here, but just wanted to get started. My name is Charles Morton and I'm the Clinical Director for Community Integrated Services. We have been working with DDA clinical and training staff to kind of come up with some more resources to help provide information to our staff about working with individuals that are struggling with the use of various substances that are affecting their life that are making it more of a challenge for them to be integrated and successful in the community. So Deanne from DDA was able to connect us to the Opioid Response Network and Steve and Emily. And Steve is going to do a training today to kind of start us off on discussing stigma of those individuals that we were talking about. So I will turn it over to Emily who will talk a little bit about the ORN and introduce Steven. So we appreciate your time and setting this up. Thank you. Hi everyone. My name is Emily Mossberg and I am a coordinator with the Opioid Response Network. And I want to acknowledge that funding for today's presentation was made possible in part by a grant from SAMHSA. The SAMHSA funded Opioid Response Network assists states, tribes, organizations, and individuals by providing free training and technical assistance on topics related to prevention, treatment and recovery for opioid and stimulant use disorders. We have consultants in all 50 states who can respond to local needs and anyone can submit a request for assistance on our website at opioidresponsenetwork.org. And the Opioid Response Network is honored to be partnering with Community Integrated Services to bring you today's training on stigma and bias. This training will be led by our amazing consultant and trainer, Steven Samra. Steven is a leader in the substance use recovery field and has many years of experience providing training and technical assistance on topics related to substance use disorder. He brings true passion to his work and has dedicated his career to assisting and advocating for marginalized disenfranchised populations. And with that, I am honored to pass it over to Steven. Emily, thank you. That's awesome. And Charles, so much gratitude just for allowing me to come in and speak to your team. Same to Deanne. I know she was instrumental in making this happen. And for all of the folks listening to me, you have a couple of really powerful leaders. Just, I know this because I engage all over the country and this was a pretty rigorous discussion about getting folks some additional information. So it made me feel really confident that the information that's coming your way has been fully vetted and in many ways, reviewed and approved by folks that are essentially making the rules for everybody. So that's a really powerful and encouraging things for me. And it's really also super important that we talk about stigma and we talk about it first. And there's reasons for that. One of the biggest ones is that stigma is a primary barrier, particularly for people with a substance use condition or disorder that keeps them from treatment. And even if they do decide on treatment, it often ends their treatment early as well. And unfortunately, unsuccessfully. There's a couple of handouts that are available. You won't need any of them for today's session. They're basically language guides. There's a little bit of a kind of a pocket guide around stigma, just so that you have it. And I think that the last thing I'll share before I talk a little bit about myself is that when we talk about reducing or deconstructing stigma and bias, it is not one and done. And I suspect you all know that anyway. Stigma is really pernicious. It evolves, it knows how to navigate. It sounds crazy, but it does. And it's really hard to stamp out. So, excuse me. And for me, because stigma has such an impact on everything else that we wanna do, I always start at the kind of at the front of the line, given that it's gonna be real hard for us to go upstream and prevent any of this at this point, we're gonna have to work to sort of dig ourselves out of it. So, with that, let me just share a little bit. I'm of course, Stephen Samra. I'm living in Nashville at the moment. My home is really the Reno Tahoe area. I've spent most of my life in the West. I don't mind being here in Nashville in the winter, that's for darn sure. And I've been doing this work. I'm a dedicated specialist, which basically means a senior associate for an organization in Boston that works with the Opioid Response Network. And I've been happy here for about the last 25 years, got a few kids and I got a couple of kids with a substance use disorder. So, the information I'm sharing is really important to me, to I think all of you, I hope, all of the folks that you serve and all of the families that you go home to. So, with that, let's talk about what we should be able to do by the time we're done. We should have no problem talking about the three types of stigma. Now we're gonna be able to explain what an intervention and courtesy stigma is. We'll be able to talk about the backbone of stigma and why that matters. And then we should be able to discuss a little bit about implicit bias and why that matters as well. We should be able to share and use person-first language to reduce stigma. I'm hoping you'll be able to list at least two strategies for reducing stigma and bias, I'm certainly gonna give them to you. And then describe any ways that we as providers might inadvertently re-traumatize a client as we're engaging with that. So, it's a lot here, but I think as we get into it, it won't feel like it's an overwhelming amount of stuff we gotta do today. So, we need to sort of understand what we mean by stigma when we kind of throw that term out. And as you can see, there isn't a single definition. The first two are good, they're okay, they're fine. But it's that third one. This one comes out of Johns Hopkins School of Medicine. And for me, it's the most concise. It means stigma means labeling, stereotyping and discrimination. And one example of this is using disparaging or judgmental terms to refer to things like mental illness, addiction, people with a substance use disorder or treatments for the diseases. Stigma is entrenched within this idea that something like an addiction, it's a moral failing and it's a personal choice. And worse, the rates of stigma are really high both in the general public and within the professions where members interact with people with behavioral health challenges. That's addiction, that may be mental health challenges, it could be trauma, homelessness, et cetera. But it is folks with behavioral health challenges. And we know that mental health conditions are also heavily stigmatized. Unfortunately, this stigma permeates all of our healthcare system. And behavioral health actually has some of the worst perpetrators of being stigmatizing. So in order to understand this, we need to understand the three different sort of primary types of stigma. There are five that I'm gonna talk about, but it's these first three that we're gonna talk about that I think are the meat of the matter here, okay? So I'll start up here with macro or structural stigma. You'll hear it both ways. Sometimes it's called institutional stigma. But what this is, this is where stigma is made, okay? This is how stigma finds its way into the public. And what it is, is it's the laws, the policies, the regulations, the protocols, the practices that actually produce and then maintain stigma at every level, local, regional, and national. And within institutions like healthcare and criminal justice. This stigma, this structural stigma, it's discrimination that's in the healthcare system. And it often will use language that leads to a lower quality of care, limited and often very fragmented access to treatment, an overuse of coercive approaches, those kinds of things. And usually the bias will target something specific like an easily stereotyped attribute, race, gender, nationality, sexual orientation, or your age. The recent transgender ban in the military, that's a really good example of a macro level stigma, okay? All right, let's talk about MESA or public stigma. And you'll probably hear it more as public stigma. This is how we're gonna think about others and it involves three different processes. We first, we label the differences, then we connect those differences to some stereotype we have, and then we do what the main purpose of stigma is. We separate and we sort us from them. We're not like them. They're doing something that we don't approve of and that's down, right? Those people, okay? When we do that, we create a marked loss in social status. And all that means we kicked them to the curb. We'll have nothing to do with them. They're not us, they're them, and they don't belong with us. You can think about this in terms of what we did to folks who smoke, right? So there is some benefit to stigma and stigma has been used for good, if you wanna call it. That seems like a kind of an odd way to get there, but I can remember smoking on an airplane. If you did that today, you probably wouldn't make your transfer and the air marshal on your flight would be sitting next to you pretty quickly. So this public stigma occurs in the closest circles of our relationships, which makes it that much worse. This is our family, the people in the community that we're connected to, our peers, and folks who provide our treatment and care. And they're usually rooted in some fear and distrust and maybe some betrayal and often a lot of disappointment. I mean, if you think about those of us who provide the healthcare services and we see people regularly returning to use and overdosing again and those kinds of things, it gets, it's really easy to feel disappointed. It really is that all your effort is not impacting a person in the way that you're kind of hoping it would. The other thing I want you to think about is that many of those attributes, they're also trauma activating for a number of people. The thing about public stigma though, is that it's difficult to maintain it when a biased person, somebody who's part of this stigmatizer group, excuse me, are able to witness really firsthand the reality of real recovery looks like. We see public stigma in the memes and the signs that really point to, eh, it's a moral failure, right? Or, you know, it's their fault and, you know, all they should do is just say no, those kinds of things. So there was an image that was circulated online. I think that made it into some print media and it wasn't too long ago, but it was a picture of a couple in a car and I think it was taken in Ohio actually, and they were clearly nodding out heavily under the influence of an opioid. I don't think they were overdosing, but they were definitely out and they had kids in the backseat of their car. And I don't care who you are, if you saw that picture, it would have a knee-jerk stigmatizing response to it. It's really hard, really hard not to get an attitude about seeing that image. That's the power of public stigma. And it's why at that structural level where the stigma's created and then pushed out, somebody took that picture, made the decision to push that into the public and they knew what those responses would be from that picture. They perpetuated and then pushed out stigma to the public and we did what the public does, saw it, responded to it, reacted and understood really well maybe that it wasn't stigmatizing, but holy cow, that's terrible. It was terrible. But to push it out the way that they did, to evoke that response, what did that do for us? It did nothing for that couple in that car or their kids. And it just blacked the eye of folks who are struggling with a serious brain disease and made them that much less likely to come in to get help. If this is how they're gonna be treated out here, what's gonna happen to me when I go in there? It's not hard to understand that. Public stigma is where we enact it. We create it up at the structural level, at the public level, we're giving it to folks. That's where it happens, okay? And finally, we're gonna talk about micro or self or internal stigma. All those terms are used, but you'll probably see it internal or self stigma. These are the judgments and the negative opinions and the evaluations that we're gonna hold about ourselves as we hear these judgments. And they will and do affect the way that we feel and the way that we act. This is the stigma that keeps people from seeking services and it keeps them from staying in services long enough to obtain a benefit from them. It also causes a terrible loss of hope and self-esteem and your confidence, and it creates a really vicious circle. And I believe we're gonna come up, I'll talk a little bit more about that, using substances to cope with the shame and the guilt that comes with all that stigma. So we know that, and I'll get to this, but we know that stigma, when it is, especially when it is applied to somebody who is using substances, can not only reinitiate substance use if they were in a period of abstinence, but it can increase the use level that the person is already doing. And there's plenty of research behind that. And in fact, I'll show you a little bit as soon as we get through a couple more of these slides. So why do we even bother? What's the deal? What do we get when we use stigma? What does it bring to our table? Well, it provides excuses for us to distance ourselves and ignore people that we don't wanna associate with because they're not like us, right? They're them, they're not us. They're a way for people to hurt others and brand them of being unworthy of love and patience and even opportunities. We don't come out like, yep, we're out to hurt you, but at the end of the day, we have hurt, we've harmed them. There are also ways in which we can express disapproval of the behavior of other people, and we can discourage that behavior by that separation, right? You wanna be with us over here. Well, then you've got to change your behavior because until that happens, you're them, you're not us, you're them. So we know that stigma allows one group of people to feel superior to another group, I'm better than they are. It allows one group to feel safe and less vulnerable because, well, that can't happen to me, I'm not like them. It allows people to discredit other people while promoting their own personal and social agendas, their goals, maybe their objectives. And it also allows a group to control another group, and it does it by diminishing the wholeness of that person and people down to some stereotype, right? So here's what I mean by that. If I say the word addict, what comes to your mind? I mean, we all have an image of addict in our mind. If I say a mentally ill person, what comes to mind? And if I said a person with a substance use condition, how does that impact your mind? Clearly addict, we have good condition stigma there and you know that we can go right to that. So the point I'm making is that it's real easy in how we phrase things to smash a person down to nothing. And that's really how they feel at the end of that sort of interaction. Worthless, hopeless, nothing matters and clearly I don't have a place in this world. It sounds terrible and it sounds almost at times unbelievable that other people could have that kind of an influence, but they do. They do all the time. And if you're wondering whether or not stigma works the way it's intended, I suspect you're not because I think you all know. But again, this was a study by Johns Hopkins. I'm kind of fond of those folks. Only 22% of people surveyed were willing to work closely with somebody who was suffering from a substance use condition and only six in 10 were willing to work closely with somebody who had a mental health condition. So we've made a little progress on the mental health side but boy, do we have a long way to go really for both sides yet. So we all know that prejudice and bias and blame and discrimination and stigma is a big part of our society. Prejudice and bias and blame and discrimination and stigma towards folks who use drugs or who deal with serious mental health, it's been rampant. It's been encouraged. It's even been codified in the laws and regulations to discriminate against those folks. And the historical span of the failed war that it's not on drugs, it's on the people who use those drugs, it continues to this day. So when we're marginalizing and we isolate and we shame and we exclude people who have an addiction challenge or substance use challenge, a mental health challenge or all of the above, we impact that person's ability to find and keep a job, get real affordable housing, live a satisfying and productive life in their community regardless of what that looks like for them, right? And if there's something like a criminal record, especially of either drug convictions or some kind of violence, yeah, that person has more stigma than Carter's got pills and it's intersectional stigma too. We'll talk a little bit about that. When I say that, it's just multiple stigmas. You may have been incarcerated. You may have had a substance use disorder. You may be a black woman. There's all kinds of things here that you've been stigmatized around and they just layer themselves, right? So when you're talking about stigma, you're not just talking about the three types I shared, you're talking about everything from historical trauma to the environment that you find people in and so on and so forth, right? There is a lot of ways that people are stigmatized and there's a lot of ways that those stigmas all kind of cross and then exacerbate each other. There's two other things I wanna share that I didn't on that other slide, on the main slide. And one of them is intervention stigma. And all that means is that we are stigmatizing the actual intervention, the treatment. This is not a condition stigma. This is an intervention stigma. And if you need an example, you can think about in the 80s, how we came at HIV and even today, how many of us see medications to treat an opioid use disorder, right? Those are intervention stigmas and they are really strong stigmas. As a matter of fact, I had a conversation at a prevention conference, a CADCA conference a couple of years ago. And I was at a table with a number of physicians who prescribed buprenorphine and methadone. And they said that they don't even talk about it to their peers in the medical profession because they are looked at as why would you ever take your education and your license and go into that field of medicine? Are you crazy? So if the docs are stigmatizing the docs who are doing the treatment, we're in trouble. That's a problem. So that intervention stigma, it's real, it's powerful. I mean, think about how you feel right now about medication-assisted treatment and what you've heard about it. And you should be able to pretty quickly identify, yeah, it's got some stigma attached to it. Yep, it surely does. The other one that was on that slide, it's called courtesy stigma. And all courtesy stigma is, is that whoever the target of stigma actually is, their friends, their family members, the folks that they were acquainted with and associate kind of regularly, they all get that same kind of stigma. They all get the sort of shame and guilt and embarrassment that comes because, oh, my son, my daughter, my husband, whatever it is, has a substance use issue or whatever it may be. So if you think about that, you can pretty easily see why families don't wanna talk about it. They do not wanna air their dirty laundry to strangers. And often what ends up happening for them is they don't know where to turn. So they mind their own Rolodex. Who do I know that, you know, didn't Bob, our neighbor have this issue a few years ago with their kid? They'll go talk to him. Bob, the neighbor, say something like, well, I showed him tough love and I threw him out of the house at 18 and said, you're not allowed to come here until you're off those drugs. I ain't seen him in 10 years. And I heard he was homeless in New York. That was an actual conversation that I had with somebody. Ain't seen him for 10 years and I think he's homeless in New York. So you threw him out because you didn't like his behavior. And now he's so far beyond any help you might be able to give him. You don't even know where he's at. It doesn't sound, it's not how I would wanna parent my kids. And I have four of them. It isn't how I parented my kids. And I still have two that have substance use challenges. So it happens, but it's courtesy stigma that keeps families quiet. They don't wanna talk about it, okay? When we've internalized all this stuff as the target of that stigma, we start to believe it. And when we believe it, we lose any self-esteem we have. And there are times when it never comes back. So it's why we don't come for treatment. It's just why we won't come for treatment. And when you think about it, as you look at this cycle of stigma, right? How does it impact us? Well, it excludes people who have a mental health or a substance use challenge from all kinds of the normal life activities. You don't want that dude here. You don't want that girl here at the football game. You know what happened last time, that kind of stuff. When we internalize that prejudice and discrimination, I can't go to that football game. There's no way I'll go there. Those people, I got treated really bad last time. I can't do it. That prejudice and discrimination keeps us from speaking about it. We're not gonna talk about it. And if you look at the cycle, that public stigma I talked about, it's at the top because it got pushed out. This person was the target of it. The discrimination and prejudice and fear all bubbles up. You can feel that. It damages your self-esteem. It takes away any hope that you've got, any chance of getting beyond this. And because the people who are treating you often treat you with stigma, why would you go back to that? So now you feel like, yeah, I really am a piece of crap. I'm believing all this stuff that people are talking about me. Tally, I have a lot of shame. Man, I feel terribly guilty. I don't think I can handle this. I just don't think I'm done with this recovery crap. I ain't going back to treatment. They ain't doing nothing for me at all. You know what? I can't stand it. I need a break. I need a break. And I know what will give me that break. Take the break, right back at the top. We've used and we get to start the cycle all over again. And there are people, self included, that have been trapped in that cycle for more than a decade. For me, at least two, probably close to three decades right in that cycle of stigma. And it wasn't until I started, I was in recovery and started learning about stigma, that I realized that's me. And that at some point in that cycle, if we can break it, we have a chance. If we can't break that cycle, you won't even be able to talk to them because they're not going to come to you. So that cycle of stigma is real. And we're going to talk about the backbone of stigma now and why stigma is so hard to get out of our daily existence. We know it's pervasive and we know it's really hard to reduce and it's next to impossible to eliminate because it evolves. It'll just keep looking for the right target. And when it finds it, it'll attach itself to it and public stigma will do the rest. So, when we talk about the backbone of stigma, what they're trying to tell us is that there are reasons we're unable to get beyond our own stigmas even when we know that they're stigmatizing. So, how they came to this was that, let me give you the sort of the context here. In 1996, the University of Chicago does these general social surveys and they compared their stigma responses in the 96 study with other surveys that had been done in the previous decades in the US and this was focused on mental illness stigma. And when they did that, this is 96, that comparison showed public knowledge about mental and substance use disorders actually increased and particularly it increased around the neuro bio understanding that these were bonafide diseases. And I think I'm pronouncing bonafide, I think it's bonafides, I apologize. But there was greater public awareness of the stigma associated with them, but that public stigma still remained high. They did it again in 2006, found even greater sophistication in the public's knowledge of disorders and treatment, stigma levels were high and they didn't decrease over time. Researchers kept looking at this and what they realized was that there's this backbone of stigma that exists. And you can see the five areas that they've identified. But when you look at those, it doesn't make a lot of sense. So let me just share, let me add a little bit more to this. So lack of trust in intimate settings. Do you want cousin John, we love cousin John, but cousin John's got a really bad crack addiction. Now, do we want cousin John in the same room with grandma's pocketbook after she receives her social security check for the month? What about possible contact with a vulnerable group? Do we want cousin John in the same room as grandma or with a vulnerable child or your 14 year old daughter or granddaughter? Potential for self-harm. Who do I call when my new renter, John, lights his hair on fire at three in the morning? I had a landlord ask me that question. Being opposed to power or authority. If we tell John he's got to go, will he obey? What if he turns violent? What if he just ignores us? What do we do? And then finally, this unsure how to interact with a person with a mental illness or a substance use condition. What do I say in that? What do I do? Things even get kind of scary. That's the backbone of stigma and they're really difficult to overcome. And I'm going to show you, we're going to try, okay? So I'm going to pull this little old drug user survey up and you can feel free if you want to respond in the chat. But sometimes I like to keep this anonymous just because some of these questions are tough and some of the responses we have, they may be stigmatizing. So all I want you to do is take a look through this and when you're reading these questions, trust your gut, right? How did you respond that first, before you really were able to think about it and use your prefrontal cortex and get rational and say, yes, this is wrong. I shouldn't do this. And this is the right way to come at it. What was your gut? Because I can tell you the one that says, if a woman is pregnant, she has a responsibility to stop using drugs. I can't, how do I argue with that? And yet I have no idea what has been happening in that person's life that would drive her to continue using while she was pregnant. So I can't make the judgment call, even though I'm sick inside because I don't want her to do that, right? But it's not my decision. And so if I had to answer this, if a woman is pregnant, I'd have to say strongly agree. And I know that, I know better because I don't know anything about her history. So this is the backbone of stigma. These questions, we're grappling with them and I surely hope you guys are too, but you can already tell just looking at them, how do I answer these truthfully, all of them, right? Because some of them are gonna, I mean, if they don't trigger a bit of your own stigma, you're a miracle person. You need to come and train for me because I don't know anybody that could go through every one of them and not have some bit of stigma, kind of bubbling up through this. So that's the backbone of stigma. And I shared all of that because I want you to understand this is not a one and done folks. This is a marathon. It isn't a sprint. It takes time. It takes time just to understand, oh, that was stigmatizing. And you'll see yourself do that pretty regularly until you get a handle on it because we stigmatize all the time. I do, my wife does. It's part of our culture. It's part of who we are and it's part of what we've been trained to do, both in work and in our communities. We also know that stigma exacerbates any illness that we're dealing with. And there is a marvelous researcher, Dr. Nora Volkow. She's with the National Institute of Drug Abuse, an amazing stigma warrior and an opioid expert. She's an amazing person. And she recently was, she had a couple of blog posts that were really interesting. She said here that dismissal of things like addiction or obesity, things like eating disorders as just problems of self-control ignores the fact that for us to be able to exert that self-control, we kind of need proper function of the areas in our brains that regulate that behavior. Stigma not only inhibits help seeking, it often weakens the impact of that help when they actually access it. And we know damaged self-esteem and hope in that person creates that rationale, we talked about it, to keep things secret so we don't have to deal with that pain. And that self-doubt then negatively impacts our desire for and our commitment to treatment, recovery, we don't even, we want none of that. We don't know what that means. And clearly, if we're trusting that mainstream community, it may not be anything we really want either. Last time we asked them for help, they took our kids and threw me in jail. And that stuff happens. So when that shame, guilt, and lack of self-esteem all coalesce, yeah, that's good time for self-medication to kill that pain. And the moment that person uses that cycle we talked about earlier, it comes back. So when we think about this internal, this micro stigma, the outcomes of it, depression, decreased hope, worsening symptoms, less likely to seek help, and less likely to advocate for themselves. They basically have given up. So what's happened? They've just given up. And I can tell you in the last year of my own journey through addiction, I was waiting to die. And I just was too much of a coward to put enough dope in my spoon to make it happen. But I was relatively certain it was just a matter of time. I had overdosed three different times anyway. So yeah, it definitely exacerbates illnesses, both physical and mental health. Here's my favorite doctor of all time. Again, the reason I'm sharing this is because as people come in to the house for the services that you provide, and they're using, what we need to understand is that folks who are using can be influenced by how they've been treated in the past and stigmatized in the past. And here's what I mean. Dr. Volkow had this, she was doing some street medicine. She was out on the bricks and she found somebody and he was injecting heroin into a horribly infected leg. And she told him, you really need to go. You need to get to the ER. That means to be clean or you could lose it. He said, I'm not going. I'd rather lose my leg. I would rather die right here than to go back to that ER and be treated the way I was treated. Here's a man who has a disease, who is horribly sick, who now has a physical disease, and he would rather die than go to get the treatment that he desperately needs in order to survive, to use another day. So that's the power of stigma, that the man was willing to give up a leg, give up a life because he didn't want to be treated like that anymore. That's pretty powerful, it's pretty powerful. All right, I want to talk about bias for a second because in my mind, this is worse than stigma. And it's worse because it happens unconsciously to us and our clients, the folks that we're engaging with see it. And we don't know what's happening, but they have finely tuned BS meters, and they do. And when that happens, it creates bias in them too. All right, so let's just take a quick look at this and we'll come back on the other side. Your brain, by some accounts, receives roughly 11 million pieces of information each second, but your conscious brain is only able to process about 40. How do you handle all the rest? You handle it because you're really using two brains. Your conscious brain, which works with facts and data, has very little capacity and processes information slowly. And your unconscious brain, which is habit and intuition driven, has huge capacity and is really fast. One of your unconscious brain's best tricks is its ability to recognize patterns and use them to assign people and things to categories, allowing your unconscious brain to deal with all of the known, not dangerous issues, and leave only the few unknown or dangerous issues to your conscious brain. This allows us to recognize a pattern and act on it, rather than having to think about every interaction as if we were experiencing it for the first time. We can glance at that four-legged animal and know if it's a wolf or a cocker spaniel. That recognition allows us to make assumptions about the animal facing us, that the wolf belongs to the wild animal category and is likely to be dangerous, or that the cocker spaniel is in the domestic dog category and not likely to be dangerous. The assumptions we make about these pattern groups are likely to be based on our own experiences, on information we have gained from our culture or background or from the media we listen to or people we admire. Unfortunately, those assumptions are often wrong. When we categorize people, our brains apply two other tools. One is affinity bias, a hardwire preference to respond positively to people who look, sound, and act like ourselves. Brain imaging scans show that when people are shown images of faces that differ from their own, it activates, in milliseconds, activity in the part of the unconscious brain that alerts us to possible danger. This may reflect a survival tool left over from ancient times when danger often came from those outside our immediate group. Today, however, this means the associations and biases are likely to be unconsciously activated every time when we come across a member of a group, even if we consciously reject group stereotypes. In addition to affinity bias, our unconscious brain categorizes people into groups and then connects those groups to our learned ideas or constructs about what is good or bad. Now, we've decided whether someone is like us or not and whether they're good or not all within milliseconds of meeting them. So, what can you do to manage your unconscious biases? You've already started by just learning about unconscious bias. Now, identify your own biases and address one at a time by building inclusive habits. Remember, if you do not intentionally, deliberately and proactively include, you will unintentionally exclude. So, what I wanna say about that, I think that the takeaway from it, this stuff happens unconsciously and in milliseconds. And in that period of time, we make a decision whether or not the person is good or bad and whether or not what we're gonna do, is this person dangerous? And it impacts the quality of the care that we're gonna bring to the table, even when we recognize that we may have a bias. I certainly have one around alcohol. My family, we're very abusive and violent folks with alcohol use disorders, all of them. And it was a very difficult environment to live in. And then I did street outreach and the number one drug of choice for folks on the street is alcohol. So, how do I do that? Because I really have a bit of a toot around folks who kind of get a little too involved in their drink. So, how do you do it? Well, you recognize, you're not gonna get rid of your biases, but you recognize you have them. And you can work to suspend them. And I do. The other thing I do though, is I'll develop some sort of a treatment plan or some sort of an approach, a recovery approach. Then I'll have somebody else take a look at it. And if it gets real bad for me, I'll hand it off. Now, I know it's not possible for everybody, but I've also worked directly through those biases. And I feel like I was able to get somebody housed in their social security and those kinds of things. So, I think I was able to do it. I'm just saying that I know I have a bias there. And so, I have to be extra careful about how I engage with folks who disclose that alcohol is a drug of choice for them. So, the real world impact of implicit bias is terrible. There's a lot of this stuff out here. I'm gonna show you a video. I'm not gonna play it. It's a little long, but there's a lot of this information out there. And researchers who employed the implicit associations test, this is, you can Google project implicit. They've got a whole bunch of these IAT tests that you can take on your own. And it helps you identify, you've got some biases here. I strongly encourage you to check out a couple of them. When I did, I won't tell you what all the results were, but I will tell you I needed some time for self-reflection and impetus for change because they were pretty bad. They were. And these biases consistently and implicitly associate black with negative attitudes like bad and unpleasant, and with negative stereotypes like aggressive and lazy. So, think about that. We consistently and implicitly associate black with negative. So, if we're wondering why there's such disparity in healthcare, criminal justice, et cetera, I would say this may be one of the reasons. I'm gonna come back to this if I've got time, I wanna make sure I get this content to you. This stuff is important. And this is, I think, what's going to be probably the most important as you interact and engage with the folks that you're working with. Because words matter. And that old saying, sticks and stones will break my bones, but words will never hurt me. Words will hurt you far more than sticks and stones will. And they'll last a lot longer than the bruise from the stone. They'll last for the rest of your life. So, words matter. And why I have this up here is because there is, this was done by the Recovery Research Institute. It's a shop out of Harvard. Gentleman John Kelly runs it and the man is a preeminent researcher. And this was a little study that they did where they found this powerful evidence that exposure to certain terms at random will actually induce a cognitive bias that affects clinical judgments and quality of care. And if you look at that slide, you can see words matter when they responded. These were providers who were given the same case and the only difference at all was the label. One was labeled substance abuser and the other person with a substance use disorder. And if you think back about that little exercise, what comes to mind when I say addict versus person with a substance use disorder? This is what happens to people. Folks who have a substance use disorder treated a lot differently and a lot better than the person who's the substance abuser. When that word or those words were used in the minds of the providers, that person, that substance abuser, less likely to benefit from treatment, more likely to benefit from punishment, more likely to be socially threatening, more likely to be blamed for their substance related difficulties, less likely that their problem was the result of a disease or illness, that they were more able to control their substance use without any help. And worst of all, and you can look at the right side of this slide, those differences were large in magnitude, not, you know, kind of, they're huge, they're huge. So, you know, we know everybody should be treated with some dignity and respect. They're human beings at the end of the day. I get it. If Charles Manson comes in and, you know, he's in for therapy, I don't know that I could treat him with a lot of respect, but human dignity and respect. And as part of this effort to end the discrimination, the segregation, the things that are happening, we gotta work on the language that we're using it and we gotta do it all the time. You can't be a bystander anymore around stigma. You can't do it because words can hurt, they can limit, they can convey long lasting messages and they keep people from coming into treatment. Words matter. I shared this person first language and I used a disability language guide for it, but the principle is the same. I spend a lot of time in the addiction and the mental health person first language, but it's still the same principle. And this is a handout to you, by the way, you have this whole book and it's a short little toolkit and this is in it. But it just puts the person first, right? It doesn't describe what's wrong with the person. It tells us it's a person who has something, right? Person who's dealing with something. It elevates the personhood, not the disorder. And the language is pretty simple, not hard to learn, but it's gotta be practiced and put into action and you can do that. When I talked about how pernicious and sneaky stigma is and how it evolves, this is what I mean. SAMHSA's Office of Recovery recently promoted an important language change that helped reduce stigma and bias. And what they did was they changed from substance use disorder to substance use condition. I reached out to this guy, Sean Daniels, who's somebody I was working with to start a recovery community organization for artists in Florida. And I mentioned this to him and this is what he said. It does sound less like something you're screwed to get. And when he said that, I thought, yeah, that's why we did that. That's why, because it's not stigmatized yet. It won't be long and it will be because people will understand, oh, that's the old drug addiction stuff right there. But this is how we stay ahead of stigma. And as I said, words matter, right? Words matter. Strengths-based, trauma-informed, person-first and person-centered language improves care. It improves engagement. It improves trust. And it improves the dignity and self-respect of everybody that's doing it and involved in it. We avoid these kinds of terms, right? We don't call people addicts and that's not a schizophrenic. We use person-first language. It's a person with a mental challenge or a substance use condition, but we don't identify the person as the disease or the disorder. We normalize the use of medications for mental and substance use conditions. They're lifesaving. They're no different than insulin for diabetes or mybenicar for my high blood pressure. We wanna use terms that are like, that sound like they're medical. We use medically supervised withdrawal and return to use. They're more accurate than relapse and taper. Those words have stigma attached to them. The moment you say them, you have thrown that stigma out there and other people connect right to it. They know that, they understand that, get that well. It's person-first, strengths-based, trauma-informed language. We get beyond our bias and our stigma. We do it by acknowledging we got them. We do trainings. We attend them, we convene them. We create, train the trainers and we do this regularly because if we don't, it's really easy to forget and just move on with the busy of our day. We build and explore relationships with folks who are outside our group. How do you ever get to know whether or not what you're hearing is a big generalization or learn for yourself, engage with folks who may not look like you. Think about folks as people, not as the group. I can remember, this is gonna sound terrible, but my family used to say, well, every house that has Hispanics living in it has black velvet wallpaper. I don't know where they got that. I've never seen black velvet wallpaper anywhere in my whole life. And I've been in a whole bunch of my Latino, Latino brothers and sisters homes. I've never seen black wallpaper. And we wanna learn about and practice cultural humility, cultural proficiency and cultural competency. And let me just say, none of us are ever gonna be masters of cultural competence. It's not gonna happen and don't try, but definitely go to the point that you have interest, that you would like to know a little bit more about, you know, the culture that you're, you know, you're engaging with or that you're, you know, you're trying to learn about. We're not going to be professionally, you know, culturally competent. And when we are up against a engagement, you know, interaction where we aren't culturally proficient, we got to be able to say, this one's beyond me and I need to hand it off. That's a real hard thing. I know for, for, you know, peer specialist workers, recovery coaches, I'm not down in any of them. I'm just saying it's, it can be difficult to do that. So the other thing I will encourage you again, go to Project Implicit. It's worth spending some time there. And if you really want to know what's going on inside you, it'll tell you, it'll definitely tell you. All right, so here's our role, providers, policymakers, you know, we need to intentionally and persistently reduce stigma in our workplace. I don't care that, you know, that's got to be one of our primary sort of mission objectives. We don't have to write it into the mission, although I would love that, but it needs to be always on our mind. We need to challenge providers and communities to be aware of and act to identify and reduce stigma and bias. And we got to remove these harmful, pejorative stuff in the, the, you know, the documents and the flyers and the things that we, you know, that face the public, because we see that. And, you know, if we saw a flyer that had stigmatizing, we wouldn't come. And you would wonder, nobody ever comes for our services. That's why. And we're not going to tell you, we're just not going to show up. One of the fastest ways that you can do this in an organization, in a house, you know, in a, in a group, you, if you've got existing materials, particularly if they're electronic, you've got them in a Word document, lovely, because all you need to do is use your find and replace feature, start looking for these terms. If you've got a, you know, a person first language guide, look for the terms. If you find them, just replace it. It's that simple. And it's really fast. And words matter, right? They matter. So internal documents are important, but anything public facing is critical. So if you, you know, if, if you don't have a whole lot of time and you're interested, that's where I'd go first. Public facing, whatever you might get the clients, if there's a handbook, et cetera, that's where to start. For you, you can treat folks with evidence-based and best practices. And I think, you know, I suspect you all do that anyway. You can speak out and you should speak out against stigma, bias, and discrimination. There are no bystanders anymore. We can't, we can't do it. And we don't have to be jerks about it, but we do need to call it out. And then we need to explain why it's so stigmatizing because a lot of us won't get it. We don't understand. We just don't. And there's no shame in that. We want to keep folks hope alive. A lot of, a lot of us lose a lot of our hope. And we don't believe that we're worth the hope either, right? We want to treat people with respect and dignity. And we've talked about that already. If you can partner with peer support workers in any capacity, they bring tremendous value in quick engagements, building credibility, and then sharing that credibility with clinicians or with house managers, with the folks who need the relationship, but recognize how difficult it is to build it. This is a speed relationship, bit like speed dating kind of thing. And it works. Be proactive here, be mindful of your language, do the language audit if you can. You know, those things matter. But be proactive. Okay. I want to talk just a minute about trauma. I know it's a little weird to have trauma inserted into a stigma training, but the reason I want to talk about trauma is because when it's connected with stigma, it is highly volatile. And folks can be trauma triggered, trauma activated is the new term, because triggered is then stigmatized. So excuse me, trauma and stigma go hand in hand. And I would just tell all of you, every single person that comes into your facility in any capacity as somebody you're serving, you should just expect them to have a trauma history. You don't even need to know what that history is. They don't have to tell you. Because the treatment, the approach is going to be the same whether they have it or not. You're going to come at it in a trauma informed approach. It's what you're going to do. So if they have trauma, you're doing it right. And if they don't have trauma, you're doing it right. Trauma results from an event or a set of circumstances that an individual experiences that is outside their locus of control is a serious threat that scares them to the point that they may not make it out alive. And even if they can't consciously think that, you know, think about a three year old who is being screamed at by a drunk uncle. I was one of them. It's outside their ability to control. They can't get away from it. And it's a serious threat. That kind of trauma is what creates a brain change in a person and rewires parts of their brain that shifts their worldview. This is a deep topic that I could go all day on. I just want you to understand that the influence of trauma on our stigmatized individuals exacerbates all of that stigma and keeps shame and guilt in the forefront for them. It's hard to get past that. I know that because I have to deal with it. So what is trauma informed care? It's a whole bunch of stuff. It really is. You can see it. It's safety. It's trust. It's choice. It's empowering the folks that you're engaging and working with. It's collaborating with them rather than expert, you know, expert patient relationship. I know what's wrong with you. I know how to fix you. You really don't in this sort of situation. And what we say then is not, I know what's wrong with you or what's wrong with you. The better question is, what's happened to you and how can I best support you? That's trauma informed care. And if you see that, you know, our little flashing message here, seeing through a person centered trauma informed and healing centered lens coupled with the actions of hundreds of thousands of small words and positive actions, that's trauma informed care. It's not hard. It's not hard to dive into the spirit of trauma informed care. It is hard to implement it fully and carry it out continually. It gets easier over time. But this also isn't a marathon this or excuse me, it isn't a sprint. And you can, you know, you can kind of assume if you're trying to do a trauma informed organization, it's a two or three year effort to get there. So it takes some work to get there. But I would, I would, I would say that for every, every house, every, every one of you who is engaging with people who are, you know, service recipients, just assume they're they have trauma in their background, and understand what trauma informed care is. And I think you're gonna, in the near future, end up doing a little motivational interviewing training. I'm not positive about that. But when you do MI, a lot of MI is wrapped in trauma informed care. And the, you know, bringing motivational interviewing together with trauma informed care is what got me in recovery in 2000. And without that, I'd be dead by now. There's no question. I was not interested in treatment. I was not interested in recovery. And it was because of trauma informed care, a therapist who used it, a therapist who stepped over a boundary and disclosed his own history to me. And that man, in many ways saved my life. There's no question. And he used trauma informed care. And he used motivational interviewing to get me there took me two years. But I've been in contemplative, active use for 10. So I think that two years is not a, you know, it's not bad, better than 10. So this is why I'm in front of all of you guys. And I keep this slide until the end. I'll disclose a little bit as I go through. But if I'd have showed you this at the front and disclosed, I would have triggered bias. There's no question you you have it. And I would have triggered it. Now look at that picture. Guy in the prison, big old methadone bottle, I triggered some stigma, right? And some bias, it's you, you, there's no shame here. There's no shame that that would happen. It's what happens. It's why we need to pay attention to the impact of bias and stigma. And you know, I was one of these folks and I struggled to address a long term heroin addiction. It was a poly substance addiction, honestly. And I did that more than three years in that sort of pre contemplate or excuse me, contemplative, you know, effort to stop, I couldn't do it, I just couldn't do it. And it was my partner that said, you can have the stuff in your pocket, or you can have me but you can't have both and I need you to make a decision. And I think I made the right decision. It was one of the first ones I had made in 40 years, and I've been with her 24 years today. Well, actually, in April, 24 years, but 24 years, I have a wildly successful recovery. I've been employed for 14 years at the same company. And I have never ever held a job for more than three years previously. And I was fired from every one of them. So I am a, I feel like I, I'm adulting, it's what I'm doing. I've grown up, I'm an adult, 64 years old, I hope so. But I've done that. And I've achieved the milestones that SAMHSA's laid out for me. And, you know, I am living the satisfying and productive life in my community that SAMHSA talks about is, you know, that what we strive for in recovery. But here's what I want to leave you guys with. Every freaking day, to today, I still feel the painful and the demoralizing and the hope-killing effects of that stigma that's been heaped on me decades ago now. I still struggle to look in the mirror and even like the person looking back at me, let alone love that person. Thank God I learned about the brain changes that addiction and trauma do, because I can say today, I did all those things, but in a way, you know, it was my diseases that were, you know, had me out of control. And when I'm under control, I've got medication, and I, you know, structure in my life, I can thrive and I did. And all of us can, we all can do this. The onus is on all of us, right? To make what folks need, not what we think they need, we need to make what they need available to them. And a lot of times it isn't anything like what we think they want or need. So it's why we got to talk about it, right? And we need to be able to talk to them in a way that they'll trust us enough to say, I'm doing way too much heroin and I got to stop or it's going to kill me. That is an honest conversation that a whole bunch of us would like to say to somebody, but we're scared to death. If we've got children, you might take them, you might call the police when we leave. We don't know, that stuff has happened to us in the past, right? So I tell you, I can't, you know, I can't look at myself in the mirror. All it takes, I could go all day and do 101 great things in my day, screw one thing up, and for the next week, that's what I'm thinking about. How I screwed that up, I can't do this job, I'm an imposter. This is, I should just quit. That happens a lot, happens a lot. I can't ask for a salary increase because I know inside I'm really worthless. And I should just be grateful to have a job. I can't even go to the pharmacy to pick up my medications because the stigma in pharmacies is, it's, yeah, it's so bad that two weeks ago, I changed my pharmacy because I was struggling with one of my prescriptions, I get buprenorphine, and it got sent to another pharmacy and they were out of the medication and wouldn't get any until April. And, you know, I had reached a point where I'm done. I'm not doing this anymore. I don't get any benefit from this buprenorphine. And this hassle that I'm going through with the pharmacy is ridiculous. And I stop, and I'm tapering myself. I'm reducing my dose under medical supervision. But it was stigma, and maybe this is a stigma for good, it was the stigma of the pharmacy that made me leave. And had I not had the level of control about my own addiction challenges and my recovery and my use of, you know, medications for opioid use disorder, I probably would have gone back out. I probably would have, because I wouldn't have had the stability of, you know, of recovery. And that stability has carried me a long, long way. So many times, the impact of that stigma was the basis for my use that day. And there's a whole bunch of my brothers and sisters going through the same thing. They're coming into your houses. They're walking down the street. They're all over the place doing the same thing. And they just, like I did, try to hide from that stigma, cope with it, and then just accept at some point that what they're saying, it's true. So let me close this session with something I probably have said before, but, you know, it's important we understand this. It really isn't the drugs that are killing us. It's the stigma that stops us from the treatment before we get so far into it that we don't really have a chance anymore. You guys are all in control of how we perceive you. And at the end of our day, the most important thing to remember, really, about this whole presentation is that we don't come for treatment because of stigma and bias. And we need treatment early because of stigma and bias. And we will fight tooth and nail to get away from that stigma and bias. And if we can't come in because of stigma to get the support and the help we need, you know, you can just look out on the streets today. You see exactly what's happening. I know it's a little different than what you guys are dealing with, but it isn't that much different. And it's not a, you know, huge step to hit the slippery slope and end up where I was, you know, 20, 30 years ago. So that brings me to the end of this particular training. I'm happy to respond to questions. You know, you can put them in the chat. You can just unmute and shout them out at me. And if you don't have any, I gave you about eight, seven minutes of your day back. So thank you for letting me share. Let me throw this to Emily. Thank you, Stephen. If you want to go to the QR code slide, we do have a quick survey. As a grant-funded program, your feedback is very important to us. So please take a moment to provide some feedback. Even if you can't do it now, please take a moment later.

Stephen Samra

substance use recovery

stigma

bias

treatment outcomes

implicit bias

person-first language

strengths-based approach

trauma-informed care

addiction

recovery journey