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Recovery: The Family’s Process of Healing and Hope
CMHACY Conference
Steve Hornberger, MSWMay 2014
Pacific Grove, CA
Three Questions
Generally, in my community when someone hears a family has an alcohol or drug problem they believe…
Working with a family in need of alcohol or drug treatment is challenging because…
I have been successful working with a family receiving drug treatment when I …
Why are we here today
1 in 10 Americans
1 in 5 families 1 in 7 workers 1 in 20 newborns 35% of ALL school
children
1 in 8 veterans 1 in 2 homeless 1 in 4 elderly 80% of those in jail 60% of families in children and youth
services
Unmet Prevalence
In 2012, 23.1 million people aged 12 or older needed treatment for an AOD problem.
Of those, only 2.5 million received any treatment.
The System Gaps
Of the 20.6 million who needed treatment but did not receive it, only 1.1 million (5%) felt they needed it (denial gap)
Of that 1.1 million, 347,000 (31%) said they made an effort but were unable to get it (treatment gap)
753,000 (69%) reported making no effort (motivation gap).
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Why are we here today
In 2005, federal, state and local government spending as a result of substance abuse and addiction was a least $467.7 billion or 10.7 % of their combined $4.4 trillion budget.
For each dollar of the $467.7 billion spent, 95.6 cents went to shoveling up the wreckage and only 1.9 cents on prevention and treatment, 0.4 cents on research, 1.4 cents on taxation or regulation and 0.7 cents on interdiction.
Impact
½ of all children (35.6 million) live in a household where a parent or other adults use tobacco, drink heavily or use illicit drugs.
13% of children under 12 live in a household where a parent or other adults use illicit drugs.
1 in 4 children under the age of 18 has a family member who abuses alcohol or has alcoholism.
Intergenerational Connections
Approximately 45% of all NYS clients admitted to being a “child of an alcoholic or substance abuser”
A child of an AOD abuser is 3 to 4 times more likely to develop AOD problems as well as negative health, educational and employment outcomes
Over 90% of all women in residential substance abuse treatment report history of child abuse and/or neglect
Some CA BH Facts 1
Beliefs: About 3 in 5 (58.9%) 12- to 17-year-olds in California
in 2011- 2012 perceived no great risk from drinking five or more drinks once or twice a week.
About 7 in 9 (77.9%) 12- to 17-year-olds in California in 2011-2012 perceived no great risk from smoking marijuana once a month
About 3 in 10 (31.9%) 12- to 17-year-olds in California in 2011- 2012 perceived no great risk from smoking one or more packs of cigarettes a day
Some CA BH Facts 2
Usage: Among 12- to 17-year-olds in California, the mean
age of first marijuana use was 13.8 years, and the mean age of first cigarette use was 13.2 years.
about 195,000 youths (6.2% of all youths) per year in 2008-2012* reported using cigarettes within the prior month
about 353,000 youths (11.2% of all youths) per year in 2008-2012* reported using illicit drugs within the prior month
Some CA BH Facts 3
Treatment: among persons aged 12 or older with illicit drug
dependence or abuse, about 117,000 persons (12.4%) per year in 2008-2012 received treatment for their illicit drug use within the year
among persons aged 12 or older with alcohol dependence or abuse, about 212,000 persons (9.1%) per year in 2008-2012 received treatment for their alcohol use within the year
about 947,000 persons aged 12 or older (3.1% of all persons in this age group) per year in 2008-2012* were dependent on or abused illicit drugs within the year
Some CA BH Facts 4
Mental health: about 259,000 youths (8.4% of all youths) per year in
2008-2012* had at least one MDE within the year prior to being surveyed
about 83,000 youths with MDE (32.0% of all youths with MDE) per year in 2008-2012 received treatment for their
72% of youths reported improved functioning from treatment received through the public mental health system
Parent who is abusing alcohol or other drugs
May be less attentive to the child while drunk or high
May be unable to fulfill their role as a parent, including providing medical treatment
Is more likely to be diagnosed with a co- morbid psychological problem
Parent who is abusing alcohol or other drugs
May be chronically physically ill from using drugs or alcohol
Spends times procuring, using, and recovering from the alcohol or drug use instead of parenting
May be engaged in illegal activities
Places financial stress on the family system
Adverse Child Experiences Study
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Adoption of Health-risk Behaviors
Social, Emotional, & Cognitive Impairment
EarlyDeath
Adverse Childhood Experiences
Death
Disease, Disabilityand Social Problems
Conception
Scientificgaps
Adverse Childhood Experiences Study
Fairly common
Generally clustered
Have a cumulative effect on healthy development and health care status
HOPE
National Prevention Strategy
Priorities
Tobacco Free Living
Preventing Drug Abuse and Excessive Alcohol Use
Healthy Eating
Active Living
Mental and Emotional Well-being
Reproductive and Sexual Health
Injury and Violence Free Living
27%
23%
6%5%
5%
All Other Causes 34%
Five Causes Account For 66% of All Deaths
Heart Disease
Cancer
Chronic Lower Respira-tory Disease
Stroke
Unintentional Injuries
Source: National Vital Statistics Report, CDC, 2008
EXTERNAL ASSETS
Support 1. Family support2. Positive family communication3. Other adult relationships4. Caring neighborhood5. Caring school climate6. Parent involvement in
schooling
Empowerment 7. Community values youth8. Youth as resources9. Service to others10. Safety
EXTERNAL ASSETS (2)
Boundaries & Expectations
11. Family boundaries12. School boundaries13. Neighborhood boundaries14. Adult role models15. Positive peer influence16. High expectations
Constructive Use of Time
17. Creative activities18. Youth programs 19. Religious community20. Time at home
INTERNAL ASSETSCommitment to Learning
21. Achievement motivation22. School engagement23. Homework24. Bonding to school25. Reading for pleasure
Positive Values
26. Caring27. Equality and social justice28. Integrity29. Honesty30. Responsibility31. Restraint
INTERNAL ASSETS (2)
Social Competencies
32. Planning and decision making33. Interpersonal competence34. Cultural competence35. Resistance skills36. Peaceful conflict resolution
Positive Identity
37. Personal power38. Self-esteem39. Sense of purpose40. Positive view of personal
future
DRUGS
BRAIN MECHANISMS
BEHAVIOR
ENVIRONMENT
HISTORICAL
ENVIRONMENTAL
- previous history- expectation- learning
- social interactions- stress- conditioned stimuli
- genetics- circadian rhythms- disease states- gender
PHYSIOLOGICAL
A complex behavioral and neurobiological disorder
Source: National Institute on Drug Abuse Presentation
Risk and Protective Factors
What is a Risk Factor? Something in a person’s life that increases the chance of a problem occurring.
Risk Factors include: Availability of ATOD Family history of addiction – 4X Parental use or positive attitude toward use Other problems in the family: abuse, poverty,
domestic violence Behavior/learning problems Friends who use and think it is fun or “cool” Early use
Risk Factors in FamiliesRisk Factors in Families
• Lack of love, caring, and support
• Low expectations for children’s success and school performance
• Lack of adult supervision and severe or inconsistent discipline
• Lack of family rituals (e.g. family gatherings)
• Poor family management or communication
• Sexual and physical abuse
Risk and Protective Factors
What is a Protective Factor? Something that increases the likelihood that substance abuse can be resisted.
Protective Factors include: Relationship to an adult outside the family Involvement in activities: clubs, scouts Positive self esteem Involvement in religious activities, providing
hope, purpose, see beauty in the world, connection to Higher Power
Risk and Protective Factors
Family Protective Factors include: Strong bonds between children and parents Involvement in children’s lives Clear limits/rules with consistently enforced
consequences Clear, honest respectful communication Chores for all family members Family Rituals
Primary Conclusions
1. People were always more important than programs.
2. Often just one person made the difference.
3. Programs that helped simulated living in a healthy family.
4. Gandhi’s Story
1. People were always more important than programs.
2. Often just one person made the difference.
3. Programs that helped simulated living in a healthy family.
4. Gandhi’s Story
Wellness Models Are Emerging
HEALTHY l I NOT ILL--------- l ----------ILL l l l NOT HEALTHY
A Person/Family Centered Approach
Is Strengths Based –Assumes people have abilities, capacities
Role focused, not problem focused (problems interfere with performing desired roles, diagnosis is not a role)
Promotes direction of the process by the person/family
Adopts an individualized approach to services (not a cookie cutter set of programs)
Where changes made in individual circumstances may have system wide implications that benefit others (innovations)
CMS Definition
“...identify and access a PERSONALIZED mix of paid and non-paid services and supports that will assist him/her to achieve PERSONALLY-DEFINED OUTCOMES in the most inclusive community setting. The individual identifies planning goals to achieve these outcomes in COLLABORATION with those that the individual has identified , including medical and professional staff ….”
Putting the Pieces Together in a Person-Centered Plan
GOAL as Defined by Person
Strengths to Draw Upon Barriers Which Interfere
Short-Term Objective• Behavioral• Achievable• Measureable
Interventions/Action Steps• Professional/”Billable” Services• Clinical & Rehab• Action Steps by Person in Recovery• Roles/Actions by Natural Supporters
HEALING
What Do They Need?
Caregivers: Words to share
experiences
Understanding of family disease
Time with their children for healing
Making amends and forgiveness
Children:• Words to say what
happened
• Understanding of family disease
• Time with their caregivers to heal
• Knowledge that it isn't their fault
Family engagement/involvement:Why is it important?
Because it works!
Because it is the right thing to do
Stakeholders are advocating for it
System reforms are mandating it
Family Involvement Works
Treatments involving families result in
Higher levels of abstinence (50 vs. 30%) Fewer drug related arrests (8 vs. 28 %) Fewer inpatient episodes (13 vs. 35%)
Science Practice Perspectives. Vol. 2 No 2 August 2004 NIDA
Family engagement/involvement
Increased involvement equals increased ownership equals improved outcomes
Services can be organized on a continuum from family friendly to family focused to family centered to family driven.
Collaborative partnership of expertise, resources and experience.
What Do They Need?
Caregivers: Words to share
experiences
Understanding of family disease
Time with their children for healing
Making amends and forgiveness
Children and Youth:• Words to say what
happened
• Understanding of family disease
• Time with their caregivers to heal
• Knowledge that it isn't their fault
Talking Helps to Break the Silence
40
Talk with the children and family members affected by alcohol and drug addicts and explain the disease and 7 Cs
I didn’t Cause it
I can’t Cure it
I can’t Control it
I can take better Care of myself:
by Communicating my feelings
making healthy Choices
by Celebrating myself.
What families must re-learn
Authority and discipline
Roles and responsibilities
Problem solving
Communication
Having fun together
Showing affection
Parent’s Support
Who in your family is already supportive of your recovery?
Who in your family is in recovery too?
Who keeps a healthy distance from family members who are not so stable?
How has your child’s caregiver been helpful in your recovery?
Who could help identify when you are headed in a negative direction? Who would see the warning signs?
How can these people help you maintain your recovery? How can you ask them for help?
EXAMPLES FROM
OTHER SYSTEMS
Healthcare
Institute of Medicine 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” Respect patients’ values, preferences and
expressed needs Coordinate and integrate care across boundaries
of the system Provide the information, communication, and
education that people need and want Guarantee physical comfort, emotional support,
and the involvement of family and friends
Healthcare cont
Institute for Patient and Family Centered Care lists the following core concepts of patient and family centered care: Respect and dignity Information Sharing Participation Collaboration
Child Welfare
Child Welfare Information Gateway
family-centered and strengths-based approach
partnering with families in making decisions,
setting goals, and achieving desired outcomes
motivating and empowering families- to recognize their own needs, strengths, and resources - to take an active role in working toward change
Juvenile Justice
National Juvenile Justice Network Engage in deliberate outreach to meet families
Ensure family members are an integral part of advocacy
Empower families to participate in advocacy through education and training
Assist families with individual and system advocacy
Listen to families
Create a clear structure for engagement and participation
Level the field by providing adequate information and support
RECOVERY
What is Recovery Perspective Substance dependence, while often manifested
by socially unacceptable behavior (for which there must be responsibility), is an illness. This illness can best be prevented when science is used to inform family and community-based efforts to protect and build resiliency.
The illness is best treated by early identification and intervention or, if not halted before its acute development, by a continuity of care over a lifetime that is built on measures of individual wellness and ongoing opportunities for recovery
What does the science say
Millions of Americans today receive health care for mental health or substance use problems and illnesses. These conditions combined are the leading cause of disability and death among women and the second highest among men. Institute of Medicine, 2006
Treatment is effective: When given a continuum of care, relapse rates for the treatment of alcohol, opioids, and cocaine are less than those for hypertension and asthma and are equivalent to those of diabetes (all of which are also chronic illnesses). Compliance to addiction treatment is greater than compliance rates for treatment of hypertension and asthma. O’Brien and McLellan, 1996
What does science say 2
Treatment is Effective and Sustainable
Addictions treatment has resulted in: 67% reduction in weekly cocaine use, 65% reduction in weekly heroin use, 52% decrease in heavy alcohol use, 61% reduction in illegal activity, and 46% decrease in suicidal ideation one year post treatment.
These outcomes are generally stable for the same clients five years post treatment.
Continuing Care is Cost Effective
A recent study of a lifetime simulation model (multiple episodes of treatment over a lifetime) shows that for every $1 spent on treatment (chronic care provided in a continuum of care) society accrues $37.72 in benefits. Zarkin et al., 2005
What does the recovery research say
Recovery Supports: Increase entry and involvement in treatment
– Moos & Moos, 2005
Can be the basis for self and peer care shown to be effective in addressing any illness requiring continuing care – Flaherty, 2006
Are often low-cost or free (such as peer-support groups, recovery mentors, recovery check-ups, et al.) – McKay, 2005
Reduce chronicity (reoccurrence/relapse) and diminish stigma – Moos & Moos, 2005
Addiction and Chronic Care
Compliance Relapse Rate
Addiction/Chronic Illness Rate (%) (%)Alcohol 30-50 50Opioid 30-50 40Cocaine 30-50 45Nicotine 30-50 70
Insulin Dependent Diabetes Medication <50 30-50 Diet and Foot Care <50 30-50
Hypertension Medication <30 50-60 Diet <30 50-60
Asthma Medication <30 60-80
WHAT IS YOUR DEFINITION OF
RECOVERY?
Recovery definitions
Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. (CSAT 2005 National Recovery Summit)
Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. (Betty Ford Institute, 2007)
My definition of recovery is life. Cause I didn’t have no life before I got into recovery. (Pathways study participant H.W.
42 years old African-American male)
SAMHSA’s new working definition A process of change through which individuals
improve their health and wellness, live a self-directed life, and strive to reach their full potential
Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way;
Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society;
Community: relationships and social networks that provide support, friendship, love, and hope.
Recovery oriented systems of care 2
Recovery-Oriented Systems of Care shifts the question from
How do we get the client into treatment?
to
How do we support the process of recovery within the person’s life and
environment?
Recovery and Resilience Oriented System of Care
CLOSING THOUGHTS
The Vision
A community where all members of a family affected by alcohol and other drugs know there are knowledgeable and caring others who: understand what they are experiencing, care about them and are available, can help them find emotional and physical safety, can support their healing, health and wellness.
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Opportunities and Challenges of a Lifelong Health System
Goal of system to optimize health outcomes and lower costs over much longer time horizons
Payers, including Medicare and Medicaid, increasingly responsible for care for longer periods of time
Health trajectories modifiable and compounded over time
Importance of early years of lifeSource: Halfon N, Conway PH. The Opportunities and Challenges of a
Lifelong Health System. NEJM 2013 Apr 25; 368, 17: 1569-1571
Quality Care as Driver of Change
The next generation of measures will:Define quality as improving the life of a
person;
Place functional outcomes on par with clinical outcomes;
Create measurement processes that track outcomes over time since functional needs and personal goals change
Bruce Chernof, MD, Pres and CEO The SCAN Foundation March 2014
What you can do personally
Take good care of yourself, family, friends and colleagues
Learn about addiction and recovery, advocate for system collaboration and become a change agent
Define and monitor outcomes at four levels, the status quo is not good enough
Be bold, imagine a community where people live better lives, where children are safe, healthy, happy and educated, where people achieve their aspirations
Provide hope
What we can do together
Raise awareness,
Find allies,
Take action to end: Silence Stigma Disparities
Promote the many roads to recovery
Proposed Shared Vision
A community where all are safe, healthy and well, where each has a sense of belonging, purpose and opportunities to achieve their aspirations.
Web Resources
Al-Anon and Alateen www.al-anon.alateen.org Faces and Voices of Recovery
www.facesandvoicesofrecovery.org Federation of Families for Children’s Mental
Health www.ffcmh.org Join Together www.jointogether.org National Association for Children of Alcoholics
(NACoA) www.nacoa.org National Center on Substance Abuse and Child
Welfare (NCSACW) www.ncsacw.samhsa.gov
Web Resources 2
National Center on Addiction and Substance Abuse at Columbia (CASA) www.casacolumbia.org
National Clearinghouse for Alcohol and Drug Information (NCADI) www.ncadi.samhsa.gov
National Institute on Alcohol Abuse and Alcoholism (NIAAA) www.niaaa.nih.gov
National Institute on Drug Abuse (NIDA) www.nida.nih.org
Substance Abuse and Mental Health Services Administration (SAMHSA) www.samhsa.gov
Web Resources 3
National Center on Addiction and Substance Abuse at Columbia (CASA) www.casacolumbia.org
National Clearinghouse for Alcohol and Drug Information (NCADI) www.ncadi.samhsa.gov
National Institute on Alcohol Abuse and Alcoholism (NIAAA) www.niaaa.nih.gov
National Institute on Drug Abuse (NIDA) www.nida.nih.org
Substance Abuse and Mental Health Services Administration (SAMHSA) www.samhsa.gov
Additional Resources
NW ATTC Addiction Messenger http://www.attcnetwork.org/ series
Series 16 (2004) on Recovery, Series 17 (2005) on Family Treatment,Series 29 (2008) Family Participation in
Addiction Treatment SE ATTC and Florida Certification Board,
Engaging Family Members Into Adolescent Drug Treatment (2008)
http://www.scattc.org/pdf_upload/Engaging_Families_Adolescent_Drug_Tx_FinalWEB.pdf
Additional Resources 2
Generational Patterns of Resistance and Recovery Among Families with Histories of Alcohol and Other Drug Problems: What We Need to Know (2008)
Addiction recovery: Its definition and conceptual boundaries (2007)
http://www.williamwhitepapers.com/
Additional Resources 3
The Institute for Health Improvement www.ihi.org http://www.ihi.org/NR/rdonlyres/C810CCBB-2DEB-4678-994A-57D9B703F98D/0/PartneringwithPatientsandFamiliesRecommendationsApr08.pdf Institute for Patient and Family Centered Care
www.ipfcc.org http://www.ipfcc.org/pdf/CoreConcepts.pdf
Child Welfare Information Gateway http://www.childwelfare.gov/pubs/f_fam_engagement/ National Juvenile Justice Network www.njjn.org
“An Advocates Guide to Meaningful Family Partnerships” http://njjn.org/media/resources/public/resource_1665.pdf
Additional Resources 4 PCORI Engagement Rubric
http://www.pcori.org/assets/2014/02/PCORI-Patient-and-Family-Engagement-Rubric.pdf
IHI High Impact Leadershiphttp://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx
2013 Behavioral Health Barometer CAhttp://store.samhsa.gov/shin/content//SMA13-4796/SMA13-4796CA.pdf
Motivational Interviewing with Adolescentshttp://doczine.com/474033.html#/Motivational_Interviewing_Strategies_to_Facilitate_Adolescent_.../
CONTACT INFORMATION
Steve Hornberger, MSW
Independent consultant
