (HELP) advanced legislation to address the opioid epidemic. Addressed were issues pertaining to workforce, recovery residences, and medication-assisted treatment (MAT), among many others. We are now in the process of waiting for both bodies to take up the legislation on their respective fl oors, where the enemy is rarely the content, but more often the calendar.
On April 24, the HELP Committee held a markup of an opioid package which included forty separate components authored by thirty-eight senators (HELP Committee, 2018). The introduction of this Opioid Crisis Response Act of 2018 and subsequent markup is the result of over half a year and six hearings on the topic. On April 25, the House Energy and Commerce Subcommittee on Health held a near eight-hour markup session including sixty-four individual pieces of legislation, some still in discussion draft form, offered by both Democrats and Republicans aimed at addressing the
opioid epidemic. Following the markup, the Health Subcommittee adjourned with fifty-seven bills—56 of which were opioid-related—reported favorably to the full Energy and Commerce Committee (Energy and Commerce Committee, 2018). Both committees addressed our depleted substance use disorder (SUD) workforce. House bill HR 5102, the SUD Workforce Loan Repayment Act, was sponsored by Rep. Hal Rogers (R-KY) and Rep. Katherine Clark (D-MA). The same language is found in the Senate bill, championed by Sen. Maggie Hassan (D-NH). According to Rep. Rogers’s website,
CCAPP is unifying the addiction field 2400 Marconi Avenue P.O. Box 214127 Sacramento, CA 95821
Education “CCAPP is educating addiction counselors by supplying quality options for schools and providers”
Membership “CCAPP is supporting and advocating for programs and professionals in the addiction field.”
Recovery Residences “CCAPP recognizes quality sober living by registering recovery residences.”
T (916) 338-9460 F (916) 338-9468 www.ccapp.us
Credentialing “CCAPP is the largest, most respected SUD counselor and prevention specialist certifying organization in California.”
The legislation will improve access to desperately needed treatment for the millions of Americans struggling with a substance use disorder. Experts report that only 10 percent of the 22 million Americans with a substance use disorder receive treatment. This treatment gap is largely attributed to the shortage of workers in the substance use disorder field. The Substance Use Disorder Workforce Loan Repayment Act offers student loan repayment of up to $250,000 for participants who agree to work as a substance use disorder treatment professional in areas most in need of their services. The program will be available to a wide range of direct care providers, including physicians, registered nurses, social workers, and other behavioral health professionals. . . . To qualify for the program, participants must agree to be employed in a full-time SUD treatment job in a high need area for up to six years. That job must involve serving in a direct patient care role, and can include serving as a physician, registered nurse, social worker, recovery coach, or any other role listed in the bill, as well as any additional titles added by the Department of Health and Human Services. Participants may serve in a wide range of facilities, so long as they are located in an area with a shortage of mental health professionals or a high rate of drug overdose deaths (“Rogers, Clark,” 2018). Also addressed were potential higher standards for sober living environments. In an effort led by Rep. Judy Chu (D-CA), the Ensuring Access to Quality Sober Living Act was introduced in the House of Representatives. Cosponsors include Rep. Raul Ruiz (D-CA) and Rep. Mimi Walters (R-CA), among others. According to Rep. Chu’s website, This bill would authorize the Substance Abuse and Mental Health Services
Counselor | August 2018
CCAPP About the Author
Administration (SAMHSA) to develop best practices for recovery residences that promote sustained recovery from substance use disorders. Recovery residences, often known as sober homes, are family-like, shared living environments that are free from alcohol and illicit drug use, and centered on peer support and connection to services that help individuals just out of treatment continue on their journey to recovery (“Rep. Chu,” 2017). A plethora of other issues were also addressed by these bills, including a modification of the IMD exclusion, allowing for ninety days of inpatient treatment coverage under Medicaid; the establishment of a new program called “CORC,” which would recognize specific treatment facilities as nationally designated Community Opioid Recovery Centers; allowing the Centers for Disease Control and Prevention (CDC) to work with communities to reduce the spread of needle-sharing infections, such as HIV and hepatitis; and several others. The process of course is long, as the bills must be accepted by leadership for
Andrew Kessler, JD, is founder and principal of Slingshot Solutions LLC, a consulting firm that specializes in behavioral health policy and federal policy liaison for IC&RC.
References “Rep. Chu introduces bipartisan bill to improve sober homes that assist in opioid recovery.” (2017). Retrieved from https://chu.house.gov/media-center/pressreleases/rep-chu-introduces-bipartisan-billimprove-sober-homes-assist-opioid “Rogers, Clark lead federal effort to reduce the shortage of substance use disorder treatment professionals.” (2018). Retrieved from https://halrogers.house.gov/ press-releases?ID=F39DDD1C-5449-4653-B30F8776445443A8
consideration on the floor. While the House bills may receive a vote in the near future, the Senate tends to move slower. If both bills pass their respective chambers, then a conference must take place. Take into account that this is an election year, and the calendar becomes an even bigger enemy. In sum, the process will continue for quite some time. c
US Energy and Commerce Committee. (2018). #Subhealth votes to advance fifty-seven bills to combat the opioid crisis, reauthorization of ADUFA and AGDUFA. Retrieved from https://energycommerce. house.gov/news/press-release/subhealth-votesto-advance-57-bills-to-combat-the-opioid-crisisreauthorization-of-adufa-and-agdufa/ US Senate Committee on Health, Education, Labor, & Pensions (HELP Committee). (2018). Alexander: Senate Health Committee unanimously passes bipartisan bill to take the next step in helping states fight opioid crisis. Retrieved from https://www. help.senate.gov/chair/newsroom/press/alexandersenate-health-committee-unanimously-passesbipartisan-bill-to-take-next-step-in-helping-statesfight-opioid-crisis
New Movement Ignites Interest and Hope PRE-ARREST DIVERSION: PATHWAYS TO COMMUNITY POLICE, TREATMENT AND COMMUNITY COLLABORATIVE
d Ex Live
pport • Peers • Engage men t
perience • Victims of
r y Su ove Rec
The Prearrest Diversion he attempt to address addiction U M N I M T Movement effectively, and to prevent it when CdOGoals/Outcomes/SoluYt Today, another movement is buildion possible, has spawned the developare ing, and it is the police who are h s S ment of multiple “movements” asking for a new approach to adTREATMENT dressing people with substance AND/OR over the past century. Most use or mental health disorders. SOCIAL SERVICES have responded to the times (INTERCEPT 0) They want what the addiction in which they were created, field and the families of those SelfActive Naloxone Officer Officer with these disorders want: and all started because of Referral Outreach Plus Prevention Intervention* available treatment and recovfrustration with solutions AVAILABILTY OF ALL PATHWAYS MAXIMIZES OPPORTUNITIES ery support instead of arrest that were failing to fix the and incarceration when these people are not threats to others. problems they wanted fixed.
The criminal justice system has Law Enforcement • Sheriff NACoA facilitated the draseen the diminishing relapse State Troopers • Probation • Parole matic growth in the early 1980s and recidivism rates in clients of (INTERCEPT 1, 3, 5) of the Adult Children of Alcoholics drug courts and the shorter time to Sh s n r a re (ACoAs) movement while it was develfamily reunification when parents get dP nce o C oping as the voice and champion for the treatment and the family participates ro b l e / m s / C h a ll e n g e s long ignored and neglected Children of in a whole family support program PATHWAYS TO COMMUNITY Alcoholics (CoAs) whose childhood years like Celebrating Families! As a result, Self-Referral Individual initiates contact law enforcement forcame a treatmentto referral (without fear of arrest), preferably this a warm handoff treatment. set them up to become the next •generaheal.withTherapists these conferencnewto movement is gaining the supExample: Police Assisted Addiction and Recovery Initiative (PAARI) Angel Program tion of addicted people. Active Outreach • Law enforcementes and returned home with a new view port of those working in the criminal initially IDs or seeks individuals; a warm handoff is made to treatment provider, who engages them in treatment. Assisted Addiction of and Recovery (PAARI) Arlington; Response Team (QRT) ACoA Thousands of ACoAs Examples: who Police remained theirInitiative clients; manyQuick established justice arena. Naloxone Plus • Engagement with treatment as part of an overdose response or a severe substance use disorder at acute risk for opioid overdose. silent their whole lives suddenly realized support groups; Al-Anon established The movement is called “prearrest Examples: Drug Abuse Response Team (DART); Stop, Triage, Engage, Educate and Rehabilitate (STEER); Quick Response Team (QRT) they were not alone and they ACoA meetings; the movediversion” and it focuses on developOfficercould Preventionspeak • Law enforcement initiatesAl-Anon treatment engagement; no charges areand filed. Examples: Crisis Intervention Team (CIT); Law Enforcement Assisted Diversion (LEAD) Social Contact; Stop, Triage, Engage, Educate and Rehabilitate (STEER); Mobile Crisis; Co-Responders; Crisis/Triage/Assessment out loud about their truth and begin to ment rolled across the country. ing a warm handover to treatment and Centers; Veterans Diversion help for people suffering from substance *Officer Intervention • Law enforcement initiates treatment engagement; charges are held in abeyance or citations issued, with requirement for completion of treatment and/or social service plan. Examples: Civil Citation Network (CCN); Crisis Intervention Team (CIT); use or mental health disorders. Instead Law Enforcement Assisted Diversion (LEAD) Assessment; Stop, Triage, Engage, Educate and Rehabilitate (STEER); Veterans Diversion of ticketing and arresting such individTo learn more about the PTAC Collaborative, contact Jac Charlier, National Director for Justice Initiatives at the Center for Health and Justice at TASC, at firstname.lastname@example.org or 312.573.8302 uals, police chiefs want their officers to guide users to treatment and recovery support so that they can become decent citizens again. There is a growing awareEight times a year, the JOURNAL OF SUBSTANCE ness that putting sick people in jail proABUSE TREATMENT presents specific guidance tailored to a wide range of substance abuse duces more sickness, higher costs to the problems, with an emphasis on techniques prison system, and higher costs to soand treatments you can immediately apply to ciety when these individuals complete enhance the recovery of your patients. their sentences and are released without Individual Domestic: $218 less 20%= $174 recovery or the skills necessary to lead Individual International: $236 less 20%= $188 healthy and productive lives. For more information or to order: The prearrest diversion move• Visit: www.elsevierhealth.com ment is called the Police, Treatment, • Call 1-800-654-2452 (US and Canada) and Community Collaborative (PTAC or 1-407-345-4000 (other countries) Subscribe today and save 20%! Collaborative), and it is a major national • Fax 1-407-363-9661 Mention DI1100 when ordering collaboration of police organizations, MO9050 treatment organizations, and community systems. It has been propelled by a group of founding member organizations
© 28 August 2017
M M U NITY
Offer your patients
Counselor | August 2018
NACOA and it held its first national summit in March 2018, bringing together teams of like-minded people from individual communities who developed ways to work collaboratively to develop an effective prearrest diversion program in their communities. The PTAC Collaborative has established the “PTAC Guiding Principles for Behavioral Health Practice” (2017). It believes that these principles must inform treatment and/or social service providers. They are:
Promote Hope, Health, and Dignity
This is about promoting these ideas “throughout the engagement, treatment, and recovery continuum” (PTAC Collaborative, 2017).
“Fair, impartial, and culturally competent treatment and services need to be available for all types of individuals, no matter their nation of origin, gender identity, sexual orientation, race, religion, or culture” (PTAC Collaborative, 2017).
Systems, Providers, and Staff Must Recognize that Recovery is an Individualized Process
PTAC and its partners must “understand the cycles of change as individuals move through the stages of recovery. To be effective, helping responses and resources must align with the individual’s change process” (PTAC Collaborative, 2017).
Respect that Recovery is a Journey, Not an Event
Treatment and service providers and other prearrest diversion partners must recognize “the differing stages of readiness for SUD treatment programs and the recovery process,” as well as people’s understanding of their recovery. “Efforts that reduce harm to the individual and offer multiple paths to wellness” should be included (PTAC Collaborative, 2017).
Coordinate Care along the Services Continuum
“It is vital that providers work as part of a system that extends beyond
TOP REASONS TO ATTEND FOUNDATIONS EVENTS
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Oct. 1-4, 2018
behavioral health to encompass physical, mental, spiritual, and social health. PTAC systems of care engage with treatment and service providers in their community to create a network of services and supports across the continuum” (PTAC Collaborative, 2017).
Identify and Reduce Barriers for Access to Services and Service Delivery
“Making services easily accessible to the community, law enforcement partners, and consumers” is critical for a diversion program (PTAC Collaborative, 2017). Prohibitions/exclusions that are dated should be reviewed to reduce barriers for access to services and recovery supports. Expanding accessibility to medication-assisted treatment (MAT) and to medicationassisted recovery (MAR) programs is also important and needed.
Apply Holistic, Integrated Care
A network of service providers would include those who can “address and prioritize safety and other basic, real-life
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NACOA problems such as homelessness, domestic violence, chronic medical conditions,” and income and employment supports so people can benefit from treatment services and recover (PTAC Collaborative, 2017).
Incorporate Promising and/or Evidence-Based Practices
“Recovery and support services should include best practices or promising practices supported by research” (PTAC Collaborative, 2017). There should be ongoing education for both professionals and consumers to facilitate utilization of such practices.
Evaluate Process Measures and Outcomes
Outcomes of prearrest diversion and linkage to care programs need to be evaluated “as well as services including recovery supports by assessing individual and aggregate outcomes of those entering treatment and other services via various pathways” (PTAC Collaborative, 2017). Evaluation should include the entire care continuum from early engagement to long-term recovery.
Utilize Outcomes and Research to Evolve Care
“PTAC encourages a continuous evolution of collaborative data strategies that work to inform policy; measure the impact of interventions, services, and supports; and improve the quality and outcomes for consumers, their families, and communities” (PTAC Collaborative, 2017).
Unwavering Commitment to Ethical Conduct and Practice
“Professional ethics are at the core of PTAC. PTAC, not-for-profit, and forprofit behavioral health services; law enforcement; community; and other prearrest diversion program partners have an obligation to articulate basic values, ethical principles, and ethical standards. . . . These principles are relevant to all entities, regardless of their professional functions, the settings in which they work, or the varying populations served” (PTAC Collaborative, 2017).
PTAC is a national collaborative working to become part of the DNA of 10
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alternatives to arrest and incarceration. The public has come to understand that our country can never address the addiction epidemic and related social and criminal justice problems through the arresting of sick people who need treatment and recovery support. The data is clear. This practice, followed for decades, cannot benefit society nor the arrested individuals who spend a portion of their lives incarcerated, not rehabilitated, passing a heavy and costly weight onto the prison system, the court systems, the school system, the foster care system, and thousands of families for generations. The behavioral health professional community understands that there are new and effective enhancements to traditional treatment and that there are thousands of people in long-term recovery who are creating recovery community support organizations across the country to provide recovery coaching and support for individuals and their struggling family members. The time to move further upstream is now, and PTAC is stepping into that gap nationally so that collaborative teams can be created locally to foster prearrest diversion and save more lives and more families. With the many enhanced supports for finding recovery and wellness, its thirty founding member organizations, including NACoA, have modeled the effectiveness of open, inviting, and persistent collaboration as PTAC has evolved. Further, it has inspired teams in local communities to establish their own collaborations involving police, district attorneys, and entities in the community that can provide the recovery supports that are beyond behavioral health service providers. All are invited to become part of the national collaboration or to work with colleagues in police work, criminal justice, faith, and other social service entities to create their own prearrest collaboration in their home communities. The PTAC collaborative has developed three “buckets” of membership:
1. PTAC Business Bucket
These are organizations that commit to be responsible for the business of PTAC. This means they do the following:
n Commit to the financial and time resources needed to create and maintain PTAC as a formal entity n Provide their logo to PTAC (and PTAC distributes their logo out to the field) n Distribute e-mails to their networks (and PTAC distributes their e-mails to PTAC lists) n Make the business decisions of the organization (including grants, funding, staffing, conferences, direction, strategy, etc.) in consultation with PTAC leadership.
2. PTAC Leadership Bucket
These are individuals and organizations that commit to stepping into or maintaining a leadership role with PTAC. These organizations participate in the following ways: n Commit to providing leadership and support for the business of PTAC in one or more strategy areas, tools, and/or deliverables n Provide their logo to PTAC (and PTAC distributes their logo out to the field) n Distribute e-mails to their networks (and PTAC distributes their e-mails to PTAC lists)
3. PTAC Member Bucket
These are individuals and organizations that participate in PTAC as they are able and as much or as little as they desire. Why is NACoA a founding member organization? Because we are saying “No more!” to creating any major solution or strategy to address and conquer the addiction epidemic that ignores the children affected by parental addiction. The addiction field has been too silent for too long. We are the children’s voice, and we intend to be heard. c Acknowledgements: The author is grateful to PTAC and its leader, Jac Charlier, for the use of its material to support this column.
About the Author Sis Wenger is NACoA’s president and CEO.
References Police, Treatment, and Community Collaborative (PTAC Collaborative). (2017). PTAC guiding principles for behavioral health practice. Retrieved from http://www2.centerforhealthandjustice.org/sites/ www2.centerforhealthandjustice.org/files/ publications/PTAC_Guiding_Principles.pdf
Schadenfreude: Celebrating the Misfortune of Others Maxim W. Furek, MA, CADC, ICADC
ike Sunday afternoon visits to London’s fetid insane asylums, we stare and gawk, fascinated yet repulsed, at unfortunates like Joseph Merrick (1862–1890). Joseph Merrick—incorrectly identified as “John Merrick” and also known as “The Elephant Man,” his degrading stage name—attained a macabre celebrity status not because of wealth, success, or glamorous looks, but because of a grotesque physical deformity.
Merrick was a nineteenth-century Englishman who attained the highest rung of notoriety in a freak show as a sideshow oddity. Freak shows were popular throughout the world, with people being inherently curious about those who are different— deformed, crippled, and seemingly less-than-human. Joseph Merrick was virtually enslaved and exploited, suffering an unimaginable fate. In a cruel and barbaric spectacle, Merrick’s hunched over and disfigured frame was paraded in front of adults and children who paid the sum of two pence to stare in shock and disbelief, feeling pity and horror at the pathetic, humanlike monster. A large overhanging sheet of canvas advertised a life-size “frightful creature that could only have been possible in a nightmare” (Treves, 1885). Joseph Merrick’s birth appeared to be normal and healthy before he began to develop serious physical deformities. As a child, Merrick’s body became a misshapen growth of twisted horror. His skin turned thick and gray-hued, with fleshy, oversized tumors and a distorted swelling of his right side, including his right hand. According to Kugler, “By the time he was twelve years old, Joseph’s hand was so deformed it became useless. The growths on his skin were now large and repulsive for most people to look at” (2018). Because a circus elephant had frightened Merrick’s mother during her pregnancy, his parents and an unsophisticated medical community concluded that the child had contracted elephantiasis, “a disorder of the lymphatic system that causes parts of the body to swell to a huge size” (Kugler, 2018). But according to a radiologist at the National Institutes of Health in 1996, Merrick was afflicted with Proteus syndrome, an extremely rare genetic condition with prevalence lower than one in one million (Kugler, 2018). Merrick’s deformity repulsed throes of gawkers as it lined the profiteer’s pockets with shining coins. The lucrative equation between curiosity and monetary reward was easily determined. Still, the shameful exploitation of Joseph Merrick, the greatest of all “sideshow freaks,” was neither new nor unique. According to Hingston, “The Elephant Man traveled around with the likes of Jo-Jo the Dog-Faced Boy, Krao the Missing Link, and Herr Unthan the Armless Wonder” (2018).
Sadly, unfortunates like The Elephant Man have always been oppressed and revictimized, but writer Ed Hingston conversely maintains that this may have presented a positive opportunity: “While it might seem degrading to us now, appearing in a ‘human oddity’ exhibition allowed freaks to earn a decent living and recover some self-respect” (2018).
The word schadenfreude comes from the two German words schaden and freude, which mean “harm” and “joy,” respectively (Shrand, 2017). The term refers to the enjoyment derived from the misfortune of others, the satisfaction of seeing someone else in pain or being humiliated. Schadenfreude is a common emotion that is experienced at some point in our lives. People with poor self-esteem, threatened by overachieving individuals, are more likely to experience schadenfreude. Researchers believe that schadenfreude can be self-affirming for “threatened” individuals, allowing them to feel better about themselves as they boost their selfaffirmation (Bryner, 2011). Much like yesterday’s public executions, hanging holidays, and other morbid examples of communal mob entertainment, schadenfreude assumes many forms. Ambulance and fire chasers, obituary scanners, voyeurs, and rubberneckers are among those seeking titillation through the misfortunes of others, often high-profiled politicians, athletes, or celebrities. Collectively they demonstrate a cultural pathology that I have labeled “celebrity blood voyeurism.” Rubbernecking, the pedestrian act of craning one’s neck and staring at something of fascination, has been described as a human trait that is associated with morbid curiosity. It can be the cause of traffic jams—sometimes referred to as “gapers’ blocks” or “gapers’ delay”—as drivers slow down to observe the destruction from a crash.
A Touch of Romance
Another example of schadenfreude can be found in the infamous slums of Rio de Janeiro, Brazil. Called favelas, these slums are a pathetic and exploited tourist destination, satiating the appetites of the rich and famous. The slums, populated by shanty towns, “brutal gang warfare,” “powerful drug lords,” and professional kidnappers, offer a dangerous and sad existence to those calling it home (“Rio de,” 2018). A Brazilian travel and cultural website promotes the slum area as a major tourist attraction. Detailed in their “Interesting Secret #2,” Rio de Janeiro slums attract thousands of tourists. The majority of Rio’s residents see the neighboring favelas as dark, violent places that drag down the reputation of their www.counselormagazine.com
CULTURAL TRENDS c i t y. Fe w e v e r v e n t u r e t h e r e. Foreigners, on the other hand, find some aspects of the slums endearing. The uninhibited energy of the locals and the lives they lead fascinate newcomers. There is a touch of romance in these crowded, shoddily constructed communities that attracts people interested in experiencing the real Brazil (“Rio de,” 2018).
The Ninth Ward
The Ninth Ward of New Orleans, Louisiana, an area embroiled in exploitation and controversy, is America’s version of the favelas. In 2005, Hurricane Katrina made a direct hit on the city, causing an estimated $100 billion in damages and nearly two thousand deaths in Alabama, Louisiana, and Mississippi (“Hurricane,” 2009). Many of the licensed bus companies operating in New Orleans focus on the hurricane. An article in The New York Times reported, With names like ‘Hurricane Katrina – America’s Greatest Catastrophe,’ they
charge about $45 for firsthand glimpses of vine-covered houses and abandoned properties. “We’ll drive past an actual levee that breached and see the resulting devastation that displaced hundreds of thousands of US residents,” Gray Line, one of the largest tour companies, promises on its website (Brown, 2012). But that morbid example of “disaster voyeurism,” where tourists gawk in awe at the devastation in one of the hardest hit sections of The Big Easy, has been terminated. After a 2006 ordinance, New Orleans’ hurricane-themed tours are no longer allowed to cross the Industrial Canal and enter the Lower Ninth Ward (Gerdes, 2012).
Donald Trump Jr.
Soon after Vanessa Trump filed for divorce from Donald Trump Jr., Erin Keane, writing in Salon, observed that “public response has run the gamut from delighted scorn to handwringing over the spiritual utility of schadenfreude in these ugly times” (2018).
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Those “ugly times” were the domain of social media. Junior was met with derision when news of his unfortunate marital breakup was announced. Keane documented, If the Clintons and the Obamas embraced the celebrity culture surrounding the presidency like none since the Kennedys, the Trumps have exploited it, ruthlessly and with unprecedented eﬃcacy, all the way from Fifth Avenue and NBC into the Oval Oﬃce. As the old chestnut goes, live by the sword, die by the sword, and nowhere is that maxim honored more thoroughly than in politics and celebrity culture. Just like his father and his sister Ivanka, [Donald Trump] Junior has wholeheartedly embraced both cutthroat worlds (2018). It became even more cutthroat after TMZ reported that Vanessa Trump “received an envelope with white powder, and a hate letter for Don Jr. that read, in part, ‘You the family idiot. This is the reason why people hate you. You are getting what you deserve’ ” (“Donald Trump,” 2018). The white powder was discovered to be cornstarch. As one of the Trump family inner circle, Junior’s exploits were fascinating. He appeared as one of his dad’s advisors on The Apprentice and jetted across the globe, finalizing business deals that only a Wall Street investor could comprehend. But to some, Junior projected an aura of privilege, arrogance, and condescension. With his celebrity came a reverse karma: what goes up must come down. “The feeling of schadenfreude is felt so universally,” says Joseph A. Shrand (2017). In his article, “The Science of Schadenfreude,” Shrand writes that “we all have a dark side” that is rewarded at someone else’s expense. “We cannot help but bask in delight when certain people, especially certain popular celebrities, politicians, and other public figures make embarrassing mistakes,” he notes. (Shrand, 2017). Junior’s castigation was not unique. He had now entered the dubious brotherhood of other disgraced politicians including Gary Condit, Bill Clinton, Larry Craig, John Edwards, Mark Foley, Gary Hart, Eliot Spitzer, and Anthony Weiner. There were Continued on page 32
Counselor | August 2018
Laying the Groundwork for a Medication Conversation Michael G. Pipich, MS, LMFT
herapists and counselors can have very different opinions on the role of psychotropic medications in mental health care. The majority of mental health professionals appear to agree that medications are necessary in the most severe forms of psychological disorders, especially when psychosis is present. But many are still confl icted about when it is appropriate to broach the subject of medication referrals, especially if patients have never taken psychiatric medicines before. As a therapist or counselor, you might fi nd yourself feeling stuck about dealing with this important issue for any number of reasons as well. As a psychotherapist specializing in the treatment of bipolar disorder, I routinely discuss issues regarding psychotropic medications with individual patients and families involved in therapy, even when substance abuse is part of the overall condition. Though I am not a prescriber, I have found that these medication issues are frequently present as relevant therapy topics both before and after medication becomes integral in the overall treatment plan. And since most actual therapeutic contact is performed by therapists and not prescribing physicians, I believe it is vital for all therapists to develop a thoughtful, well-informed medication conversation to present to patients and families when it is clinically appropriate. So let us take a look at how to form a medication conversation that is adaptable to most individual cases. It is first important to appreciate why discussing medication is so important. If you have not done much in the realm of discussing medication issues in therapy,
you may be asking yourself, “Why’s this my role? Shouldn’t I leave this to the doctor?” But in modern psychiatry, it is often therapists who are in the primary
position to discuss the need for a medication consult. Typically patients new to mental health care, relationship counseling, life coaching, or any number of
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OPINION adjunctive treatments will not seek out outpatient psychiatrists or other prescribing providers to treat their presenting problems. Without an adequate clinical assessment and acknowledgement of the possible need for medication, new patients will not know to ask about medication, or may suspect the need is present, but will avoid any inquiry. Moreover, once medications have started or if patients are already taking them, the therapists’ role as collaborators in medication treatment is not complete. Potentially several therapy sessions could occur between medication appointments, leaving therapists in better observational positions to help assess medication efficacy and side effects. I have found that many physicians appreciate the support and feedback either provided to patients to pass on to doctors, or given directly to doctors with patients’ consent. This kind of collaborative care ultimately improves outcomes and makes life easier for everyone. There are many resources available to therapists to aid in their understanding of basic psychopharmacology that are worth investigating, especially within certain specialty areas such as psychostimulants for ADHD, Suboxone for opioid dependency, mood stabilizers for bipolar disorder, and others. Therapists do not have to possess an extensive knowledge about all psychotropics; a fundamental understanding is often enough to introduce the possible need for consultation and to spot potential problems, with a collaborative intervention plan to keep overall treatment on track. Just as important as staying informed on psychotropics, therapists should evaluate their own personal biases for or against medications. This is as necessary as any countertransference issues that can become barriers to effective therapy. If you have witnessed medication-related problems professionally or personally, or perhaps have suffered with medication issues in your own life, maintaining objectivity becomes a real challenge. This can be made even harder with objections you may have regarding certain pharmaceutical industry practices. Biases with anything in life are inevitable, and I believe there is no way to totally purify our positions, especially as we care for vulnerable people. But without 14
Counselor | August 2018
a reasonable self-evaluation, therapists may avoid the medication conversation because of the dislike for medications or the companies that make them. Or conversely, therapists might push too hard for medications without really listening to the concerns of patients or families in a therapeutic context. Projecting anxieties about medications onto patients and families can lead to delayed improvements and a breakdown of healthy, collaborative treatment structures.
Without an adequate clinical assessment and acknowledgement of the possible need for medication, new patients will not know to ask about medication, or may suspect the need is present, but will avoid any inquiry. Instead, the personal feelings therapists have about medications can be used to increase the level of sensitivity for the medication conversation participants and the feelings that they are likely experiencing. Not that therapists should reveal their own issues; they should otherwise use them constructively to anticipate fears and questions that can be addressed with balanced information and therapeutic compassion. It is critical to understand that fears and concerns expressed by patients and families can be reasonable or irrational, and come from various sources in life. Thus, not only should therapists validate the impact of these fears, but they should also inquire into the origins of the fears in a nonjudgmental fashion. A deeper understanding of fears allows for an accurate, fact-based discussion, and just as importantly, enhances trust in the therapeutic relationship. The final piece in medication conversation development involves a thorough understanding and acknowledgement of the stigma against psychiatric medication. Over the years, I have heard many patients say, “I don’t want to take pills because it means I’m crazy.” Beyond the apparent irony of that statement, I believe here that “crazy” actually refers to a sense of profound shame borne of the
historical stigma associated with mental illness. Today, it is much easier for most people to go to counseling, but taking medications remains taboo. Therapy can be thought of as life-enriching, but to many people medication means being sick and broken. Thus, the medication conversation must explore the possibility of shame in patients and family members. Alongside shame and stigma is the question, “How will medications change who I am?” Notice that the deep concern embedded in this question is not about whether or not they will get well, but instead is about whether or not there is a loss of control within them. Identity issues very often are revealed through this process, which can be explored to increase overall therapy results. Again, sound information and sensitivity to the fears and concerns of patients and families can set a productive framework for medication collaboration, as well as advancing therapy for all involved. While there may be a degree of urgency in pursuing an outpatient medication consult, patients and families may still require some room to digest therapists’ recommendations. Making that decision cannot take too long, but can be advanced when therapists remind patients and families that they are always available to address new concerns as they arise. This includes the eventual discussion of going off medications or testing life without them, even if they are producing good results. The medication conversation never really ends; it simply progresses through phases as therapy progresses with it. Therapists and counselors in different capacities will consistently face medication issues in the people they treat. Laying the groundwork for a healthy, productive medication conversation not only provides an informative and emotionally safe place to discuss fears and concerns, it also adds to the overall therapeutic experience to improve all treatment outcomes. c About the Author Michael G. Pipich, MS, LMFT, is a psychotherapist and author of Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder (Citadel Press, Sept 2018). He practices in Denver, Colorado, and can be reached at MichaelPipich.com.
Slow Down, You’re Going Too Fast, Part I John Newport, PhD
ne of my favorite songs from the 1960s is “The 59th Street Bridge Song (Feelin’ Groovy),” originally released by Simon and Garfunkel in 1966. I was mesmerized by the lyrics, which I still sing daily on my morning walks along the desert trails. This wonderful, free-spirited song begins with, “Slow down, you’re going too fast—You gotta make this morning last / Just kicking down the cobblestones, looking for fun and feelin’ groovy,” and ends with, “I’m dappled and drowsy and ready to sleep / Let the morning time drop all its petals on me / Life, I love you—All is groovy” (Simon, 1966).
The spirit of this song really resonated with me as at the time I felt “trapped in the fast lane,” working in a high-stress job with a health care agency that was grossly understaffed in relation to our overwhelming scope of responsibility. Yearning to break free from my shackles, I was enthralled by the idyllic, free-flowing, live-in-the-moment approach to life this wonderful song portrayed. Little did I know that, some fifty years down the road, the pressure-cooker lifestyle I was caught up in would be accepted as the norm by a huge percentage of frazzled American workers.
The American Dream on Steroids
A young man emigrated from India five years ago to New York, where he works as a financial analyst for a major commercial bank. Throughout most of the year he works upwards of 120 hours per week, leaving less than seven hours per day for sleeping, eating, entertainment, and other non-work-related activities. Despite this grueling existence, he prides himself in that as a twenty-three-year-old he ranks among the top 6 percent of American earners (Hewlett & Luce, 2006).
Thanks to smartphones, notepad laptops, and other hightech paraphernalia, more and more workers are finding that the demands of their jobs have encroached upon their personal space and family lives on a constant basis (Seiger, 2018; “NYC bill,” 2018). Findings of the 2017 annual Gallup work and workplace survey indicate that among employees who use e-mails at work, a full 63 percent check work-related e-mails outside of normal working hours either frequently (36 percent) or occasionally (27 percent). Furthermore, over half of these employees (53 percent) perceive that it is important to check e-mails while away from work in order to get ahead in their workplace. Gallup survey findings also state that in 2013 a full 37 percent of workers surveyed felt that their companies were understaffed in relation to the amount of work that needs to be done (Gallup, 2017). In New York City, the “city that never sleeps,” concern over the intrusive impact of off-the-job electronic communications has reached the point where City Council Member Rafael Espinal has introduced a proposal that would bar employers from requiring workers to respond to nonemergency e-mails, texts, and other digital communications outside regular work hours. Quoting from the bill’s sponsor, “Work has spilled into our personal lives. We’re always connected to our phones or a computer once we leave the office” (Hajela, 2018). He adds that it is critically important for people to be “able to draw a clear line between the workplace and their personal lives, to give them time to connect with their family and friends, and reduce their stress levels and be able to go back to work and perform at their optimal level” (Hajela, 2018). Placing this into perspective, these off-the-job intrusions come on top of increasingly longer workweeks. For the years 2013 and 2014 combined, Gallup survey results estimated that the average workweek had climbed to 46.7 hours (McGregor, 2014). The reported workweek was even longer for salaried workers (averaging forty-nine hours), a group that is exempt from requirements that they receive overtime pay. Indeed, half of salaried full-time employees reported they work fifty or more hours each week (McGregor, 2014). A decade-old Harvard Business Review article titled “Extreme Jobs: The Dangerous Allure of the Seventy-Hour Workweek” graphically portrays the pervasive “workaholic ethic” that permeates our culture (Hewlett & Luce, 2006). Extensive research conducted by the authors portrays the emergence of “corporate hero” prototypes as modern warriors with a gross addiction to adrenaline, who wear their over-seventy-hour workweek as a “badge of honor,” along with their gravitation toward fast-paced work under tight deadlines, an inordinate scope of responsibility that extends far beyond the confines of one job, around the clock availability to their clients, and the gargantuan salaries and other perks associated with their top level, pressure-cooker jobs. Feeding into this workaholic frenzy is management’s desire to www.counselormagazine.com
WELLNESS squeeze as many hours of work as possible out of these “exempt” employees before springing for another fully-loaded salary.
A heavy work ethic has permeated our nation since its inception and we are the epitome of an uncontrollably materialistic culture. While the US contains less than 5 percent of the world’s population, environmental scientists report that we eat 15 percent of the world’s meat, use 20 percent of the world’s energy, and produce 40 percent of the world’s garbage (Elert, 2012). I submit that our wanton consumption is driven largely by a corporate ethos that enshrines pursuit of profit to the max, accompanied by an incessantly aggressive campaign to convince us that “more is better.” Most unfortunately, this prevailing ethos fosters a mindset among corporate leadership that tends to view workers as mere tools of production. I earnestly believe that the majority of workers harbor noble aspirations, together with a high level of dedication to their work, their families, and society at large. While economists claim that we now have a near full-employment economy, major corporations routinely lay off thousands of workers when reported earnings fall below projected targets. This fosters a deep-seated sense of insecurity among workers, leaving them increasingly vulnerable to intrusive practices that threaten to undermine the quality of their lives and relationships with friends and family.
The Price We Pay
So now let us take a look at the price we pay for all of this. At a societal level, we pay a heavy price in terms of erosion of core values that have historically promoted balanced, fulfilling lives and a commitment to caring for others. I believe that when a heavily influential segment of society tunes out the human side of business, we all tend to become desensitized to the detrimental consequences of our individual and collective choices and actions. Not the least of these is the rampant devastation of our precious natural resources, seemingly with no regard to preserving the livability of our planet for future generations. Let us now take a brief look at some data suggestive of overall ramifications of 16
Counselor | August 2018
our excessive workaholic culture affecting our overall state of health and well-being. In the realm of addiction, our nation’s epidemic of rampant workaholism provides a perfect set-up for relapse to alcohol and/or drug abuse, unless people in recovery institute appropriate preventative measures. This is an area where adhering to the wisdom inherent in Twelve Step slogans—particularly “easy does it” and “one day at a time”—can provide tangible assistance. Our nation also harbors an astronomical number of people suffering from anxiety disorders and major depression. Anxiety disorders annually affect some forty million American adults age eighteen and older, or 18.1 percent of the population (ADAA, 2016). Major depression, the leading cause of disability, affects more than 16.1 million adults, or 6.7 percent of the US population age eighteen and older (ADAA, 2016). According to an article in The New York Times, our rate of suicide, the tenth leading cause of death, reached a thirty-year high in 2014, claiming 42,773 lives (Tavernise, 2016). I suspect that the dehumanizing aspects of our accelerated, fast-lane culture are a significant contributing factor to these disturbing statistics. Finally, we need to consider the effect on our families of our cultural addiction to living on overdrive. Indeed, the American family is in a deeply troubled state of affairs; some 40 percent of all children are born out of wedlock and our collective divorce rate has hovered at around 50 percent for decades (CDC, 2017; APA, 2018). Frazzled parents, caught up in selfabsorbed pursuits and/or attempting to juggle too many external demands, are far too often either unwilling or unable to experience meaningful, in-depth involvement with each other and their children. Smartphones and iPads have become the nation’s babysitters—pathetic substitutes for caring human interaction. Among frightening numbers of children as well as adults, meaningful direct communication has become a lost art. This disturbing trend fosters a growing sense of isolation, despair, and loss of purpose among a large segment of our population. This poses truly frightening ramifications concerning the future plight of people in our society and indeed throughout the world, concerning their ability to live truly meaningful lives
within the context of an increasingly uncaring and depersonalizing world. In the second and final column in this series I will provide suggestions concerning steps we can take both individually and collectively to counteract this devastating epidemic of “hurry sickness” in our society. Until next time—to your health! c About the Author John Newport, PhD, is an addiction specialist, writer, and speaker living in Tucson, Arizona. He is author of The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. You may visit his website www.wellnessandrecovery.com for information on wellness and recovery trainings, wellness coaching by telephone, and program consultation services that he is available to provide.
References American Psychological Association (APA). (2018). Marriage & divorce. Retrieved from http://www.apa.org/ topics/divorce/ Anxiety and Depression Association of America (ADAA). (2016). Facts & statistics. Retrieved from https://adaa.org/ about-adaa/press-room/facts-statistics Centers for Disease Control and Prevention (CDC). (2017). Unmarried childbearing. Retrieved from https://www.cdc. gov/nchs/fastats/unmarried-childbearing.htm Elert, E. (2012). Daily infographic: If everyone lived like an American, how many earths would we need? Popular Science. Retrieved from https://www.popsci.com/environment/article/2012-10/daily-infographic-if-everyonelived-american-how-many-earths-would-we-need Gallup. (2017). Work and workplace. Retrieved from http://news.gallup.com/poll/1720/work-work-place.aspx Hajela, D. (2018). Boss buzzing you after hours? NYC proposal would let you say buzz off. Retrieved from http:// www.mcall.com/business/mc-nws-new-york-city-afterwork-contact-20180406-story.html Hewlett, S. A., & Luce, C. B. (2006). Extreme jobs: The dangerous allure of the seventy-hour workweek. Harvard Business Review. Retrieved from https://hbr. org/2006/12/extreme-jobs-the-dangerous-allure-of-the70-hour-workweek McGregor, J. (2014). The average workweek is now fortyseven hours. The Washington Post. Retrieved from https://www.washingtonpost.com/news/on-leadership/ wp/2014/09/02/the-average-work-week-is-now47-hours/?noredirect=on&utm_term=.d5f63dd47d04 “NYC bill would shield workers from bosses’ after-work emails.” (2018). Retrieved from https://www.nbcdfw.com/ news/local/Bill-Would-Make-it-Illegal-for-New-Yorkersto-Respond-to-Emails-During-Non-WorkHours-477737223.html Seiger, T. (2018). Proposed NYC bill would bar employers from requiring after-hours work. The Atlanta Journal-Constitution. Retrieved from https:// www.ajc.com/news/national/proposed-nyc-bill-wouldbar-employers-from-requiring-after-hours-work/ cDKKqoGPeDbDnnWMLJ1QJP/ Simon, P. (1966). The 59th street bridge song (feelin’ groovy) [Simon and Garfunkel]. On Parsley, sage, rosemary and thyme [Record]. 1966. New York, NY: Columbia. Tavernise, S. (2016). US suicide rate surges to a thirty-year high. The New York Times. Retrieved from https://www. nytimes.com/2016/04/22/health/us-suicide-rate-surgesto-a-30-year-high.html
TOPICS IN BEHAVIORAL HEALTH CARE
The Bermuda Triangle of Care Coordination: Medical, Psychiatric, and Substance Use Disorders Dennis C. Daley, PhD, & Ann Giazzoni, LCSW, MBA
any patients with substance use disorders (SUDs) have significant medical and psychiatric problems. SUDs can cause or worsen numerous health conditions related to the central nervous system (e.g., impaired memory or seizures), digestive system (e.g., cancers of the mouth or esophagus; or inflammation of the pancreas), hepatic system (e.g., inflammation or destruction of the liver tissue; fatty, diseased, or scarred liver), cardiovascular system (e.g., weakening of heart muscle; stroke; high blood pressure), musculoskeletal system (e.g., broken bones; swelling of the joints; polyneuropathy or damage to nerve tissue), or respiratory system (e.g., lung damage or disease). SUDs also contribute to HIV, hepatitis, and other infectious diseases. Individuals with long-term addiction have a reduced life span due to poor health habits, accidents, and medical diseases. SUDs are also associated with a significant increase in psychiatric comorbidity. Rates of SUDs are higher among patients with mood, anxiety, personality, eating, and attention deficit disorders. Severity levels of each condition may vary from mild to moderate to severe. In our care management program, we serve many patients who have SUDs and medical and psychiatric disorders. In addition, many of these patients have social problems that affect their physical and mental health such as poverty, housing instability, detachment from families, and nonsupportive social networks. These patients may have limited internal and external resources to help them cope with multiple problems that impact their overall functioning and quality of life. This article will discuss multidisciplinary care coordination and interventions that are helpful to patients with multiple, high-priority needs. It is easy for patients with these multiple problems to get lost in treatment systems. This is especially true when people present to one system—such as a hospital emergency room—with a major complaint, but have other significant problems that affect their medical functioning and quality of life. For example, John, who has a long history of addiction and IV drug use, was admitted to a medical unit for
endocarditis. In addition to the symptoms of this medical condition, John has been using heroin daily for the past several months and was recently kicked out of his apartment for failure to pay rent. In the past his medical team treated his medical condition, detoxified him from heroin, and suggested he continue addiction treatment upon discharge. According to a SAMHSA report, 7.9 million adults in the United States had a co-occurring mental health and SUD (Ahrnsbrak, Bose, Hedden, Lipari, & Park-Lee, 2017). In 2015, the former NIMH director Thomas Insel explained that median reduction in life expectancy for those with mental illness was 10.1 years. He further clarified, “Most
of the early mortality was attributed to natural causes such as acute and chronic comorbid medical conditions (heart diseases, pulmonary diseases, infectious diseases)” (Insel, 2015). This suggests that a coordinated approach to care is needed to address the multiple disorders and problems presented by patients seeking help for a medical, psychiatric, or SUD.
The Need for Coordinated Care
Providers across various medical, psychiatric, or addiction treatment systems may not work together to coordinate care for complicated patients such as John.
As a result, patients may feel frustrated or even fail to comply with the recommended treatment plan because they feel their needs and problems are not being adequately addressed. The challenge we face is how to coordinate and provide integrated care and service coordination for patients with these multiple disorders to insure proper care for all problems. The challenge for providers is determining which problems or disorders to prioritize since each one seems to be a high priority for patients. From the perspective of providers, patients with complicated, high-priority needs often take a significant amount of time. In addition, these patients have a www.counselormagazine.com
TOPICS IN BEHAVIORAL HEALTH CARE high frequency of utilization of inpatient and emergency rooms, making their care difficult to track. Patients with complicated, high-priority conditions such as HIV, schizophrenia, and opioid addiction frequently seek care at hospitals; primary care physician practices; community agencies; and behavioral health and substance use treatment programs. Many of these patients receive multiple medications from different providers. Polypharmacy issues put some patients at risk for side effects that are not managed well, which may cause noncompliance issues. Patients being prescribed opioids and benzodiazepines by different prescribers are at greater risk for an unintentional overdose or to develop a SUD. Additionally, some patients who develop SUDs and cannot afford medications may transfer their addiction from drugs like prescribed opioids to cheaper, illicit street drugs like heroin or fentanyl.
In one case, a health insurance case manager gets a call from a patient asking for help with a referral to SUD treatment for alcohol and cocaine problems. The case manager searches for treatment services for the patient and completes conference calls to find out which provider will offer an evaluation appointment to the patient to determine what treatment may be needed. During this process, the case manager discovers there are transportation problems as well as untreated diabetes and depression. What seemed like a relatively simple call to connect to a patient to a SUD treatment program has involved many calls and connections to multiple medical, psychiatric, and SUD providers. It may take coordination among multiple providers to work together to assist a patient like this. In some cases of more severe medical conditions requiring close medical care in an addiction rehabilitation program, the case manager finds it difficult to locate a program that will consider treating the patient. In another case, the case manager received a call from a hospital emergency department that a patient with multiple problems was taken there by first responders following a heroin overdose. The case manager discussed the discharge plan with the medical team and patient navigator, and agreed to contact the patient 18
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by phone on a daily basis until the patient engaged in treatment for opioid addiction. We have found that assertive outreach is needed by many of these patients to help facilitate their entry into care for problems such as an opioid addiction.
Helping Patients with Multiple Problems
So what works? For patients with chronic conditions, it is valuable to have a treatment perspective of wellness and recovery because their care is a journey, not a destination, since many of their multiple conditions are chronic. The key is a recovery approach to caring for these patients as well as having rapid outreach and intervention when patients are ready to receive help. Providers should understand that connection with complicated patients may be sporadic at times as a result of their noncompliance and dropping out of treatment systems. Creating a plan with these patients is important to see what priorities are important to them. Having knowledge of what interventions are available is also important for rapid response and intervention. An example case is Shirley. She is a fifty-year-old with bipolar disorder and chronic obstructive pulmonary disease (COPD) from years of smoking addiction. Shirley has been to the emergency department sixteen times in the past six months since she has trouble breathing. Shirley has only been to her PCP once during this time. She has also been referred to home care, but refuses to let anyone in her home. Shirley’s behavioral health provider can see her decline, but is unaware of the medical emergency room visits that have occurred. Case managers from physical health and behavioral health have started to work together to help Shirley. With the input of Shirley’s health insurance case manager, information is provided to the behavioral health case manager and the emergency department. The goal is to link Shirley with transportation to the pulmonologist to create a plan with Shirley to improve her breathing. Shirley signed a release of information so her many treatment systems can work together to remove any barriers to care. Her behavioral health and physical health providers are communicating—with her permission—to ensure connections to care occur. Shirley also agreed to have a
peer navigator come to her house and discuss how to get connected with community supports. As a result, Shirley now has her oxygen for night time and her medications delivered to her in blister packs so she knows what to take for each day, and she no longer goes the emergency room. Shirley also cut down significantly on her tobacco use through a tobacco education program and agreed only to smoke outside. Although the ideal is cessation of smoking, a harm reduction approach is needed for some patients who may not agree to stop all of their alcohol or drug use.
Future considerations to help members with complicated medical, psychiatric, and substance use issues include increased communication between providers in medical, psychiatric, and addiction systems of care. Shifting the view of care from a disease model to a person-centered wellness and recovery model is important to keep patients engaged in services and actively involved in their care. Hiring staff with clinical expertise in medical, psychiatric, and SUD treatment is also helpful in coordination of care. In summary, it takes a team approach among multiple providers willing to work together, with patients at the center, to improve care of patients with high priority medical, psychiatric, and substance use problems. c About the Authors Dennis C. Daley, PhD, served for fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. Dr. Daley has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research. Ann Giazzoni, LCSW, MBA, is program manager of physical health/behavioral health integration at the University of Pittsburgh Medical Center Insurance Division.
References Ahrnsbrak, R., Bose, J., Hedden, S. L., Lipari, R. N., & Park-Lee, E. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/ NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm Insel, T. (2015). Blog post by former NIHM director Thomas Insel: Mortality and mental disorders. Retrieved from https://www.nimh.nih.gov/about/directors/thomasinsel/blog/2015/mortality-and-mental-disorders.shtml
High Medical Service Utilizers Gerald Shulman, MA, MAC, FACATA
f considerable concern, particularly to general or acute care hospitals, are patients who are high medical service utilizers (HMSUs), particularly those admitted for withdrawal management (i.e., detoxification). Staff complain that they see these people—who they uncharitably refer to as “high fliers”—over and over again for withdrawal management with no discernable improvement. Some people have even postulated that this kind of utilization by HMSUs plays a role in increasing health care costs as well as negative consequences such as impairment of patients’ cognitive abilities (Kouimtsidis, Sharma, Charge, & Smith, 2015).
According to The ASAM Criteria (MeeLee et al., 2013), one of the primary goals for withdrawal management is the completion of detoxification and timely entry into continued treatment. However, in other than organized withdrawal management programs, staff sometimes view their responsibilities as simply providing the actual withdrawal management
services without emphasis on the timely entry into continued treatment. Said another way, staff view the detoxification as a discrete event rather than as an initial step in a disease management process. Given that addiction is a chronic, relapsing brain disease, this would be analogous to stabilizing diabetics who have been hospitalized for insulin shock or
diabetic ketoacidosis, then discharging them without a follow-up plan for managing the disease, or stabilizing people with bipolar disorder in a hospital after a manic event without a plan to control their mood fluctuations after discharge. In these examples, the diseases are treated as if they are acute disorders (i.e., the episode that precipitated the admission) rather than chronic conditions. This misguided approach is seen clearly in Medicare, which pays only for acute stabilization of psychiatric problems or detoxification for substance use disorders (SUDs) in an inpatient hospital, although it will reimburse for cardiac rehabilitation after an adverse cardiac event. If the role of nursing staff is viewed as traditional nursing, the problem of SUD-related HMSUs will continue. The first part of the intervention to reduce
COUNSELOR CONCERNS the readmissions is an ASAM dimensional assessment (Mee-Lee et al., 2013). In this assessment we can conclude that ASAM Dimension 1 (acute intoxication, withdrawal potential) will have been resolved by the hospital’s withdrawal management procedures. Problems in Dimension 2 (biomedical conditions and complications) will also have been identified. Acute Dimension 2 problems (e.g., a wound that needs cleaning and debridement) can be resolved during the hospitalization. Dimension 2 chronic problems (e.g., diabetes or hypertension) may be addressed with a care plan that includes appropriate medications and referral for follow-up treatment. The problem becomes more complex with the assessment of ASAM Dimensions 3 through 6. In contrast to a “detoxification unit,” nursing staff are generally not trained to do such assessments, might view them as outside their normal scope of practice, and may be resistant because of the additional workload. When a hospital does not have an organized withdrawal management service and patients are assigned to services where there are available beds, it is called “scatter bed placement.” Furthermore, in general hospital nurses may be assigned to services as needed based on census. Therefore, an addictiontrained nurse may be transferred away from detoxing patients to some other medical, surgical, or orthopedic service to meet staffing needs. Or, conversely, nurses without addiction training may be transferred into general medical and surgical services where there are patients undergoing detoxification. In addition to the need for training in assessment, these nurses would have to make referrals to respond to the assessment data, which would require them to have extensive knowledge of resources in the community. A finding of homelessness in Dimension 6 would require assessors to be aware of services in the community that could remedy that situation. All in all, the burden on nursing staff seems to be untenable. Obviously, ASAM Dimension 5 (relapse, continued use, continued problem potential) is the key to interrupting this revolving door and there are two nonexclusive approaches to achieve that end. The first is induction of antiaddiction drugs and evidence-based practices. Oral naltrexone 20
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and its injectable, extended release form Vivitrol can be used for alcohol and opioid dependence, but opioid dependence requires seven to fourteen days of abstinence after last use in order not to precipitate withdrawal. Patients can be inducted on buprenorphine combined with naloxone/Suboxone while still hospitalized. In terms of costs, most commercial insurance companies will pay for the medications and Alkermes, the company that produces Vivitrol, will pay for up to $500 per month in copay assistance. In most states Medicaid will pay for either Vivitrol or Suboxone. Inductions must be followed by referrals to providers who can continue the medication once patients have returned to their home areas. This can be accomplished by referral of patients to covered physicians by the nursing staff. The second option is to hire individuals—social workers, alcohol and drug counselors, and others—with addiction qualifications who could travel throughout hospitals to wherever the detoxing patients are, do the assessments, and make appropriate referrals for continued treatment and acquisition of any necessary nonclinical services such as housing. This second solution would incur additional staff costs. There are two considerations here. One is whether additional expenses would be offset by a reduction in the repetitive admission of patients who have poor or no form of health care reimbursement, which is still a cost to the hospitals providing their care. The other issue is to assure that cost considerations do not negatively impact the provision of quality care. c About the Author Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
References Kouimtsidis, C., Sharma, E., Charge, K. J., & Smith, A. (2015). Structured intervention to prepare dependent drinkers to achieve abstinence: Results from a cohort evaluation for six months postdetoxification. Journal of Substance Use, 21(3), 331–4. Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D., Miller, M. M., & Provence, S. M. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Carson City, NV: The Change Companies.
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In spite of a half century of rapid growth, specialized addiction treatment holds only probationary status as a cultural institution in the United States. The growing backlash against addiction treatment is exposing critical areas of institutional vulnerability that could and should set a needed agenda for positive systems transformation. The field must assertively address these needs if it is to prevent revocation of its status and assure its future viability and the continuity of recovery support for the individuals and families it is pledged to serve. When the first serious criticisms of Alcoholics Anonymous (AA) broke into the public press in the early 1960s, many within the AA fellowship looked to AA cofounder Bill Wilson to provide a point-by-point response to such criticisms. Instead, Wilson suggested—on the pages of the AA Grapevine in April 1963—that criticisms of AA could be best met with public silence, internal self-reflection and, where needed, concerted selfcorrection. He further suggested that AA should offer thanks to its critics in such circumstances. The treatment industry would be well-served to heed Wilson’s advice instead of responding only with defensive counterattacks on its critics. Efforts by the National Association of Addiction Treatment Providers, the American Society of Addiction Medicine, NAADAC: The Association of Addiction Professionals, the National Alliance for Recovery Residences, and the Association of Recovery Community Organizations are to be commended for their work elevating service and ethical standards within the addiction treatment and recovery support arenas. c This article appeared as a post on the Faces & Voices of Recovery RecoveryBlog on June 1, 2018. It can also be found on William White’s personal website: White, W. L. (2018). Recovery porn: A story of healers and hustlers. Retrieved from http://www.williamwhitepapers.com/ blog/2018/06/recovery-porn-a-story-of-healersand-hustlers.html
Enjoy this sneak peek of Counselor's August 2018 Issue!