Yeah, no, thank you for the time. And I guess I just want to say, yeah, while folks are logging on, first of all, just we really appreciate the partnership here with, we're going to have Emily introduce Steven, but this is actually the second time they have joined us to do this training. We had a smaller group of folks that have come to do this particular topic and received really good feedback. As I mentioned in the email out to the region, my hope is that we get into a regular cadence of actually offering trainings every month on a monthly basis that relate to various rotating topics around mental health, behavioral health, substance use disorder, wellness in general. Just really a space to give folks an opportunity to hear, learn, hopefully expand your resource awareness and just tools in the really important work you're doing. So mainly wanted to just say thank you, welcome, and that little bit of a plug is that you will see more emails and introductions to trainings. The next one, in fact, will be on, it's one that we did a few months ago, also got a lot of positive feedback about that's around suicide prevention. But for this morning, I hope folks received. I sent out some great handouts that are shared with us that will be reviewed here in the meeting. If for any reason that's not the case, please message me, teams me, and I can figure out what might have happened. Joe Smith was telling me this morning I sent a reminder he might not have received that. Anyway, our guests are more important to hear this morning than I am, but I do want to welcome folks that thank you. And we hope to have plenty of rich opportunities for discussion and training moving forward throughout the year. Thanks, Deanne. So good morning, everyone. My name is Emily Mossberg, and I'm a coordinator with the Opioid Response Network. Before we get started, 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 organizations and communities by providing free training and consultation on topics related to prevention, treatment, and recovery for opioid and stimulant use disorders. To do this work, we utilize consultants who are located in all 50 states and who can respond to local needs. And anyone can submit a request for assistance on our website at opioidresponsenetwork.org. Today, the Opioid Response Network is honored to be partnering with Washington State DDA to bring you training on stigma. This training will be led by our consultant and trainer Steven Samra, who I am excited to now introduce. 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 and disenfranchised populations. And with that, I will go ahead and pass it over to Steven. One note, this is being recorded, and this session recording will be available in about a week if anyone wants to revisit it for those who are not able to attend live. All right, go ahead, Steven. Thank you all. Awesome, Emily. Thank you. And Deanne, thank you for having us here. It really is an honor. Folks, I'm Steven Samra. I am a senior associate with C4 Innovations, my parent company. I'm a senior consultant, a recovery consultant, for the Opioid Response Network. But I think most importantly, I have the lived experience of pretty much everything we're going to be talking about today. I'm a person in long-term recovery, and I'll share a little bit more about that, and really the impact that stigma has had and continues to have in my own life to my family. And once we get through this, you'll understand what I mean. So we're diving in. We've got a lot to cover. And by the time we're done, we should be able to identify and describe the three types of stigma. There's actually five, but I like to keep them separate. And we should be able to explain both courtesy and intervention stigma. And I apologize that's not on here. We should be able to talk about at least two reasons that somebody might want to stigmatize somebody else. We're going to look at the backbone of stigma and why that matters in making the stigma reduction really challenging. We're also going to talk a little bit about the impact of implicit bias and why that matters. And frankly, I honestly think that the bias piece is more insidious than stigma. And we'll talk about why shortly. We should be able to talk about the importance of person first language, and there should be a resource there. But let me just say the handouts that I know Deanne sent around, you won't need them today. But everything I'm talking about will connect to those handouts. And so the thing about stigma training is it's not a one and done. I mean, really, it's a marathon, not a sprint. And it takes time. It also takes revisiting some of the information to really get a deeper understanding of the impact of that stigma. And that's really what I'm trying to drive at. I'll help you understand what it is, what the types are. But it's really the impact for all of us, both on the target of that stigma and the people around them, that's going to matter. And then we should be able to list a few strategies to reduce both stigma and bias, both in your personal life and in your professional life. All right. So on the slide here, what you see is no single definition for stigma. There just isn't. And the first two definitions on the slides, I mean, they're OK. They convey what I think needs to be conveyed. But it's the third bullet there, the Johns Hopkins definition. And I just think this is really clear. Stigma means labeling, stereotyping, and discrimination. And one example of this is using disparaging or judgmental terms when we refer to things like mental health, addiction or substance use, people with a substance use disorder, and oddly enough, treatments for this disease. It's entrenched in this idea that something like an addiction, it's a moral failing and personal choice. And worse, rates of stigma around this are really high, both in the general public and then within these professions where folks interact with people who may have addictions, mental health challenges. And one of the worst offenders of that is health care. We also heavily stigmatized mental health conditions. And this bias and stigma, honestly, it permeates the entire health care system. And those of us in behavioral health were kind of some of the worst perpetrators. I'm not pointing the finger at anybody. I'm just saying that as we talk about bias in a little bit, it'll become clearer to you why the behavioral health and health care field has a challenge here. So before we go much further, it's really important we identify and understand the three primary types of stigma. And you may see these listed differently. You may see them broken down differently. But these are the three primary types of stigma. And this is how stigma moves from idea out into the public and towards the target. So we're going to start with macro structural and institutional stigmas. Some folks call them societal stigma, although I think that's confusing when we start talking about public stigma. You'll get that in a minute. So what macro or structural stigma is, it is when we integrate negative attitudes and behaviors about things like mental health, substance use, and this includes social, emotional, and behavioral problems. We incorporate them into the policies, practices, and cultures of organizations and social systems. This is education, health care, employment. And what is important to understand about the structural level is that what folks do as they develop these kinds of policies, program manuals, flyers for your institution, you have the opportunity as you're drafting it to either perpetuate stigma or to begin reducing and deconstructing it. And it's all built around the language that you use. And we're going to dive into that shortly too. But it's all built around the language that you're using, that you're putting into those documents, into public policy. Anything that we know is likely to end up in the public domain. So when we start shifting to public, some call this MESO. It's macro, MESO, and micro. I just think of it as public or interpersonal. And it is a community stigma. And what this does is it encompasses the attitudes and feelings expressed by many folks in the general public towards people who might be dealing with a mental health condition or a substance use disorder. And unfortunately, their family members are included in this. We're going to talk about why that is such a problem, I think, yeah, on the next slide. Finally, let me say one other thing about that public stigma. If you, there was a picture, several, I have a real hard time with time spans, but it was a while ago. And it was a picture of a couple that was overdosed in their car, and they had children in the back seat. That's public stigma. That's a powerful piece of public stigma because you can imagine what the gut reaction was by almost anybody who saw that picture. And so that stigma did exactly what it was intended to do. Stigma separates and sorts, and it sorts us from them. We're not like those folks. We're different than them. So when we are talking about that internal or that micro or self-stigma, these are the judgments and the negative opinions that come and we hold about ourselves because of that public stigma. And it has powerful influence on how we feel and how we act. When we see this piece of stigma targeting somebody, what we know is that this is the stigma that may and often does keep people from seeking services, and it causes a loss of hope, a loss of self-esteem, no confidence. And what it does is create a vicious cycle of coping with substance misuse to deal with that stigma. And we're going to talk about that as well in a few minutes. I think that's what I want to share here. I want to just mention intervention stigma since it's on the slide. What intervention stigma actually is, is instead of stigmatizing an individual, this is stigmatizing a particular intervention, like medication-assisted treatment. That's a really good example. In the 80s, in the 90s, there was in the 80s, early 90s, HIV care, horribly stigmatized. So the intervention stigma piece is targeting the actual medical approach to whatever it is that they're dealing with, whether it's the disease of addiction, serious mental health challenge, et cetera. So when we think about intervention stigma, the one thing I can share is I was at a prevention conference a few years ago, and I happened to be sitting at a table with a number of physicians who were involved in addiction medicine. And one of them at my table said, listen, we don't even raise the idea that we prescribe buprenorphine or methadone, because as soon as we do, our peers, the other physicians in their orbit look at them differently, and they get stigmatized for that. And so when you hear that, what that actually is, it's courtesy stigma. And what that means is that family members, people associated with folks who have a mental or substance use condition, they all get the same joy of the stigma that our target gets. And what happens when they do that is that they internalize those messages just like the target would. There's an increase in a sense of guilt and shame. And God, I guess I could have done better. What did I do wrong? That is why family members keep this hidden, because they also will deal with the same kinds of stigma, the same kinds of looks, the same kinds of avoidance. And remember, we're talking about separating and sorting. So here's a family now that is not like us. And so it's them. And any time we can dehumanize somebody, it's easier to stigmatize. If you think about the term illegal alien, there's nothing human about that, nothing. And so it just becomes an easier way to remove the humanity from a person and gauge and judge them by their group. Right? All right. Hey, Stephen, we have a question from DM. She asks, could you share for those who may not be aware, when is MAT used? Absolutely. Absolutely. Or medication-assisted treatment, yeah. Yeah, so medication-assisted treatment, it's also called MOUD, M-O-U-D, Medications for Opioid Use Disorder. What those medications are used for are when you have a chronic opioid disorder, an opioid addiction. And I know this sounds crazy to a lot of folks, but we treat an opioid addiction by using an opioid. And the difference between those opioids is that the basic street opioid has a half-life of about maybe four hours before folks start coming down. And it's not long after that that they begin to bump up against withdrawal symptoms. And so when that is happening, there's a lot psychologically and physiologically that's going on in their bodies. And it results because of a reduction in a particular brain chemical, dopamine. And so what we know is that if you pull all of the opioid out of somebody, not only is there a seriously bad withdrawal period for about anywhere from four to seven days, but about two weeks later, the nerves get what's called this excitability. And those nerves are actually stimulating the individual's desire to use. They're uncomfortable. It's a terrible position to be in when you are withdrawing from an opioid. It's why 90% of those who use medications for an opioid use disorder are, I'm sorry. 90% who don't use it are really likely to relapse. Or the better term, as we're talking about stigma, is return to use. And there's a reason that we don't use the term relapse. Because instantly, when I say that word, I suspect folks have a particular image that pops up. And we're going to talk a little bit about that when we start talking about why words matter. Because they do a lot. And you'll see that, OK? All right. I wanted to talk just for a minute about stigma and IDD. Because it's the same kinds of stigma. But you're so welcome. But even though we're dealing with just continuous stigma and exclusion for folks with IDD, and get this. They're family members. Gee, it sounds like courtesy stigma to me. There does appear to be a positive trend towards more strengths-based approaches for promoting acceptance and belonging for folks with IDD. That's why I'm in front of you. That's why I'm here. And there are some novel and alternative methods to anti-stigma interventions. And there is some promise in that. But we still need to do a ton of research, particularly around folks with profound IDD. And we need to do that just to understand how and to promote the belonging, acceptance, dignity, respect that every single human being deserves. We all deserve that. And the review that they did here, as they pulled this together, it highlighted something that I think gets missed a lot, but I know is beyond critically important. And that's the influence of culture on both the experience of stigma and the approaches to promote acceptance and belonging. So for us as a service provider, we really need to recognize and respond to different cultural values and practices in a culturally competent way. And it's not that you need to know the entire cultural accoutrements, but that you're culturally competent enough to engage with somebody from a different culture really, really matters. There is all kinds of ways to stick your foot in your mouth, step all over your toes, and never even realize that you've done that. So that cultural competence piece, that cultural humility where you turn the cultural mirror on yourself and you do a little bit of self-introspection, those things are really important for us. So when we think about the future, what is that going to look like? Culturally, contextually responsive. We need to adapt to meet the needs of individuals, but families as well, and communities. Now, obviously, this is all in a given context and time and place, and it's hard to just give you a concrete, this is how it's going to be. But we're not going to broad brush this culturally specific idea for everybody. And we know that the need to develop interventions that promote belonging for people with IDD, it requires a person-centered approach and it requires understanding individual needs and priorities. And it requires us just at least understanding those broader cultural values that the individual may hold. And the bummer is that this Western focus on independence and productivity and an army of one, it often will perpetuate stigma and it'll advance more exclusion for folks who have IDD. And it will be important for those of us who do anti-stigma work to think through how our community is currently functioning. And do we need to reconceptualize what our community is doing? Do we need a trauma-informed care community? I think that would be a really smart thing. I realize the lift is pretty big, but we're trying to get to a place where people are accepted and they belong and it doesn't matter what their ability is or what their contribution might be. Individuals who have IDD, their families, the communities, our providers, we can all get involved and build in these communities. That idea that it takes a village is really true and it requires kind of all hands on deck and what's called whole person care. I see a question here, how does focusing on independence and productivity perpetuate exclusion for the IDD population? So what I'm saying is that there is this understanding, at least what I grew up with, that you need to stand on your own, you go find a job, you live a man's life as a man. And that is sort of the cultural norm in the Western focus, right? It is about individualism. It is about being independent of pretty much any other control. And so when folks aren't, when we do need some support, when we are dependent on, maybe it's reasonable combinations, it could be something like that and our productivity might be a little lower. It just may, it depends on what we're talking about in terms of the disability. And where the stigma piece comes in here isn't from all of us, it's from folks who see individuals who are not like them, right? And those folks appear to be getting maybe some extra benefits, maybe some extra support and none of that may be true, right? None of it may be true, but the perception can be. And once that perception's there, we know that it just drives stigma because remember again, separate and sort. And if folks don't want another group of people there, we see this with peer support workers all the time. And it becomes stigmatizing simply because of what you're trying to do as opposed to what other people think you should be doing. I hope that made a little bit of sense. It really focusing on independence and productivity for us, awesome. For a large chunk of our population, what are you doing that for? Why do you even bother? Because there's a bias that those of us who deal with the mental health condition, you know, developmental disability of some sort, and I certainly do, aren't, you know, equal and, you know, able to stand with those normal people. It's, stigma's tough. I want to see, there was a comment that just came in. I have very close ties with people who have suffered from substance abuse disorders. And when people see these people losing that control, it's, yes, it's like they start to treat them like children, like their hands need to be held. I will say, yes, Miranda, perfect. That's exactly what I meant. That's exactly what I meant. And sorry to rush off from you, Amber, but this is really, really true, what you're saying, that, you know, their hands need to be held. Listen, here's what, you know, here's what I just sort of landed on in the last couple of days. We're headed towards September, which is recovery month for, you know, the recovery field. And, you know, it's all about celebrating recovery. And I'm totally with that. But here's the thing. I don't know that we need to celebrate recovery all the time. Maybe we keep it in September because the rest of the time, it isn't really about celebrating recovery. It's about being able to expect recovery from the folks that we're working with. And the reason I say that today is because we know today that what's happening to them as they deal with an addiction is a disease. It is absolutely a brain disorder. We can see it on MRI. We, you know, we know that this is a brain disorder that hijacks the reward system. That's what happens. So when we're thinking about how do we support folks, listen, a lot of people have had a sort of victim mentality, particularly folks who've been incarcerated, spent time in state hospitals. They just, it's like, you know, they haven't had to make decisions for a long time. Everything is kind of decided for them. And, you know, when they return, there is an expectation that folks will continue to do that. And where that shows up often is when you give somebody a referral to go and, you know, you need to go see this doctor. And, you know, instead they went to the coffee shop and hung out with, you know, their friend or something like that. You know, we see it a lot. And, excuse me, I'm looking at Christine. I guess my confusion is that IDD community is very active in advocacy for inclusion and independence. So the idea that advocacy creates exclusion. So yeah, Christine, let me share with you. It's not the advocacy that creates the exclusion. Not that at all. What it is is a separate perspective that comes from outside of our community that looks at us with stigma. They see us as different. They don't really see us as, you know, being able to, you know, step alongside them and do the same kind of work. And even though, you know, it's likely we can, many of us, but that's not the perception that folks outside our, you know, our community actually have. Now, you know, I'm speaking generally here, right? And not everybody is like that. It is the focus on getting this, you know, everybody, you know, up to speed to, you know, particular cultural ideal of, you know, America. And many of us don't fit that cultural ideal. And if we don't fit it, people who are ignorant and I say that only from the perspective that they just don't have the knowledge, they don't understand. We already know the views they hold because we've experienced them. Many of us have experienced them for a long time, like decades. So we get that. So what I'm trying to say here is never stop advocacy for inclusion and independence. And in fact, what we need to do is stand up and shout it, right? Because one of the things I do in my work is put our behavioral health challenges in the faces of people who want to stand in judgment of us. And I do it because I recovered. I've been in recovery for 24 years and I have, you know, significant mental health challenges. I have a opioid use disorder and a poly drug use disorder. And if you can't tell by now, I also have severe inattentive type ADHD. So, you know, I have all of those things that, you know, I have been stigmatized around and I've been incarcerated. So, and I've been homeless and I'm a trauma survivor. You know, there is so much that, you know, folks can stigmatize me around. Well, guess what? You can do what you need around stigma, but I've stepped over that. And the only way that we're going to get beyond this is to normalize the things that have happened to us, the things that have happened to our family and the damage that stigma and bias from our larger community has done to us and what it's done to our ability and our desire to come in for treatment, all right? I want to just check the chat here. Amber here is saying, there's nothing more discouraging for the people I care for. I am so with you, Amber. And what that does is destroy trust, right? Our trust, and it adds bias on our end, not just so much on the provider's end, but on our end. And yes, Grace, it's more about how we put the expectation of independence and productivity as defined by non-disabled neurotypical folks on the IDD community. Boom. All right, and Joe, I see Joe Smith's comment in here. Maybe we're looking at two different points in one's life. Steve is referencing a point in the life of someone in recovery. And I actually, I mean, you'll have to forgive me. I talk from a kind of a recovery standpoint more so than I probably would just common language. But it's relevant when we think about folks who are the targets of stigma, whoever those folks may be. And there's a whole lot of us who have been targeted by stigma. And it's not that stigma can't work in sometimes good ways. Look at what we did to people who smoke tobacco. Folks are, they're not smoking tobacco on an airplane anymore. And usually they're out in the field and it's cold and they're all huddled together. I feel terrible. I am a reformed ex-smoker, but I'm not a rabid one. So, excuse me, I'm gonna move on, but I wanna see, there's one last comment. Actually, another one just came. So Christine said, okay, so I think you're saying that stigma comes from the belief that independence and inclusion is a one size fits all ideal that is created by non-disabled individuals. Yes, but in a general sense, right? Not every single non-disabled individual is going to be that way. But enough of them are that the stigma continues to perpetuate. And so all of that advocacy and making our voices heard, it really matters because one of the best ways to reduce stigma is to put one of the targets in front of a population that does that stigmatizing and then let them train around stigma. That's one of the best and most effective ways to shift the paradigm. And it's again, why I'm in front of you and why I do, really I do stigma work all over the country. It's really important that there's a face that goes with it that shows that they can overcome it. All right, so how and why do we use stigma? Well, we use it to maintain distance, right? They're not like us, it's us versus them. And we do maintain distance. We hurt other people with it. We brand them as unworthy of trust and love. You're not worth anything. And for a very long time, that's exactly how both me and my sister grew up. It's a way of expressing disapproval. Smokers, right? That's what happened. Feeling superior. Smokers, I mean, I'm sorry, but I think there's some people that are better than they are, is I don't smoke. It helps you feel safe too, because in your group, if you're us, you're not them. And you have the protection of a group around you, okay? Sorry, I just saw this from Chris. And I just, I wanna look at it. I kinda wanna read it to everybody. Correct me if I'm wrong. I think stigma comes from the fact that Western focus is on handling problems by oneself. You got it, Chris. Society sometimes, you should be coming up and doing this session right here. Society sometimes expect both people with IDD and SUD to handle their problems by themselves. So the idea that someone doesn't handle it that way, I couldn't have said it better, Chris. And in fact, you did say it much better than I did. When I say pull yourself up by your bootstraps, that's exactly what I mean by that Western focus, handle your business on your own. You don't need any help, right? And if you get help, you're weak. That's pretty common. That was really, really well done, Chris. Thank you for sharing that. So we also use stigma to promote our own agenda. Whatever that may be. I always think about Mothers Against Drunk Driving. They promoted the heck of an agenda. They were wildly successful and they used a lot of stigma to make that happen. In fact, that stigma is still felt today. Sorry, I just went off of one. We also use it to control others, smokers, and we use it to express fear because they're not like us. We don't know. We don't know about whether or not they're dangerous, whether or not we can trust them. We just don't know. And if we don't know whether or not we can even trust somebody, then I would say I'd be kind of scared about that. All right, so we all know that prejudice and discrimination and bias and blame and stigma towards folks who are dealing with a mental health, an addiction challenges, whatever it may be, it's been rampant. It's been encouraged. We've even codified it into laws and regulations to discriminate against those folks. And we can just look at the historical span around the failed war. It's really not on drugs, but on the citizens who use those drugs. It is continuing to this day. And when we marginalize and we isolate and we shame, and particularly when we exclude people who have these challenges, a behavioral health challenge, we impact everything about that individual, their ability to find and keep a job, to get into some sort of affordable housing. And if they've got a criminal record, particularly of a drug conviction, it's almost impossible. How do we access quality healthcare? Not just go down to the free clinic, not that that's not quality, but it's almost emergency, right? And most folks who are in poverty, if you've got something going on with your teeth, you're not gonna get a root canal. You're gonna get a full extraction and they're likely to push dentures on you. That's how it works when we are at the mercy of what's available to us, particularly when we're in poverty. And we know that courtesy stigma makes it really challenging to be accepted by the family and friends, because they can't deal with that shame and guilt. It's not theirs, it's ours. And it puts a damper on anything healthy that we would do socially, because nobody wants us. So what does that leave us with? Well, one of the things that leaves us with is a community within the drug world, a culture that we can join, that we can get pretty proficient in pretty quickly. And that's what we're left with. It's drugs and the people who use them. Honestly, that's kind of where we land. I can't even think of another avenue, an outlet for somebody who has nothing. And we don't, when we're shunned and we're pushed out of our communities, we don't want to wander off and sit under a tree and wait to die. We adapt and we overcome. And I don't care what your functional capacity is, if you keep getting beat down, there's a point where you're gonna have to adapt and overcome, because if you don't, it's hard to continue on in your existence. And I certainly have been there and I had plenty of suicidal ideation around some of the stigma. And so what I'm just pointing out is, when you look at the cycle, the public stigma brings the pain, right? It's the discrimination, it's the prejudice, it's the fear heaped on that person's shoulder. Whether they're using substances, whether they're just re-entering from a state hospital or a jail, it doesn't matter. And when that happens, the self-esteem takes a huge hit. It devastates folks and they internalize that stuff and they begin to believe it about themselves. And when they do, that's self-stigma. They're building their own stigma. They are just reinforcing the things that they've heard about themselves. When that happens, shame and doubt, of course, because a lot of the stuff is shameful and it becomes more shameful when people stigmatize us for it. So what's the point of treatment? What's the point of doing this recovery? Nobody's gonna believe that. And I'm just gonna be dealing with how folks have treated me for a very long time, discrimination, prejudice, and fear. So what do we do? Well, we know how to take a break and we know what we need to take that break. So we use it. And we get right back up to public stigma. And then you can just repeat this over and over, particularly in the drug world and particularly with an opioid use disorder until death. If they never get treatment and they won't come in because of stigma, how can we support them? How do we help? If you can't access somebody to even offer something different, we're in serious trouble. All right. I'm sharing this drug user survey. You don't have to answer to it. If you want, feel free. You can put anything you want in the chat. But the reason I wanna share this is because, and Grace just posted some here. Grace, I gotta tell you guys, listen, I have that bad ADHD and man, it's easy for me to get distracted as you probably can tell. Grace is saying, I will not apologize for what I did to heal from the hurt that you caused me. And I always think about that with stigma because there is no right or wrong way to heal, everything is individualized. And it's hard for some people to understand that there's more than one way to do something. Grace, it's spot on. It's why we use multiple pathways into recovery. It's, you know, it's why we try to support folks who are standing up to that stigma. And Marnie says it goes to the internal locus of control and then the external locus of control. And sometimes the external can lead to the internal. You guys are spot on. I mean, that's absolutely true. So why I have this drug survey up is because as you read through those questions, they can be pretty difficult to respond to for some folks. And I always think about the one that says, if a woman is pregnant, she has a responsibility to stop using drugs. And I appreciate that, Emily. Thank you. And, you know, my gut and, you know, I admit I'm a man, but my gut goes right to, well, of course that, you know, I've had four children and, you know, my partners stopped when they realized they were pregnant. But I also recognize today that I have no idea what is going on in that person's life that would drive them to continue using while they were pregnant. And for me to stand in judgment of them, stigma. I'm not doing that. I just won't do that. I like that. Am I? Marnie, that's great. So the whole point of this drug user survey is to point out to all of you that trying to eradicate stigma, it's not easy. And it's because some of these things that we're seeing on this survey are, you know, there are reasons that folks see, you know, see people differently and they can't shift away from that very easily. All right. I'm looking at Roberta here. Supported stigmatizing certain individuals and activities by devaluing, not funding sometimes. One of the big issues of stigma is that healthcare providers, especially behavioral healthcare, often receive less money. So that's spot on. Things like Special Olympics, segregated social activities, group employment, even group living. I mean, here's, Roberta is nailing it. And what she's saying basically is that we're personally separating and sorting by using things like segregated social activities, right? And I understand why, but I think at this point today, with what we understand about behavioral health as a disease, we can't do this anymore. You know, I think about the idea and I said this, you know, earlier, or I wrote it earlier, because I've been thinking about it for most of the morning. But, you know, we're coming to that recovery month time and it's just, to me, yeah, we'll celebrate it in September, that's great, but we should expect this, right? We should just expect it. There is an expectation that we understand you have a brain disease, we understand what you need to, you know, to get through most of this in terms of treatment, and then you're gonna have to decide the pathway you wanna take and what kind of recovery support you have. If we, that's what we need to do so that there isn't shame and guilt and stigma that's connected to, you know, the things that we, you know, that we in the community wanna do, and, you know, may have a disability. I think it's a shame that, you know, people would exclude me because I've got a bipolar disorder or I've got an opioid use disorder. In fact, if you do that to me today, I'll raise holy hell in every public forum I can because you can't bystand. We have to speak out about stigma. If we don't, you already see what happens. It perpetuates it. And this is why I had you look at that last, that, you know, drug user survey, because the backbone of stigma is one of those pieces that keeps stigma high. And let me explain. So in 1996, there's a, University of Chicago performs what's called a general social survey. And they do it, I think, every 10 years. And they compared the stigma responses in the 96 study with other studies they've done in previous decades. And what they found was that the public knowledge about mental and substance use disorders increased, particularly related to neurobiological underpinnings, right? And that, yeah, these are actual diseases. So there was a greater public awareness of the stigma, but the public stigma still remained high. They did it again in 2006, an even greater sophistication in the public's knowledge, stigma levels still high, and did not decrease over time because a core of five prejudice items persisted. And they labeled that the backbone of stigma. And so what you're seeing there, it often doesn't really make a, you know, a whole lot of sense until you connect it. And in terms, and I'm gonna use a, you know, person with a substance use disorder here to talk about this, but I mean, really, you could apply it to folks who, you know, are struggling with, you know, a mental health challenge, you know, dealing with IDD. I mean, there's a whole bunch of places where you could, I mean, come out of jail, you could be homeless. And it's these kinds of things that will keep that stigma heaped upon you. So in terms of lack of trust, do you want Cousin John? We love Cousin John, but he's got a severe crack addiction. Do you want Cousin John in the same room with grandma's pocketbook after she receives her social security check? What about possible contact with a vulnerable group? Do we want Cousin John in the room with our, you know, our granddaughter or our 15-year-old daughter? I'm not saying Cousin John would do anything to either one of them, but it is putting them in contact with a potentially vulnerable group. The potential for self-harm. Do you, you know, when you see that, I'll just give you this example. I had, I moved somebody into housing, and the person was homeless, and the landlord pulled me aside and he said, who do I call when my new renter, John, lights his hair on fire at three in the morning? That was actually asked of me. And thankfully I was able to give him a decent answer, but it was just surprising. And then being opposed to power or authority. If we tell John he's got to go, will he leave? You know, will he turn violent? What's gonna happen? What if he just goes quiet and doesn't even acknowledge we've asked him to leave? And then finally, just unsure how to interact with a person who's dealing with a, you know, a mental or a substance use challenge. What do I say or do? And what if things get weird or scary on me? These are the backbones of stigma. They're really hard to overcome. And, you know, as you think back on those drug user survey questions, probably, you know, a little easier to understand why this is. All right. So I'm gonna talk a little bit about Dr. Nora Volkow. Christine, that's a good question. How do you discern stigma from a healthy boundary? And what I would say is it's going to probably be most the most power is going to be understanding the language around stigma and the language around healthy boundaries. Almost all of this has to do with language and the words that we use, the words that we write and the images that we use to convey certain things, right? You know, the image of a couple overdosing their car with children in their backseat, pretty stigmatizing. You could have used an image that, you know, just showed a car in a parking lot, you know, maybe, you know, a syringe on the ground, something, even that would have been really stigmatizing. So discerning stigma from healthy boundaries is really going to be in the language that we use to set those healthy boundaries. That's where it's gonna happen. And remember that as you develop that, you know, whatever it is that we're writing up for, you know, here are healthy boundaries and, you know, maybe they're doing a, you know, an exercise in what that looks like. Maybe we're training them around what boundaries are. But it's important that we are the ones who make sure at the structural level, right? That macro level, whatever we're drafting, whatever we're gonna do or say around these healthy boundaries is carefully worded to avoid stigma. And one of the easiest ways you can do that is a language audit. I'll talk about that in a minute. It's quick, easy, pretty simple. So the reason I have this up, and I mentioned Dr. Nora Volkow, she is a stigma warrior. I love her to death. I wasn't happily married. I'd probably chase her to the ends of the earth. She is just fantastic. And she's, you know, strikes at my own heart. And she's a global expert on behavioral health and its impact on stigma and bias, especially related to addiction, and most importantly, co-occurring mental health issues. She'll tell you that dismissal of things like addiction, obesity, things like eating disorders as simply problems of self-control really ignores the fact that for us to even be able to exert that self-control, we require the proper function of the areas in our brains that regulates that behavior. And so when you see how stigma exacerbates illnesses, well, it does because it stops people from even trying to find help. And it often will weaken the impact of the help when somebody actually does access it. We know that there's damaged self-esteem. We know that folks keep this stuff quiet. They don't want to continue in that cycle of stigma. And the self-doubt, just all it does is shut them down. There's no reason for me to do anything because I don't believe in myself and nobody else cares. And then the shame and guilt and that self-respect or lack of self-respect, we know that what is coming is likely the need for a break from having to deal with that. That is a super painful thing to continually cycle and ruminate around. And we know what'll give us the break from that. It's what got us into trouble in the first place, but it works. So when we look at those internalized stigma outcomes, again, less likely to seek help. We won't advocate for ourselves. Our symptoms get worse. Our hope goes away. And depression is a pretty common piece, as at least for me, suicidal ideation. And Jim's got a question here, given the amazing comments made here. Yeah, it is. I get a copy of the chat text, Jim. So let me check in with Emily after we finish, but I think that's doable. And you're right, there's a lot of good comments here. Yes, sorry, I responded directly to Jim, but I said, yes, we can grab that. Awesome, sorry. No, no, thanks, Stephen. You're welcome. The media doesn't do us any help either here, guys, okay? We know that this was done, I'm trying to remember how far back. This is a little bit old, as you can see from the citations on the slide. But what they found is that in 39% of stories around mental health issues, an association made between persons with mental illness and dangerousness. Treatment mentioned in a quarter of those stories, and only 16% included recovery as an outcome. And we also need to understand the evidence from the media in its influence on stigma, it's negative. And they play a really important role in stoking fear and intensifying the perceived dangers of those of us who deal with the mental health and or a substance use disorder. We often are portrayed as violent, and it promotes these associations of mental illness with dangerousness and crime. What happens anytime you have a lone white person shoot up a school or a church? It's lone wolf mental illness. It's not terrorism. Although, frankly, from my perspective, it is. It's not considered terrorism. It's considered a mental health issue for that person. And then the media often, they don't see treatment as helpful, and they have really pessimistic views of being able to manage an illness and even the possibility of recovery. Now, the reason I said that that's changing is because a whole bunch of us, self-included, we have been training journalists all over the country around language use, because it really, really matters as all of you are seeing, right? It really does. So here's my favorite person ever. And one of the things that Dr. Volkow had written, she has a blog on the National Institute of Drug Abuse, which is in itself now a stigmatizing word because it's not abuse anymore. But what happened with Dr. Volkow was she was on the street, she saw somebody who had a really badly infected leg, and he was injecting heroin into it. And Volkow said, you better get to the ER, that is serious. And he said, I'm not going to the ER because I've been treated so bad the last time I went and the time before that, and the time before that, I'd rather cut my own leg off, I'd rather die out here in the street than to have to go and be humiliated again. And she pointed out that while that's bad enough, there's another really sinister aspect. And I absolutely can attest that this is true. Beyond just impeding the provision or seeking of care, stigma may actually enhance or even reinstate things like drug use. And it plays a key part in the vicious cycle that drives folks to continue using. Yes, Jim, you're absolutely right. You're absolutely right. And I'm looking at Crystal's discussion on naltrexone. Absolutely, that's really a good point. And there's a whole bunch of neuro bio information I have around this, Crystal. I just do it in a different presentation, but I think you would really appreciate it because yeah, you're spot on. All right, so anyway, Dr. Volkow, and now let's take a minute here, and we're gonna just watch a little bit about implicit bias. And I'm conscious of time, so I wanna make sure we get through everything. See if I can get this thing to play. Sometimes it does, sometimes it doesn't. Will it go? Come on. And I tested all these before I even came in. All right, so let me just say, I'll talk about implicit bias for a second. It looks like it's trying to load it. Boy, that's... All right, nevermind, I'll be quiet. Maybe. Yeah, that's not very encouraging. I know I have an internet connection because I'm hoping you all can see me. I can see you. I'm gonna stop it because I'm not gonna waste any more time. Here's what I want you to know about implicit bias. Implicit bias happens within milliseconds, and it happens unconsciously, and it gets triggered whenever you see another person. So we tend to see individuals as representations of a particular group rather than as an individual. And we tend to favor and prefer and associate positive characteristics with the folks that our group belongs to. And we tend to associate negative characteristics to groups that we're not members of. We're not like them. Nope, we're not like them at all. These tendencies are the foundations for stereotyping, prejudice, and ultimately can result in discriminatory decisions, actions, even if what we're consciously thinking isn't at all like that. That's not at all what we were thinking. Implicit bias carries your experiences, your life experiences, and it gets reinforced by sort of repetition of seeing examples that fit that bias or that stereotype, whatever that looks like. And I'm really bummed that you couldn't watch the video because it helps us understand why when we see people outside of what we look at as a white guy, black, brown, red, our Asian brothers and sisters, those all trigger a bias because they're outside of my group. I have an affinity for people who look and sound and act like me. We all do, and there's nothing wrong with that. But the problem with bias is that it happens unconsciously. It does and can impact the quality of your care even when you're conscious that you have a bias and that you really need to pay attention because you may short the person some really important care. And here's the thing, we have it too. So when we show up at a provider's location, our bias is that, you know, you're asking us to return to you for help. The last time we showed up, you took our kids, you suspended our driver's license, you put me in jail, you forced me into withdrawal with an abstinence-only approach, and I could continue on. So a lot of us are not particularly thrilled to be put in front of a provider because we trigger our implicit bias instantly as well. So here now, we have two biased individuals coming together and it takes some work to get beyond that. And I think it's one of the reasons that we're seeing a slow but definite progression towards understanding that two sides bring bias together. And if we want to, you know, increase the number of folks receiving treatment, that, you know, we wanna increase recovery supports, we need to talk to those folks because we need to know what they need, not what we think they need. And this stigma piece and this bias piece can really interfere here. So, you know, you can't get rid of it. But one of the things that you can do is to identify what's going on inside of you. And that's a big piece of cultural humility, right? Just shine the light inside and take a look. And the reason I want us to do that is because the real world impact of implicit bias, it is sneaky and it is pervasive. And we know you're gonna, when I say that the implicit associations test, I've got a link for that coming up. But researchers who use that found that the majority of tested Americans harbor negative implicit attitudes and stereotypes towards black dark-skinned people. The majority of tested Americans. And they consistently and implicitly associate black with negative attitudes, bad, unpleasant, and negative stereotypes like being aggressive or lazy. So, that's sometimes kind of a big lift for some of my white brothers and sisters to handle. So, let's just see. And let me hope that this one plays. Look, it's got the little YouTube dot. You see this and you wonder, did he lose his keys or is he blatantly stealing that bike? In broad daylight, he hammers. And then saws on the chain. When that doesn't work, he pulls out an industrial size bolt cutter. And when he's asked, he fesses up. Have you lost the lock? No, not exactly. But he's not a real thief. Justin Kelly is an actor and our hidden cameras are rolling. What happened? Nothing, I just, I can't get through the lock. I mean, I know it's weird, but you wouldn't happen to know whose bike this is. We're getting stuck. Yeah. All right, good, thank you. It was odd that somebody had all that equipment. But you didn't do anything. No. That's true. That's the bottom line. Lots of people stop and stare. A few even question the actor. Justin has to ask, is that your bike? I guess technically no. Okay. Okay, bye. In over an hour, about a hundred people pass by. Only George and Arlene try to stop him. Some tell us they plan to call the police later. Others say they're scared. Keep moving. This woman and her friends give our thief the benefit of the doubt. When we ask why, Bisa Washington tells us first impressions matter. I remember thinking, young white men don't usually carry burglar tools. So we all make assumptions, huh? I'm thinking maybe he works for the park. We replace our white thief with this young man, Matlock. Remember, both actors dress in a similar way and are about the same age. Is that your bike? Uh, nah. Then what do you cut the chain for? Right away. Right away, somebody yelled. Wow. Within seconds, another person confronts our thief. Is that your bike? Technically it's not, but it's gonna be mine. More people converge. We only took one. Is that around the south end? When you call the police, he's like stealing somebody's bike. Are you taking that bike, is that your bike? No, it's not, sir. Oh, why are you doing that? Is this, I mean, is this any of y'all bikes? Is this your bike? It's not, it belongs, it belongs to someone. To who? Well, not to you. And sure enough, one man whips out a cell phone to call 911. Yeah, there's someone out there taking a bike here. Our actor triggers more reaction. Some people are even snapping pictures for evidence. I got you, bud. I got you. Guy's stealing a bike, he's biked over here. Once everyone moves away, we reset our cameras and within minutes, another outraged man is yelling. Are you trying to steal that bike? Excuse me, sir, but the bike's been here for days. Like, no one's gonna take it. Well, that's not your bike then. Yeah, okay. You can't just come in and take something from somebody. Excuse me, sir, I'm not- Okay, I'll just take your tools right here. Is this yours, sir? don't touch my stuff, sir. Please, sir, do not touch my stuff. Well, you're touching somebody else's stuff? Yeah, yeah, all right, but this has been here. Like, who's gonna take it? Well, that doesn't make it your property. Technically, it does. No, it doesn't technically. It's not yours to take. When we bring out our cameras, David Robb wants us to go after the thief. That kid in the red shirt- He's hacking away at a bike that's not his. And he has a right to take it and steal it. And he's come here- She may not look like- So I'm gonna stop it because I want you to know that that is, I mean, I don't know anything more powerful than what I just watched to really confirm the bias differences. And, you know, I think it's pretty clear just what happened between those two young men, that bias is super powerful. And affinity bias is also super powerful. The white kid looked like everybody in that park that was coming up to him. And the black young man didn't look at all like him. One of them, not one of us, right? Yeah, absolutely, Grace. Absolutely blatant racism. And, you know, I mean, racism is a bias. I mean, it's just, yeah. All right, so what and why I've been talking about bias and, you know, that words matter and stigma. This is a really good research piece. That was done by John Kelly out of the Recovery Research Institute. It's a Harvard, you know, Harvard program. John's a fantastic researcher. And one of the things he did recently was he gave the exact same case notes to two different sets of providers. And on one, he referred to him as a substance abuser. And the other one as having a substance use disorder. And what he found was that if you use the term substance abuser, people thought that were doing that case, that that person was 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 use, and less likely that the problem was a disease thing, right? They couldn't control it. And they were more able to control it without any help. So from one word, right? Two words, substance abuser. And the person that has the substance use disorder got none of that. And one of the easiest ways for you to just give it your own little test, close your eyes and conjure up what you see as an addict. And then close your eyes again and conjure up what you see as a person with a substance use disorder. I suspect they're gonna be pretty radically different. And worse, notice that all of these subscales here, they're large, they're really large. So we're talking about a massive amount of bias. Look at punishment, 67%. Let me tell you, the strongest heroin I've ever used, I got in Folsom Prison. So if you think that punishing us is gonna do something that stops, something like substance use or the mental health challenges many of us experience while we're in, forget it. You can see, attribution blame, 76%. It's shocking that this is our medical profession. Yes, Miranda, exactly, exactly. Or more susceptible. I remember being in an ER, I was a paramedic for years and needed to give Demerol to an Asian man who was in a car accident. And boy, everybody in the ER was like, oh, you gotta be really careful because Asians can't handle much opiates. That may be true, but I just remember thinking, why didn't you just say, hey, go lower on the dose with that generalization? It would have been just as easy for me. The point is, words really matter. And you have a handout that moves you through some of the change in how we're using the language, but know that, I love the quote from John, it's not just a matter of being nice. What we know now is the actual exposures to these terms induces the implicit bias. And it happens unconsciously, so you're not even aware that it's been triggered. Don't even know. And away you go carrying this bias and the person you're working with is likely to have a similar bias towards you. So what we want, strengths-based, trauma-informed and person-first language. And we avoid terms that are labeling, right? Schizophrenic, addict. We use person-first language, a person with a substance use disorder, an individual with a mental disorder. And today, now we change disorder to conditions. A lot of us just haven't gotten all the way through all of our work to make those changes, but it is done because of stigma. We normalize the use of medication, period, for mental and substance use disorders. I used to say when I'd go in to see my addiction psychiatrist, listen, I might be a dope fiend, but I'm not crazy. I don't need any mental health help. I wish I'd have gotten the mental health help 30, 40 years ago, because it would have changed my life. The moment I started my mental health meds, I was able to come off of buprenorphine and my entire life changed. It really changed. So we gotta normalize the use of medications for the things that we're dealing with. And we need to use terms like medically supervised withdrawal or return to use, not a relapse, not a detox. If you, again, just conjure up in your head what each one of those terms mean, and you'll know right away. All right, this is an awesome video, but I wanna make sure that I cover the rest of the stuff. And if we've got time, I'll come back to this and we'll exit out on this, okay? Marnie, that's a really good question. And here's what I would tell you about that. This is a job for you and your team. I can't explain how you're gonna want to walk through those complex modalities. But what I do know is that if you have an understanding of trauma-informed strengths-based person-first language, and all you need is a language guide to kind of get there, well, it's a little bit more than that. But if you have that, as you're thinking about how do we translate this complexity, I need your language. I need what you and your team puts together. I can't tell you, but you know. And once you have that language, the understanding of person-first and strengths-based language, and I suspect all of you do, somebody mentioned MI, motivational interviewing. You guys have got it going on. We're just talking about how best to really support and minimize the amount of stigma that we're pushing out. And it's not gonna be perfect, folks. There's no way that it's gonna be perfect. So when I said earlier, perform a language audit. All you need to do, if you've got the, most documents we keep in Word. I know we set a lot of them into PDF and imagery, but if we've got Word documents, it's use, search, and replace. That's all you need to do. Look for stigmatizing language. If you find it, remove it, put in the appropriate person-first language. It's really not hard, but you've got to do internal and external documents. Everything that somebody outside of your organization, a client, a patient, whoever it is, whatever they're gonna see, you really need to have that reviewed and stigma-proofed to the extent that's possible. All right, we can get beyond bias. And I mentioned that project implicit test. The address is at the top of this screen. You can stop in there. You can do your own. They got all kinds of bias quizzes and they're short. They're easy to do, but I will say this. If you do, you probably should give yourself about a half hour afterwards to kind of process what you just went through. Because when I took a few of them, I found things about myself that I didn't really care for. And so I started working to change those things. And that's all we can really do for each other and for ourselves. So this is the role of our providers and our policymakers. We must use person-first, strengths-based language. And we can't be a bystander when we see stigma. We're not gonna be jerks about it, but we're gonna say, hey, that's kind of stigmatizing. Let me explain why. And here's the better way to say that. And if they take that, great. And if they don't, then you can call them again. I'm telling you that's stigmatizing. And really, if you're gonna continue to use that, we prefer not to hear from you. I mean, we don't have to be jerks about it, but we need to stand in its face. Because if we don't, you are tacitly approving what's happening. We need to challenge our providers and our communities to be aware of, but then act to identify and reduce those forms of stigma. And we talked about this already. Harmful substance or pejorative mental health labels, gotta go. They gotta go. Because they're so stigmatized that just saying addict, just saying mental illness conjures up all kinds of things that all point to that's them, that's not us. And personally, what can you do? Treat it with evidence-based and best practices. Whatever you're doing, we need evidence-based and best practices. Anecdotal stuff, we all have, some of it's worked, some of it hasn't, but we know evidence-based and best practices, we've got the data behind it. We speak up, no bystanding. We've gotta keep our hope alive, because without hope, there's no point in getting better. We wanna treat everybody with, everybody. I don't care if they're affected or not, they deserve respect and dignity as a human being, period. I know that might be hard with Charlie Manson, I get it. But generally speaking, we partner with peer workers when we can, and there is great value in a peer worker supporting the recovery journey or the maintenance journey of anybody who is in treatment or working towards recovery. And then we're gonna be proactive. We're person-centered, we're strengths-based, we're trauma-informed, we understand what's going on, we recognize our biases, we know the impact of stigma, and we do our best every day to minimize that stuff. We're not gonna be perfect, ever. We need to commit, and we need to continually commit to that. I'll show you this picture, because I do wear my past on my sleeve. I'm not ashamed of this picture. It was part of what happened to me. And I think it's important that we face it, because me, I'm the guy on the right there, if you couldn't tell. But there's a million more of me's out there. There's probably 10 million more. And if I could recover from that, listen, I'm not celebrating recovery, I'm expecting it from my brothers and sisters. We can do this, and we have multiple pathways to get there, and we have a lot of support that we never had before, and we're not afraid to step into that stigma. So with that, I'm gonna send you all on your way. Before you run out at the end of this video, I'm gonna pull up a QR slide, because I need an eval, and I really want the good, the bad, and the ugly. Without the ugly, I don't know where I can improve. So I wanted to thank you guys. Let me get this video playing. And Emily, thank you. That's awesome. That's awesome, popping that baby up. Here we go. ♪♪ My name is not those people. I am a loving woman, a mother in pain, giving birth to the future, where my babies have the same chance to thrive as anyone. My name is not inadequate. I did not make my husband leave us. He chose to, and chooses not to pay child support. Truth is, though, there isn't a job base for all fathers to support their families. While society turns its head, my children pay the price. My name is not problem and case to be managed. I am a capable human being and citizen, not a client. The social service system can never replace the compassion and concern of loving grandparents, aunts, uncles, fathers, cousins, community, all the bonded people who need to be, but are not present to bring children forward to their potential. My name is not lazy, dependent, welfare mother. If the unwaged work of parenting, homemaking, and community building are factored into the gross domestic product, my work would have untold value. And I wonder why my middle-class sisters, whose husbands support them to raise their children, are glorified, and they don't get called lazy and dependent. My name is not ignorant, dumb, or uneducated. I live with an income of $621 and $169 in food stamps. Rent is $585, at least $36 a month to live on. I am such a genius at surviving that I could balance the state budget in an hour. Never mind that there is a lack of living wage jobs. Never mind that it's impossible to be the sole emotional, social, and economic support to a family. Never mind that parents are losing their children to the gangs, drugs, stealing, prostitution, social workers, kidnapping, the streets, the predator. Forget about putting money into our schools. Just build more prisons. My name is not lay down and die quietly. My love is powerful, and my urge to keep my children alive will never stop. All children need homes and people who love them. They need safety and the chance to be the people they were born to be. The wind will stop before I let my children become a statistic, before you give in to the urge to blame me, the blame that lets us go blind and annoying, and to the isolation that disconnects us. Take another look. Don't go away, for I am not the problem, but the solution, and my name is not those people. Folks, thank you all. I know we're right at time. Jim, that was really kind. Paul, thank you so much. And I'm happy to, anytime. Joe, you knew, you already knew. And Deanne, thank you so much for coming. Thank you so much, Stephen, really powerful. And shout out to Joseph Smith, yes, who also was so helpful in getting this all organized. So thanks, Emily. Thanks everybody else for joining us this morning. We look forward to seeing you at our next training. Thank you all. Thank you, Stephen.

mental health

stigma

substance use disorder

developmental disabilities

cultural competence

person-centered care

advocacy

bias

trauma-informed

implicit bias test

evidence-based practices

resilience