1. Chemical Dependency in Child Welfare Presented by: MeLinda Trujillo, DBHR Amy Martin, DBHR

2. Introductions
Trainers
MeLinda Trujillo – Treatment Manager Division of Behavioral Health and Recovery
Amy Martin – Youth Treatment Manager
Division of Behavioral Health and Recovery
Training Ground Rules and Personal Reactions
Trainers will introduce themselves and provide the participants with their professional experience.
Trainers will review the ground rules for the training session-
-Ask questions as they arise
-One of the trainers will a response when the answer to a question isn’t known
-As we review the material, questions you may have that are related to a later slide will be reserved until that segment of the training.

3. Training Agenda Introduction The Basics of Alcohol and Other Drugs
Collaborative work with other Professionals & Families
Trauma in Substance Abusing Families
GAIN SS Screening Tool

4. Introduction to Alcohol and Other Drugs A Basic Understanding
BEGIN THIS SECTION BY 1:45pm
In this component of our training, we’re going to provide you with a very basic understanding of:
The Addiction Disease Model
The connection between alcohol and drug use and child abuse and neglect
The impact of drugs on the brain
The context for treatment and recovery

5. Why Do People Use Alcohol and Other Drugs?
Biological
Psychological
Social
Cultural, and
Environmental factors
Research notes that men and women often experience different progressions from substance use to abuse and dependence.
Often times individuals will begin using substances to alter their current emotional status. Referred to as “self medicating”, there are reasons that this occurs.
It is FUN!

6. Levels of Substance Use and Risk of Child Abuse and Neglect
General categorization of substance use is as follows:
Substance use
Abuse
Dependence.
Any level of substance use by a parent can place a child in imminent harm, create present danger or create impending danger of physical abuse and/or neglect.
It is important to determine if substance use is a factor in an unsafe situation for a child. HANDOUT
Handout – “Levels of Substance Use and Related Safety Threats”
Always want to gather more information

7. Impact of Drugs on the Brain
Causes significant changes in brain chemistry
Disrupts normal communication between neurons.
Continued use can impact the ability to experience pleasure.
Engaging in a compulsive behavior, even in the face of negative consequences.
Inability to limit intake of the addictive substance
Long lasting or permanent changes to the brain
A person’s inability to self-limit their intake of drugs and/or alcohol is a hallmark of addiction.

8. Brain Scan What can you see from the picture?
- Long recovery process but you can recover
What are the implications as a social worker when your client is using?
Know they will have problems processing information
What can you do to help them manager their tasks?
Work with other service providers
Have them write it down
Stagger their due dates
Condense their schedules

9. Treatment Works
Periods of abstinence, or reduced substance use are a result of effective intervention and treatment
Treatment outcomes show a decrease in negative outcomes for addicts
Relapse is part of recovery. Increased and/or continued support and interventions assist in regaining abstinence.
Decrease in negative outcomes for addicts can be assessed by:
Looking at the number of domestic violence incidents
Understanding the increase or decrease in the number of disrupted families
Understanding and interpreting employment histories and inability to maintain long term employment
Increased public costs for law enforcement and the courts
Inability to obtain or maintain employment leads to dependence of public welfare systems at a cost to the public
Increased medical and hospital costs, and
Increased admissions to psychiatric hospitals
Research shows even if someone is mandated to go to treatment, it can be effective
Increase insurance dollars for substance use treatment WHY? Reduces costs elsewhere
Addiction treatment doesn’t cure the disease. The goal of treatment is to:
Provide patients the tools to help them manage their addiction (and medications are among those tools)
Teach them how to use those tools to achieve and maintain recovery

10. Types of Treatment Continuum of Care in Washington State
Acute detox
Sub-acute detox
Intensive Inpatient
Recovery House
Long Term
Intensive Outpatient
Outpatient
Aftercare
HANDOUT
It’s crucial to understand that depending on the person, different treatment modalities might be more or less beneficial. It may take a client numerous attempts at treatment to be successful. Variables that could impact someone’s success include modality failure, the program itself may not be a good fit for the client for some reason or another, the client may not be ready for the type of selected treatment (i.e. client may need to be in Intensive Inpatient but is only able to participate in Intensive Outpatient).
Acute detox – most expensive – hospital setting. Alcohol/benzodiazepines can have seizures and die. Heroin when having withdrawals, they wish they could die
Sub-acute detox – 3-7 days maybe longer. Not in hospital setting
Intensive Inpatient – per WAC – 20 hours per week of services plus more
Recovery House – per WAC – 5 hours per week of services + reintegration into their home environment, community, etc.
Long Term – pregnant/parenting, ITA programs, up to a year (decisions based on progress)
Intensive Outpatient – All persons in Intensive Outpatient treatment (youth and adults)  must follow ASAM criteria:  The length of treatment is determined by the patient’s progress on their individualized care plan. 
Outpatient - The length of treatment is determined by the patient’s progress on their individualized care plan. 
Aftercare – 12 step programs, Oxford Houses, recovery supports

11. Opiate Substitution Treatment
Client receives medication :
To assist in stabilizing brain chemistry
In conjunction with outpatient counseling.
Effective ONLY with opiate class drugs
Pregnant mothers generally are prescribed this modality as a way of remaining free from illegal substances and maintaining their pregnancy
Infant will likely need to detox after its birth as a result of this method of treatment
Of a number of treatment options methadone is the most commonly used modality.
Methadone treatment is the most modality most commonly encountered in child welfare. Combined with psychiatric, drug counseling; it has a high probability of being effective.
GROUP ONE – quit using after 2-3 days on medication help – then in recovery
GROUP TWO – use medication for neurochemical stability to help with behavior change
GROUP THREE – get off the medication, then they relapse and have to put them back on it.
THERE IS NO WAY TO TELL HOW THE CLIENT WILL REACT.
You give them the tools and skills along with the medication, just like someone diagnosed with hypertension.
Opioids are no longer ruling their lives – they are in recovery.
Suboxone – combination of buprenorphine and naloxone. If you take it, crush it, shoot it, then naloxone takes over- meaning you can’t get high on it
BUPRENORPHINE:
16-24 mg dose to stabilize
Pregnant women study – decreased hospital stay and symptoms with buprenorphine babies vs. methadone babies. Methadone is the preferred method of treatment for pregnant women with opioid dependence.

12. Referral Issues/Options
Treatment access
Obtaining Funding
Knowing the Resources
Jeff:
Treatment Access:
Funding issues
ADATSA (CSO then ADATSA AC, 6 months treatment over 2 yrs)
County Contracts
County Committees
Contract for services in each county
Services may vary from county to county
Multiple family members needing chemical dependency treatment.
In most case treat parent first.

13. Certified Chemical Dependency Provider Directory
A directory that includes chemical dependency service providers certified by the Division of Behavioral Health and Recovery (DBHR). Certified agencies are listed alphabetically within each county.
Address:
How to locate treatment services in county
How to locate DBHR regional administrator
How to locate County Coordinators
How to locate DBHR Staff

14. Tools for Working with Substance Abusing Individuals in the Child Welfare System
UAs are a tool to be used in monitoring levels of a substance (decreasing/increasing levels) in a person’s system
UA Best Practice will be discussed in more depth during 2 day training
Random, observed UA’s are the most accurate type of testing
UAs are a tool and can be augmented by the client.
UAs should not be the basis in deciding permanency – such as reunification
Other methods for collecting information on a person’s level of usage are hair follicle testing, oral swabs and blood tests – these tend to be less utilized due to increased cost of testing
Color system for UA’ing

15. Need for Collaboration
Expected family outcomes may differ based on perspective
CA looks at safely reunifying children with parents.
CDPs are working with the client to address addiction
CA concerns about the family need to be shared with the CDPs
It is critical the CDP and CA Social Worker understand the very different roles each have with the family.
CDP confidentiality guidelines are based on 42 CFR Part 2. CA Social Workers guidelines are based on Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Redisclosure of information received from a chemical dependency program are subject to 42 CFR Part 2. HANDOUT
Programs subject to both sets of rules (42 CFR Part 2 & HIPPA) must comply with both, unless there is a conflict between them. Generally, this will mean that substance abuse treatment programs should continue to follow the Part 2 regulations.
Educate CDP on DCFS Issues.
Help them understand the time constraints placed on you.
Consider team consultations on mutual clients.
CDPS are typically unfamiliar with the Adoption and Safe Families Act (ASFA, and the Indicators for the Progress in the Substance Abuse Recovery Process handout may be helpful to social workers.
2. Take into consideration of the needs of both the DCFS worker and the CDP.
Refer to Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues, The Center for Substance Abuse Treatment, Treatment Improvement Protocol number 36, has good information on this.
3. Confidentiality and the Protection a Client’s Privacy:
Chemical dependency confidentiality regulations have been one of the major sources of conflict and concern between treatment providers and DCFS workers. In developing a collaborative understanding it is important that DCFS workers respect the need of treatment providers to protect patient confidentiality.

16. Keep in mind that… One person can’t collaborate.

17. Child Safety
CDPs are not trained to the policies & procedures of CA in great depth.
CDP risk factors mean something very different. They can provide information related to treatment progress that can help the social worker to better understand potential risks of abuse and/or neglect of children involved.
Parents diagnosed as chemically dependent may not be as responsive to skill development training (anger management classes, parenting classes, etc.) if their recovery program has not been established.
Refer to copy of the Children’s Legal Rights Journal handout on pages of their manual.
Point out the Indicators for the Progress in the Substance Abuse Recovery Process matrix on pages of the handout.
Distribute copies of the revised matrix developed to reflect terminology more familiar in the chemical dependency treatment system in Washington State.
State that the CDP does not normally have the training to determine risk factors for children of their patients. The CDP can provide information related to the progress in treatment that may be helpful to the Social Worker to determine risk to child(ren).
Those parents diagnosed as being chemically dependent are not likely to respond to anger management, parenting, or other skill development training if they have not established a recovery from their chemical dependency. Therefore, it is important to emphasize the need for their participation in treatment.
Refer to your supervisor, when in doubt!

18. Some Progress/Contemplation/Prep Moderate Progress/Prep/Action
INDICATORS FOR PROGRESS IN THE SUBSTANCE ABUSE RECOVERY PROCESS: ZERO TO THREE MONTHS
Zero to Three Months
Poor Progress/
Precontemplation
Some Progress/Contemplation/Prep
Moderate Progress/Prep/Action
Substantial Progress/Action/
Maintenance
Chemical Dependency Treatment
Parent remains in denial of substance abuse/chemical dependency and has not completed substance abuse screen.
Reduction of initial resistance and defensiveness
Parent has completed chemical dependency assessment and entered into chemical dependency treatment
Attendance in chemical dependency treatment becomes more consistent
Regular attendance in chemical dependency treatment
Parent has recognized and accepted the negative consequences of own substance abuse
If applicable, parent has participated in collaborative service planning meeting with child welfare worker and chemical dependency treatment worker
HANDOUT

19. Trauma in Substance Abusing Families

20. Working Definition of Trauma
Trauma is the unique individual experience of an event or enduring conditions in which-
The individual’s ability to integrate his or her emotional experience is overwhelmed; or
The individual experiences a threat to life,
bodily integrity or sanity.

21. Exercise Questions What originally brought you into the field?
Which clients do you most enjoy working with? What is it about them that you enjoy?
Which clients do you least enjoy working with? What is it about them that you do not enjoy?
What was your role in your family growing up?
Do you see any relationship between your role and the clients you enjoy or don’t enjoy?
Let’s agree to confidentiality
Bullet 2 and 3 – counter-transference

22. Group Discussion What did you notice your discussions?
How was this activity for you personally?
What if any emotions came up?
Helping profession – people still trying to fulfill the role.
Mix up the group from who they are sitting with because it mimics what we expect our clients to do – share their experiences with someone that they don’t know/haven’t built that trust, yet.
What is a way we protect ourselves?? Play it safe and share the bare minimum information OR pass altogether on sharing.
What we share depends on our mood/day too. Some days it is easier to talk about than others.
Remember the uncomfortable feelings/vulnerability that you feel right now…

23. Some Consequences of Trauma
Alcohol, tobacco and other drug abuse to manage intense emotional states
Other self destructive behaviors
Either numb or over-reactive emotional states
Attention problems
Self destructive behaviors – overeating, sexual acting out, undereating, cutting, etc.

24. Over/Under Responsibility
A reframe of co-dependency as a concept - is taking responsibility for myself legal?
Does each spouse take on responsibilities that make sense to the situation?
Do the children take on parenting roles?
Children placed in this role may have difficulty accepting and recognizing help and support. They may feel they have to be strong for parent or parents.
Focus on others to avoid focus on self.
Maintain known dysfunctional family dynamics better than unknown family dynamics.
A co-dependent person may:
Have control issues;
Be focused on what others are doing or not doing;
Be focused on protecting people from themselves;
Be focused on pleasing others; or,
Sacrifice their own best interests for others.

25. Self Care for Practitioners
Often secondary trauma is experienced while working with clients.
As professionals, we are sometimes triggered on a very deep level by experiences that we had long thought were dealt with.
It’s crucial to ensure that you have ways of caring for yourself and working through these experiences.
Issues of transference and counter-transference arise with clients most often when we haven’t cared for ourselves.
Often secondary trauma is experienced while working with clients and as professionals, we are sometimes triggered on a very deep level by experiences that we had long thought were dealt with. It’s crucial to ensure that you have ways of caring for yourself and working through these experiences rather than having a moment with a client that might be unhealthy (overly identifying, crying, etc.)

26. Victimization and Connection to Substance Abuse
90% of public behavioral health clients have been exposed to trauma (Muesser et al., 2004)
Most have multiple experiences of trauma
34 to 53% report childhood sexual or physical abuse (Kessler et al., 1995)
43 – 81% report some type of victimization
Use substances as a self-care technique

27. Resiliency Factors Intelligence Determination Quality of relationships
Creativity
Caring for self
Accepting help from others
What are other strengths you’ve observed in clients that have helped them to be resilient? Flip chart responses

28. Introduction to Global Appraisal of Individual Needs – Short Screen (GAIN-SS)

29. Global Appraisal of Individual Needs – Short Screener (GAIN-SS)
A validated screening tool used with adults and youth (ages 13 years and older).
The GAIN-SS identifies a need for a chemical dependency, mental health or co-occurring assessment. The identified needed assessment would be referred to and completed by a community professional.
This tool does not identify service needs, only the need for further assessment.
HANDOUT
ASK: Have you taken a GAIN training??
Voluntary tool that the social worker fills out.
The policy guides the use of the GAIN-SS screening tool. The tool can be utilized within any program area, but generally is administered during the CPS investigative process.
(Provide definition of co-occurring) - Generally refers to a mental health and substance abuse-related disorder.
Interaction of both disorders is complex and may require several assessment appointments.
Important to remember that the presenting disorder does not preclude presence of another disorder.

30. When to administer the GAIN-SS screen:
During the first 45 days of an open CPS investigation
If a case is not going to be transferred and is a high standard referral, a GAIN-SS screen must be completed
FVS or CFWS social workers will complete a GAIN-SS screen if one has not yet been completed during the CPS investigation
CHET Screeners will administer the GAIN-SS to youth 13 years and older if one was not administered during the investigation
If a GAIN-SS was not completed within the initial investigation phase by the CPS worker, there are other opportunities to complete this with your client. When the case transfers to either CFWS or FVS, you are able to sit with the client and complete the GAIN-SS. Please remember that this is a tool that is administered by the social worker. During the administration of this tool, you will be able to use your own understanding of body language as well as the manner in which the client answers the questions.
The GAIN-SS form in FamLink is located under the “Treatment” icon which will be demonstrated for you in a later FamLink computer lab module.
In CPS-Any investigation that is a high standard and will not be transferred to any other program area, such as FVS or CFWS, must have a GAIN-SS completed.
The GAIN-SS is administered by the social worker for any adult identified as the subject on an intake, parent(s) or person(s) acting in loco parentis and living in the child’s home.
In FVS-Adults and/or youth in the development of a voluntary service plan when the family is voluntarily engaged in services. It will also be administered on cases transferring from CPS that have not yet had a completed screen.
In CFWS- (same as FVS)
In FRS- Adults and/or youth identified for intervention during Phase One contact with the family.
CHET Screeners- will administer the screen for youth 13 years and over. The CHET screener is responsible for completing the initial GAIN-SS if one has not been previously completed for the youth.

31. Results of Mental Health Component of GAIN-SS
If an adult or youth answers “YES” to the suicide question, regardless of any other answers, the social worker/CHET screener will:
Refer the client to the local crisis line, or
Notify a Designated Mental Health Professional (DMHP) to the positive suicide response on the screen

32. Mental Health and/or Substance Abuse Assessment - Referral Process
If the screen results produce two or more “YES” responses, the social worker will:
Make a referral to a community mental health provider or substance abuse professional for further assessment
If there are substance abuse indicators and mental health indicators, the social worker will make a referral to a community professional for a co-occurring disorder assessment
A referral can be made even if there are no questions with a “YES” answer on the screen
If a client is already involved in substance abuse or mental health services, a new referral is not needed.
If you make a referral – it is the client’s responsibility to follow through. Only a judge can court order treatment. Someone can refuse services but with that, comes consequences.

33.   Reflecting…
What, if anything, did you find out/discover about yourself and your work during this session?
What would you like to be sure to take with you and hold onto from this session?
What, if anything, would you like to get rid of or eliminate from your regarding your work with clients or in their behalf?
What, if anything, moved you during this session?
The purpose of this activity is to assist participants in recalling key aspects of the overall chemical dependency presentation as well as feedback on the session.

34. Thank You Questions? MeLinda Trujillo melinda.trujillo@dshs.wa.gov
Amy Martin