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Recovery: The Family’s Process of Healing and Hope

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1 Recovery: The Family’s Process of Healing and Hope
CMHACY Conference Steve Hornberger, MSW May 2014 Pacific Grove, CA

2 Three Questions Generally, in my community when someone hears a family has an alcohol or drug problem they believe… Working with a family in need of alcohol or drug treatment is challenging because… I have been successful working with a family receiving drug treatment when I …

3 Why are we here today 1 in 10 Americans 1 in 5 families 1 in 7 workers
1 in 20 newborns 35% of ALL school children 1 in 8 veterans 1 in 2 homeless 1 in 4 elderly 80% of those in jail 60% of families in children and youth services

4 Unmet Prevalence In 2012, 23.1 million people aged 12 or older needed treatment for an AOD problem. Of those, only 2.5 million received any treatment.

5 The System Gaps Of the million who needed treatment but did not receive it, only 1.1 million (5%) felt they needed it (denial gap) Of that 1.1 million, 347,000 (31%) said they made an effort but were unable to get it (treatment gap) 753,000 (69%) reported making no effort (motivation gap).

6 Why are we here today In 2005, federal, state and local government spending as a result of substance abuse and addiction was a least $467.7 billion or 10.7 % of their combined $4.4 trillion budget. For each dollar of the $467.7 billion spent, 95.6 cents went to shoveling up the wreckage and only 1.9 cents on prevention and treatment, 0.4 cents on research, 1.4 cents on taxation or regulation and 0.7 cents on interdiction.

7 Impact ½ of all children (35.6 million) live in a household where a parent or other adults use tobacco, drink heavily or use illicit drugs. 13% of children under 12 live in a household where a parent or other adults use illicit drugs. 1 in 4 children under the age of 18 has a family member who abuses alcohol or has alcoholism.

8 Intergenerational Connections
Approximately 45% of all NYS clients admitted to being a “child of an alcoholic or substance abuser” A child of an AOD abuser is 3 to 4 times more likely to develop AOD problems as well as negative health, educational and employment outcomes Over 90% of all women in residential substance abuse treatment report history of child abuse and/or neglect

9 Some CA BH Facts 1 Beliefs:
About 3 in 5 (58.9%) 12- to 17-year-olds in California in perceived no great risk from drinking five or more drinks once or twice a week. About 7 in 9 (77.9%) 12- to 17-year-olds in California in perceived no great risk from smoking marijuana once a month About 3 in 10 (31.9%) 12- to 17-year-olds in California in perceived no great risk from smoking one or more packs of cigarettes a day

10 Some CA BH Facts 2 Usage: Among 12- to 17-year-olds in California, the mean age of first marijuana use was 13.8 years, and the mean age of first cigarette use was 13.2 years.   about 195,000 youths (6.2% of all youths) per year in * reported using cigarettes within the prior month   about 353,000 youths (11.2% of all youths) per year in * reported using illicit drugs within the prior month  

11 Some CA BH Facts 3 Treatment:
among persons aged 12 or older with illicit drug dependence or abuse, about 117,000 persons (12.4%) per year in received treatment for their illicit drug use within the year among persons aged 12 or older with alcohol dependence or abuse, about 212,000 persons (9.1%) per year in received treatment for their alcohol use within the year about 947,000 persons aged 12 or older (3.1% of all persons in this age group) per year in * were dependent on or abused illicit drugs within the year  

12 Some CA BH Facts 4 Mental health:
about 259,000 youths (8.4% of all youths) per year in * had at least one MDE within the year prior to being surveyed about 83,000 youths with MDE (32.0% of all youths with MDE) per year in received treatment for their 72% of youths reported improved functioning from treatment received through the public mental health system

13 Parent who is abusing alcohol or other drugs
May be less attentive to the child while drunk or high May be unable to fulfill their role as a parent, including providing medical treatment Is more likely to be diagnosed with a co- morbid psychological problem May be less attentive to the child while drunk or high May be unable to fulfill their role as a parent, including providing medical treatment Is more likely to be diagnosed with a co morbid psychological problem

14 Parent who is abusing alcohol or other drugs
May be chronically physically ill from using drugs or alcohol Spends times procuring, using, and recovering from the alcohol or drug use instead of parenting May be engaged in illegal activities Places financial stress on the family system A Parent who is using drugs and alcohol affects the children around him or her in many ways. May be chronically physically ill from using drugs or alcohol Spends times procuring, using, and recovering from use of the chemical May be engaged in illegal activities to obtain their substances Places financial stress on the family system

15 Adverse Child Experiences Study

16 Adverse Childhood Experiences Study
Fairly common Generally clustered Have a cumulative effect on healthy development and health care status

17 HOPE

18 National Prevention Strategy

19 Priorities Tobacco Free Living
Preventing Drug Abuse and Excessive Alcohol Use Healthy Eating Active Living Mental and Emotional Well-being Reproductive and Sexual Health Injury and Violence Free Living Source: National Vital Statistics Report, CDC, 2008

20 EXTERNAL ASSETS Support Empowerment 1. Family support
2. Positive family communication 3. Other adult relationships 4. Caring neighborhood 5. Caring school climate 6. Parent involvement in schooling Empowerment 7. Community values youth 8. Youth as resources 9. Service to others 10. Safety Those in bold, CF! addresses and impacts.

21 EXTERNAL ASSETS (2) Boundaries & Expectations Constructive Use of Time
11. Family boundaries 12. School boundaries 13. Neighborhood boundaries 14. Adult role models 15. Positive peer influence 16. High expectations Constructive Use of Time 17. Creative activities 18. Youth programs 19. Religious community 20. Time at home

22 INTERNAL ASSETS Commitment to Learning Positive Values
21. Achievement motivation 22. School engagement 23. Homework 24. Bonding to school 25. Reading for pleasure Positive Values 26. Caring 27. Equality and social justice 28. Integrity 29. Honesty 30. Responsibility 31. Restraint

23 INTERNAL ASSETS (2) Social Competencies Positive Identity
32. Planning and decision making 33. Interpersonal competence 34. Cultural competence 35. Resistance skills 36. Peaceful conflict resolution Positive Identity 37. Personal power 38. Self-esteem 39. Sense of purpose 40. Positive view of personal future

24 A complex behavioral and neurobiological disorder
HISTORICAL PHYSIOLOGICAL - previous history - expectation - learning DRUGS - genetics - circadian rhythms - disease states - gender ENVIRONMENTAL - social interactions - stress - conditioned stimuli BRAIN MECHANISMS Now here’s where we start to understand the complexity of addiction, and this could be for any person. Each of us starts out with a certain set of genes and other biological factors (point to physiological) Then we are exposed to historical factors like our expectations about a drug or our social condition (point to historical) and of course the environmental factors (point to environmental). These factors affect the brain and how it functions, even before we start using alcohol or other drugs. When the drug enters the brain, it creates its own set of new conditions and adaptations for the brain. These affect behavior and environmental cues. Do you see how this all plays together? BEHAVIOR ENVIRONMENT Source: National Institute on Drug Abuse Presentation

25 Risk and Protective Factors
What is a Risk Factor? Something in a person’s life that increases the chance of a problem occurring. Risk Factors include: Availability of ATOD Family history of addiction – 4X Parental use or positive attitude toward use Other problems in the family: abuse, poverty, domestic violence Behavior/learning problems Friends who use and think it is fun or “cool” Early use

26 Risk Factors in Families
Lack of love, caring, and support Low expectations for children’s success and school performance Lack of adult supervision and severe or inconsistent discipline Lack of family rituals (e.g. family gatherings) Poor family management or communication Sexual and physical abuse

27 Risk and Protective Factors
What is a Protective Factor? Something that increases the likelihood that substance abuse can be resisted. Protective Factors include: Relationship to an adult outside the family Involvement in activities: clubs, scouts Positive self esteem Involvement in religious activities, providing hope, purpose, see beauty in the world, connection to Higher Power

28 Risk and Protective Factors
Family Protective Factors include: Strong bonds between children and parents Involvement in children’s lives Clear limits/rules with consistently enforced consequences Clear, honest respectful communication Chores for all family members Family Rituals

29 Primary Conclusions 1. People were always more important than programs. 2. Often just one person made the difference. 3. Programs that helped simulated living in a healthy family. 4. Gandhi’s Story

30 Wellness Models Are Emerging
HEALTHY l I NOT ILL l ILL NOT HEALTHY

31 A Person/Family Centered Approach
Is Strengths Based –Assumes people have abilities, capacities Role focused, not problem focused (problems interfere with performing desired roles, diagnosis is not a role) Promotes direction of the process by the person/family Adopts an individualized approach to services (not a cookie cutter set of programs) Where changes made in individual circumstances may have system wide implications that benefit others (innovations)

32 CMS Definition “...identify and access a PERSONALIZED mix of paid and non-paid services and supports that will assist him/her to achieve PERSONALLY-DEFINED OUTCOMES in the most inclusive community setting. The individual identifies planning goals to achieve these outcomes in COLLABORATION with those that the individual has identified , including medical and professional staff ….”

33 Putting the Pieces Together in a Person-Centered Plan
GOAL as Defined by Person Strengths to Draw Upon Barriers Which Interfere Short-Term Objective Behavioral Achievable Measureable Interventions/Action Steps Professional/”Billable” Services Clinical & Rehab Action Steps by Person in Recovery Roles/Actions by Natural Supporters

34 HEALING

35 What Do They Need? Children: Caregivers: Words to say what happened
Words to share experiences Understanding of family disease Time with their children for healing Making amends and forgiveness Children: Words to say what happened Understanding of family disease Time with their caregivers to heal Knowledge that it isn't their fault 35

36 Family engagement/involvement: Why is it important?
Because it works! Because it is the right thing to do Stakeholders are advocating for it System reforms are mandating it Changed the order . Most important is because it works! Don’t know where you wanted to put this slide.

37 Family Involvement Works
Treatments involving families result in Higher levels of abstinence (50 vs. 30%) Fewer drug related arrests (8 vs. 28 %) Fewer inpatient episodes (13 vs. 35%) Science Practice Perspectives. Vol. 2 No 2 August 2004 NIDA

38 Family engagement/involvement
Increased involvement equals increased ownership equals improved outcomes Services can be organized on a continuum from family friendly to family focused to family centered to family driven. Collaborative partnership of expertise, resources and experience.

39 What Do They Need? Caregivers: Children and Youth:
Words to share experiences Understanding of family disease Time with their children for healing Making amends and forgiveness Children and Youth: Words to say what happened Understanding of family disease Time with their caregivers to heal Knowledge that it isn't their fault 39

40 Talking Helps to Break the Silence
Talk with the children and family members affected by alcohol and drug addicts and explain the disease and 7 Cs I didn’t Cause it I can’t Cure it I can’t Control it I can take better Care of myself: by Communicating my feelings making healthy Choices by Celebrating myself.

41 What families must re-learn
Authority and discipline Roles and responsibilities Problem solving Communication Having fun together Showing affection

42 Parent’s Support Who in your family is already supportive of your recovery? Who in your family is in recovery too? Who keeps a healthy distance from family members who are not so stable? How has your child’s caregiver been helpful in your recovery? Who could help identify when you are headed in a negative direction? Who would see the warning signs? How can these people help you maintain your recovery? How can you ask them for help?

43 EXAMPLES FROM OTHER SYSTEMS

44 Healthcare Institute of Medicine 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” Respect patients’ values, preferences and expressed needs Coordinate and integrate care across boundaries of the system Provide the information, communication, and education that people need and want Guarantee physical comfort, emotional support, and the involvement of family and friends

45 Healthcare cont Institute for Patient and Family Centered Care lists the following core concepts of patient and family centered care: Respect and dignity Information Sharing Participation Collaboration

46 Child Welfare Child Welfare Information Gateway
family-centered and strengths-based approach partnering with families in making decisions, setting goals, and achieving desired outcomes motivating and empowering families - to recognize their own needs, strengths, and resources - to take an active role in working toward change

47 Juvenile Justice National Juvenile Justice Network
Engage in deliberate outreach to meet families Ensure family members are an integral part of advocacy Empower families to participate in advocacy through education and training Assist families with individual and system advocacy Listen to families Create a clear structure for engagement and participation Level the field by providing adequate information and support

48 RECOVERY

49 What is Recovery Perspective
Substance dependence, while often manifested by socially unacceptable behavior (for which there must be responsibility), is an illness. This illness can best be prevented when science is used to inform family and community-based efforts to protect and build resiliency. The illness is best treated by early identification and intervention or, if not halted before its acute development, by a continuity of care over a lifetime that is built on measures of individual wellness and ongoing opportunities for recovery

50 What does the science say
Millions of Americans today receive health care for mental health or substance use problems and illnesses. These conditions combined are the leading cause of disability and death among women and the second highest among men. Institute of Medicine, 2006 Treatment is effective: When given a continuum of care, relapse rates for the treatment of alcohol, opioids, and cocaine are less than those for hypertension and asthma and are equivalent to those of diabetes (all of which are also chronic illnesses). Compliance to addiction treatment is greater than compliance rates for treatment of hypertension and asthma. O’Brien and McLellan, 1996

51 What does science say 2 Treatment is Effective and Sustainable
Addictions treatment has resulted in: 67% reduction in weekly cocaine use, 65% reduction in weekly heroin use, 52% decrease in heavy alcohol use, 61% reduction in illegal activity, and 46% decrease in suicidal ideation one year post treatment. These outcomes are generally stable for the same clients five years post treatment.

52 Continuing Care is Cost Effective
A recent study of a lifetime simulation model (multiple episodes of treatment over a lifetime) shows that for every $1 spent on treatment (chronic care provided in a continuum of care) society accrues $37.72 in benefits. Zarkin et al., 2005

53 What does the recovery research say
Recovery Supports: Increase entry and involvement in treatment – Moos & Moos, 2005 Can be the basis for self and peer care shown to be effective in addressing any illness requiring continuing care – Flaherty, 2006 Are often low-cost or free (such as peer-support groups, recovery mentors, recovery check-ups, et al.) – McKay, 2005 Reduce chronicity (reoccurrence/relapse) and diminish stigma – Moos & Moos, 2005

54 Addiction and Chronic Care
Compliance Relapse Rate Addiction/Chronic Illness Rate (%) (%) Alcohol Opioid Cocaine Nicotine Insulin Dependent Diabetes Medication < Diet and Foot Care < Hypertension Medication < Diet < Asthma Medication <

55 WHAT IS YOUR DEFINITION OF RECOVERY?

56 Recovery definitions Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. (CSAT 2005 National Recovery Summit) Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. (Betty Ford Institute, 2007) My definition of recovery is life. Cause I didn’t have no life before I got into recovery. (Pathways study participant H.W. 42 years old African-American male)

57 SAMHSA’s new working definition
A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way; Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; Community: relationships and social networks that provide support, friendship, love, and hope.

58 Recovery oriented systems of care 2
Recovery-Oriented Systems of Care shifts the question from How do we get the client into treatment? to How do we support the process of recovery within the person’s life and environment?

59 Recovery and Resilience Oriented System of Care

60 CLOSING THOUGHTS

61 The Vision A community where all members of a family affected by alcohol and other drugs know there are knowledgeable and caring others who: understand what they are experiencing, care about them and are available, can help them find emotional and physical safety, can support their healing, health and wellness.

62 Opportunities and Challenges of a Lifelong Health System
Goal of system to optimize health outcomes and lower costs over much longer time horizons Payers, including Medicare and Medicaid, increasingly responsible for care for longer periods of time Health trajectories modifiable and compounded over time Importance of early years of life Source: Halfon N, Conway PH. The Opportunities and Challenges of a Lifelong Health System. NEJM 2013 Apr 25; 368, 17:

63 Quality Care as Driver of Change
The next generation of measures will: Define quality as improving the life of a person; Place functional outcomes on par with clinical outcomes; Create measurement processes that track outcomes over time since functional needs and personal goals change Bruce Chernof, MD, Pres and CEO The SCAN Foundation March 2014

64 What you can do personally
Take good care of yourself, family, friends and colleagues Learn about addiction and recovery, advocate for system collaboration and become a change agent Define and monitor outcomes at four levels, the status quo is not good enough Be bold, imagine a community where people live better lives, where children are safe, healthy, happy and educated, where people achieve their aspirations Provide hope

65 What we can do together Raise awareness, Find allies,
Take action to end: Silence Stigma Disparities Promote the many roads to recovery

66 Proposed Shared Vision
A community where all are safe, healthy and well, where each has a sense of belonging, purpose and opportunities to achieve their aspirations.

67 Web Resources Al-Anon and Alateen www.al-anon.alateen.org
Faces and Voices of Recovery Federation of Families for Children’s Mental Health Join Together National Association for Children of Alcoholics (NACoA) National Center on Substance Abuse and Child Welfare (NCSACW)

68 Web Resources 2 National Center on Addiction and Substance Abuse at Columbia (CASA) National Clearinghouse for Alcohol and Drug Information (NCADI) National Institute on Alcohol Abuse and Alcoholism (NIAAA) National Institute on Drug Abuse (NIDA) Substance Abuse and Mental Health Services Administration (SAMHSA)

69 Web Resources 3 National Center on Addiction and Substance Abuse at Columbia (CASA) National Clearinghouse for Alcohol and Drug Information (NCADI) National Institute on Alcohol Abuse and Alcoholism (NIAAA) National Institute on Drug Abuse (NIDA) Substance Abuse and Mental Health Services Administration (SAMHSA)

70 Additional Resources NW ATTC Addiction Messenger series Series 16 (2004) on Recovery, Series 17 (2005) on Family Treatment, Series 29 (2008) Family Participation in Addiction Treatment SE ATTC and Florida Certification Board, Engaging Family Members Into Adolescent Drug Treatment (2008)

71 Additional Resources 2 Generational Patterns of Resistance and Recovery Among Families with Histories of Alcohol and Other Drug Problems: What We Need to Know (2008) Addiction recovery: Its definition and conceptual boundaries (2007)

72 Additional Resources 3 The Institute for Health Improvement Institute for Patient and Family Centered Care Child Welfare Information Gateway   National Juvenile Justice Network “An Advocates Guide to Meaningful Family Partnerships” I think we should trauma resources and MH resources.. We seem to be hitting JJ and Child Welfare but what about Schools? Given that we find our children in all these child serving places we should give some resources that get them connected to those agencies or fileds. …. What do you all think?

73 Additional Resources 4 PCORI Engagement Rubric
IHI High Impact Leadership  2013 Behavioral Health Barometer CA  Motivational Interviewing with Adolescents

74 Independent consultant
CONTACT INFORMATION Steve Hornberger, MSW Independent consultant


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