My name is Emily Mossberg. I am a technology transfer specialist with the Opioid Response Network. Before we start this training, I wanna briefly share some information about the Opioid Response Network and the work that we do. So the Opioid Response Network was initiated back in 2018 in response to the opioid crisis in our country. We are funded by a grant from SAMHSA to provide no cost training and consultation to enhance prevention, treatment, recovery and harm reduction efforts across the nation. Through this work, we utilize a pool of consultants who are located all over the country and who can respond to local needs. We operate on a request basis and anyone can submit a request for assistance on our website at opioidresponsenetwork.org. Today, we are honored to be here with you to provide training on stigma and substance use disorders in the context of working with people who have intellectual or developmental disabilities. As I mentioned, this session is being recorded and our session today will be led by O-RAN consultant, Laurie Ann Eldredge, who I will now go ahead and introduce. Laurie Ann Eldredge is an assistant professor at East Carolina University in North Carolina. She is a public health implementation scientist and her research is designed to bridge the gap between research and practice by the translation of empirical evidence into evidence-based curriculums, interventions, and the establishment of policy change. She focuses on how the impact of laws, policies, regulations, access to services, and healthcare delivery are affected by social determinants of health. Her research has been influenced from 16 years of professional applied experience with individuals with comorbid diagnoses of mental health, physical and intellectual disabilities, and substance use disorders. All right, and with gratitude, I'll pass it over to Laurie Ann. Thank you so much. I'm so glad to be here today and I just want to confirm that it's being recorded. We've hit record. Okay, good. Just want to make sure. I'm going to share my screen. All right, so today we're going to be talking about some factors that contribute to drug abuse independence. We're going to identify some major categories of drugs and describe their effects, the methods, and the potential for misuse independence. We're going to identify some social issues related to psychoactive drug use and its prevention, treatment, and harm reduction. We're also going to talk about the impact of illicit drug use on people with intellectual disabilities and identify the social and psychological financial impacts of addiction with people with intellectual disabilities. So this presentation is going to be divided into two slide decks. So the first one we're going to be focusing primarily on what is substance use disorder, and then the second slide deck, we'll take a brief break, intermission, and then we'll have a second slide deck where we focus on stigma. So we're going to be beginning by watching a brief video, and then we will move into the other material. So I'm going to end this slideshow just so I can show you the video. This is Susan. Susan loves to bike. While out for a ride, she falls and breaks her arm. Special cells called neurons send a signal through a spinal cord to the brain, which interprets the signal as pain. Susan understands the pain means she needs to go to the hospital, and her body is equipped for survival, helping her not to panic so she can seek help. Many of her neurons are covered in proteins called opioid receptors. These receptors act like a brake to slow down the neuron's ability to send pain signals. When injured, her body releases natural painkillers called endorphins. Like a key in a lock, endorphins activate opioid receptors, slowing down the pain signal and preventing a panic. Susan gets treated for the broken bone, but three months later, her arm still hurts, and now that pain is making her feel depressed and anxious. So her doctor prescribes an opioid painkiller. There are many different opioids, but they all share a chemical similarity to our own endorphins. This allows them to bind to the same opioid receptors and stop pain signals. But that's not all they do. Deep inside Susan's brain is a region called the ventral tegmental area, or VTA for short. VTA is full of neurons that produce a chemical called dopamine. When something good happens, dopamine is released, giving Susan a feeling of pleasure. This helps teach her brain to keep seeking out good things. To keep dopamine neurons in check, inhibitory neurons keep the brakes on until something good comes along. Just like the pain neuron, these neurons are covered in opioid receptors. When Susan takes the painkiller prescribed by her doctor, the opioid receptors turn off the inhibitory neurons and release the brake on the dopamine neurons. The rush of dopamine temporarily eliminates Susan's depression and anxiety, and she feels relief, calmness, and even euphoria. As Susan continues to take the painkillers, her brain responds by trying to regain its balance. Her inhibitory neurons work extra hard, even when the opioid receptors are activated, and it becomes harder and harder for her dopamine neurons to release dopamine. Susan finds that she needs to increase her dose of painkillers in order to feel comfortable. This is called tolerance. Eventually, Susan's pills run out. Inhibitory neurons that had been working overtime are left loose, clamping down on those dopamine neurons and shutting them off almost completely. Now, not only is Susan in pain, but the depression and anxiety come back. On top of that, Susan feels ravaged by an inescapable physical sickness far worse than any flu. Susan's body is going through withdrawal. Most people who take opioids for a long time tend to experience some withdrawal, but they can still stop taking the pills and return to normal. But for people like Susan, it's not so easy. Her genetics and the environment she grew up in put her at a higher risk for addiction. Her withdrawal symptoms aren't just unpleasant, they're unbearable. Susan thinks the only way to feel normal is to find more opioids, and this is how the cycle of opioid addiction emerges, driven by a brain trying to regain its balance. But there is hope for Susan. Though the road to recovery can be challenging, and there may be setbacks, treatment can retrain Susan's brain. With the help of medication and therapy, Susan finds pleasure in her life once again. Just stop that and share this. So I'm just confirming you guys can see the screen, the PowerPoint. So, yes. Okay, thank you. So I'm really happy to be here today and I'm looking forward to talking about some topics that are really important to me. One of the things that I always like to share when I'm presenting is that, you know, substance use and addiction is close to my heart and to my life. I have family members that, and I've lost family members related to the complication of substance use. I also have family members that have intellectual disability. I grew up in a very rural community that had very limited resources and so it's really important for me to share this because it shapes what I do and the work that I do. And today I hope that we, as we go through the slides, that we all are learning something new and that we're taking one item, one thing that we can change in the way that we engage with our clients. I'll be talking about a lot of different things, but, you know, it can get a little bit overwhelming when we think about all of the things that are, that can be changed. But I'm just asking you to think about one thing. So as we go through these two presentations, try to think about one thing that you might be able to change or start doing to engage differently with the people that you work with. So we're going to begin by talking about the process of addiction. So there's a misperception that addiction is a choice or a moral problem and all you have to do is stop. But nothing could be further from the truth. The brain, just like the video we just watched, the brain actually changes with addiction and it takes a good deal of work to get back to that normal state once we've engaged that level of dopamine. And the more drugs or alcohol you've taken, the more disruptive that can be to the brain. There's three stages in this addiction cycle. So we have this binge or intoxication stage, withdrawal, negative effect or preoccupation, and then the preoccupation and anticipation phase. These three stages create an incentive, it develops habits, it provides this reward system and it engages our executive functioning and it creates deficits in our executive functioning. It also provides powerful compulsive behavior. And that's where that drug addiction really comes in, that powerful compulsive behavior. So these domains of dysfunction correspond with these neuroadaptions that change in these areas of our brain. And so we kind of talked about, we saw that in the video where our brain is changing when we're engaging with substances. So when you're becoming addicted to a substance, the normal hard wiring or the helpful brain processes can begin to really work against us. And the drug and alcohol can hijack that pleasure and reward circuits in our brain and really hook us on wanting more and more of that substance. Now, this isn't just the way that our brain works. It's not just for individuals that have atypical development. We're talking about this affects everyone. So individuals that have intellectual disabilities, their brain and reward system works the same. So they are just as susceptible as anyone else to experience all of these things related to addiction. So addiction, as we said, it is kind of hijacks your brain and it can send your emotional danger sensing circuits into overdrive, really making you feel anxious and stressed when you're not using drugs or alcohol. And at this stage, people are often using drugs and alcohol to help them not to feel bad rather than the pleasurable effects. So there goes a stage where people use substances because it produces euphoria and pleasure. As the substances take over and hijack your brain, individuals tend to start using substances to relieve the feelings of anxiety, depression, and such, and not necessarily for those pleasurable effects anymore. So repeated use of drugs or substances can really damage the central decision-making parts of our brain. And that's known as our prefrontal cortex. And in this area, in this region, that should really help us recognize the harms of using an addictive substance. So when we're using substances, we begin to damage this section of our brain, our prefrontal cortex, that helps us to understand the harms. So then that also kind of plays against us in that sense. So when people have done brain imaging scans and studies of people addicted to drugs or alcohol, they show a decrease in activity in that frontal cortex. And so when it's not working properly, people have a really difficult time making the decision or choice to stop taking substances, even if they realize that the price of taking the drug is extremely high. Like they're losing their housing, or they've lost their job, or they end up incarcerated, or family members are, they're having lots of relationship problems with family members or friends. So they recognize those things, but they continue to take it. So I think it's important to note that with all the kind of science and all the work and the research that's gone on around addiction, we are able to pinpoint why some people become addicted and others people don't. And that's important to understand. And I think that's where some of these misconceptions of addiction as a moral or a behavioral issue is that it's a complex disease, and we're still doing a lot of work. And there's a lot of issues related to addiction that are, there's some that are genetic and some that are environmental, and we'll talk about that as we move forward. The key is, is that addiction is a disease. And it's been diagnosed, to diagnose having an addiction, that a medical professional would use the DSM to identify whether or not someone would have an addiction. And these are the 11 criteria on the screen that an individual, that a medical professional would use to identify if addiction is happening. Now with those, let's say the medical professional has identified that an addiction is occurring, there are specific categories that they're looking at. And these categories are physical dependence, risky use, social problems, and impaired control. And you can see on this chart, the 11 categories, so impaired control, for example, would be using more of a substance or more than intended. Social problems would be neglecting responsibilities or relationships. And risky use would be using in risky settings. And physical dependence is needing more and more of a substance to get the same effect, known as tolerance. Now, there's different levels of severity of substance use disorder. Like many other illnesses, addiction can get worse over time. So, similar to like the stages of cancer, there are levels of severity that describe, substance use disorder. So, when you speak with someone who has a diagnosis of cancer, they'll say I have stage 1, 2, 3, 4, right? Substance use is very similar. There's different stages and categories. So, these guidelines are used for clinicians to help determine how severe a substance use disorder is, depending on the number of symptoms. Okay? So, the symptoms that were just on the slide just a few slides ago, if you have two or three of those symptoms, that indicates a mild substance use disorder. If you have four or five, that indicates a moderate substance use disorder. Six or more symptoms would indicate a severe substance use disorder. So, a severe substance use disorder is also known as having an addiction. Okay. So, clinicians determine the severity level of a substance use disorder to help them to develop a treatment plan. The higher the severity, the more intensive level of treatment is needed. So, most patients are most likely going to need ongoing treatment and recovery support using a chronic care model for several years. And a clinician should monitor that. So, if you have an individual that has been diagnosed with a substance use disorder, an addiction, this type of treatment needs to be done over a prolonged period of time and with continual support. So, when we're talking about addictions, there's a lot of different types of addiction. Okay? So, I'm just going to give a brief list of some addictions. And as you're listening, you can identify some common addictions or addictions that you're aware of as well. So, alcohol, drugs, food, sex, shopping, work, gambling, technology. When I was working with clients, I had a client that had a severe addiction to soda, caffeine, sugar. So, really, addictions can come in lots of different forms. So, I want to talk about these factors that contribute to drug use and dependence. We're going to really kind of focus on drug use for these slides. But I want you to know that when you're working with your clients, they may be experiencing other addictions besides drug use. And some of these factors can contribute to those as well. So, we have biological factors. That's our genetics and our brain chemistry. We also have psychological factors. That would be stress and mental health disorders. And then we have our social factors, peer pressure, family dynamics, socioeconomic status. So, addiction tends to run in families. And certain types of genes have been linked to different types of addiction. But not all members of an affected family are necessarily prone to addiction. But it does run in families. As with heart disease or diabetes, there's no one gene that makes you vulnerable. Factors can also raise your chances of addiction. So, growing up with an alcoholic, being abused as a child, being exposed to extraordinary stress, all of these social factors can contribute to the risk of addiction and overuse. And the earlier you start using substances, the greater the likelihood of having a substance use disorder or addiction later in life. Many people, people with intellectual disabilities are especially vulnerable to possible addiction. So, people with intellectual disabilities have a higher rate of psychiatric comorbidities. Several studies have found that the rate of psychiatric disorders range between 30 and 50% among people with intellectual disabilities. So, this co-occurrence of psychiatric disorders and substance use disorder is really common. So, research, not surprisingly, has found that people with intellectual disabilities have alarming high rates of trauma. And I think if you think about your clients on a whole, and you think about the stress and traumatic experiences that they've may experienced in their life, you could probably attest to that statistics, right? These very high rates of trauma in the population. Additionally, individuals with disabilities are four times more likely to be a victim of a crime than someone who's non-disabled. And more than 90%, 90% of all people with intellectual disability will experience a sexual assault sometime in their life. So, these are just examples of some trauma, right? Being a victim of a crime, experiencing sexual assault, or some other type of assault. These are all factors that can contribute and lead to a substance use disorder. So, for the next few slides, I'm just going to briefly go over and review a few different drug types so that you're aware of what these are. When I began working with individuals with intellectual disabilities, many individuals that I worked with, and also when I work with case managers that are working with individuals with intellectual disabilities, they share with me, like, we don't even know what we're looking for. We didn't study substance use disorder. We don't know what types of drugs and what they do. And so, I think it's really important that we have just some very basic information about some different types of drugs. So, stimulants. These examples would be cocaine and amphetamines. And their effects are increasing energy and alertness, and the abuse potential is high. And then we have depressants. Alcohol and benzodiazepines are some examples of those. The effects that that would have on an individual would be relaxation or sedation, and the abuse potential is also high. So, the higher the abuse potential, the more likely that there will be an addiction. Opioids. Heroin, prescription painkillers, fentanyl. The effects would be pain relief or euphoria, and the abuse potential is very high. Hallucinogens, LSD, silobine. This alters your perception, and the abuse potential is variable. They're still doing a lot of research in this area. Cannabis would be marijuana, and the effects on your body would be relaxation or altered senses, and the abuse potential is moderate. When we're talking about individuals that have intellectual disabilities, there's very limited research, but the research that does exist shows that individuals with intellectual disabilities tend to use marijuana and alcohol more than any other substance. And so, it's important to know what those effects are. We also want to think about our clients who are responsible for taking their own medications, because some of these medications can be prescribed, like opioids or even medications for ADHD, which can cause alertness. And so, are they actually taking their medications? Is somebody else taking their medications? Are they taking too much of their medications? So, being aware of what the medications are, if they are considered a controlled substance, and what it does to their body, and really watching that is really important as a provider. So, one of the things that I think is really important for us to understand is, and it is really a critical aspect of substance use services is the intersection between prevention and harm reduction. So understanding primary, secondary and tertiary effects helps us to support a comprehensive approach to tackling this substance use. So primary prevention. So primary prevention aims to stop substance use before it starts. So this involves education, community programs, policies that promote healthy behaviors. For example, education programs that inform people about the dangers of substance use, public campaigns that discourage substance use, regulations that limit access to addictive substances, all fall under primary prevention. And these initiatives focus on reducing the risk factors that lead to substance use disorders. So as a care provider, as a caseworker, as a person working with someone with intellectual disabilities, we should be engaging in these primary prevention tools. We should be talking about, educating and informing our clients about the dangers and risks of substance use. The other thing is, is just because someone uses a substance doesn't necessarily mean they have a substance use disorder. That was one thing that would come up often when I was working with individuals with intellectual disabilities, as well as people would become very concerned if someone had a glass of wine or a beer or a margarita and with their meal once a month. And it's like, that's not a substance use disorder, but that's another issue related to stigma and people with intellectual disabilities. But we should talk about that prevention and we should be addressing it and talking about it and engaging in those talks with our clients on a regular basis so that they understand that if they're using the substance, marijuana, alcohol, or if they're using some other pill or if they're anything like that, that they understand what the dangers are and the risks of using and the risks of addiction and what that could look like. So secondary prevention really targets the early detection and intervention of substance use. It aims to identify and address issues before they escalate. So regular screenings for substance use, brief intervention and counseling services are prime examples of secondary prevention. By identifying substance use early, we can intervene properly and prevent addiction and its associated harms. So harm reduction really plays a key role here too, particularly in the management of emerging substance use issues. So by ensuring individuals have access to resources and supports to make informed decisions about their health. So when I was working with clients, I would sometimes work with individuals that were starting to engage in new substances, right? Maybe they were using marijuana and now they're, you know, kind of engaging in trying cocaine or crack at that point. And so we would engage in doing some brief intervention, also engaging in decreasing their harm. So using clean materials when they're using and different things like that. Engaging their healthcare providers. So often I would go to psychiatrist appointments or to medical appointments with my clients. And I would recommend what types of screenings, right? When I go to the doctor, they're screening me for substance use. They're asking me about my tobacco use or my alcohol use. They should be asking those same questions of the individuals that we are supporting. And if there's any concern in those doctor's appointments, if they're screening positive, there should be additional assessment and referral at that point. And we should be aware as providers that those questions should be asked in those medical appointments so that we can help support our clients. And that tertiary prevention really involves managing and mitigating the impact of substance use disorders. The goal is to improve the quality of life and reduce harm for those that are already affected. So they have an addiction and now we're working on mitigating and managing the disorder. This is where harm reduction strategies really become crucial. For instance, a needle exchange program helps to decrease the risk of infectious disease and promote pathways for rehab and recovery. Treatment programs, mental health services, support groups also fall under this tertiary prevention, helping individuals manage their conditions and maintain the highest quality of life. When I was working with individuals with intellectual disability and substance use disorder, this is the area that I was working in. These are individuals that had already been identified as having a substance use disorder and addicted to substances. Typically, majority of my clients were coming from a locked placement. So it would be a state hospital or a correctional facility related to their harm reduction. That's how they got there. Related to their substance use is how they ended up in those facilities. And so really working with them to improve their quality of life at that point and engage in consistent treatment. Additionally, one of the big things that we worked on is that harm reduction piece. So one of the things that we would encourage our clients and we would talk with the medical professionals about was mixing substances. A lot of our clients had many medications but they were taking substances in addition. And those may be a variety of things, alcohol, marijuana, cocaine, methamphetamines. So when we were working with them, we would talk about one, the dangers that can occur and two, maybe using less of a substance, maybe only using one substance. So talking about how we can decrease their harm when engaging with the substances that they were using. The intersection of prevention and harm reduction is where we find most of our effective strategies for addressing substance use. So primary prevention reduces the initial risk, secondary prevention catches those issues early on and tertiary prevention manages long-term conditions. When I conducted interviews with service coordinators of individuals working with people with intellectual disabilities, I interviewed a whole bunch of them and what I found from interviewing them and then from also from my professional experience is that often we were catching individuals with intellectual disability at the tertiary point, just way down the line. We were not catching them in primary or secondary at all. It was all the way at the end and individuals just kind of fell through the cracks until often the legal system was involved and then they were mandated to receive some type of treatment or services at that point. My goal and our goals should really be to engage in those first two sections, which is that primary, which is reducing the initial risk and that secondary is catching it early on so that we can address it and not go all the way to a substance use disorder or to full addiction. So harm reduction is integrated in each of the levels that we've talked about today and it ensures that individuals receive the support and resources they need regardless of the stage on the health continuum. So I think it's important to realize how harm reduction fits in each of these areas and how we can engage in that. So considering the opioid crisis for example, primary prevention includes education about the dangers of opioid misuse and the policies to control prescription practices. So that would be an example of a primary prevention. Secondary prevention involves screening for early signs of addiction and providing access to treatment. And then the tertiary prevention and harm reduction might include providing a person with naloxone to reverse overdoses and offering testing supplies and then also connecting individuals to long-term treatment options. Really this holistic approach to substance use must be incorporated in all three levels of the prevention alongside harm reduction strategies. So when we're doing that, we can not only prevent substance use and its associated harms, but we can also support those that are already affected, ultimately leading to a healthier community. All right, so I really like the SAMHSA states working definition because one of the things I learned when I was in practice was that things changed all the time. I would tell my staff that the one constant was change. So the moment that you feel like this is how it's going to be is the moment we're gonna make some change. That's just how it worked when I was working with individuals with intellectual disability and substance use disorder. There was a lot of variables, peoples. Lives could change very dramatically. They could relapse, they could get kicked out of their home or be moved. There was a lot of things that were happening, right? So I do appreciate that SAMHSA says this is a working definition, which really allows us to know that this may change and it may be adjusted. So this is the SAMHSA, this is how they define recovery as a process, this working definition of recovery. It's a process of change through which the individual improves their life and wellness. They live a self-directed life and they strive to reach for their full potential. I think it goes really nicely with the population of individuals with intellectual disabilities, because as an advocate for individuals with IDD, I have preached and advocated for this self-directed life. And I think that language is comfortable to us. We understand that language. That language is the same for recovery as well. So it really blends well together and it can go hand in hand. So this really, this definition from SAMHSA really underscores the dynamic and individual nature of recovery, which is not a one size fits all journey. And it's really deeply rooted in a personal process. So when we're thinking about this process, when we're working with our individuals that have maybe a potential substance use disorder or addiction, thinking about the recovery model and really thinking about how this is gonna be a personal process for them. It's gonna be key for us as care providers, because one person may thrive and do very well in AA or NA, alcohol anonymous, narcotics anonymous. Another person may not do well there. They may do much better in a faith-based organization. Someone else may do much better in a one-on-one situation. So as you're moving forward and you're working with your clients, remember that this is their journey. It should be self-directed and it should be, there's so many different pathways. So one may not work for the next. And it's just important to remember that as we move forward. So I think it's important to think about these impacts of substance use disorder. We have social, psychological and financial impacts. So some of those impacts may be social isolation or strained relationships. Psychological be increased mental health issues or lower self-esteem. Financial could be the cost of treatment or loss of employment opportunities. So there's a lot of impacts that can happen with substance use disorder. And specifically for the impact on people with intellectual disabilities. One, there's really high risk factors. There's an increased vulnerability. There's a limited understanding of consequences. So we've already talked about that prefrontal lobe and the decision-making with substance use, how it becomes affected and kind of hijacked and it changes over time. And you take someone who has an intellectual disability that may already be slightly impulsive. So they may have a limited understanding of these consequences. There may be challenges in treatment such as communication barriers or a need for tailored services. And those, so individuals with intellectual disabilities, they may not thrive in a traditional treatment facility if the organization staff are not going to engage in tailored interventions. Again, support services, there's really a need for specialized programs. We're lacking that throughout the nation but really we need specialized programs because people with intellectual disabilities are experiencing substance use disorder. And then family and caregiver involvement. People with cognitive disabilities, they have a higher rate of psychopathology than their counterparts. And this is displayed in higher rates and dual diagnosis of substance use and mental health diagnosis. So every single client that I worked with that had an intellectual disability and a substance use disorder also had a mental health diagnosis, every single one. So individuals, we talked about the risk of having a mental health diagnosis and how that can increase the risk for having a substance use disorder. So those things can kind of go hand in hand and it's their risk factors. Additionally, people with intellectual disabilities may have a higher rate of developing a substance use disorder and they often experience more adverse effects when they use substances. So those adverse effects can be related to those things that we just talked about, those impacts, those social, those psychological and financial impacts. So they're experiencing those more adversely than others. There is a substantial lack of substance use disorder prevention, recovery, harm reduction and treatment programs serving the population. And so what tends to end up happening is that the way that our medical model is kind of set up and the model and how we provide care is really kind of siloed where we have clinicians that do healthcare and then we have clinicians that do substance use disorder, then we have clinicians that do work with people with intellectual disabilities. So what ends up happening is often us as care providers is that we need to be that conduit. We need to be that advocate when we're engaging with healthcare providers so that we can advocate for our clients to receive the types of treatment that is needed. Miranda, I see that you have your hand raised. Go ahead. Hi, as you're talking here, I just keep thinking about, we have a lot of conversations organizationally around power and choice and this idea of like calculated risk or appropriate risk. Right. And so I keep thinking about advocating for treatment, advocating for health, advocating for wellness and then where's the line really, like trying to tow that ethical line of like, well, if it's this person's choice to continue drinking at this rate or to consume marijuana at this rate, who am I as a direct support professional to say, well, you've crossed the line into addiction and now your choice is removed. I just, I really, I struggled with, I'm struggling with that in this moment. Like what's our ethical responsibility versus what's this person's choice? Right. Well, I think that when we're talking about individuals, that use substances, it boils down to their choice. We're talking about individuals with intellectual disabilities, again, it's their choice. But what can we do as an advocate, as a care provider, is to make sure that we are, one, if we suspect that substances are being abused or we are very, not even suspect, we're very aware that substances are being used in an excessive fashion, right? Or we suspect that they're abusing their medication because they keep running out, something like that, right? This is a great time for you as the direct support person to engage with that medical professional, engage with your primary care doctor, engage with your physician's assistant, engage with that clinician, with that talk. As a direct support person, our role is not to diagnose or to say that someone has a substance use disorder. Our role really is to assist them in getting the knowledge and the information necessary so that they can make informed decisions. And one of those ways is to make sure that we're engaging the right medical professionals. We engage with the doctor and we say, hey, that might look like as a DSP where you talk with your client and say, hey, you have a physical coming up next month. And you talk with your client for like the four weeks about let's talk about how much alcohol you should be drinking. What is the safe amount of alcohol with the medications that you're taking? Can you even drink alcohol? Like, what does that look like? And kind of go in there and then just have a conversation with the medical professional assisting the client to have that conversation, I think is really important. I think that sometimes there's just, what I found working with my clients is that often there was the assumption that people with intellectual disabilities were not using substances. And that's why it got to the point of tertiary support because we weren't doing that prevention piece was ignored for so long. So when we're working with individuals, even if we don't suspect it, I'm thinking like those 18 to 22 year olds, 18 to 27 year olds, we should be engaging in chat and talk in conversations about what are substances? What is a substance? What are drugs? What are the risks? And you take this medication and when you use this, this could happen. So that they're aware of some of those side effects. Many of our individuals are on medications and so there could be effects that could be happening. And so there may be other issues that are going on. The individual may say, well, I drink, I like to go over to this place and drink because my friends are there. So maybe we need to engage as a DSP in engaging in other healthy relationships, right? Maybe the person's struggling to engage and make friends and they want those connections. That's often what I found. That's from my practice experiences that many of my individuals that I worked with and engaged with were using as a way to engage with other people, which then led to much more complicated addiction issues. Because once your brain is hijacked, then you have that tolerance and that dependence, it becomes really, really difficult. So I think engaging in that prevention piece of developing positive social relationships, talking about risk factors, being aware that if that individual has a family member or has experienced trauma, that these are factors that can contribute to substance use. But I think the bottom line is, is that unless you go through legally the legal path, you can't force someone not to use a substance. It's gonna be very, very difficult, whether they have an intellectual disability or not. So does that answer your question, Rhinda? Yeah, yeah, it does. I think also as just have been ruminating as you're talking about, I do think that there is this notion that, oh, we don't have, they don't have access. Like the people we serve don't have access, the people we serve don't have access. The people we serve don't have, you know, oh, all of our medications are locked and they're delivered by a professional. And so also, you know, being, having observed some things, like I'm just thinking about like kind of, I don't know, there's a participant that I got to hang out with who was drinking non-alcoholic beer, but just had cases of non-alcoholic beer in his room and just constantly consuming non-alcoholic beer. And the reason he was consuming non-alcoholic beer is because at some point, he stopped drinking alcoholic beer. So it didn't really take the addiction away, we just substituted a different substance that maybe isn't as, you know, is not as mind altering, but still. They decreased the harm. And that's where we talk about that kind of harm reduction piece. So, you know, when I was working with clients, we would, for example, I'm gonna give an example of one client. He would, he had his own apartment. His medications were delivered to his apartment. He had DSPs that came into his house, but he took his own meds. But he also could have anybody over that he wanted. And his family would come over often. He had quite a few cousins. They would come over. And his cousins would smoke crack in his house. And he allowed that to happen. And this was a real concern from the support staff. But again, this was his choice and it was his life. And so we had a plan for that, which I'm not gonna go into for this training. But what we worked with him on was if they're smoking crack, could you do something else, smoke a cigarette, smoke marijuana? You know, we were trying to decrease his risk. And so what he would do is he would engage in a lesser substance, basically, in that environment. So, because whenever he used crack cocaine, lots of problems would occur and arrest would happen. He would get arrested. And that's why we had him, because crimes would be committed and different things. So what we worked on is, yeah, he was still using substances. I mean, he was still using marijuana. He was still using alcohol. He was, you know, but he wasn't using crack cocaine. And he wasn't going back to jail. And so that is a part of harm reduction. Now, you know, what I've, so when we talk about harm reduction is, Miranda, you're giving a good example. Maybe it's not what we would identify as the ideal health path, right? But it's improved health. I had a client that had a very severe addiction to soda. And so part of that was just decreasing the amount of soda that they were drinking in a day. So that they weren't, you know, it wasn't, they were drinking so much, it was washing out their seizure medications. And then they were having seizures and being hospitalized and having really severe consequences. So working in that realm of kind of that reducing harm, is important for this population because you may, and any populations working with substance use, again, this is self-directed. They may not want to stop at that point. I remember, that's what actually got me off on this kind of train of thought is that you had talked about a client who was so addicted to soda that they refused services. Like at some point they were like, I don't want your services anymore. I'd rather drink soda than engage with your program. And that's something there where I'm like, having met some of the people we serve and, you know, we do have adolescents in our programs and hearing about the way they sometimes have chosen to interact with the world. I wonder about kind of expanding our ideas about addiction, like soda, we can refuse services because we'd rather drink soda, right? Versus, oh, it's crack cocaine. Right. Well, and I think- Consequences to both. There's consequences to both. And that's why, you know, in the beginning, I mean, in this, you know, presentation, I'm really focusing on, you know, substances, but it's important to understand that what I'm talking about in this, the impact of substance use disorder and those types of things and these risks, these are related to addiction. And so when I talked about that slide, like what are those addictions? Our clients may have addictions and they're experiencing these, they're having these negative impacts in their life, right? And you gave the example that I had previously given about an individual that had such a severe soda addiction that they refused all programming and housing and medical care. And they actually were living on the street. They chose to not have a home, not have a job, not have a program. And they wanted to live on the streets so that they could drink soda. And so that's an addiction, okay? That is like, when we talk about those impacts, those social, psychological, financial impacts, clearly there's some clear impact there. So when we're working with our clients, they may have, there may be a substance use addiction, but there may be something else that is a driving force that's an addiction in their life. And it is important as DSPs that we have done the training and the work that we can kind of start recognizing those signs, those symptoms and engage with our clients so that we can provide, you know, effective support for them at that point. And kind of improving, increasing, increasing support and decreasing harm is really, should be our goal. I mean, our ultimate goal is to prevent from this from ever happening, but it happens. And unfortunately, often with substance use within this population, we're seeing it once it's become so dysfunctional where there's a lot of impact, you know, typically criminal justice system has been involved in some way, so. Sorry, I just wanted to mention, there was a question in the chat. Oh, yes, go for it, you read it. What you were saying before about addressing substance use among clients. Are you able to see it? I can read it. Yeah, will you read it for me? The question was, does that still apply when our participants don't have the capacity to make their own treatment decisions or have a guardian? So, you know, it is complicated when someone has a legal guardian, right? And I think that when they have a legal guardian, the court has been involved and the courts and a legal guardian can at that point mandate that someone goes to treatment, mandate that somebody receives certain types of programming. And so that can occur in this population. It can occur in all populations. In some states, for example, I used to live in the state of Indiana and in the state of Indiana, they could mandate individuals that had substance use disorder into treatment. Like they would be in locked placement. If they, let's say they had so many DUIs or they had so many crimes related to you or so many hospitalizations even, the court system could step in and mandate that an individual goes to treatment. Now, not all states are set up that way, but what happens is with individuals that are in care and people with intellectual disabilities, older adults, sometimes individuals with different types of cognitive disabilities, they may have a guardian and a legal guardian. And in that sense, then the individual, their rights don't exist in the same nature for an individual that doesn't have that. But I think it's really important to know that just because somebody says they're their guardian doesn't mean that they're their guardian. So I worked with quite a few individuals that had parents that would come in and say, I'm their guardian. And I would say, okay, where's the legal paperwork? Because this individual is over the age of 18 and there is no legal paperwork. This is just something they would say and people would say okay to. But the reality was is that this person, this client of mine did not have a guardian and could make their own decisions and could self-direct their own care. And so I think it's important as, it was very important to me as an advocate and is to make sure that the people that were in the individual's life were acting in best interest. And sometimes they are, but they need to be acting in best interest legally as well. So it does make it a little bit different when you have a legal guardian because the legal guardian does have the right to make legal decisions. But again, it depends on the type of guardianship, right? And it becomes complicated depending on the state. Does that help answer your question? You can unmute. I'm not sure who asked it. I can't see the chat. Yeah, and I mean, I get what you're saying, but also doesn't the legal guardian have to make their decisions the same way that the client would? So then we're kind of back to the same cycle of, well, they don't have capacity to make these choices, but their guardian needs to be making the choices in the same way the client would. And are you referring to like a conservatorship, like a legal guardian that has legal, they have gone to the court and they are the legal guardian. They have the right to make all decisions for that client. Yes. Yeah. So in that situation, I did have a couple of clients that had conservators, right? And their conservators were family members. What I found in those situations is they were parents. They would, for example, if they felt that the client needed to be hospitalized because of a mental health concern, they did that. Now that client may not have chosen to go to treatment or into the hospital, but because they were conserved and their conservator said that they were, that's what they were doing. And they had the legal right to make those decisions. Then, and the court had said that they had the legal right, then that's what happened. So I think that as advocates, if we're seeing that a guardian is creating unsafe decisions or choices in environments, then as an advocate, it's our responsibility to report that. Going back to the example of people that would come in and tell me they were the guardian of so-and-so, that was often the situation of a parent or a brother or sister making very poor decisions for their loved one. And it often related to that parent, sibling, wanting access to the client's, one, the client's medications, because that family maybe had a substance use disorder, and so they wanted those medications. And this is from real life experience, and two, access to money, to the client's social security funds. But then they weren't actually the legal guardian. But I think if you are seeing that a guardian is stepping in and creating very unsafe, and this is a person that's conserved, and they're creating really unsafe environments for their client, then it's our responsibility to report that. So if you have a conservator that's providing lots and lots of alcohol to someone who has a seizure disorder, then that would be something that should be reported. Thumb up. Okay, perfect, thank you. All right, so to kind of just wrap up here a little bit, some of the ways that we can offer support is one, that education and awareness. So we know our clients, we know that our clients are unique and they have lots of different strengths and abilities. So really tailoring how we provide education and information to them and provide awareness towards substance use and addiction in general. As you know, we've talked about addiction can come in many different forms. That is something that we can do to help support. Additionally, we may be able to help support in support networks. So for example, if someone was going to a AA meeting or an NA meeting, it may be helpful for us to engage in talk before the meeting, instead of just going there and dropping them off and leaving. If they're willing, provide support, such as practice what they might say, engage in that role-playing, right? It may be helpful to do family counseling or different types of relationship counseling and to advocate for that. Additionally, as a support staff, advocating for services. So as I mentioned, often I would work with people outside of the IDD care community. And there was definitely stigma and feeling that individuals with intellectual disabilities didn't experience addiction or substance use. And so really advocating for those services. And then if someone is engaged in services, advocating for inclusive treatment programs. So providing support to the treatment facility on the ways in which your client engages with material. Many of my clients could read, but comprehension was a concern. So when we were working with them, we would have them read, but then we would break it down and really talk about it because that comprehension was something that was really struggled with. I could have them read four pages out of the big book and then I would ask them, what did that mean? And they wouldn't be able to tell me. And so really being able to provide that information and help other, it's an inclusive treatment facility that we engage with them and help them to tailor their services. So one of the things that I think is super important as a support staff is that we are creating housing that is supportive, that's stable and that's safe. Housing options for individuals with intellectual disabilities and individuals with substance use disorder really should, again, be supportive, safe and stable. One of the things I found so often with my clients is they were coming out of incarceration and then placed in environments where maybe it wasn't safe, where there was apartment buildings that there was a lot of substance use. I also had a lot of clients that engaged in substance use in their apartment complex because it was being sold, it was kind of a lower income environment that was maybe not the safest place for their recovery and didn't encourage a drug-free lifestyle. Vocational and employment training is a great way that we can provide support because when we do that, we're giving them purpose, we're allowing them to regain skills and achieve independence. And this is really important for long-term recovery. When I'm working with individuals that don't have intellectual disability, have substance use disorder, this is a big piece. So it goes hand in hand because learning those skills on how to just take care of yourself and be able to support yourself is empowering and is really needed. So as a support staff, that is something that's really important. We can also work on those relationships and building friendships in those environments as well. Advocate for that early intervention. You have an 18, it doesn't even matter how old they are, advocate that if you're supporting them in a medical appointment and the medical professional is not screening for substance use, ask them why they didn't do it. I've been saying, oh, aren't you going to screen for substance use? They should be screening if they're female, they should be advocating, the medical professional should be recommending mammograms and they should be recommending prostate exams and colonoscopies. They should be doing screening for tobacco, alcohol and substances. These are all things that should be happening more in a medical appointment when we're supporting our clients. If those things aren't happening when you're going to a medical appointment, as a DSP, we can work with our clients to help them advocate for it in their doctor's appointment, or we can help as well. Doing some role play with our client before we go in, that's a great way, but advocate for those screenings, advocate for those brief intervention programs when we are in those medical appointments. And then also implementing comprehensive strategies. So, oftentimes substance use, intellectual disability, mental health diagnosis, it's complex, it's multifaceted. And so when we're supporting people in recovery and preventing the initiation of substances, it's important that we are really implementing a lot of different techniques. Again, as I said, it may be more primary where we're doing education, it may be more secondary where we're engaging in that screening, or in those harm reduction approaches as well. All of those things are really vital as we provide support. So, some of our key takeaways today would be that understanding addiction and its impact on people with intellectual disabilities, it's crucial. Addiction occurs in this population, and that addiction can range from a lot of different things. It could be a substance, it could be a soda, it could be shopping, it could be sugar, it could be alcohol, sex, it can be lots and lots of different things. So, as a provider, it is key for us to engage in prevention, treatment, harm reduction and support strategies, so that we can help make a significant difference in their life, and hopefully, ideally, prevent serious addiction from occurring. So, I'm gonna stop sharing for a moment, and just open it up. I see there's a question in the chat. Okay, I think I answered that one, okay. But if there's any questions from the audience or any comments, we can do that, and then we'll take a little break, and then we'll come back. So, is there any questions or comments? All right, so, for this presentation, we're gonna talk about stigma and support that we can provide, enhancing substance use treatment for those with intellectual disabilities. So, our first presentation was really about what is a substance use disorder, what is an addiction, and now we're gonna talk and really kind of dig into stigma and ways that we can support our clients. Was there a comment in the chat? I think I might've saw something in the chat. Emily, was there something? No, we just noticed he was eating some snacks. Okay, okay, perfect. All right, I think it's important that we start off so that we're all kind of on the same page and that we can define some terms. So, the first one is intellectual disability. So, this is a term that we use is intellectual disability. So, this affects cognitive functioning, such as learning, problem solving, and judgment, adaptive functioning, such as activities of daily living and communication skills or relationship skills. This occurs prior to the age 18 in the early developmental years. And then we have cognitive disability. So, often cognition and intelligence are used synonymously, but they're different, they're not synonyms. Cognition refers to the person's ability to think and learn, remember, use judgment, make decisions. Intelligence refers to the person's capacity to learn and understand information. It's important to remember that some cognitive disabilities may affect a person's intelligence, but this is not always the case. And so, it's just important to remember that. And then sometimes individuals will use the term neurodivergent. So, neurodivergent is a non-medical term that describes people whose brains develop or work differently for some reason. And this means that people have different strengths and struggles from people whose brains develop or work more typically. While some people who are neurodivergent may have a medical condition or a diagnosis such as intellectual disability, it may also happen that people where the medical condition or diagnosis hasn't been identified, they don't have one. So, you may find that some people that you're working with will prefer the term neurodivergent versus the medical diagnosis of intellectual or developmental disability. We've already really dug into substance use disorder, but a substance use disorder is a medical diagnosis and that it affects a person's brain and their behavior. And someone with a substance use disorder is not able to control the use of their drugs, alcohol, even when it causes problems with their home, health, work, school, all of those things. And then what is health literacy? Health literacy is the degree to which an individual, individuals have the capacity to obtain, process and understand basic health information and the services needed to make appropriate health decisions. So, this is where we're really focusing on how we can support our clients is to build up their health literacy so that they have the capacity to obtain, process and understand the information and that they're able to make appropriate decisions for their health. So, let's dig in a little bit about the current research on the intersection of substance use disorder and intellectual disability. We kind of touched on that in the previous training, but we wanna just review this a little bit more. So, research has shown that people with intellectual disabilities and cognitive impairments is frequent, or people, research has shown that cognitive impairment is frequent among individuals who use substances. So, that means that their brain may be working differently, right? Thus, being able to capture if a person has a cognitive disability is really vital in providing appropriate pathways to care. But we've seen that studies have shown that providers are not screening for cognitive impairments. So, they're not screening for intellectual disabilities and other cognitive impairments. Such as ADHD, dyslexia, dementia, those types of things. So, that further complicates the matter for providers. And they may not be screening for substance use disorder among patients who have a diagnosed intellectual disability or even a cognitive impairment. So, what we found in research is that medical professionals tend to skip over screening of individuals that have a diagnosed cognitive impairment and that includes intellectual disability. So, people with intellectual disabilities face unique challenges related to obtaining healthcare services. And this is really because our systems haven't been set up to accommodate for their needs. The need for tailored services has been repeatedly documented in literature. But more importantly, providers such as yourself may not even be aware of the substance use or if you're working with a healthcare provider, they might not even be aware that someone has an intellectual disability. So, this really creates complication when we're providing care. And that's related to that system of care is the way that it's set up and kind of those siloed. So, it's been documented over and over again that people with intellectual disabilities have difficulty accessing, engaging with healthcare providers. Often, healthcare is provided in very separate systems. So, you go to the doctor for cold and flu symptoms, and then you go to the heart doctor, and then you go to the dietician over here, and you go to your neurologist over here. And what tends to happen is that these care providers may not be communicating with one another, depending on how your medical system is set up and the type of system in which you're engaging. But most often, it's very separate. And what ends up happening is that the patient, the client is required to share all their information with all their providers. And this really creates an issue for individuals that have cognitive impairments. So, as a care provider, as a support staff, it's key that we assist our clients in being able to navigate that system, that healthcare system, that's very complicated, and being able to assist them in sharing their experiences with their other care providers so that they're getting the appropriate level of care. So, additionally, people with intellectual disabilities, they have a higher rate of psychopathology than their counterparts, and this displays a higher risk of dual diagnosis. So, individuals that have intellectual disability, when they have a higher risk of having a mental health diagnosis, which can make, again, as we talked about, that substance use disorder, that can be a contributing factor. Additionally, individuals with intellectual disabilities that do engage with substances have a higher risk of developing a substance use disorder than their peers that don't have an intellectual disability. And there is an overall lack of prevention, treatment, recovery, and harm reduction programs for people with intellectual disability. So, we're going to talk about stigma for a little bit. And so, stigma is when people have a strong feeling of disapproval about something. And so, oftentimes, people have certain opinions about groups and people, and these feelings can be positive or negative. And sometimes, these opinions can lead to a behavior. And in the next few slides, we're going to be talking about and defining and giving examples of what an attitude, a behavior, stereotype, prejudice, and discrimination, what those are, and we'll discuss how these five items may contribute to a person having a strong feeling of disapproval and how they contribute to stigmatizing behavior. And we're going to provide a definition and example for each of these pieces, and what I'd like to note is that when I was developing these slides, these examples were developed from a focus group of people with intellectual disabilities that also had a substance use disorder, and they were in a treatment program. So I worked with them, and we created these examples. So all the examples that I'm giving you are lived experience. Additionally, these slides were developed with clients, so that we could share them with clients. So any of the things that I'm sharing on these slides, I encourage you, as we talked about providing education and resources and kind of that prevention, this is one of those things that you can use that you can engage in conversation and talk about stigma with your clients. So attitudes. So an attitude is a way of feeling or acting towards a person, a thing, or a situation. It's a set of emotions, beliefs, behaviors towards a particular object, person, or thing, or event. You know, this may be a love of sport, dislike of a certain actor, or being negative towards something that you need to do. And an example of an attitude is, if I share my diagnosis, people will think differently about me. So this person thinks that if they share their diagnosis, that there will be an emotional reaction towards them. The person believes that sharing will affect the way they are treated due to a prior established positive or negative belief that they've learned. And behavior. So when we talk about stigma, we usually associate it with specific behaviors. A person performs a behavior. It's how someone acts. It is what a person does to make something happen or change or to keep things the same way. We talk a lot about behavior in the world of intellectual disability. I continually hear, you know, behavior this, behavior that, behavior that. So we should all be very familiar with behavior. And we know that often, you know, behavior is because we want something to happen or we want something to stay the same. It's a response to things happening. And this can occur either internally, like within ourselves, such as in our thoughts or our feelings, or externally. So there's something happening in our environment, including with other people. And so an example of behavior that was given when I was doing this focus group is that my mom is overprotected of me because of my disability. So this person believes internally that their mom is acting protectively because of their disability. And so this person thinks that the environment in which they live is being adapted to prevent them from experiencing their full independence. Okay. And a stereotype. The stigma is usually associated with stereotyping. The stereotype is when we overgeneralize what we believe about a person or a group of people based on what we have been taught or seen. So stereotypes can be hurtful because they are usually not true. So an example would be, quote, people with disabilities can't read. So here's a statement that's simply not true. This is a stereotype. An opinion formed on an uneducated, not well-informed guest. So when I was talking with a few of our clients during the focus group, they said that this was one of the stereotypes that really bothered them a lot. Stereotypes can lead to prejudice. And prejudice is believing those stereotypes and disliking others without knowing them. So people who are prejudiced have a negative or even aggressive attitude towards a particular group for no reason. And the example would be, quote, they put us on the back burner. So this person thinks that all people with disabilities are not important. So now this might just be the person's internal subjective attitude. But nevertheless, it has been informed by the actions that they have observed towards them or towards other people or towards a group of people that they identify with. And so this person really believes that other stereotypes are causing this action and are identifying these activities as prejudice. Discrimination. So another word or action that is defining stigma is discrimination. So we must really understand that the word discrimination means to identify differences between objects, sounds, colors in our environment. But discrimination can be harmful when we discriminate against an entire group of people that has the same trait, such as an age, race, gender, religion, or disability. An example of discrimination was that people think differently about me. They put me down. I have to work harder to be accepted by them. So this person is experiencing being excluded because of their disability, and they feel that they need to prove themselves constantly, to be respected and valued. They must work much harder to earn respect in their community, than people without disabilities. And they've been discriminated against because of their disability. So stigma is when people have a strong feeling of disapproval about something. Sometimes these opinions can lead to a behavior. We just discussed examples of attitude, behavior, stereotyping, prejudice, and discrimination. We shared how these five items may contribute to a person having a strong feeling of disapproval, and how they may contribute to stigmatizing behaviors. All of these examples, attitude, behavior, stereotyping, prejudice, and discrimination, are part of what makes up stigma. So when we think about stigma, related to the intellectual disability population, we talked about some of those negative things in the slides previously, about you can't read, or not being treated the same way. Sometimes I'll hear people say things like, oh, I just love people with disabilities, because they're so loving, they're so kind. That's a stereotype as well, right? That's part of stigma, kind of grouping everybody together. So these stigma, behavior, stereotypes, they can be positive or negative. And one of those stigmas is that people with intellectual disabilities don't use substance. Miranda, you had your hand raised. I was just saying, along with that, we tend to infantilize people with intellectual developmental disability. Oh my gosh, they are so cute. And then we baby talk to them, which I think goes hand in hand with the idea that they can't use substance. You're exactly right, Miranda. One of the things that happens with that infantilization is that it takes away from the individual's ability to make choice about their life, right? You don't have to be a doctor to make a choice about their life. You don't have to be a nurse to make a choice about their life, right? You talked about baby talk. Sometimes doing things for them without asking, just doing it, just going ahead and taking control without allowing them to experience the situation. I mean, a great example would be cooking, right? Like, I'm just going to go ahead and cook this meal versus allowing the individual to cook the meal themselves, right? And maybe providing support during that. And so stigma can affect in the individual in many ways. If people are, for example, when they, one of our clients, when they're talking about behavior and how they're talking about their mother being over protective, it was similar, like, I don't want him to work. I don't want him to go to school. I don't want him to ride the bus. I don't want this. I don't want that. Like, it was because she was so concerned about him having an intellectual disability that it was preventing him from growth, right? And causing a lot of problems in that area. So thinking about stigma with your clients, thinking about maybe your own, like, how you engage with stigma personally towards your clients, how you've engaged with and encompassed stigma in your, as you have worked with individuals with intellectual and developmental disabilities is key as we move forward. When we talk about that infantilization or even stigma, when we're engaging with other healthcare providers, you may experience this. Your clients are experiencing this. If you are sensing this and feeling this, imagine what your client is feeling, you know? It's directed towards them, so it's going to be even more so. So being aware of it is so, so very important. When we think about stigma and substance use, it's really important because we're talking about individuals that have stigma related to an intellectual disability. Then we have stigma related to substance use. You may even have stigma related to a mental health diagnosis. It becomes really complicated. So as a DSP, as a direct support staff, as a case manager, being aware of this is really, really important. And start talking about it. Start talking about it and finding out, like, are certain activities not being done or are you not engaging in certain things in your life that you want to? And how we might be able to support that. Because stigma can be really harmful, right? So how does it affect me as a client, right? So stigma can be really harmful in different areas of our lives. So that emotional area. So it may make it difficult for us to, regarding our feelings and our ability to handle our emotions during those difficult times. Physically, that's related to our body, our nutrition, our exercise, our weight. It may affect how we like our job or our work. It may affect our social connections with other people. It may affect us spiritually. It may affect us intellectually and our brain health and our growth from learning. Environmentally, it can affect us. So that's like the areas that we live, we play, we work in. Do we feel safe? Do we feel clean? Do we have the resources that we need? And it may affect us financially. So if we ignore these areas, it can cause us to feel kind of out of balance. If we're feeling like, if we're experiencing stigma, we're not nurturing one of these areas, we can really kind of throw our life out of balance. And if we keep ignoring them for a long period of time, we can have really significant problems for us. So for example, for physical, if I eat healthy food, I exercise and I drink enough water every day, my body's going to feel good and I'm going to be able to focus on my activities. If I don't eat healthy foods and I don't exercise and I don't drink enough water, I may have high blood pressure, diabetes, headaches, and I may not feel very well. Another example may be for social. If I get out and I spend time with nice and supportive people in my life every day, I may be in a good mood. I may feel really good about myself and the environment in which I live. But if I don't spend time with people, I may start feeling lonely and sad and it may start affecting my self-esteem and it may start affecting other areas of my life. So the next few slides, we're going to talk about how these areas of our life, how they can be affected. So again, I just want to remind you that when these slides were developed, they were developed with people with lived experience of intellectual disability and substance use and mental health diagnosis. And so they were talking, these are examples of how stigma affected them. And so it's important for us to hear the voice of who we're working with. And so that's what these slides are about. So how does stigma affect me emotionally? They shared, I feel embarrassed to talk about myself and uncomfortable asking for help. I feel like people are putting me on the back burner. I get sad and lonely and I carry a lot of pain around. So these are all things that were shared that people felt that how stigma affected them emotionally. And for physically, they shared, I spend more time alone and the stress hurts my body. I live alone. And so no one will call me names and I don't go out much. I may not get referrals for preventative medical care for things like high blood pressure or diabetes. And what about occupationally? I don't have a lot of choices when I look for work. I want to go to school so I can get a better job, but I don't know how to. People think I can't do the job. And socially, they say, I stay quiet. I feel like I have to hide who I am. I have to work harder to be accepted. And sometimes it's hard to make friends. My family can be overprotective when I want to meet new people. And I just want to share, you know, one of the things that was really powerful when I was doing these interviews and these focus groups was the underlying theme of hiding who they were. And I think that that is the biggest thing about stigma is that every single person that I talked to you felt that they couldn't share who they really were. And some of those things were related to their intellectual disability. Some of it was related to their mental health and some of it was related to their substance use. But they felt that they had to hide pieces of themselves. And think about it. If you have a, you know, co-occurring disorders, substance use, mental health, and intellectual disability, that's a big part of who you are and how you're functioning and how you're engaging with your environment. And you feel like you can't share that. And you feel like you have to hide those things. That really affects the way that you engage in your community. So, as you're working with individuals, it's, I think that's an important piece to kind of keep in your forefront of your mind of thinking about are these people able, are the people that I'm working with and that I'm supporting, are they able to be their genuine selves in these environments? Do they feel that they can be who they want to be? And so, how does the stigma affect me spiritually? I don't go to church because I'm afraid people don't want me there. I lose hope when life is really hard. I'm embarrassed to ask for help from my spiritual community. Intellectually, I may have difficulty focusing and making decisions and people don't think I can do things and I can't grow that way. Environment, I have limited choices for housing and health care. My family worries about my safety. Again, you know, I just think it's really important that we think about that housing piece more. Thinking about, are our consumers in safe housing? Do they feel safe? Is an environment where they can thrive in all these areas of their life, right? Socially, occupationally, physically, intellectually, spiritually. Can they thrive in that environment? Often my clients, as I mentioned, their apartments and their homes were in environments where they struggled to thrive in those environments because of the environment in which they lived. We know that environment can affect substance use, right? And so as individuals that are advocating for housing and assisting people to find housing, thinking about that and talking with our clients about, are you going to be able to thrive in this environment? And how are you going to thrive before picking a specific place to live? And then financially, I have less opportunities for jobs and it makes me stress about paying my bills. People don't trust me to budget my own money. So those were all things that were shared about a stigma. I'd really like to hear from the audience a little bit and if you're watching this and as a recording, what I'd like for you to do is just kind of jot down a couple examples from your experience of working with individuals of attitude, behavior, stereotyping, prejudice, discrimination, could be one of those. And then I'd like for you to share with us kind of your experience of what you've experienced. I know that working in this population, I could come up with lots and lots of different examples and unfortunately, I wish I couldn't, but unfortunately I can. But I think it's helpful for us to share and share our experiences. And so I'd like to hear from you guys about some examples that you've encountered of stigma when you're working with your clients. So you can unmute or put it in the chat. I think I don't get the opportunity to be direct with clients. But what I do for the work that I get to do with SOCR is I look at a lot of plans. I look through like shift notes and I work with staff. And one of the things that's become a little bit of a peeve of mine is staff say all the time like when they're talking about their clients, they're talking about the people they support. And it's always with such love and affinity. Oh my gosh, my people love to eat. Oh my gosh, food is their favorite thing. And to me, it's so non-specific. And why are we limiting what can be interesting to a whole human to mealtime? That's something that I see a lot that I think is very stereotyped. Like they see something that brings joy and then that becomes that person's entire personality. And it goes back to that in the first video that we showed of Susan, of opening those pleasure zones, right? Food brings pleasure. Our brain is hardwired to seek pleasure, period. Neurologically, everybody's brain is hardwired to seek pleasure. Food brings pleasure. It opens those pathways. So of course, when we're working with our clients, we're gonna see pleasure when they're eating. But we should be seeing pleasure in other areas of our life. Because we are complex individuals. And all humans are. And so we should be finding pleasure in lots and lots of different activities. And if we are narrowing it down on just food, then unfortunately, we could be contributing to a possible addiction to food, right? Where we're seeking that out and then we have negative consequences. So developing opportunities and exploring ways for individuals to experience pleasure outside of that would be amazing, right? Because then you can be like, oh wow, that you know, just like all, you know, anyone would, you know, we all have different hobbies and interests and not one fits for everybody. But yeah, I think that's a it's a great example. I would see that often. I saw that so much. It's specifically, and I don't know if we have any behavioralists on the line or if any behavioralists are gonna be taking this. I saw that often when I was working with behavioral and behavioral programs, where there was like engagement with food or drink. And one of our big things when I was working was stepping outside of that and looking at more things that brought pleasure to an individual's life outside of that, such as, you know, interaction with people, hobbies, and it really engaging in other outlets. It's really powerful. What else? With behavior too, this kind of pervasive notion that we need to extinguish behaviors rather than seeing behavior as a form of communication. There's two sides to this too that I have experienced. That, yeah, seeing behavior as something to extinguish or control rather than as communicating some things. And that's how you define behavior in the beginning of this. Like we engage in behaviors to shape our environment. Right. And then this wants to, rather than looking at the reason we're having the behavior, it's to immediately engage in, you know, a script or a plan that extinguishes the behavior. Right. And seeing behavior is somehow like manipulative. Right. That's something that I have seen. And then the other piece of that is having behaviors be defining of the person. Right. Especially behaviors that happened long ago. Yes, there was a client that I got to have contact with who had bitten someone and then hadn't bitten anyone for like a decade. Right. And then you hear about the client and the first thing you hear is, oh, be careful, they've bitten people. You need to watch out. And that behavior hadn't occurred for a very long time. And so seeing the behavior as being manipulative or dangerous and then letting it be a defining piece of who that person is. I mean, it really is. It's discriminatory. It's discriminatory and harmful. Right. And, you know, one of the things that I saw often with with my clients is because the majority of them were involved in the legal system. They were, you know, often using substances and were arrested for a crime that they committed while they were intoxicated. And so that follows them. Right. And then also having a criminal record is additional stigma. But one of the things I want to talk about, you know, like with with behavior and environment is that. So often my clients were living independently or living with their families and they engaged in substance use as a way to fit in to their environment. Often they talked about engaging with substances because they wanted to spend time with their cousins, their siblings, their aunt, their uncle, their mom, their dad. And they were all drinking alcohol together. They were all smoking weed together. They were all they were doing drugs together. And so they engaged in that as a way to be a part of the group. This also happened often in apartment complexes where individuals would be you know, they want to engage. They want to have friends. So they go outside and begin to engage with individuals that are maybe selling substances or obtaining substances. And then they then they get wrapped up in, you know, an unhealthy relationship. Right. But they're really seeking relationships and connection. And so we found often in the group that I worked with is that developing healthy connection and support was really, really vital to to navigate that. Additionally, I just want to, you know, I think, you know, when someone is experiencing stigma, one, they can they feel it in their environment. And I think we can think about even our personal selves of like stigma that we've experienced in our lives. Right. And how it affects the way that we navigate and engage. And that's no different for individuals with intellectual or developmental disabilities. I during this focus group, I asked them about which diagnosis would they be more most willing to share to to a care provider or to to anyone. And it was quite interesting. They shared that they would share that they had a mental health diagnosis first. And this was across the board. They share that they would they would share a mental health diagnosis first. They said people are more willing to talk about depression, anxiety now. And so I feel more comfortable sharing that one first. The second one was a substance use disorder. I'm more willing to share that I have a substance use disorder. The last one, and they said they probably wouldn't they would be very uncomfortable sharing it was that they had an intellectual disability. Now, that is telling. That is very, very telling for us as providers. That, you know, a group of individuals telling me I'm very uncomfortable sharing this. I don't want to share it. I don't want to talk about it because of stigma. Because of what they feel that they're going to have to navigate through and and how they feel people are going to react to them because of the diagnosis of intellectual disability or developmental disability. I find that to be really, really interesting and very telling for the individuals that we're working with. So I want to talk a little bit about what we can do to kind of develop pathways of care and to improve the type of care that we are providing. So the first thing is there was a recent assessment of services in the state of California for people with a variety of disabilities, intellectual disabilities and developmental disabilities. And they found that the providers for substance use disorder treatment facilities, they were making the physical adaptions, okay, that were needed to be addressed. So that would be like ramps, handrails, lighting, modified bathrooms. Yet there were no specific policies or procedures concerning adaptions for people with intellectual disabilities or even cognitive disabilities of any diagnosis, right? And this is not a unique occurrence. I mean, this doesn't just happen in the state of California. This happens across the country. I've talked to lots of different substance use disorder treatment facilities and I hear the same thing over and over again. That these adaptions are viewed as a physical adaption, but when it comes to procedures, policies, or even adapting the material that they are providing, that's not occurring, right? So that means that these services are not being tailored to the needs of individuals. And I'd like to point out when we first started, we talked about how individuals that use substances, that their cognition is affected. So all people should be receiving this tailored service because it's not just people with intellectual disabilities, but it's all people, right, that have a substance use disorder, their cognitive abilities are being affected. And so really identifying specific tailored needs and services is so important for them. So we're going back to that health literacy and this is a huge thing. So at the beginning of this training, I said, pick one thing that you can do to change the way that you engage and interact. And health literacy is a big piece of that. I would love if people picked, I'm going to work on improving the health literacy of the people that I work with. So health literacy is a great way to improve care. It is vital for all people. If people do not know how to obtain, process, understand, or know how to even act on the information provided to them by substance use providers, then the person is not receiving equitable treatment, prevention, or harm reduction services. It's the responsibility of the provider to assess whether their client is, or patient, is obtaining and processing and understanding that information. But unfortunately, that doesn't happen very often. And so they, it is their responsibility to provide information that's understandable and that they comprehend. But I can tell you even right now, sometimes I'll go to a doctor's appointment and I leave and I have a hard time understanding what they shared with me. I have a hard time understanding how to read lab results or to understand what additional tests I may need to do or services I need to go. So again, this process of health literacy, this is a struggle across the board. So as a DSP, as a care provider, as an advocate of individuals that are going into doctor's appointments or going into services such as substance use disorder services, helping our clients with health literacy is huge. So one way we can do this, so how do we assess it, right? Like very simple way, one way we can do this is by assessing how the client understands the information. So this can simply be done by asking one question, how are you going to use that information? And then let the client answer. At that point, you will understand, do they, did they obtain the right information? Did they process it? And do they understand? If they know how they're going to use the information appropriately, then you know that they are literate to this health situation. But if they are not able to tell you how to use the information provided in the appropriate way, then that is a cue for you to go through that process again, right? Repeat it. Use different language. Engage with materials that may have color or pictures. And so, you know, one of the things that I think is so important is that oftentimes we rely, as an advocate, as a person who engaged in a lot of medical appointments, I saw over and over and over again, and I have to admit that I was guilty of this as well, is that sometimes we just wait for somebody to ask if they need help. Well, when I was conducting the focus groups, one of the things that one of the clients shared with me is they said, quote, I get intimidated to ask for help because I don't want people to think I'm dumb. And that was really, you know, kind of a light bulb moment because, you know, it is key for us to be able to create an environment where we're asking the right questions to assess their understanding so that we can then determine what additional information, if any, can be provided at that point. So assessing health literacy is huge. It is a game changer for our population because, again, they'll be able to act on this for themselves. And, again, the simplest way to ask after they've received some information is just to ask how are they going to use that information that they've received. It's really powerful. So we can improve access to substance use disorder prevention, treatment, harm reduction services for people with intellectual disabilities by exploring a person's lived experience. So one of the things is to, you know, really, our goal should be to create a space where a person is heard and that the services are tailored for that population. Remember when I was talking about that SAMHSA working definition of recovery, we talked about that it's person focused and that often the language of recovery language and language of the intellectual and developmental disability kind of spheres, we really come together. So when we're talking about increasing inclusivity, we want to, one, not make assumptions about a person's ability based on their diagnosis or the way they look. That goes back to that stigma piece, right? We want to get to know the client, assess their health literacy. We don't want to make these assumptions and, like, create stereotypes and engage in those behaviors based on a diagnosis. So, you know, an example that I'll share that I've heard over and over and over again is about people would say people with Down syndrome, they're so loving, they're so kind and so loving. Well, you know, we're making some big assumptions there. You know, we're making some big stereotypes and some big assumptions based on a diagnosis. I don't want people making assumptions about me based on a diagnosis and the people that I've worked with did not either. So it's important to remember that when we're working with individuals with intellectual and developmental disabilities, sometimes you can't see those things. But it doesn't necessarily mean that they're not there. So I often, when I was working in mental health, it was really interesting because I would hear over and over again from case managers, social workers, you know, so-and-so's not engaged in treatment. So-and-so is non-compliant in treatment. So on and so forth. And, you know, I knew that they had intellectual and developmental disability or an intellectual disability. So I would ask specific questions to the social worker about what, basically, how did they assess the health literacy of the person? And then I quickly would find out that, you know, the services were not being tailored and that they didn't, you know, if they couldn't fit into the mold, then they were just identified, labeled as non-compliant with treatment. And so one of the things that I think is really powerful and something that we can do is to really educate the people that we engage with and that we work with about simple ways to engage clients into treatment. One, by that health literacy, it would be a perfectly appropriate question in a group therapy to say, how are you going to use this information? And it's a way for us to assess it, right? So language is super powerful. It can really affect the way that people receive our services. And so thinking about the language that we use and when we use it is going to be so, so important. So when we, ideally, what we want to do as well is to train people on disability and inclusivity that are outside of kind of our silo. Remember, I talked about how kind of the healthcare system is set up in different ways. And so when we are supporting our clients, working with our clients to be able to advocate for themselves, have them do the training, right? Have them say to the care provider what they need. You know what? I would like to have these instructions given to me, printed out. I'd like them in picture form. Can I record the instructions? Because I like to listen to it over and over again, whatever it might be. But, and we can help our clients to be able to identify what helps them and then have them advocate for themselves. But, you know, when we are talking about stigma, one of the things that we can do is really to address it, right? So as I mentioned, stigma has been linked to clients not accessing services related to disability. It's also been identified as linked to clients not accessing substance use treatment facilities. So it's really feasible and really not far-fetched to assume that many clients are not engaging services if they experience both of these diagnoses, right? If they're experiencing substance use and have a disability, it's really feasible that they are not accessing the services that are needed to help support them because of stigma. So that stigma can really affect the way in which the provider engages with the client or patient. It also affects the way that the client interacts with the care provider or the medical professional, the treatment provider. So we talked about this common form of stigma, this infantilization. And again, it's when someone treats someone like a child or denies their maturity and age or experience. And so often this may look like we are addressing the DSP or we're addressing the care provider or the parent instead of the individual. I can tell you that happened in almost every single doctor's appointment, every single therapy appointment, all the mental health appointments, all of the substance use appointments. That happened 99.99% of the time. People wanted to talk to me and not them. So as the advocate, what did I do? I said, the appointment is with so-and-so. I would just redirect their attention. I don't have to do it in a mean way. I don't have to be rude, but I'm addressing stigma. So the appointment is with, I'm going to just say name, the appointment's with Mary. You can talk with Mary. And then when the question was asked, I would look at Mary, let Mary answer. When the provider was talking, I would always be looking at Mary and engaging with the client in that way. It also can really be this infantilization where an individual isn't allowed to be a person to express their own experiences or their own interests. I would see this sometimes in different kind of care home environments where an individual wanted to go to a specific church, but it didn't fit in the calendar. Or an individual wanted to go to a certain event or be engaged with certain people, but it wasn't, again, it didn't fit into the schedule of events at the home. And that can also be problematic as well. So when I was doing the focus groups among people with lived experience, it was shared that, again, my mother is overprotected. We talked about that, and that was part of stigma. She worries too much, and it makes me feel I can't do things on my own. I'm an adult, and my family feels that I can't make the proper decisions about my life. So when we're working with family members, it's important, again, that we address stigma and that we are addressing some of these kind of common misconceptions that people with intellectual and developmental disabilities can't experience, you know, adulthood, right? And so it's so key that as a DSP, as a care provider, that we are engaging with the people that are involved with our clients' life in a way that we can address stigma and work through that. So when we're thinking about that, how can we take action? How can we take approach to addressing this stigma? One thing is to build awareness. One thing is to build awareness about substance use. So again, talking about it, that goes kind of with that primary prevention, talking about it, educating people, knowing that substance use among people with intellectual disabilities occurs and it happens. Addiction and intellectual disability happens, it occurs. Addressing this bias straightforward is a really great start in general. Tailoring services that encompass the entire agency, so that provide substance use disorder. So when we're, if we're assisting a client to obtain substance use disorder treatment, being able to assist the, you know, from the operator all the way to the back of the room, right, into the group therapy room, being able to provide information about how to build rapport and to engage in a welcoming and appropriate manner is vital. And so we can do that by example, and we can also do that by engaging with the care providers and providing resources to them about how to tailor services and to create an environment where an individual will feel comfortable asking for help or asking for clarification or questions, right? That's so vital for individuals with intellectual disabilities that they feel that they are comfortable to ask those, ask for help or ask for assistance. So some of the ways that we can do that, do this is one, we recognize and engage individuals and give some training to the other care providers about cognition level. Again, we talked about cognition. Cognition is, you know, the ability or the way that we learn, right? So sharing how an individual learns and teaching the individual how to advocate, to share how they're learning, their best learning styles, that's going to be key. So if it's listening, so that means they need to record something, if it's role-playing, if it's engaging in reading it over and over again, practicing all those skills and engaging our substance use disorder treatment programs to practice some of those things, right? And as a DSP, one of the things that we can do is kind of help them along the way. Hey, you know, you can advocate for yourself by asking if you can get the questions, like, can you get the topic of group for tomorrow so that we can practice it tonight? Like, that would be a great tool that a DSP could use and help their client who's going, you know, in treatment. Again, maybe it's providing a quick training on, you know, language skills, literacy, a number of concepts, you know, to the treatment center, right? It's, for example, you know, one of the things that I found is that in substance use disorder treatment, they use a lot of metaphors to explain addiction, explain the addiction cycle, explain addiction. And that was really difficult for a lot of my clients. And so we would work with treatment providers about not using metaphors and using more concrete language and examples. Sometimes metaphors work really well with individuals, but a lot of my clients really struggled with that. So it was important for us to be observant and to see when individuals were struggling and so that we could talk about that. Often my clients would engage in treatment, they would have a staff with them. And so after the sessions, they would engage, have a one-on-one session with their direct support staff. And that was a great time to kind of clear up any confusion related to language or literacy, number concepts, those types of things, right? Additionally, memory can be of concern. So if your client's having difficulty with memory, sometimes having cue cards. So we would often practice, we would get the topic for the group therapy session, the treatment session ahead of time. We requested that from the centers that we worked with. They would give it to us. We would work with our clients, but some of them would have memory concerns. And so we would kind of have cue cards for them so that they would be prepared to be able to engage in treatment the way that they wanted to engage. And so sometimes what would happen is we didn't do those things, and that's when we would get that they're noncompliant, they're not engaged in treatment. Well, they're missing some key points or they feel uncomfortable because of stigma, right? So one of the things that I really want to do as we move forward here is I want to talk about a couple examples of clients, these are real-life examples that I've worked with, and kind of come up with solutions or ideas in which we could engage or provide support for our clients. So what I'm going to do, I'm not sure if it's going to work in this screen. Let's, no. Okay, I'm going to stop sharing. I'm going to share on the other slide. So hold on just one moment. Hi, my name is Sam. I use he him pronouns and I'm 38 years old. I'm kind of a quiet person and I don't have many friends. When I was growing up, I was in special ed in school. I had two friends there, but I graduated when I was 22 and I didn't see them anymore. I stay in a group home with three other people. There are staff members that come to check on us and make sure we take our meds and stuff. They help us to make food and clean up. I have to take meds because I get really nervous all the time. A job coach from the program helped me to get a job at a grocery store doing stocking. Having a job is hard because sometimes I have trouble reading the labels on stuff or a customer will come and ask me a question and I don't know the answer. I get really stressed out if I have to ask for help because I don't want people to think I'm stupid. I used to be so worried about messing up at work that I would miss days every week. A good thing about my job is that I have one friend there. We like to watch movies and collect cans to turn them in for money. One time I had missed so many days at work that I got in trouble with my boss. I got so scared about losing my job and my friend shared a medicine with me called Vicodin to help calm me down. It really helped me. My friend gets it for me and I use it every day now and I have hardly missed any work in a while. One time I ran out of the Vicodin and I got really sick like puking and stuff and I was even more nervous than normal. Now I make sure I don't ever run out because I don't ever want to feel like that again. Don't tell anybody I told you, okay? My friend said that they can get in trouble if other people know and I don't want them to get in trouble. All right, so one of the things that I really want to point out in this, in that example, is that Sam was really, one of the key things that you kind of heard through that was that connection piece that we've mentioned before. He was connected at school, he had friends, then he began working, he had a friend, and he's concerned about losing that friendship again. So when working with individuals that are experiencing that connection, they're really seeking that connection, what is something that we could do to help support Sam in that environment? If he came to us and said, please, I don't want to get my friend in trouble, and you're finding out that he's also using Vicodin, what are some things that we could do to help support him? Is it, I see Callie and is it Rich or is it Adam? You can either type it or unmute. Sorry, my computer froze. Yeah, I just wanted to kind of hear what you might do, what would be your, some ideas that you might do to help support Sam? A lot of what it comes down to when dealing with something like that, at least with my clients, I only have a few that are on that level of Sam, where they can go out and work and they can communicate their needs. So mostly what he, one particular client I'm thinking of, is he just wants somebody to talk to and to listen to. And he mainly listens to people that he believes are in authority. So because of my position, it makes it easy for him to come to me and he talks to me about stuff. And I can provide him feedback. And he will take it well in regards to how if a staff provides him feedback, he'll most likely get upset. Right. Because he'll think that they're talking down to them, to him. And I'm kind of thinking like, if Sam came to you and shared that he was using, Vicodin from a friend, what do you think your next steps might be at that point? Well, I'd have to get more information from him because I'd be concerned about the Vicodin. I'm not a nurse. I don't handle the meds. And I don't know how the Vicodin might affect any medication he does take. Because let's say that Sam takes antipsychotics. There's a lot of difficulty that comes from when you mix medication with that type of meds. And so there's a possibility that Sam could get injured, get ill from taking that Vicodin and mixing it with what he already has. So I would really want to talk to him and gather that information so that I can better serve his needs. But I also want to make sure that I'm being empathetic with him. I don't want him to feel pressured. I don't want him to feel like he's doing something bad. Right. One of the things that I would encounter, I understand your situation where you talked about your role and you're viewed as an authority figure. And then other people that are engaging with him that he feels maybe aren't authorities and causing tension. Right. That's a common experience that I could see. And I've seen it. I've seen it before in my practice. One of the things that I might do in this situation would be to talk to Sam about, let's say that Sam lives in a kind of independent living with a few other people and DSPs come in and out throughout the day. But I might ask about who are you most comfortable out of all the staff that comes in and works with you? Who are you most comfortable with talking about with me? I'm going to be there. I want to support you. And then empowering another relationship as well to occur in that environment, because Sam's going to need a lot of support through this. And so I would try to nurture some another relationship as well, because you're not to be able to be there all the time. Right. And then that way, Sam's feeling in control of that relationship and then bringing that person in. Right. And kind of building that relationship up, going on. I would definitely have Sam assessed by, I think that's great feedback that you shared, assessed by a medical professional. Again, if Sam's on multiple medications, this could be really harmful to just cold turkey. And Sam also shared that he got really sick when he stopped taking it previously. So it would be really important to have him assessed by a medical professional and move forward there. And then, you know, from that point, what I would do is I would begin to engage Sam in other relationships, other friendships, trying to develop other relationships. Over and over again, Sam shared about relationships and how those things were important to him. So creating opportunities. So if I was a, you know, care home provider, I would be creating opportunities where he would be able to engage in other healthy healthy relationships that may be with, like, I'm trying to think like maybe Special Olympics, it may, maybe he doesn't want it. My clients would not go, that I worked with, wouldn't go Special Olympics. So I give that example, knowing that my clients would not go. But mine would, mine would definitely go to a coffee shop. They would definitely go to poetry readings, or they would definitely go to farmers markets. They would volunteer for lots of different things. So as a care provider, that's what I would, I would start creating opportunities for engagement outside with a different person. Callie, let me read yours. I would remind Sam, I'm a mandated reporter and I expect he has his friends, but I'm concerned for his safety. So I'm, you know, I guess you could technically do a adult protective services report, but I'm not sure that if Sam is engaging in substance use on his own volition, like he's choosing to engage in it, then he may, they may not do anything. I also have concerns that it wasn't actual Vicodin, Fentanyl. Yeah, yeah. Okay. I also have concerns that it wasn't actual Vicodin, Fentanyl is everywhere, informing Sam of the real risk of not only real medications, but the fake ones. I think that's great, Callie. That is a huge piece. Like we talked about with that harm reduction. I do this even with my own kids and college students and students all over. I will show them the real pill versus a fake pill and ask them, like, we have them try to do identification. And I'll tell you right now, they can't, they can't identify. I can't identify it. And so, you know, you may do some education on, on that. I think that's great. I think it's great to provide Narcan, especially if you're concerned it's doing Vicodin. He may be on other prescription opioids. You don't, I mean, I don't know. I'm not, you know, I don't know his medication list, but he may, um, it may be a fake pill mixed in there. Right. So, um, all of those things would be really key to, um, to engage and talk to, um, I think the key at this point with, with Sam is one of the things, you know, that I would hear often with my clients. And I think this is a good example is not wanting to get other people in trouble, um, especially people that you care about. Um, and so engaging, I think Callie, you make a great point. When we're working in the environment, we are mandated reporters. So some things are definitely going to need to be reported. Um, what they do with it is up to them that point. But I also think that it's important that we are creating a trusting environment for Sam so that with multiple, um, staff people, so that he's feeling comfortable to, um, to engage and to talk about what he's experiencing. So, um, we are just right, we are right there on time. So what I, um, in, in closing, I think it's the key points that I want to really drive home, um, is that substance use and intellectual disability, it occurs. Um, it's, it's not one or the other way it happens. Remembering that our clients are navigating through many systems of stigma to obtain treatment, to engage in, um, in care and that the care is sometimes subpar. Um, and that as advocates and as, um, DSPs and care providers, our role can really assist in helping our clients advocate for appropriate, appropriate care, appropriate screenings, appropriate, um, recovery programs and appropriate treatment. So sometimes we have to step up a little bit, um, and give a little bit more information. Um, and again, that health literacy piece is so important when we're engaging with our clients. Um, you know, as Callie said, talking about fentanyl and giving an information, like as we give that information, we work with a, you know, a medical professional and they do an assessment, finding out how they're going to use that information would be really, really important. Are they going to test their substance? Are they going to, um, try to come off of it? Are they, you know, what are those things, right? Um, we may want to look at doing some counseling services for Sam as well, and looking at some behavior cognitive things to deal with his anxiety. So there's a lot of things that we could do, right? But I think the key is sitting down as a team and really focusing in on creating that individual plan, um, and then being able to help, um, advocate for that plan to happen and advocate with the client to, to navigate it. So thank you so much. Um, there is a survey that's been placed in the chat. Feel free to fill that out. Um, but thank you so much for, um, engaging and participating today. And if you have any questions, I will, um, put my email in the chat. And so if you have any questions, feel free to reach out to me. Um, but thank you so much for your time. I appreciate it. Thanks, Lorianne. Thanks, everyone. This, um, right, this recording will be available in about two weeks, and I'll, I'll be sending that out. Thanks so much, Emily. Thank you, Lorianne. I really appreciate all your work, um, and that you're willing to share this with us. Thank you so much. Thank you so much. Everybody have a great day. You too. Bye.

Emily Mossberg

Laurie Ann Eldredge

Opioid Response Network

O-RAN

SAMHSA

substance use disorders

intellectual disabilities

developmental disabilities

addiction stages

prefrontal cortex

stigma

prevention strategies

harm reduction

treatment strategies

direct support professionals