So, yeah, good morning everybody. Welcome back to our, I know this is our 2nd one with ORN, it's really our 3rd because we did the de-escalation one that was even before this one. So we are going to talk today about harm reduction. So, let's see. Logistics wise today. Yeah, well, it's the 9 to 11, we'll take a short break somewhere in the middle, just to kind of give us a break from staring at our computers. And then we'll end a little bit before 11 to give you some time. As always, do your best to take care of yourselves through the process if you need to get up and stretch. If you can have your cameras on, great, we'd love to see you, but of course do what you need to do to take care of yourself. Please ask questions. I want this to be a discussion as we go through, we're a pretty small group here so we should be able to stay on target, on task, even if we have some questions or even go down some little tangents here and there, that's okay. Because harm reduction is a big topic, it's something, it's a huge part of what you all are doing. So I definitely want to have a dialogue around it. Okay, so, well, we've been introduced to the ORN, so I can just kind of reminder with this, it's SAMHSA funded. It's built to help with technical assistance like what we're doing here, education and training as well. Each state has its own technology transfer specialists, such as Emily. And here is the, the website's probably the best way to get, if you want to request. I mean you already have the, you're getting some services here but if you ever want to request more services or for a different agency, you can go to that website, there's a giant orange button that you can push on there to request, put a request in. Email and website tends to be the best. I know another tech person tried calling the phone number and we're not quite sure where that goes. So I would recommend the email or the website. So our objectives for today. So we're going to introduce the concept of harm reduction, because folks have some different ideas of what it is and what it isn't and there can be some feelings around it. It's also helpful to kind of look at some of the history of it because it has a longer history than, than many of us realize and it started in places that we don't necessarily remember. We're going to look at why it works. And why we do it, because it is really important especially something like harm reduction where progress can be slow and it can be really hard to see it, what's happening. It's important to be able to have that anchor of, we know this works and this is why this works. We're going to look at the history of harm reduction, which is, it's an interesting history that it's gone through in fact some of the earliest harm reduction actually started here in Tacoma, Washington. We're also going to talk about the myths that are associated with it. And then also looking at harm reduction and supporting change. So diving into harm reduction. So, yeah, to define it, it's an approach in behavioral health, which works to meet people where they're at while supporting positive and incremental behavior change. So it's not forcing something on them. Instead, it's kind of seeing where what they're willing to do and where they are at and figuring out how to, what are ways that we can help them move forward in ways that they're willing to or are interested in moving forward. We're going to look at strategies and resources that reduce negative consequences of harmful behavior. This is the core of harm reduction, because we're looking at ways to... We're looking at behaviors that are potentially harmful and how do we reduce that, the risk of that harm. And then we're also going to center on compassion, dignity, respect, and consistent positive regard. And that last one is probably the most important part. All the work we do, it can be really challenging because for many, many different reasons and finding ways to remain consistent with that positive regard is really crucial. So, we actually see harm reduction in almost every day. One of the ways that it originally started was seatbelts. There was actually Ralph Nader, a huge proponent of seatbelts. It's kind of something that people don't realize about Ralph Nader. That's one of the ways he became well known. And seatbelts and speed limits are both examples of this because you think of driving a car is inherently risky. Putting sunscreen on, because yeah, being in the sun is risky. And what are ways that we can mitigate that? Of course, birth control is definitely something there. Cigarette filters. Yes, we can debate whether or not the filters are actually helpful or not, but they are at least an attempt at harm reduction. But we look at this in many different ways. You can look at this even in some things around gun use, around putting guns in safes or having locks on your guns. Yeah, there's all kinds of things where we look at, there's something that we're doing that has an inherent risk, but we don't want to stop doing it. So, what are the things that we can do to make it safer? So, yeah, and behavioral health, it refers to reducing harm in high-risk situations. So, some parts to this with harm reduction, it acknowledges that substance use happens, that it happens on a continuum, and progress can be made anywhere along that continuum. So, what it means by it happens on a continuum, there are going to be some folks that are using really problematically, really heavily. There's a lot of danger and risk in the way that they're using. And then there are going to be folks that dabble in it a little bit, and every point in between. And with any one of those places on that continuum, progress can be made. So, the purpose of the picture on the side here goes to this, of recognizing that small victories build on each other and propel the person forward. What I think of with the ladder here is, the ladder on the left is harm reduction versus the ladder on the right is abstinence-based approach for substance use disorder. So, you can see there's all the little tiny rungs, and so it makes it easier for the person to reach it, whereas with abstinence, we're setting this really high bar that may be out of reach for folks. And so we just set them up, unfortunately, for failure, because we're actually demanding that they do something that's actually not possible for them in the moment. Which is where hair kind of stands in contrast to the abstinence-only approach. Yeah. So, the trouble with abstinence, it actually doesn't work for the majority of people. It only works for about a third of folks, at best. And so, and even that, there's questions in there. And so, we recognize that piece of just, can we just get them to stop? Unfortunately, it's not really possible. It doesn't tend to work. And unfortunately, the other problem here is it creates this dichotomy of success. So, it's a black and white, either success or failure. And whereas harm reduction allows there to be a little bit more gray area, which is really important for being able to help people move forward. And ultimately, this leads to a case of the efforts. So, it's really where, yeah, you can see there's just, what's the point? So, our philosophy with this, some of the tenants are honoring the dignity and humanity of all people, regardless of what their status is, and making sure that we remember this piece. We also believe that people are capable of change and will do so when they're ready and when the circumstances allow. So, no matter what, never letting go of that chance that they are going to be willing to change at some point, or there's going to be some change that they're willing to do. And our goal is really just to figure out what that is or be patient and wait for it. Looking for nonjudgmental, compassionate care and consistent positive regard. So, this is a big piece of this of, no matter what, even if it looks like the person is, quote, failing, which we don't want to use that terminology, but if it's looking like they're not going well, making sure that we hold them in positive regard. I like to, and this is going to come up when we talk about motivational interviewing, one of the ways I get out of this is change the question in my mind from what's a matter with you to what matters to you. And kind of looking, okay, you're having what looks like a rough time, or for some reason it's seeming like using a lot of substances right now is a good idea. Help me understand what that is, why that seems like a good idea right now. And that will lead me to what matters to them. Our focus is keeping people safe and alive. That's the goal of harm reduction is, no matter, our goal is, above all else, do everything we can to keep them alive. The maximizing quality of life is, of course, in there as well, and it's right there behind keeping them alive. And figuring out what are the ways that we can ease their path and make it, their life, at least a little bit better, if not a lot better. This really, we have to remember that they see, they are the expert on themselves, and they have to be the leader of the process, because if they're not the leader of the process, it's not really going to go anywhere, unfortunately. Because they're not going to have buy-in, and that, in the end, it just, the change won't be able to sustain itself. And then harm reduction philosophy also defines success as any movement towards positive behavior change, whether or not it has anything to do with substances. It's anything that's, okay, yep, you know, hey, they're relating to people a little bit better. Hey, they're making sure that when they use, that they've got someone around, or they're taking care of things before they get high. Anything that might be the case. And realizing here that at every moment, someone is doing the best that they know how. That goes back to that piece of, for some reason, that amount, increasing their substance use is a good idea for, or feels like a good idea for them right now, because they're trying their best, they're doing what they feel like is the right thing for themselves in the moment. And there's something that makes that seem like the right choice right now, whether or not it is, though. Is another question. And then realizing recovery is an ongoing process and is nonlinear. And this can be really challenging. When I work a lot with folks in harm reduction, especially if they come from an abstinence background, I've had someone said, a supervisee said to me once, it feels like I'm a rat on a wheel. And what they were talking about was the fact that it just, because of this nonlinear piece, it can feel like you're just, you're not making progress and that you're going in circles. The part with this, though, is that yes, even though you may be going in circles, and it may be one step forward and two steps back, the hope is over time, over the long period of time, you are going to generally see them moving in the right direction, even though it may not be as fast as you'd hoped. The part that's interesting, though, is that the change doesn't happen in a steady fashion either. Sometimes it just clicks and boom, the shift happens, but it can be a while. So some pieces that kind of review here quickly, kind of remembering addiction is a chronic disorder of the brain. And so it's something to recognize here. And it's helpful to remember this because here other brain disorders include schizophrenia, Alzheimer's and epilepsy, that it's interesting because with schizophrenia, which many of you are working with folks that have schizophrenia, we realize it's the illness, but it's easy to fall out of it with substance use and start to blame them for the action because they're the ones taking the substance. But if we can keep remembering that it's a chronic disorder of the brain, we don't want to blame someone for their symptom. Yeah, definitely shares same features as chronic illnesses, heart disease, diabetes, asthma. Can tend to run in families. So there's a heritability or there is evidence of a genetic component to it. But there's also some of how the environment that they're brought up in onset and course that is influenced by environment and behavior. So the environment that they're in is going to have an impact. You see this all the time. The ability to respond to appropriate treatment, which usually which usually included medication and long term lifestyle modification. So that's what's pointing here is that it's like other conditions. It tends to do best with proper medication as long combined with significant lifestyle modifications. So some statistics about addiction. So 60 percent of people entering treatment will have a recurrence of substance use. So it's more than half. Now, you are working in an environment where there are folks maybe using more. They haven't actually stopped. This is even when they do get in. It's a lot of them tend to have we might use the term relapse. Relapse isn't the greatest term because it's kind of stigmatizing. It says there's either in or out. It's a binary term. Instead, we would say 60 percent of people have a recurrence of use or return to use. So this is their recognizing and it's interesting when folks are using a lot of substances or struggling with substances, there's this tendency to want to back away. Oh, just let's let's let that run out. I actually need to lean in a little bit more because it's Jenna and this is similar to even behaviors that are happening. The person that you least want to give the attention to is the person that probably needs it the most. And if they're using a lot of substances, that's a sign that they're they're needing more support. So and luckily, this doesn't happen where you're at, but it's unprecedented to discharge individuals for having symptoms of a condition for which they're seeking treatment. It's something that, yeah, kicking folks out for using it's you're kicking them out for having a symptom of the condition you're supposed to be treating them for. That's it's backwards. And then discharges for substance use put clients at high risk. So, yeah, and this I imagine you're kind of aware of. But, yeah, putting them back out because that's going to mean that they're back out on the street. Just like other chronic conditions. It's just, okay, yeah, these lapses happen. Sometimes there's a treatments not quite hitting the mark, right? Or we're not doing it. Just like other chronic conditions, there's lapses that don't indicate failure. They're just a re-emergence rather they signify the treatment needs to be re-evaluated and adjusted. It's just, okay, yeah, these lapses happen. Sometimes there's a treatments not quite hitting the mark, right? Or we're not doing it, what we need to do. So it's common for folks to move back and forth. Remember, progress is not linear. So what is needs to be adjusted? So we have to think about why people use substances first and foremost. So here we're going to talk about how addiction is a biopsychosocial disorder. And so what this is referring to, if you're not familiar with that, it's the biological, psychological, and social components. And so it's meant to be a way of looking at this holistically of all of the spheres of influence on someone. So from a biological factor, we can look at genetic factors, pain. Those tend to be some of the bigger ones. And you can imagine with opioids, they might start with pain because they're pain relievers, and then it ends up growing from there, but it can also be emotional pain. Of course, there's psychological, which is unaddressed trauma, stress, and incredibly high levels of shame. So sometimes I've had a supervisor once call and say, yeah, that she basically saw addictions as a shame-based disorder. I would agree. There's incredible amounts of shame. It's part of what makes it really difficult for folks to talk about their substance use is because they're really ashamed of it and they're afraid of what you're going to think if they open up and discuss it because they may have had to do that with certain other folks and have been judged. And then socially, is it boredom, loneliness, is there something in the environment that they, like violence or poverty, that they're needing to cope with? But it's usually multiple things. It's usually, it's not unusual for there to be something from the biological, psychological, and social altogether or all of them. So how can we help identify and address the factors? So here's an important one and it is another one to kind of hold. The substance use is a symptom, it's not the problem itself. And so, yes, we'll talk about harm reduction and what's going to look at their use and talking about it, but if we can get out of our minds the fact that the substance is the problem, it's not, it's a symptom, it's there because of something else, it's the other thing that, the other thing or things that need to be addressed. Which is where it gets us into harm reduction and why it works. So let's talk about trauma a little bit here. Because trauma is, it's a subjective and, and is defined uniquely by each individual. So this, it's kind of a broad term. Now, these parts here are something to note to help someone define whether it's a trauma. It usually is marked by feelings of powerlessness and fear. And this is important because trauma can be a little overused in some ways. The tricky part is, it is subjective. And so if someone is saying it's traumatic, we have to believe them and work with it. The example I have is, I have, there was, I was doing a suicide training one time and someone brought up that they, they were on a call line for suicide and someone had called in that was thinking of suicide and because they had gotten a B in, on a test. And this is an example of trauma being subjective. Because if the person on the line had said, that's not a, that's not an emergency, you would have lost them. And so this is just remembering that even if you're feeling like, yeah, I don't quite feel like that's a trauma, we do need to look at it. So here, helpfully helpful, if anyone's wondering whether they've been traumatized, something you could ask them is, were there any feelings of powerlessness or fear? So SAMHSA has worked with stakeholders really to try to create a broad definition that works. And here's what they've got. So individual trauma results from experiences that an individual perceives as physically or emotionally harmful, and that has lasting or adverse effects on their functioning and well-being. It's pretty good. Sometimes I've heard folks say like big T, little t, like big trauma, little trauma. But it's up to you to kind of where you want to go with that. But it's up to you to kind of where to work with that. ACEs, so adverse childhood experiences. Some of you may have heard of these. And what we're going to talk about is a study that used the ACEs questions in one of the largest studies, it was called the ACEs study. So it was a collaboration between Disease Control Prevention and Kaiser Permanente in California. They, through the study, they found that there was a correlation between trauma and poor health outcomes later in life. So people with severe behavioral health disorders die approximately 20 plus years earlier than the general population. And the ACEs are measured by experiences in 10 categories of potential trauma. So it's a specific questionnaire that has 10 categories. The categories are, it asks about verbal abuse, physical abuse, sexual abuse, physical neglect, emotional neglect, divorce, death, loss of a family member, incarceration or of a parent or household member, substance use in the household, mental illness in the household, and lastly, domestic violence. So you get a score when you take this questionnaire. And depending on how high your score is, it says how many ACEs you have and how much risk you're at. So they found some pretty stark and unsettling information, if you will, because it's a lot of data that they got back. So people who have ACEs scores of four are, four is really an above, kind of a minimum of four. 242% more likely to smoke than folks that had less than a four. So it was just way above. Smokers were way overrepresented in that group. 222% more likely to be obese. 298% more likely to contract an STD. It's getting to these astronomical numbers here. 443% more likely to be addicted to illicit drugs. Yeah, develop an alcohol use disorder was 555%. And then lastly, the big whopper is 1,220 times more likely to die by suicide or to at least attempt, not die, but to attempt suicide. So it really jumped out. This was a huge study. It really drove home the effect of trauma and what trauma does to folks, but for mental health and for substance use. So where they pulled from it. So further with this kind of looking, I love that picture there of an inner child. I don't know where that art installation is. It might be at, it might be at Burning Man. It looks like it's out in the desert, but what we perceive to have decisions. So kind of coming from it, what we're, we perceive to be bad decisions or coping skills are actually survival skills. And I think I've had discussions with all of you on this of recognizing a lot of times what there there's real, there's a grain of wit and brill and intelligence and what they're doing because it really is survival skill that they're actually engaging in. So attempting to stop using without addressing the underlying causes, which we're looking at traumas here, we'll set them up for failure because what we're doing is we're taking away their ability to cope and something that's helped them get by and manage the difficulty, the difficult things that have happened to them. It gives context behavior outside being broken, junky, weak, because it really, it gets to the core of here's what they've been through. In fact, it's incredible that they're still alive. And a reminder that, again, and this, we'll say this a few times that the substance use is the symptom, not the actual problem. This study really did bring that home. So why harm reduction works? So people with a history of trauma often carry a pervasive sense of internal shame. Sometimes we call it like the sticky floor of shame where we can't, when you get in and you're trying to work with someone that has significant history, they just get stuck in their shame. Shame that they survived, shame that they should have done something different, shame that it's interesting because you look at it, it's like, how can you judge yourself this way? But it's so pervasive and common. Talk about survivor's guilt is sometimes a form of this, the shame around this as well. And where, so what's causing it is the trauma first, then there's the powerlessness and there's just something about to realize we were powerless somehow gets distorted into us taking ownership of what happened to us. And we even see this in society, like certain things where we'll say like, oh, if someone is assaulted, it's like, well, what were they wearing? It's like, well, that doesn't make any sense. But how did they have ownership of the fact that they were assaulted? Where it's baked into culture somewhere where we tend to shift things onto the survivor or victim. And that this just drives more shame. So something that's really important here is with distinguish that distinguishing between guilt and shame. Guilt in some ways can be productive. And the reason is it's focusing on the behavior. So you can kind of pick it like, let's go light here, feeling guilty about eating too much chocolate. That's focusing on the fact that you're eating more chocolate than you would like. And maybe I made the mistake of, oops, I ate more chocolate than I meant to. And caused by behaviors that violate our values. And caused by behaviors that violate our values can be healthy. So here it's a motivator because we could talk about, OK, this is reminding me that I want to eat less chocolate. And so it can be, oh, I made this mistake once. Let me think about how I'm going to do something different versus shame about it. Oh, I'm such a piece of shit because I ate chocolate. I, God, I'm just awful. I can never do it right. And then it just, there's, what's the point? I'm just worthless. Why? I can't stop myself. So that's the difference here of guilt versus shame. And in fact, we try to move to guilt if we can. And in a weird way, it's more progress. More progress because there's something you can do. You're not, you're empowered to make changes with guilt. With shame, because it's so like ingrained into you as the person, it just keeps you stuck. The problem is, is that what most of the folks that we're working with are just burdened and bogged down in immense amounts of shame. And then we get into the cycle of shame and addiction. So individuals with a deep sense of shame are linked to rates, higher rates of substance use. So, because you can think about it of what's the point? Why don't I just go get high? At least then I won't feel bad. And in some ways, more than some, that's actually taking action because it's trying to pull yourself out of the shame. Which unfortunately then leads to the addictive behavior, gives you temporary relief. But it makes things worse later because it's not actually addressing the shame. It's just kind of numbing it. For now, it's pushing it all to later. Which then means that you feel more shame, which makes you want to use more, which makes you temporary relief, and then it keeps you going in that cycle. So, yeah, it's a self-medication, trying to medicate away the shame. Unfortunately, yeah, it causes this downward spiral that we just spoke of. Now, this is where harm reduction comes in. By providing a nonjudgmental, compassionate care and empathy, we're providing, it's an evidence-based practice. Just providing empathy is. And it works by targeting the shame and promoting connection, breaking the cycle. It pulls people out of that because it's all about the connection. Because it's one of your stepping in and saying, no, I accept you. I see the good person in you. I see the value. I see the survivor in you. I see how you have incredible tenacity. And it's really pulling and seeing the person beyond or that's buried under all of that stuff there and making sure to speak to and work directly with that person. So, I mentioned the seatbelts piece, but it crossed over and the seatbelt thing is actually back into the 1960s, where we see harm reduction coming over into health was largely during the AIDS epidemic or the HIV epidemic in the 1980s. There was education efforts at first. Just teaching people to make good decisions. The hope was that that would change behavior. It didn't work. So, because they used a one-size-fits-all approach, it really had minimal success and it did not account for the context of behaviors to make change and barriers to doing so. And then, morality tightly woven into HIV prevention, forced abstinence-only approach, and the resistance to any interventions which appeared to condone drug use or sex came in. And so, this is in the 1980s. It was kind of the first sort of way into harm reduction. It didn't, unfortunately, didn't go particularly well. And we got posters like the one we have on the right here. Not great. Yeah, very judgmental. So, thankfully, harm reduction continued to try to push ahead, even though it didn't go well there. But despite knowledge of HIV diagnosis and continued to rise. So, this is kind of where it didn't work. After hearing of successes in Europe and the U.S. and the U.S. and the U.S. and the U.S. There started to become some more attention to the possibility of syringe services programs, SSPs. They weren't legal, but they started to pop up. In fact, and this is where it was 1988 when the first legal SSP was established. So, there were plenty of illegal ones first, before this one. But the very first legitimate legal authorized one actually occurred here in Tacoma in 1988. That's actually up on the hill. I don't know if it's technically hilltop or if it's actually more stadium district, but it's down off of Tacoma Way. The location is actually still there. The first illegal one was two years earlier, and that actually was in Connecticut. Today, there are more than 400 syringe services programs in more than 43 states. So, plus Puerto Rico and Washington, D.C. So, syringe services programs, if you're familiar with these, to put kind of reviewing some of the stuff here. They provide supplies, educational referrals, and promote using in the safest ways possible. The services hopefully include, and we can talk about whether you're seeing this, free legal and anonymous needle exchange, risk reduction supplies, including cookers, cotton, sterile water, condoms, possibly even pipes. And then, of course, an overdose prevention and education. Hopefully, it provides Narcan. Even some of the locations are hopefully having the outside dispenser. Vending machines, I know that's making its way in. Counseling for risk reduction. Referrals to all levels of treatment. And free infectious disease testing and referrals. And lastly, connections and referrals to medical care. And then, this is also kind of where you come in, but yeah, referrals for So, syringe service programs, they save lives. And it's been proven by the Centers of Disease, the CDC. It's for more than 30 years, and it's routinely found all of these outcomes. But providing testing and counseling and needle exchange, it's been proven to save lives. All of these outcomes. But providing testing and counseling and needle injections has helped prevent outbreaks of many diseases. 50% decline in the risk of HIV transmission. Users who are three times more likely to stop injecting drugs. So, it actually helps people work towards stopping. And this one, law enforcement, they prefer it, because benefits from reduced risk of needle sticks, no increase in crime, and the ability to save lives. And then, there's two similar cities that were compared. One with SSP had 86% fewer syringes in place in parks, in places like parks and sidewalks. So, they do reduce the amount of syringes that are out and about. Which gets us to some myths about harm reduction. So first myth, addicts and alcoholics are lazy people with no self-control. Reality, the idea of addict is a myth. We're all addicts or none of us are. It's kind of this non-binary, what they're referring to here, I say with coffee or caffeine, there's probably all, we all drink, I have my cup of coffee in the morning, I will get headaches if I don't. But yeah, it's a myth to really think of addict. In fact, it's really not a scientific term and that's why we tend, we prefer to say substance use disorder. Addiction is about self-medicating, usually for circumstances that overwhelmed our ability to cope. It is a normal human response to abnormal circumstances. So in other words, it's a way to cope with stuff that most of us won't encounter, thankfully. And then this dot, I want to, so it's somewhere between 70, the 90%, this was pulled and I don't, I'm not totally familiar with national council, but yeah, this was provided for me. Those 90% of folks treated in public behavioral health have a history of trauma. I've seen stats from SAMHSA that say it's like 70%. Whether it's 70 or 90%, it's way more than half. It's the majority of folks that are coming through the door. And that's the important part. That's the important takeaway here is it's actually safer for us to assume that someone has had a trauma than to not. And actually it's kind of like assume that they've had a trauma until proven otherwise, essentially. And there's really no harm in treating someone as though they may have had a trauma because really you're being supportive, avoiding shaming them, making sure that they feel like they're in control of their services. That's going to be good for anybody. And then as I said, we'll repeat this a number of times and it is true. It's the addiction is a symptom or the substance use is a symptom, not the problem itself. Second myth. This one's a common one. And I even hear some of their concerns like, are we just allowing them to use or are we just enabling them? And some of you may have even had this thought, and that's fair, but it's a myth because the reality shows that research has shown that harm reduction services do not make drug use worse. And they don't undermine treatment efforts. And they've actually really looked at this to see, does harm reduction enable? No, it's a resounding no. People engaged with harm reduction programs are five times more likely to access treatment and three times more likely to enter recovery compared to those who do not. And this is important to hold onto that positivity is recognizing that yes, the CDC has looked into this and it is far more likely for someone to enter treatment or to have some progress or success if they engage in what you're doing, which is harm reduction. This is a common one that feeds a lot of the whole not in my backyard, which drives a lot of people fighting against syringes, syringe exchanges, as well as the, well, we just, we've seen this with safe injection sites have been killed as well because of this, the fear that harm reduction is going to increase crime and make the community less safe. Because it's this idea that it's going to bring those people in. It's a complete myth. When, and when it's been looked at, harm reduction programs are not correlated with any increase in crime. They support people getting out of the criminal justice system as they increase participation in treatment services and also support the community safety by reducing the risk of encounters and discarded syringes. And then here are the communities that have harm reduction programs. The CDC has found that they have 86% fewer discarded syringes in public spaces. So yeah, it, it, it helps the trick. And I I've worked with a number of programs and I worked with some methadone programs as well that were frustrated because they were having crime happening at the site. It wasn't actually increasing the amount of crime. It was just now they had, it was shifting the location of where the crime was occurring. And we had to work with ways to do that of what we talked about with them as figuring out how to get folks that were coming to the methadone site to realize it's a major resource for them and that they want to do what they can to protect that resource and not dealing, not engaging in criminal activity outside of the clinic protected that resource. And so, cause it would, it would help with the way that the community would view it. So myth four, yeah, this can be there of that. And this is kind of extreme here. People won't get sober without the fear of punishment. So people won't, in other words, there's this idea that there needs to be some kind of consequence hanging over them. It's a tricky one. Cause yeah, we do find that folks that have court involvement, which would be a punishment can engage more readily in treatment. But it's not the punished, the court, the fear of the punishment that makes it work, that just gets them in the door. It doesn't actually help them get sober. The reality. Yeah. And we know this time and again, it just does not work. It it's not sustained. It just gets people pissed off. It causes them to dig in. The war on drugs has been a massive failure. And it's that provides concrete evidence of how punishment does not work. And then yeah, incarcerating people has not, does not address the reasons it doesn't go to their aces. Unfortunately, it creates further feelings of isolation and shame. There was someone, it was an interview. John Oliver did a thing on substance use, might've been opioid specifically. And he had some interesting piece there. And there was one of the experts that he talked to that was correct of when you take away everything from a person, all hope for any, any, any opportunity or anything. And the only thing they're left with is to either is to use until they go into oblivion. And this is the problem with punishment is that we keep taking things away from people to a point that they have no hope. They see no other option. And so of course they're going to use heavily because it's the only option that they feel like they have. It also puts people at risk 120 times, 29 times more likely to die of an overdose in the first two weeks post-release. This is common. And also if they were not able to use, especially if it's opioids while they were incarcerated, they are not sure where their tolerance level is at. And unfortunately it's really common for them to overdo it, go back and use at the same level or the same amounts that they were using before they went in. Of course, it's a question of whether they were not using when they were incarcerated, because it is common for that to still still happen. And then myth five, people won't get better unless they're forced into treatment. And so this is this idea again, it's kind of along the lines of the punishment piece, but recognizing that people don't come in unless they're required to. Yeah. And voluntary treatment doesn't do anything for long-term outcomes. It does give us a bump in short-term outcome and makes it more likely that people will attend. Is there a question? No. Okay. Sorry. I've been talking for a while. If anyone has questions, please put them in chat, or you can also unmute. Involuntary treatment can be a source of trauma, which perpetuates the substance use disorder. And so it's a question of whether or not they're going to be able to get better. And so it's a question of whether or not they're going to be able to get better. And so it's a question of whether or not they're going to be able to get better. And so it's a question of whether or not they're going to be able to get better. And so involuntary treatment can be a source of trauma, which perpetuates the substance use if it warrants are issued through law enforcement. So unfortunately, involuntary treatment takes away choice. The very definition of trauma makes someone powerless. And so this is, yeah, it's also something to think about too, of not just with law enforcement, but also with ITAs and voluntary treatment commitments or authorizations. That process is traumatic for folks. And so it's, we unfortunately can build resentment there and shut people down in that process. It's hard because it's one of the, it's sometimes our only tool, but it can be a problem. Of course, the risk of overdose, when they return to use, desirative outcomes are seen by scaling up voluntary evidence-based low barrier treatment, harm reduction, essentially, that what we're doing. Another myth, showing compassion to people who use drugs enables them. So a lot of things around enabling and this fear that we're just allowing this to continue. It's interesting because in that way, this is coming out of us feeling powerless to help. And so it's kind of a shift and a change on that. And so we can, if we can recognize that, that it's a feeling of powerlessness that can tend us to start to fall into these thinking traps. That's helpful to also have compassion for ourselves because it is actually out of caring. The problem is, unfortunately, it ends up shaming them. So feelings of shame and social isolation perpetuate drug use. So, yeah, to not have compassion. So tough love interventions keep people sick. In fact, there's actually, they've done a couple of studies where they've looked at what they asked people, what helped them get into treatment. And hands down, by far, some vast majority have said, it was someone who was kind and and patient with me, who sat and stayed consistently with me until I was able to get here. It is very rare that someone says, yeah, someone kicked my ass, basically, into getting this. And they were a total jerk. And that's what made it work. I'm sure you've got some folks and it's not zero. There are some folks that that does happen, but it's so much less common than having someone who's there consistently and supportive and compassionate. Which gets us to the showing consistent positive regard to a person with SUD works to combat the shame and promotes inclusion, making them feel like they're part of something. And then Bruce Alexander with Rat Park or Rat Disneyland. In fact, there are TED Talks from Dr. Alexander. But essentially, with a little bit of social stimulation and connection, addiction disappeared. What they did, essentially, if you're not familiar with this test, is they provided water that had cocaine in it. They also provided water that didn't have cocaine. So the rats had a choice between the water with cocaine and the water without. And then some of the rats had this really great Rat Disneyland where tons of socialization, they were just all this stimulation around the potential options for stimulation around them. And then another cage where they had no stimulation. They were just alone. And sure enough, they found out that the rats in isolation tended to drink far more of the cocaine water than the rats in the Rat Park or Rat Disneyland. It goes to this social stimulation and connection. Feeling part of something tends to be a huge piece of this. And tax dollars are being used so people can get high. So, yeah, the reality of this, harm reduction programs substantially reduce the risk of infectious disease. And it's a tremendous cost saving measure. So for hep C alone, one infection can be $84,000. And communities with syringe service programs see a 50% decrease in hep C. And yeah, harm reduction vastly reduces the involvement in the criminal justice system. And connects people to treatment services, breaking the revolving door, or what we call sometimes called churn. Incarceration costs taxpayers more than $48,000 per year. And that's only increasing compared to the $8,000 for average public treatment. So before I go further, questions. I've given you a lot of info. I guess one of the questions I have from listening to this was, kind of going back to the ladder example that you used earlier. And that was about like, I guess, like the goalposts. Like what are like some substantial goalposts that we might not realize are substantial? So that was my first question. And the second one is more in regards to people, more in regards to people who talk a lot about wanting to get treatment, but always back out. And then kind of dealing with that dynamic. Because I know some people may become escalated as it comes closer and back out. Some people may just disappear. And just really kind of knowing what to do in those situations. Great questions. So with that first one. Oh, shoot. Trying to remember the first one was. The second one was about kind of working with folks that back out of treatment. What was the first one again? I'm trying to. Like on the rungs to the ladder steps that might come up that we aren't expecting. Thank you. It's always when you're thinking of goals and things for them to do of what can, how can we break that goal down even further? And that's, I mean, when we look at goal setting, it's actually one of the main reasons, a big reason why people don't succeed at goals is because they set the goal too far out or the goal is too vague. And so some mile posts that you might see is. Well, might be using safe, using syringes or going to the needle exchange, getting a shot. Going to the needle exchange, getting that finding. Using in a safer way, such as that learning about safer injection methods. And being able to kind of talk about what those are. With you, ideally, and if they're injecting. One that and it's kind of an extreme example, and I may have mentioned this in some of our consult groups before, but. There was a consulting with someone and they what they did was. They had the person get a babysitter for when they were going to use. And that's actually progress because they were making sure their child was safe and taking care of while they were going to use. Yeah, others I've used smaller ones of, like, and this I know we've talked about of. Something I've seen case managers use before as setting out a budget and getting someone to start talking about how much money they're actually spending on substances. If you can get even to really like how much other other things that they might be ashamed of, like sex work, using sex workers, the services of sex workers, because that's going to cost money and getting a good idea of their full budget. It doesn't mean that they're going to change anything. It just means that they're going to get. Yeah, they're going to talk about how what is that actually costing them and how do they feel about that. And these are just some examples, it's really. How do we back away to something that's manageable that could change like like what's a negative? Yeah, it takes it like like when we consult or if you consult with each other, you can kind of brainstorm and really try to think about it because it does usually take a bunch of people to figure it out. Yeah. Yeah. And then, like, I guess I must have all the questions today, so sorry about that, Paul. From your answer, I started thinking about the clients who, what can I say, have a really hard time focusing. And then just even thinking about budgeting, I was like, that's an interesting way to look at it. But then I also thought, I feel like a lot of our clients aren't focused a lot of the time. So then I started wondering, what do you recommend is that step for trying to get their focus up? Seeing if they're, are they aware that they have a hard time focusing? And are they, and trying to figure out if they can be aware of it without being ashamed of it. This is the really difficult piece, is that, because there are so many things that make it difficult to focus. Trauma. If they have trauma, it makes it really hard to focus. If they have depression, it makes it really hard to focus. If they have too much anxiety, it's really hard to focus. And if you have more than one of those, it's even harder to focus. If they're in withdrawal, it's hard to focus. It also, flipping it too, it can be scary as hell to focus, because it's a commitment that you're making. And if you're feeling like you're a failure or you feel a lot of shame, you don't want to go there because it's like, oh, this is just going to make me feel like crap again. And so it's like stepping and recognizing, OK, there are so many things that could be possibly causing it to be hard for them to focus. What is that, and how do I have compassion for that and not get frustrated? And then from there, if they're willing to, coming back to where I started, if they are willing to look at why they have a hard time focusing or know why they have a hard time focusing, that can open the door to, OK, let's talk about ways to change that. And some things I do are like, is it OK if I interrupt you sometimes? Is it OK if I bring us back to the task? Are you going to feel like that's really rude if I do that? Even if you know that I'm doing it to just try to help, is it going to still feel rude? And then if it does feel rude, then I put it back on them of, OK, I've given an idea here. Let's see what your ideas are. But somehow, because generally, the simple answer, most of the time, I'm needing to help them stay on task. And somehow, I have to make it OK that I do that. And they recognize that I'm doing it not to be a jerk, but I'm doing it to actually try to help them with something that they're having a hard time with. OK. But yeah, it usually does. First, a lot of the folks that we work with were kind of their, I use the term, surrogate prefrontal cortex. That's the part of the brain that helps you with decision making and helps you stay on task. And for many of them, there's problems going on with that. And so in a way, we're letting them borrow our prefrontal cortex, if you will. OK. And then, I guess, in the same vein, are there activities that we can encourage to help them build that focus that seem to work well? Hmm. I mean, therapy and focusing on it in therapy, if they're willing to go to the mental health piece, because it's something a lot of what I'm kind of stumbling a little bit is I have answers, but they're going to be treatment-oriented. And I'm trying to think of ways you can, I mean, just doing the exercise together is going to help. You can also ask them if they've ever done things to try to help, anything that works. And other things like reminders, if they have phones and stuff like that can be helpful. But just seeing what tends to be useful for them. You mentioned there was a question that you had asked about folks that say they want to go to treatment, but then it comes time to go to treatment. That's totally common, and it's normal, because it's that moment of like, I want to do this. Oh, crap. It's about to happen. And it's where they'll get that confidence, but then their fear. Unfortunately, it's where if we could, and that very moment where they're like, I want treatment, be able to give it to them right there would be the best moment. Because what's happening is when someone's in a moment of crisis, they're most open to making a change. The problem is that you usually can't. You have to go, unless it's walk-in, because I know some of the services, like does Sound have walk-in? Yeah. And do you have to schedule it? Do you have to call before you go to the walk-in, or can you just walk in? You can walk in, but from my experience, that's mostly just mental health. OK. Yeah, I know of a walk-in substance use clinic, but it's in Puyallup, so that's not very useful for you, is it? But I got to see. I could ask the director there and see if they have, because it's multi-care. And I don't know how far north multi-care goes, but. But yeah, because yeah, where we're getting at, if you could get them right in that moment, it would increase it. Because yeah, the more time in between is when that motivation or the immediacy of the crisis falls off. And so hopefully, at least that gives you compassion of kind of, OK, we're running into this. This is normal. I mean, we probably have all had this experience where you were ready to do something, and then you needed to wait to do it. And then it came time to do it, and you're like, no. Yeah. Thank you. Anyone else have questions? Thank you, Dwight, for the questions. They're super, super helpful. We're at about the halfway mark, so let's take a break. So let's take a five-minute break. That's 10.06, 10.07, so we'll come back in five, which will be like 10.12. So see you all in five minutes. Welcome back. Oh, let me share my screen again here. So we've talked about what harm reduction is, the history of harm reduction, why it works, and debunked myths about it. Now let's look at how to use harm reduction and ways to use it to support change, because it is meant to support change. It's not just meeting them where they're at. It's also taking that forward, and how do we make progress, whatever that progress looks like, however small or slow it may be, or whatever speed it can happen at. So here is what's, and you may, or if you're not familiar with it, what we're seeing here is what's called the stages of change. And this is a common, it's this idea that people go through these stages when they're making a change. And so the first stage would be contemplate, or I'm sorry, pre-contemplation. So it says here, no intention of changing behavior. I'd actually even say it has no intention of changing behavior. I'd actually even say it hasn't even occurred to them yet that they need to change it. In fact, if you can see, hopefully my screen is up, but it's this idea, like in pre-contemplation, I think of you've got the person looking forward, and the problem is behind them. They can't even see it. I think that's better, because the problem with no intention to change, it sort of says that they know they should, but they're not going to. And even that, they know they should, but they're not going to, is actually contemplation. So the next stage is contemplation, where they're aware of the problem. And this is a broad range here, because it can be like, oh, what's this annoying thing flapping behind my head? They're aware of it, but they're not so sure they need to change it yet. Or what can happen, and contemplation can be all the way from like, yeah, I know it's a problem, but I don't want to change it. That's actually contemplation, because they're saying that there's part of them that's aware of it, versus it can go all the way up to, I know I really want to change, but I don't know if I can. And that can also be contemplation, too, someone being very aware of it, knowing that they want to change it, it being important to them, but them having no idea how to do it, or being afraid that they can't. So people will tend to stay in this contemplation stage for quite a while, what we call as ambivalence. And this will come up a lot more when we talk about motivational interviewing. The eventually, at some point, when they get ready to make a change, like in your example of the person that says, I'm ready to make the change, they've moved into preparation. And so they have an intent of taking action to address the issue, and they're doing the things like making the appointments, scheduling the times to go to different places, doing the things that need to happen to make the change a possibility. This tends to be a shorter phase. Folks tend to stay, and it goes even back to your example, Dwight, where I was mentioning, they'll say, I'm ready to go to treatment. And then if they need to wait even a couple of days, that's too long. In fact, we sometimes look at preparation as lasting maybe around a week at most, maybe two on the outside. But it's really where there's a conviction or a desire, a real drive to move ahead. And we need to be careful because that window is real short. Because then once, if they're successful, then they move into action. So this is when they're actually making the changes, taking the steps. And then finally, once they've made the change, there's maintenance. So sustained, they've made the change, and it keeps going. So hopefully, this is a helpful model for you to think about and kind of look at. Yeah, 24 hours there. I see what you're saying. It can be that short. You're right, Dwight, especially with the folks that we're working with. And it could be even shorter than that. But these stages, hopefully, this is useful for thinking about when you're talking to someone, where are they at? And are they truly in pre-contemplation? Are they just like, it's not even really occurring to them that there's an issue at all? It's like, I don't know why these people are going on about this. This is fine. This makes me happy. I don't see the problem with it. Versus, ah, yeah, I know it's not good. But that's when they're starting to move into contemplation. The last phase here that's important is relapse. So we'll fall back into old patterns. Now, this is an upward spiral. It's the opposite of that downward spiral that we saw on the slide earlier, the downward spiral of shame. This is an upward spiral of hope. And the reason why we call it a spiral here is because there might be that relapse in there of, yep, they started thinking about it's a problem. They got ready to make a change. Oop, they made a mistake. And fell back a little bit. You know what? I've learned from that mistake. I didn't realize that I used to celebrate as well as used to deal with my depression. Great. Let's talk about how we can avoid using in times that are of celebration. And they'll hopefully keep building and spiral upwards towards hope and recognizing that that spiral may take some time. So this is where harm reduction, meeting people where they're at while not leaving them there. So that's the important, because frequently when I start working with folks, it's like, well, yeah, that's where they want to be. OK, that's where you start the work. It's not where you end it. You're not just going to leave them sitting there. And so harm reduction includes or equals the addition of an intervention along with motivational support. And so, yeah, harm reduction is a very active thing. And it's something that we're thinking in some way that we're going to intervene or help them plan or help them talk about how to use in a safer way or talk about ways to maybe minimize the negative impact of if they're under the influence. Some of it I know is you getting them to use in the tent outside. An intervention I know we talked about in a consult weeks ago was making sure that there's heaters and stuff like that and making the safe use site a place that they want to be. And then the motivational support is kind of encouraging folks to use the site. That actually is harm reduction, because I believe you do at least at one of your locations have a tent-ish thing outside where is there a safe place to go use. And some examples of motivational support beyond what we've talked about. So affirmation, so this is where connecting and seeing their strengths, talking about times that they have actually had success or made or pointing out any time that they're even trying to cope effectively or even just thinking about coping effectively, being able to point that out. Having empathy and recognizing that this is a difficult change and that there is definitely change of any kind is difficult. Comes up a few times, but remembering to hold on to that consistent positive regard. Unconditional positive regard is another way to say it, but the consistent part is remembering to consistently maintain it. In fact, one, if you're having a hard time maintaining it, hopefully kind of talk with it and supervision and figure out ways you can either come back to it or somehow stepping back to kind of recognize, because sometimes when we start to get burned out, that this is one of the things that becomes really difficult to do. It's not just the consistent positive regard, it's also having, we call it clinical optimism, but it does apply to what you're doing of maintaining what you're doing of essentially having hope. Even though things might seem difficult or it's hard to see what progress is happening, continuing to have that hope and belief that there will be progress or hunting and finding where progress is actually happening. And exploring any reasons that they have for making the change. Because this is empowering, it helps when what we're doing is we're reminding them of the change that they want to make. So some questions that we can use. The example here, you've got the cocoon and then eventually they emerge from it. You've got the caterpillar that then makes the cocoon that eventually emerges and has the butterfly. And so what we're trying to do is encourage or let the butterfly come out and help the butterfly come out of the cocoon. If you were to make the changes, what are your reasons for making the change? So, yeah, finding out how that might be of importance or help them. Another one is if you didn't change, what, if anything, would be at stake? Another way of, like, what might you lose or what would be the risk in not changing? Like, if things keep going down this path, sometimes I even do, like, a fork in the road. Let's say, okay, so we've got the fork that goes towards the change and we've got this fork that stays the same, that goes down and just stays on the same road that you've been headed. Where is that headed and what's going to happen? What do you see happening? Another one, if you were to make the change, how would you be successful? So looking at getting them to envision that and what they would need in order to do it. Who or what could help? What would be the first or the next step? Actually, let me go back there before I get... What other questions do y'all have? I'm wondering, because I'm sure you've asked questions about change. What are ones that you all have? And if you've got questions too, you don't have to have questions. I mean, by all means, you can ask questions too, if you're wanting more. But I'm sure you have go-to's. And Paul, I'm just wanting to give space for other people to speak. I don't want to be the only one. Appreciate it. No, no, that's right. Thank you. Yeah. Thank you. So when I'm, hi Paul, when I'm supportive of change, what I use it's not more so a question. Okay. I'm more so say, so where do you see yourself? You know, when you're, you're in the future, where do you see yourself five years from now? Great. You've completed, um, like some form of stability and what would kind of support yourself in this timeframe to kind of establish that stability into, uh, you know, into fluoescent. So yeah, that's something that I've used. Um, in my outreach, uh, processes and it worked very much. Pretty good. Great. Yeah. I love how you're getting them to envision what it looks like. Um, when, when things will be different and then also kind of bringing that back to now of what can we take from now from that vision and put in motion. That's fantastic. Exactly. Thank you, Paul. Yeah. Thank you, Mina. We've had some impressive one here, ones here, but we can also have some simple ones here of what change would you like to make? I I'm wondering when we back it away and make it a little, um, not so complex. Does that, does anything, anyone think of anything? Some ones I can add in here that aren't even on here. And we're starting to get some crossover with motivational interviewing here, and that's okay, because harm reduction and motivational interviewing go hand in hand. In fact, I don't really quite know how you would do harm reduction without motivational interviewing, honestly. And so some of the things I can ask folks of on the not changing side, like what are the benefits of what you're doing? What makes that useful? What makes this seem like a good idea? Sometimes it's useful to go there and explore that. There can be downsides to it, because if someone wants to make a change, you can kind of make them less wanting to make the change. And then also, I'm sorry to interrupt, but also I give them the idea, remember that you're only reaching for a sort of a short-term goal. And what is your long-term goal? You know, that kind of enlightens them to see it in a different perspective sometimes, and it kind of brings them into the concept of saying, hey, wait a minute, they start questioning why are they doing it? Or, you know, in a sense it brings them like understanding that maybe there is a way I can change this and make it a little bit less and maybe focus something and something else that's a little bit less harmful to the physical body, you know? Great, fantastic, yeah, love that. So some other ones that we can add in, we've got the one like, if you didn't change, what would be the risk? You can also ask, what's the risk in changing? What are you giving up? What is it exactly that you're giving up? And kind of going in, and this can be useful for folks, again, to recognize that you're not gonna pressure them and that you're willing, they can talk about both sides. And that's a huge part with the folks that you're working with. I know we've talked about this at various times of China, make them realize that you're not gonna push a change on them, which is tricky, because, well, luckily now with the permanent housing, I don't, it's a little different. I think with the tiny villages, there was more of the expectation that they were gonna move out, that the village was temporary. And so now it's not necessarily thought as temporary. So at least that pressure's gone. But they're still gonna look at you as someone who's gonna come in, oh, here's the person that's gonna make me wanna make changes again. And so recognizing that you're not gonna force that or pressure them at least. Some other ones that might be useful, and we're gonna repeat most of these when we do MI. So if you don't catch them right now, that's okay. We'll have another time. But if you wanna jot them down, that can be great too. On a scale of one to 10, how important is this change to you? 10 being the most important, one not being important at all. If you do that, I recommend that you follow the question up, say a five. And I would recommend following it up by asking, what makes it a five instead of a three or a four? The reason is, is the answer you're gonna get is why it's as high as it is and why it's as important as it is, as opposed to why it's not important or what's in the way of it being important. And that's more motivating to do that that way. You can also ask on a scale of one to 10, how confident are you that you can make this change? And this even gets to some of what we were talking about before, if they're having a hard time focusing, it may be that they wanna make the change, but they're just not confident that they can. And then if you get really high importance and low confidence, that lets you know, okay, the problem isn't that you can't make this change, they don't, they see this as important, they just don't know how to do it. Now, if you get the reverse of high confidence, low importance, oh, they just don't see why it matters. Then it's a question of whether or not you wanna keep talking with them and seeing whether you can raise that level of importance at all. The others, and you could even expand on the first one a little bit here and what are your three most important reasons for making the change? Because the nice part with that one is it gets them to add, it's not just the one, it gets them to think of how things are interconnected. So those are just some possible examples here of some ways to support change. So what harm reduction is aiming to avoid is power struggles or verbal wrestling matches. That's why we have the two Rams here butting heads. It's there, yeah, it's two, they're going at it, there's gonna be a winner and a loser in that situation. And so, yeah, I think that's a really good point about how we're trying to do harm reduction. And we are not in battle. We are what we're trying to do. And so there used to be a statement that we would use saying rolling with resistance. We actually are trying not to use the term resistance in motivational interviewing anymore, but it's still was, it's one that's useful of kind of instead of meeting someone and kind of coming loggerheads with them, figuring out how to roll with that and use that momentum. So instead of confronting or focusing on kind of consistent positive regard. So even while someone, and when I work with supervisees on this, if you can find something you really appreciate or like about the person you're working with, find that and hold onto that. Because in a moment where they're pissing you off like no tomorrow, it can be your anchor to remember I need to stay consistent and positive with this person. That doesn't mean that you should allow yourself to be verbally abused. There's boundaries with this, but instead of going defensive and with that, you're still holding positive regard. You're just being firm and saying, I hear you're frustrated and it's not okay to be talking to me that way. It's not really, it's sort of confrontation. And this is really only if it's starting to get into a place where they're starting to be verbally abusive to you or they're really, so that's the one difference here. But generally speaking, when it's around something like substance use, you have no personal stake in it. So you don't wanna confront them and say, no, you know what, you need to stop using. That's not good for you. Which connected to this is arguing instead accepting what they say because it's true for them. It's their reality in the moment. This also goes to like, even if there's a thought that they're not telling you the truth, you're gonna get further with just kind of going with the flow with it and recognize it than fighting it. The only thing is, is if it's like really egregious and you just are like, well, hold on, I've got this information and now you're telling me this. But the part with that still is not getting into an argument. Avoiding power struggles. Instead is a mindful way that they are in control of their own path to recovery. So remembering that it really has to be them in the driver's seat and that if we're in a power struggle, we need to really let it go and we need to be the ones to disengage from it. So this is, it's still written as the writing reflex. It's actually now called the fixing tendency. And we'll talk more about that when we get into MI, but the writing reflex, what this was, it's the tendency for us to, like if I were to say the sky is purple, there's gonna be an urge to say, no, the sky is blue or it's gray because we're in Washington. And so there's that, yeah, when I bring up something, the conversation wouldn't feel right unless you corrected me. And that's the writing reflex. And where this comes up with when you're working with people is that moment when you hear what their plan is and it's like, oh no, that's not gonna go well. That's a bad decision. That's a really bad decision. And that's what's going on mentally in our minds as they're telling us what they're thinking of doing. We avoid voicing that because to voice that would be the writing reflex because it's the desire to kind of fix it. Like, no, wait, here's the better way to go. This would be a better decision. Another way that that can come out too is in giving advice. If we give advice, that's us trying to kind of write the conversation. So instead of doing that, what we wanna do is accept that experience allows for growth and honor the dignity of risk. So basically just remember that for them in the moment, they believe what their experience is and what they're saying. And for them, it feels like the right path in the moment. And so we're not gonna come up against that or confront or argue with them about it. We'll expand a lot more on that in motivational interviewing. That's a lot of stuff that's connected to MI there. Like I said, harm reduction and motivational MI go hand in glove. Some final thoughts with this. So looking at harm reduction interventions, they're meant to give people tools to stay safe and alive. That if you take nothing else away from this harm reduction piece, the goal of harm reduction is to do what we can to make sure that they stay alive. Because if they're alive, there's hope for change. It's only if they die that that door closes. In the short term and foster a path to other services when they're ready. So a lot of what we're doing with harm reduction too is doing things to kind of make sure that they stay alive, creating small goals to hopefully make their use safer so that they're more likely to stay alive, but also being ready and kind of patiently waiting for a doorway to open up. Examples of this. Someone coming out of a bad situation where yeah, they were maybe assaulted while they were using and they come back from it and they're like, man, I really have to do something different because I keep putting myself at risk. Window of opportunity. Or it can be even smaller than that of someone just saying, you know, I really don't like the way I feel in the morning. Window of opportunity. And this is, we're gonna work on this of getting really good. And I'm sure you already have skills, but we wanna kind of keep building those skills of being able to listen for and hear when they start to even mention a possibility of wanting to make a change. So harm reduction services have to be provided in a nonjudgmental and compassionate care and with a consistent positive regard. They must, they're absolutely essential. In fact, these kind of need to be ingrained in you. If these are harder for you doing some work on this, that's okay. And there's different reasons why, reasons why these things can be hard for folks. If you've had family members or others that have been impacted in a negative way, that can be really challenging for us sometimes to be able to maintain compassion. Even though we care and we wanna help, it can make it hard to hold onto these tenants here. And then that positive, consistent regard, consistent positive regard or unconditional positive regard or absolute worth is another way of describing that. Holding onto that. And if we start to lose that, recognize that that might be a sign of burnout and that we might need to do some things to kind of help bring that back. So PWSUD, we didn't actually introduce that acronym. That's people who use, I think actually is that acronym done right? Oh, people with substance use disorder. Oh, that's a different acronym than I thought it was. Cause there's also the acronym for people who use drugs. So PWUD, P-W-U-D. Anyway, that's another acronym that's out there within harm reduction circles. If you look up the Harm Reduction Coalition, that's how they define people who use drugs as a class and kind of recognizing that piece. But understanding people that have substance use are doing the best they know how. And no one ever has to apologize for how they had to survive. So really recognizing that. And if they're getting really apologetic, noting that you're trying to survive, there's nothing wrong with what you're doing. You're just trying to get by. The question is, what is that helping you cope with? And what is the, cause again, the substance use is the symptom, not the problem itself. And that's the part too, like that part of if it's hard to hold on to that consistent positive regard, there's nothing wrong with you. It just means you need a break. Getting frustrated is there again, nothing wrong with you, you need a break. Cause this frustration and all comes from you caring and wanting the best for people. It can also come from fear too. Cause unfortunately some part of this that I haven't mentioned in this, in meeting people where they're at and not necessarily pushing forward change, we're not gonna save everybody. And that's a really hard reality for us to hit. And I know all of you have had deaths in the village. You've seen it happen and it's part of this. And that can really help, can weigh on us over time as we recognize that, yeah, our efforts are not always going to be successful. Unfortunately, we're gonna lose some folks. The hope though is, and firmly believing that harm reduction will save more people. There would be more people that would die if we went another route. And so we are saving more people than we're losing and we're saving more people than we would if we took another route. Which gets us to self-care and it's essential for providing effective services. So yeah, making sure that this, it's incorporated. And I know self-care is kind of getting misnomer because there's, I know some people have kind of called it, it can be gaslighting. Because what, and the reason why it's gaslighting is because there's this idea that, oh, like you've got to take care of yourself when you're really living in a very, within a system that's, I don't love the term broken, but the system that is really having the struggles and we're working with a population that's there. And so there's, it's a systemic thing that's kind of causing us to get burned out. And we can't self-care our way out of that because self-care is not gonna solve the actual problem. At the same time, it's still, if we can keep an eye on it and figure out how to manage it. And some of that self-care may be figuring out how we interact with the system. I know for myself, I've been in this field for a long time and someone approached me the other day and I'm like, how did you do that? And some of it for me, at least, and again, it's just for me, it's not necessarily right for you is, I've recognized and figured out different ways to kind of, I hope it's compassionate detachment or empathic detachment is what we have of recognizing that I'm doing the best that I can working with folks and I am having some impact, but it's not gonna affect everybody. And I alone can't fix the system. And so I have and hold that mentality and that's helped me kind of sustain and stay working in a field that can be challenging. But you all have to find the way that works for you. Questions? Thoughts? And I just landed on a heavy topic, but please, any thoughts or questions or any final thoughts that y'all have? Nothing off the top of my head. And I just wanted to say like, this was a great learning training. Thank you. Thank you, Dwight. Any other thoughts or questions or anything to share? I just wanted to go back a little bit in regards to like the beginning, how useful that is. Because even in outreach, I've connected with clients more when you just show up for them and you just, you have to just be like positive and kind of like give them some form of like, you say like a statement that's like acknowledging them for who they are. And I feel like bringing that into fruition kind of, I know it's tough in the beginning, especially when you're building, you're in the rapport building stages. But as long as you're bringing that mindset, the client will start to realize that you're there for them and you want to see them somewhat in a better state than they are today. So as long as you kind of bring that positive atmosphere to them, they can kind of, it will rub off on them and then they want to connect with you more. So I've met with clients that sometimes they're like, oh, I don't want to deal with you. Or they have biases because of this. But once they see that I'm constantly there for that person, they're like, okay, I see who you are, who you truly are inside. I'm going to work with you and we're going to do this together. And obviously it's a little bit more difficult when it comes to the substance use factor of it. But I believe when that comes into fruition, they will see that and it will bring them into that mindset that maybe I can change and maybe I can kind of somewhat bring myself to kind of like at least somewhat limited. Because we're not superheroes, you know, but we're trying to bring a positive light into that client so they can understand that there is, when there's a will, there's a way. So, yeah. Thank you, Amita. Oh, no, that code doesn't work. We're doing a code at the end of. Am I, we're going all the way to the end, right? Yes, survey this time on the final session. Great, so, uh, given that. We are ready to wrap up for today. Um, of course, if you have any questions, feel free to ask them, um, our next 1, so we're, it's kind of each week from here on out. So we've got our next 1 is going to be next week. Um, and then the week after is motivational interviewing. So those, and that that will close out at least this series. It sounds like folks have been able to get the, the video link up and running. I know there was some email discussion back and forth. It sounds like that ended it got that working, which is great. This video will also be loaded there as well. And then anything else I'm forgetting Emily? No, I think we covered it all. Yeah, hopefully this should be, it's been a little slower lately, but it should be. Hopefully within a week or 2 at the most. Great. Yeah, maybe the holidays. Load things down. Yeah, for sure. Yeah. Well, thank you so much, Paul. Yeah. No, you're welcome. Yeah, I'm happy to be here. Yeah. Thank you all for being here. We'll see you next week. Thank you. Everyone. Yeah, thank you.

harm reduction

behavioral health

workshop

practical application

participant engagement

myths

positive behavior changes

historical context

philosophy

addiction

trauma

compassion

incremental improvements