Substance Use Disorder Summit 2024

Mental Health Academy

Saturday, March 2nd, 2024

Session: Notes:
Integrative Harm Reduction Psychotherapy: The New ● Only 10% of individuals with SUD go to treatment
“Addiction” Treatment Paradigm ● Trauma is usually at the heart of SUDs
Presenter: Dr. Andrew Tatarsky
Andrewtatarsky.com ● There is not one way to treat trauma or SUD. There are multiple or infinite pathways
● In the US we have a 4-part harm reduction movement
○ Grass Roots- Joining with Public Health
■ Goal: Save lives and prevent illness
○ Human Rights
■ Goal: End the WAR on DRUGS
○ Housing First
■ Goal: Support everyone’s right to a roof over their head and the health
and safety benefits that come with living indoors
○ Treatment
■ Facilitate any positive change
● Public Health Harm Reduction:
○ Honest education about drugs and risky behaviors
○ Medication for opioid use (MOUD)
■ Methadone
■ Buprenorphine
■ Prescribed heroin + morphine
○ Syringe service providers
○ Narcan availability
○ Overdose prevention sites + services
○ Supervised consumption sites
○ Drug purity testing
● Don’t use alone (neverusealone.com)
● Integrative Harm Reduction Psychotherapy
○ Clarifying personal, relational, and social meanings and functions
○ Active cognitive behavioral strategies to promote positive behavioral change
○ Mindfulness facilities both
○ Within a harm reduction frame
● Realities of people with problematic substance use:
○ Most don’t want to stop
○ Most are in pre-action stages of change, not ready to take action
○ Abstinence not realistic for most “addictive” behaviors
○ Different goals for different substances or behaviors
● Stages of Change:
○ Precontemplation: Oblivious need for change
○ Contemplation: Aware, but not committed
○ Preparation: Intends to change
○ Action: Active behavior changes
○ Maintenance: New behavior becomes the norm
● A lot of treatments require an entire abstinence approach. A lot of facilities and
agencies feel that you can’t treat someone while they’re actively using. Harm reduction
meets the client where they are at.
● Problem behaviors are an attempt to meet an unmet need
● Many agencies/interventions won’t accept patients that are not willing to take an
abstinent approach to problem behaviors.
● Do you counsel people who arrive under the influence?
○ What are the harms and risks of doing so: We also need to focus on what it
means to us that the person even showed up, even being under the influence.
The notion that someone cannot get anything out of the session if they are
intoxicated, needs to be rethought.
○ We need to do a safety assessment sometimes. What does it mean they came
so intoxicated? Is that a cry to help? Is that a warning that they are showing us
they are in need of help much more than we think?
 ○ Sometimes people take drugs or drink to even get to treatment. It has to do
with their comfort involving the work they are doing.
○ Being there intoxicated or under the influence definitely limits what we can do,
but it also is important to consider what it means.
○ Engage people with curiosity, respect, and empathy. If we make them feel safe,
that can strengthen our therapeutic relationship in order to explore deeper as to
why they showed up the way they did.
● What advice would you give to family members who are receiving help?
○ CRAFT- community reinforcement and family training (Bob Meyers)
■ This is evidence-based and it is much more effective than Al-Anon.
■ A way of supporting family members in taking care of themselves.
■ There needs to be a holistic approach. Everyone’s needs need to be
considered.
● Everyone who is struggling with substance use is suffering. If treatment isn’t working,
we traditionally blame the patient.

Interrupting Intergenerational Trauma in Substance ● Individuals seeking treatment for SUDs 30%-50% meet criteria for PTSD as well.
Use Disorders ●
Presenter: Dr. Carolyn Coker Ross ● ACES- there are adverse community experiences that have been added. They are
now studying from conception all the way to death. Traumatic experiences can happen
to the mother, which impacts the fetus. There is intergenerational trauma as well that
was added.
● Race-based traumatic stress (RBTS)
● ACES are more common in BIPOC individuals and BIPOC children.
○ 61% of black children have experienced at least one traumatic event
○ 51% LatinX have experienced at least one traumatic event
● Portion of ACEs is related to health in adulthood
● Trauma is the root cause of substance use disorder
● Trauma in childhood changes the brain
● 90% of brain growth happens before children go to kindergarten
● Trauma can become a family legacy
○ I.e. Holocaust survivors
● Intergenerational Trauma:
 ○ The effects of trauma can be passed between generations.
● Historical Trauma:
○ Multi-generational as well, but experienced by a specific group. It is related to
groups that experience oppression because of their social status. I.e. slavery,
the holocaust, Japanese Internment, etc.
○ Historical trauma requires 5 factors:
■ It is deliberate and systematically inflicted on a target
■ Not a single event/continues over time
■ Collective suffering
■ Malicious intent
■ The magnitude of trauma derails the population
● Native American Boarding Schools- horrifying.
● Post-traumatic slave syndrome
○ Example of Post-Traumatic Slave Syndrome in our current generation: a white
parent is speaking with a Black parent about their child’s progress in school.
The Black parent compliments the progress of the white child and says that
they are excelling. The white parent notices that the Black child is doing better
than her white child involving test scores. The white parent says, “Wow! Your
child is doing such a great job and far surpassing my child in their progress!”
The Black parent quickly diminishes the child’s success by saying something
like, “Oh, but they misbehave at home so much! Maybe they got lucky with their
testing scores and guessed correctly.”
○ In the past, when a slave owner complimented a slave’s child, the slave would
write it off as not being true because they wanted to protect their child and have
the slave owner feel that the child is not doing well, so they don’t sell them to a
richer slave owner. This is called appropriate adaptation.
○ Being Black in America compromises immune systems
● Over 50% of Americans have at least 1 friend or family member with a substance use
disorder
● Common symptoms of intergenerational trauma:
○ Irrational intense fears
○ Lack of trust that cannot be explained -distrust of places, communities, or
situations that they never experienced.
○ Risky health behaviors
○ Anxiety and shame
○ Food hoarding/overeating
 ○ Authoritarian parenting styles
○ High emotional neediness on the part of parents
○ Living in survival mode
● How do we present the idea of suffering from intergenerational trauma for someone in
denial?
○ Always take the educational approach
● Thoughts on IGT with individuals with learning disorders? Such as ASD, ADHD
○ ADHD is a risk factor of trauma
● Trauma informed care for parents
○ Problem: we don’t have Universal Health Care. Parents have a hard time
getting help, even when they needed it.
● What do you expect the trauma of the Pandemic will be on children?
● If a child is unaware of the generational trauma their family has experienced, how do
you support the child in our work?
● How to identify generational patterns:
○ 1. Who’s choices are you making? Did you choose them, or did you inherit
them?
○ What are your goals/dreams and are they really yours?
○ What are you struggling with over and over in your life?
● Breaking Patterns:
○ Identifying parenting patterns by looking at your own childhood
○ How did your parent’s parenting styles affect you as an adult?
○ What do you want to do differently?
○ How is your vision for your children different than your parents'?

Personality Disorders in the Populations We Treat ● The diagnosis of a personality disorder already sounds bad- “to disturb the order of the
Presenter: Dr. Malcolm Horn state of being.
● She avoids the diagnosis unless she has to on paper because it sets the client up to
be “avoided” when it comes to providing support due to being too difficult to work with.
● DSM 5:
○ Rigid, extreme distorted thinking (thoughts)
○ Problematic emotional response (feelings)
○ Impulse control problems (behavior)
○ Significant interpersonal problems (behavior)
● You need to exhibit two of the four core features.
● It’s hard to have a therapeutic relationship with someone who lacks trust in
 relationships
● A personality disorder is an enduring pattern of inner experiences and behavior. We
know that these things can shift and change, otherwise we wouldn’t bother with
therapy.
● The pattern deviates markedly from cultural norms and expectation, this pattern is
pervasive and inflexible, it is stable over time, it leads to distress or impairment.
● Cluster A:
○ Odd, eccentric cluster
○ Social awkwardness and social withdrawal
○ Dominated by distorted thinking
○ Paranoid PD, Schizoid PD, Schizotypal PD
● Cluster B:
○ Dramatic, emotional, and erratic cluster
○ Share problems with impulse control and emotional regulation
● Cluster C:
○ Anxious, fearful
○ Avoidant, OCD, Dependent, etc.
● Components of diagnosis:
○ Enduring patterns of perceiving, relating to, and thinking about the environment
and oneself
○ Remains consistent over time and across different situations
○ May not seem problematic to the individual (ego-syntonic)
○ May become less evident with age
○ Other personality disorders can be dx prior to age 18 if persistent for 1 year;
ASP cannot be dx before 18
● With SUD: ASPD diagnosis is not made unless the signs of ASPD were present in
childhood; if both SUD and ASPD were present in childhood, both dx can be made if
criteria are met
○ Recognizing that some criteria may overlap (selling drugs to support habit)
● Brain:
○ Limbic system: emotional language, communication, emotional processing
○ Hippocampus: regulates aggression and impulsivity, transfers information to
memory, learns what to be afraid of
○ Corpus Callosum: processing information, producing emotions and social
connectedness, Regulating acting out bx
○ Amygdala: regulates fight-flight, impulsivity…less reactive is psychopaths
 ○ Temporal lobes are responsible for processing auditory input as well as
processing and integrating memories with the senses
● Two courses of treatment:
○ If client has insight:
■ Expand on insight
■ MET/CBT to sustain change
■ Skills building
○ If client does not have insight:
■ Work to address lack of insight through MET thinking errors
■ If no insight attained, then “treatment” becomes about harm reduction
■ Behavior management
● Questions to build trust and relationships:
○ People are trustworthy when:
○ People can show they are trustworthy by:
○ You know you can connect with someone else when:
○ People show they are worthy of being connected with by:
○ People care when:
○ You can show someone you care by:
○ People show how they feel about themselves by:
○ You show how you feel about yourself when:
○ People can be counted on when:
○ You show you can be counted on by:

Understanding the Biopsychosocial Model of Addiction ● Moral model of addiction is still prevalent
Presenter: Dr. Amanda Giordano ○ Addiction is a personal choice
○ Person with addiction is “bad” or “weak”
○ Character flaw/moral failing
■ This is a barrier to help seeking
● Risk factors for addiction:
○ Bio:
■ Genetics, hereditary, neurobiological factors, age of initiation
○ Psycho:
■ Mental health concerns, trauma history, personality traits, adverse
experiences, stress
○ Social:
■ Environment, exposure, modeling, accessibility, availability and legality
 ● Low number of dopamine receptors could indicate higher vulnerability to addition
(Wanat et al., 2009)
● At the beginning of addiction, drugs of abuse are sought for their positive
reinforcement (pleasure); as addiction progresses, drugs are sought for their negative
reinforcement (alleviate withdrawal; Koob & Volkow, 2016; Volkow et al., 2019)
● Chronic drug use→ dopamine spikes (above and beyond natural rewards; Wanat et
al., 2009) ◦ Leads to downregulation of the dopamine system; impaired dopamine
system functioning; reduced feelings of reward; compromised executive functioning
(Simpkins & Simpkins, 2013; Volkow et al., 2019; Wanat et al., 2009)

• Bidirectional relationship between SUDs and mental health concerns (SAMHSA, 2023)
● Substance use might begin after the mental illness as a means of coping
(“self-medicating”)
● Mental health may concerns emerge after the initiation of substance use (substance
use may trigger onset of mental illness)
● Genetic predisposition or environmental factors contribute to the development of both
the SUD and mental health concern simultaneously (common risk factor)
 ● Trauma affects individuals differently
● Can lead to hyperarousal (hypervigilant, high emotional reactivity, fight or flight
response) or hypoarousal (numbing, reduced emotional response, freeze response;
Ogden., 2006)

● People of color and members of less affluent communities are targeted more heavily
with alcohol and tobacco advertisements and more availability (Lee et al., 2018;
Primack et al., 2007; Rose et al., 2019) • Opportunity for advocacy

Sunday, March 3rd, 2024

Session: Notes:
Ethical Issues in Substance Use Treatment and ● Examples in Counseling SUD Clients
Strategies to Prevent Violations ○ • Abstinence vs. harm reduction
Presenter: Dr. Kevin Doyle
○ • Medications for Addiction Treatment (MAT)
○ • Psychotropic medications
○ • 12-step programs or not
○ • Residential treatment vs. outpatient
○ • Relationships in first year
● Boundaries (multiple relationships/dual relationships):
 ○ Boundary crossing
○ Boundary extensions
○ Boundary violations
Using Internal Family Systems Therapy for ● There’s problems with the disease model and there are problems with the
Overcoming Addictive Behavior Patterns choice model of addiction
Presenter: Dr. Marc Lewis ○ If addiction is a choice, it certainly isn’t a free one.
● Environmental Factors:
○ The role of childhood trauma: abuse, neglect
○ Societal factors: poverty, racism, unemployment
● Psychological Factors:
○ Delay discounting- In substance abuse, delay discounting means that
people often choose to use drugs or alcohol now, even if they know it
could cause problems later. They might ignore the long-term risks and
focus on the immediate pleasure or relief they get from using. In therapy,
they work on strategies to help individuals resist the urge for instant
gratification and make healthier choices for the future.
○ Compulsion- similar with OCD
○ Habit
■ None of these factors determine addictive behaviors
● Today’s treatment models still ask addicts to choose
○ Value of drug vs value of abstaining
● Internal Family Systems Therapy- sees the mind like a family, where different
"parts" of you have their own feelings and thoughts.
○ You learn to lead with a calm and wise center (called the “self”), aiming
for harmony inside yourself. It’s used to treat things like trauma, anxiety,
and relationship issues by helping you better understand and manage
your inner world.
● Our internal “parts,” have feelings and opinions about one another. This creates
our internal dialogue.
● In addiction, there is the internal critic vs the defiant one
● Polarization increases with development.
Addressing the Complexities of Substance Use ● Individuals who belong to groups that are socially & culturally disadvantaged
Disorders and Psychotherapy Among Offending are more likely to experience substance use problems
Populations ● Walters (1990) Lifestyle Theory characterizes offenders by their behavioral
Presenter: Dr. Karla Sapp patterns, to include: Irresponsibility, Self-Indulgent Acts, Interpersonal Intrusive,
Blatant Disregard for Societal Rules and Norms
● Multiproblem Risk Factors
○ Macro-level factors such as social disorganization at the neighborhood
level
■ Exposure to delinquent models
○ Meso-level factors such as school, family, and peer structure
■ History of physical and sexual abuse
■ Negative parent-child relationships
■ Impoverished educational/school systems and resources
■ Homelessness/foster care placement
■ Disparities in school discipline
○ Micro-level factors such as low levels of self control and a risky lifestyle
■ Impulsivity
● What factors untangle the therapeutic not?
○ Stigma and mistrust
○ Dual diagnosis complexities
○ Legal and regulatory constraints
○ Cultural barriers
○ Past trauma & adverse childhood experiences
○ Resistance & engagement
○ Socio-economic factors
○ Marginalization
○ Lack of community support
● A-B-C-D’s of Ethics:
○ A: Actions
■ Competence
■ Supervision
■ Research
■ Advocacy
 ○ B: Beliefs
■ Differentiating among professional vs personal
■ Awareness of perceived biases
○ C: Conduct
■ Social Justice Informed
■ Trauma Informed
■ Use of Technology (i.e. social media)
○ D: Discipline
■ Awareness of Power Differential
■ Fair, Firm, and Consistent
● Evidence-based interventions for addressing substance use disorders in
offending populations:
○ Cognitive behavioral related therapeutic interventions
■ CBT (Cognitive Behavior Therapy)
■ REBT (Rational Emotive Behavior Therapy)
■ I-CBT (Integrated Cognitive Behavior Therapy)
■ CT-R (Recovery Oriented Cognitive Therapy
● IDDT: Integrated Dual Diagnosis Treatment
○ Range of Services:
■ Medication Management
■ Psychotherapy
■ Case Management
■ Support for Basic Needs
○ Positive Outcomes:
■ Reduced substance use
■ Improved mental health
■ Decreased recidivism
■ Enhanced overall functioning and quality of life for individual
among the offender population
● Holistic Interventions:
○ Mindfulness-based interventions
○ Trauma-informed care
○ Wellness programs
Xylazine: Worsening the Opiate Crisis ● From 2000-2006, cocaine was the leading drug of overdose deaths
Presenter: Dr. Frederick Dombrowski ● In 2007-2013, the leading drug of overdose deaths was that of opioids.
● In 2014-2015, heroin was the leading cause of overdose deaths
● 2016-present: illicitly-manufactured fentanyl
● Xylazine is a medication mainly used for calming and numbing animals during
medical procedures. Some people misuse it as a recreational drug, which can
be very dangerous and even deadly.
● Other names for Xylazine:
○ Tranq
○ Rompun
○ Sedazine
○ AnaSed
● closely resembles clonidine, a blood pressure medication often used to relieve
opioid withdrawal symptoms
● EFFECTS OF XYLAZINE
○ Sedation
○ muscle relaxation
○ decreased perception of pain
○ slow, shallow, or ineffective breathing (respiratory depression)
○ slowed heart rate (bradycardia)
○ low blood pressure (hypotension)
● Xylazine can be swallowed, inhaled, smoked, snorted, or injected into the
muscle or vein. There is no information on vaping.
● Onset within minutes and can last 8 hours or longer depending upon the dose.
● Xylazine should be suspected If someone appears to have an opioid overdose
with small pupils, not breathing well, unresponsive but no response to naloxone
and has a very low heart rate (30-40s) and low blood pressure.
Wellness-Based Addictions Counseling ● 8 dimensions of wellness:
Presenter: Dr. Philip Clarke 1. Intellectual
2. Physical
3. Social
 4. Spiritual
5. Financial
6. Occupational
7. Environmental
8. Emotional
● Wellness-Based Addiction Counseling
● 4 elements of wellness:
1. Balance
2. Interconnectedness
3. Holism
4. Strengths
● Informal Assessment:
○ Review the dimensions of wellness and explain the four elements of
wellness.
○ Invite client to add, revise, or delete dimensions and definitions.
○ Client then rates their level of satisfaction with each wellness dimension
and overall. (Alternative option: Wellness Pie Activity (SEE example on
next slide).
○ Prompts for discussion (p. 28)
■ “In what ways has your substance use affect your wellness?”
■ “In what ways have areas of lower wellness or wellness
challenges affected your substance use?”
■ “What wellness strengths stand out to you?”
○ Client History: Relationship between changes in substance use and
changes in wellness. Explore experiences of decreased use or nonuse.
○ Strengths-Cards (https://positivepsychology.com/strength-cards/)
● Wellness Formal Assessments:
○ Five Factor Wellness Inventory (Myers & Sweeney, 2014)
○ Perceived Wellness Survey (Adams, Bezner, & Steinhardt, 1997)
○ WHO QOL Bref (WHO, 2004)
○ Mental Health Continuum Short Form (Keyes, 2002)
○ I COPPE (Prilleltensky et al., 2015)
○ Brief Inventory of Thriving/Comprehensive Inventory of Thriving (Su, Tay,
 & Diener, 2014)
○ Brief Assessment of Recovery Capital (BARC-10) (Vilsaint et al., 2017)
● Overview of Wellness Plan (Clarke & Lewis, 2023; Fullen et al., 2021)
○ Wellness Vision
○ Goal + Subgoal + Action Steps.
■ Importance, Confidence, Readiness (Miller & Rollnick, 2013).
○ List of strengths and resources based on wellness assessment and
specific ways to apply them towards goal success.
○ List of potential obstacles and solutions.
○ List of what has helped address goals
● Wellness Vision (Clarke & Lewis, 2023)
○ The dimensions of wellness most negatively affected by my substance
use are _________________.
○ When ____________ dimensions are out of balance, my substance use
becomes more concerning or stressful to me.
○ In the past, attending to ____________ dimensions of wellness has
helped me use substances in a way that is less concerning/abstain from
substances.
○ My areas of highest and lowest wellness are________________.
○ Wellness Vision: What does balance in your life/holistic wellness look
like for you and mean to you? in past and what has not been helpful.
○ Ideas for bolstering confidence (e.g. starting smaller, self-talk, reflecting
on previous progress).
● Relapse Worksheet: (Clarke & Lewis, 2023)
● General relapse questions:
○ In what wellness dimensions do you experience the most frequent
triggers?
○ In what wellness dimensions do you experience the most powerful
triggers? Think back to a recent relapse and reflect on the following:
○ In what ways were any dimensions of wellness out of balance?
○ What dimensions of wellness were most affected by this relapse?
○ If you were able to eventually stop or slow down the relapse, what
dimensions of wellness and personal strengths were most helpful in this
 process?
○ What did you learn about yourself, your wellness, and/or your substance
use from this experience?
○ What ideas do you have for increasing wellness that might help prevent
a future similar relapse? Which wellness resources and personal
strengths can help you in this process?