Transcript of Supporting Families Through Addiction Tiedra Marshall: Good morning, I am Tiedra Marshall with the Pennsylvania family support team,

based at the center for schools and communities and I will be your moderator for today. It's my pleasure to welcome you to today's webinar session, Supporting Families Through Addiction. It is my pleasure today to introduce our presenters, Kelly Anne Hicks is a certified nurture and parent educator with Family Service Association of Bucks County. From November 2016 through October 2017, the parenting programs at Family Service have served 102 families, 123 individuals, and 190 children affected by the opioid epidemic. She has a Master's degree in education from Holy Family University and is the proud mother of a spirited three year old daughter.

Shannon Hays is a licensed professional counselor working in Pennsylvania. She holds certification as a national certified counselor and certified advanced alcohol and drug counselor. She earned a Master's, excuse me, she earned a Master's in professional clinical counseling from LaSalle University, as well as a Bachelor's of Science in Human Service and minor in Psychology from Chestnut Hill College. Shannon also holds a post graduate certificate in trauma informed practice from Bryn Mawr College. Shannon specializes in working with individuals and families wishing to overcome an array of challenges including addictions and co-occurring disorders, eating disorders, trauma, grief and loss, anxiety, mood disorders, borderline personality disorder and many other concerns. She has a special understanding of and connection to addiction and the impact on the family, that enables her to provide empathetic support to individuals in recovery and believes strongly that addiction affects the whole family.

Shannon currently works as Program Manager of the Center of Excellence Program at Family Serves Association of Bucks County, a program designed to provide care, coordination, and recovery support to individuals fighting opioid use disorder. In addition, she works as a therapist for the Bucks Recovery Center in Newtown Pennsylvania, providing support to individuals and families struggling with substance abuse and co-occurring disorders. It is my pleasure to welcome Kelly and Shannon as our presenters for today's webinar. Please be patient as we turn over presenter privileges to them. Thank you.

Shannon Hays: So good morning everybody, I guess we can just get started, thank you very much for that really excellent introduction. Hopefully we can live up to how great we sound in our bios. So just to get started, the point of this webinar is to provide information to better understand addiction and how it affects the family just at least on the surface level. Some of the services that are available to families and how to access them as well as how to talk to children and adolescents about addiction and how to support the families that you might be working with who are struggling with addiction. So we're going to fit a whole lot into a very brief period of time so we're just going to get started.

I first wanted to give you just kind of an overview on where we kind of stand with addiction in the United States today, we all hear almost every single day of the opioid use disorder that is affecting Pennsylvania, like I think we're pretty much the fourth in the nation with our struggles on, with opioid use disorder and overdose. But I wanted to draw attention to the fact that it is not the only substance that we're having quite an epidemic with and it remains to date that more people die yearly as a result of alcohol use disorder than opioid use disorder. So it's important to remember that individuals are definitely still struggling every single day with other substances.

So these are just some of the numbers, there's 21.5 million American adults, I think we had a little bit of an error there on the slide but adults that are battling a substance use disorder in 2014. 80 percent of those are struggling with alcohol use disorder. Now those individuals may also be struggling with other substances as well but it does speak to the gravity of how many Americans are still struggling with alcohol. 30 percent of Americans have had an alcohol use disorder, and that basically means at some point and time they met criteria for having an alcohol use disorder and that can flux over time. And estimated of 88,000 people die from an alcohol related cause annually, that number comes from last year, so in 2016 88,000 Americans died related to alcohol use disorder and that does account for accidents, car accidents, acute alcohol poisoning as well as diseases that are related to ongoing alcohol disorder, or alcohol use disorder.

I do think that one of the reasons the opioid epidemic takes center stage is the acute nature of all of the deaths from overdose, this alcohol use disorder generally takes longer unfortunately, to kill somebody. Okay, so in 2013 24.6 million Americans over the age of 12 had reported illicit drug use in the past month, and that ranges anywhere from marijuana through heroin. After alcohol, marijuana does remain the highest rate of dependence or abuse amongst all drugs. In 2014 an estimated 1.9 million people had an opioid use disorder related to prescription pain relievers and an additional estimated 586,000 had an opioid use disorder related to heroin. It's definitely important to note that we talk a great deal about the heroin epidemic, the rates of abuse of prescription opioids is far far far higher than the rates of heroin abuse. When we talk about the 33,000 people in 2015 that died of an overdose, two thirds of those were from prescription opioids, they were not from heroin and they were not from Fentanyl. So the heroin and the Fentanyl have definitely helped increase but the rates of prescription abuse are still incredibly incredibly high.

So what is addiction? That is a very very difficult question to answer however we do consider it a disease, it's a primary chronic disease of the brain reward, motivation, and memory and related circuitry. Disfunction in these circuits lead to the characteristic biological, psychological, social, and spiritual manifestations. So that basically means that from whichever direction somebody begins using a substance, whether it be casually using alcohol on the weekends, getting prescribed something from their dentist that takes the pain away, family influence, peer pressure, whatever it happens to be it basically, you start to have a positive effect, your brain kind of like gets used to it and then like the habit sort of develops. And then from there though, there's actual biochemical changes to

the brain, to the body that as the disease progresses it actually goes from being a habit to a disease with very real symptoms, very real consequences, and the very most simple definition of a disease is something with identifiable symptoms, clear cut progression, and will result in death or severe consequences if left untreated. So if you look at a disease in that way addiction absolutely fits into that.

And it basically, addiction is characterized by the ability to consistently abstain impairment controlling related behaviors, having cravings, developing a tolerance over time. Many substances especially alcohol, benzodiazepines and opioids, when you stop using them you go through a very physical withdrawal. For alcohol and benzodiazepine that withdrawal can absolutely kill somebody. With opioids it's only if there's additional complications can that really be fatal, however the withdrawal from it is incredibly difficult and makes somebody very very ill. So that's just a very very brief kind of like that's sort of what addiction is.

Some of the features of addiction, like as it begins often people kind of feel like they're in control of using the substance that they're using whether it be because they're taking it as prescribed or they drink but it's only on the weekends or whatever it is, it starts out seeming like it's something that they can handle, it's something that I'm an adult so I can [inaudible 00:08:44] taking this, it will be okay. But over time they very quickly begin to like lose control of their ability to do that, they find that their behavior around it is compulsive, if they're not using the substance they're thinking about the substance. They might be sitting at work thinking about where they're going to stop on the way home to get whatever it is that they need whether it be the liquor store or somebody else, and they spend more time thinking about the acquiring the substance, using the substance, and slowly that really kind of begins to take hold of most of their conscious attention.

And then that of course gets in the way of their ability to fulfill obligations, they continue to use despite consequences, despite maybe they get in legal trouble or strange family relationships or they lose a job, and the longer it goes on over time, you see the escalation of use. They develop a tolerance, they become dependent, and they start to have loses in their life, loss of positive relationships, loss of jobs, loss of freedom often to the legal system, loss of being able to have custody of their children, unfortunately sometimes loss of life. So it becomes a very all encompassing scary thing for families. And ultimately, most of the substances when you stop using you go through some physical withdrawal, that doesn't happen necessarily in the beginning but when somebody qualifies and meets the criteria for a substance use disorder, that becomes a much more realistic possibility.

So some general reasons just real quick, why individuals start using substances. Sometimes it's simply just to feel good, like often some of these diseases come from just like one decision on a weekend to cut loose so to speak, turns into a lifetime of pain and it can escalate very quickly. But often it's like going out and having a couple drinks with friends, why do you do that? To feel good. And for some people that never, often many people can control that and that's totally fine and they go about their lives but some it's like they start to feel good and they

realize it's taking some of their pain away and they want to feel better again. And slowly a habit develops and then once the habit develops, the addiction can develop.

Sometimes it's to feel better, this is often the case with opioid use disorder where people are prescribed these opioids because of an accident, because of a surgery, whatever it is. So it takes away their physical pain but they also find that it helps reduce negative experiences like their stress, anxiety, other negative emotions they're having a hard time dealing with and they feel better. We feel there is a large correlation between childhood trauma, trauma throughout your life, and opioid use or alcohol use because when you don't know how to deal with some of the things that you and your family have been through, this can temporarily quelch those feelings when you don't necessarily have the tools to do it another way. So sometimes people start using to feel better.

Peer pressure is still very alive, if all your friends are doing it it doesn't seem as dangerous, it doesn't seem as taboo, so you might try it as well. Another way they start to develop is to do better, we see this a lot especially with college students and the use of amphetamines and Adderall. In the beginning it's so that they can stay up, they can study, then they start to see some positive results for a little while like in their ability to complete homework and complete papers and stay up to study for tests. But that's a very brief window before they start having other reactions to it. So basically like you might do better for a very brief window of time but then ultimately then when you're not sleeping and you're not taking care of yourself and it becomes more that you're abusing the Adderall or you're abusing the substance, then it becomes problematic and it actually starts to make it so that you're not performing as well and then ultimately that can develop into another thing.

So this is, like it's a very brief overview of what it is that inspires people to, like how they end up. Like a lot of people are like well how did you end up even starting? And it's like sometimes it can just seem like such an innocent and in the moment kind of decision that a whole other series of decisions kind of happen after that. And for most people who have developed a substance use will say like I don't even know how this happened, like I went out on a Saturday night with my friends, now two years later I can't, I lost my job, I've lost my family, I now am in legal trouble. And it all happened so quickly and they lose control so quickly that looking back on it they can kind of see where different small decisions like influenced them over time, but how quickly it became a much bigger thing than just trying to feel better or just because of peer pressure or anything to that nature.

So a lot of people kind of ask the questions like well, I've had some drinks on a Saturday night with my friends, how come I didn't turn into an addict? And that really kind of comes down to every single person is different and it's a very individualized thing and vulnerability varies from person to person. So some of it is the characteristic of the substance, some are just simply not as physically addictive. The root of administration, if somebody, depending on how somebody is using something they get addicted to something quicker. If they are taking

something orally they're going to get, like the period of time for them to get addicted will be a little bit longer than if they were inhaling it and a little bit longer than even then if they were using intravenously. So the root of administration definitely affects the nature of the addiction.

Genetic factors, like we're definitely seeing where people can be predisposed to having an addiction and that's not necessarily, like there's the social part of that where the family of origin that you grow up in, it might be part of the environment to use drugs. But what we're also seeing now is some individuals' receptors in their brain, it takes more for them to feel the positive effects of endorphins, the positive effects of norepinephrine and all of the hormones in your brain. If it takes more of those for somebody to feel better their odds of them being able to develop an addiction or the odds of them actually developing the addiction are higher. So like somebody who it takes more for them to feel better are at a greater risk genetically to develop a physical addiction to something.

The age that they start using and stage of development, all of those things kind of play into like how severe of a substance use disorder that they might develop and how quickly they might develop it. The family environment, there is definitely correlation between people whose parents struggled with addiction, then you struggle with addiction and the siblings struggle with addiction, like if you do a genogram of a family that has a lot of addiction and mental health issues, it's rampant throughout each generation different things that people are struggling with.

Again, peer pressure, co-occurring disorders is a major piece of it, if you're struggling with anxiety, PTSD, depression, schizophrenia, bipolar disorder, many people develop addiction trying to self medicate some of the other mental health symptoms that they have so that's going to increase their vulnerability as well. As well as socioeconomic status and poverty, now addiction definitely crosses barriers there, it doesn't discriminate but if you're of a lower socioeconomic status or living in poverty, the odds of you being introduced to substances and the odds of developing an addiction over time are greater. And there's a lot of debate there, that could be from disparities in prevention, disparities in the ability to get treatment, things like that but it definitely contributes to and is a risk factor for substance abuse.

So why understand all of this addiction stuff? For one thing when you're working with families or even in your own family, if you understand the way addiction works and you understand the way the brain begins to work when you have an addiction or when there's an addiction in the family, or the risk factors from the family to develop an addiction, it just helps explain the unexplainable behavior that families witness and that kids will see and grandparents see and the parents will go through. Because the addiction, we're not necessarily specifically talking about parents with addiction but that is a little bit the focus. It kind of helps explain all of the stuff that the family's going through, like it's not an excuse for it but it helps you understand. It also reduces the stigma of the blame and the anger, the major stigma around addiction like it's something we fight everyday and it's reducing but it's still very much there.

For the recovery person it helps them understand like why do they keep using? Why do they keep relapsing? Why have they done this to their life? Because most people who are struggling, they don't look at their lives and go like oh yeah this was a very good idea like I meant to do this, I don't understand what's going on with me. And so kind of understanding this brain chemistry and the patterns and everything like that can help them understand better A, how all of this happened and B, what can they do to learn how to overcome it? It helps them thus helping on the recovery journey. And then it also helps understand triggers and cravings, like if you have anxiety and it's co-occurring with your substance use, better controlling your anxiety is going to greatly increase your likelihood of being able to maintain recovery.

So who makes up the family? We kind of just added this because especially in the face of the substance use crisis that we have in the United States, the immediate family isn't always just like the parents and two kids. Like we see, you see a great deal of older siblings raising younger siblings, so it's parents, siblings, partners of parents, the children themselves, often the extended family, grandparents uncles and aunts, close friends of the family, and we added in colleagues from work, mentors and anyone else who can support the recovery. So when you're talking about family recover those are all individuals that would be able to help support the family as they try to get their bearings and try to get on their own path to recovery. And in some cases, especially when it's the parents that are struggling with the addiction, it's those people who have to step up to the plate to help the children and often take on a lot of the responsibility. So they can also be used to like help families as they battle this, sorry about that, got a little bit distracted for a second.

So one of the things we wanted to add is like talking to kids about the addiction in the family, and I think it's important to note we are talking about parents but we're also talking about it might be an older sibling, it might be the child themselves, it might be the parent, it might be a grandparent, it could be an aunt and uncle or somebody else that's close to the family that's struggling with the addiction. It's still going to affect the child and children pick up everything and they're very, like often by the time that the conversation starts about the addiction or about what's going on in the family the kid already knows, is already confused, and has already had a lot of reactions to it, and has already been affected by the addiction. So they're already aware, so it is important to have open dialogue with the child and try to support them.

So that can be, like different ways of working with that, like it might be in your own family, something you can take home, or the people that we're working with. And then it might also be in the role of like home visitors going out to see families, this might be something you can use to help coach the parents or to help coach the families and how to talk to the child about the addiction. So the most important thing obviously is to keep it age appropriate, they don't necessarily need to know every single detail of everything, they don't need to know the certain adult aspects of it. But keeping the language that you use and level of detail that's provided, kind of like on the same level of the age and the maturity of the child.

Like breaking down the issues as simply as possible and as directly as possible, and also it's also important to kind of add that message of hope because if the child's been in a family where there's a lot of addiction, there's a lot of negativity and they might not realize that people can get better from this. Just because the family's struggling doesn't mean that they're not loved, it doesn't mean that the family's not going to get better and that there's not help available. And a lot of times when the conversation's kind of happening around what to do with the person who's struggling, the rest of the family kind of sometimes gets neglected a little bit. So just keeping the kid, the children in the conversation can help quite a bit.

Timing the conversation is also very important, you don't want to, whether you're coaching someone else to do this or you're doing this yourself for some reason, you want to make sure that you're doing it in a time when there's not distractions, the conversation's private, there's a certain amount of time blocked out for it. So it's not like a great car conversation or public transportation conversation or like as you're dropping somebody off at school conversation. You want to give it time where there's not going to be a lot of distractions, where the child can be the center of the conversation and that they can feel free and safe to express themselves, there's time to address anything that comes up, and it's kind of like a special planned out time to actually have this conversation. This should also happen face to face, not via email or text or any other type of like social media thing that we have available to us these days.

We talked about keeping it age appropriate, telling the truth. Kids know, like they know when something's going on in their family, they know when somebody is not telling them the truth, they know when everybody's trying to tell them things are hunky dory and they're absolutely not. So although you need to use different terms depending on the age of the child, always being open and honest about the problem. Children have the innate ability to read when adults are lying, explain that the addiction is a disease caused by a number of factors including genetics, environment, and the past trauma similar to the people, lost my train of thought, so yeah to just be absolutely telling the truth. Like i said they don't need to know every detail of everything but they already know something's going on so to try to make up an elaborate story to protect the parent that's not there or something like that, like they know. So it's like the more you can be honest and age appropriate but honest, it helps.

Getting educated, and that's helping to educate yourself and the child themselves just on like what addiction is, what does it mean? And there are definite ways of doing that in a child appropriate way but just helping them understand what the addiction is, how it affects the person and the decisions that they make and their behavior, and how that people can get help. Acknowledging the impact on the child is also very important, like a lot of times, when somebody's struggling with an addiction it can be a very dramatic, very crisis situation and often the focus is on keeping the person who's struggling with addiction alive, keeping them safe, and the family kind of gets lost in the shuffle a little bit. So acknowledging the impact that it has on the child and allowing them to validate what they're going through and let them voice what their experience of it has been.

Releasing the shame is also very important, like letting them know addiction isn't a shameful thing, it's a disease, it's something that the family can overcome, it's nothing they did wrong like that's a very important message for them to get. It has nothing to do with anything they did or will do, even if they've gotten that message from their parents or family members. Because sometimes especially when you get into adolescents, it'll be something, you'll hear like well if you would just behave I wouldn't use or if you would just clean the bathroom I wouldn't drink. Like so they've gotten that message so they're very affected by this, but that they don't carry the burden of it is important I think for them to know.

Putting things into perspective, children from addictive homes tell to idolize their families without even realizing that they have struggles of their own, idealize I'm sorry. So making them feel like they're important too, like making them feel like they have their own problems, their own stresses, and that everything will also be okay and that if one parent's struggling with addiction but the grandparents are stepping in, they still have people who love them, they still have adults who are going to support them. Inviting dialogue is really a powerful thing, a lot of times kids are kind of given all these messages that everything will be okay and this is what's going on, but there's not a lot of permission given I think for the dialogue of just sort of saying like hey how are you feeling about this? What do you think about this? Like how would you describe what's going on? Like hearing from the child themselves can be very powerful and very helpful for them.

And finding additional sources of support, so it's important for the kids to know who are the adults that they can go to to talk to about this? Like who are the adults that they can turn to if something happens? Like having almost kind of a safety plan for them like if something happens with mom this is who I can reach out to. Or I notice my older brother is acting this way and I don't want to go to my parents but I feel like I need to talk to somebody about it because I'm confused, maybe it's an aunt or a neighbor. So that they know that they're not alone in this and they have a number of trusted adults that they can go to. Because one of the things that really happens to children in the midst of addiction is they feel very unsafe, they don't know who they can go to, they don't know what's going on, it's very confusing and very scary, so supporting them through this, like letting them know specifically who can support them can help quite a bit. Because a lot of times they aren't sure who they're supposed to talk to and they've gotten a lot of conflicting information.

Teaching them the Seven C's. They didn't cause the addiction, they can't cure the addiction, they can't control the addiction, those three especially, that's an important message for any family that is struggling with addiction because we see so much codependency and so much like well if I get all A's on my report card my mom's going to be okay. Or as long as I'm not bad the family will stay together, you know if this happens then this happens. So they start, and this isn't just children this is many individuals who are struggling in families that are struggling with addiction. You kind of develop these patterns of like okay well there's trouble here so I'm going to be really good or like there's this so there's that. But really just understanding that they did not cause the addiction, they can't do anything to cure the addiction and they can't control it, that they can still love

the person and that person needs to go on their own journey, but they can care for themselves and that they can communicate their feelings, make healthy choices, and celebrate themselves.

It's very difficult when there's somebody especially who's in the early stages of recovery or who are in active addiction to remember to take care of yourself and that goes for the child too. Like they have needs, they have feelings, they have thoughts, they need to still make good choices and still have a structure and things like that and that there's nothing wrong with taking care of yourself, in fact it's one of the most important things in a family is for each individual in the family where there is the addiction, to try to take care of themselves. Because an addiction has the tendency to swallow up the whole family regardless of who it is that has it. So knowing that they still count, knowing that they still need to take care of themselves and that there's a lot of people supporting them. Just all of that, just like open and honest conversation and knowing that there's support for them too, can make all the difference in a family, it builds resiliency, it becomes a protective backer to do so.

Yeah, so to get help in Pennsylvania, I'm keeping this very general because I'm not sure which county everybody's from and it does vary across the state. But in Pennsylvania we do have the Department of Drug and Alcohol Program, also known as DDAP that facilitates drug and alcohol programs in every single county in the state but it varies on how it works and how treatment is accessed, et cetera. So the best thing to do no matter where you are in the state, you can always contact DDAP directly via this helpline here, the 1-800-662-4357 helpline. That helpline will connect, wherever they're calling from you connect with this helpline, they will connect to the people they need to in a county of origin that the person is calling from to get the specific services in that area and to help generally to actually connect you directly to the people you need to talk to. But they'll help you walk through that process of accessing whatever the help is for that person in need, like that is a good starting point.

So this is just important to know that this is brand new and just in the last year, we now have in Pennsylvania Act 53 which is a law here that allows a parent or a legal guardian to get drug and alcohol assessments for children and also basically court orders them to treatment if necessary. So this is anybody under the age of 17, parents can basically commit their children to treatment if it's warranted after the assessment. So this is a pretty big, well I should say ages 12 to 17, hopefully we don't see a lot of children under the age of 12 but it can happen. So it's basically a commitment to treatment anybody under the age of 17, it's just good to know that we have this. The first step is really to connect with the single county authority in the area and I'll explain what that is in a minute, to find out the specific procedures by the county. But just knowing that we have this law in Pennsylvania can be very helpful.

Act 106, so what Act 106 is, we've had this I think since the late 80's and it basically requires minimum coverage for substance abuse treatment. So if for some reason somebody has their own insurance but there is an issue like either they don't have substance use treatment under their plan or they've had a hard

time accessing it, Act 106 can help cover up to seven days of detox per year, it's 28 days per life time, a minimum of 30 days in a short term rehab, 90 days per lifetime and also outpatient treatment. So if somebody who has insurance is struggling to access that treatment, Act 106 is a way for somebody to get help. There are certain barriers to that, I will say like if somebody has purposely refused substance use coverage on their plan but it was offered to them, there is some things that make it a little more difficult. But especially with private insurance, Act 106 can go a long way to help somebody getting into treatment.

So accessing treatment, there's kind of two different routes. If somebody has private insurance, the best thing to do is to turn the card over, get the behavioral help line, and call the insurance company directly to find out what they need to do to get into treatment because each private insurance company is a little bit different. If they do not have insurance or they have medical assistance, the local SCA which is, so it's single county authority. So just a very very brief overview of that is DDAP is divided into local offices by county or county area, in some of the more rural areas like for instance Carbon-Monroe-Pike has their own SCA but it covers three counties.

That is basically like the local DDAP office who can help navigate any drug and alcohol program whether it be case management or in patient or money for treatment, anything that they have in that area, that is the best point of contact to find out what's available and how to access it. Whoever is working in that office will be able to help that individual figure out how to get into treatment, where their local assessment site is, who do they cover, what funding do they have. So that is a really good place to start as well, so it's either that 1-800 number I mentioned, or finding out the local SCA which I did, I think, yeah so that is how you find the local single county authority. Either calling that 1-800 number or it's very easy just to go to that website, put in the county you come from and it gives you the contact information for the single county authority. That is who to call for your local services that are available.

So in the state of Pennsylvania, one of the first steps is to get an assessment if you don't have insurance or you have medical assistance. Once you get that assessment they basically find the fundings for you whether that be through Medicaid or through county funding through the actual county and that's usually DDAP funds. If they need to apply for insurance they can go to that compass website, so they can go to that website, fill out everything they need to to get the insurance, print out the confirmation page and take that with them to the assessment so the assessor knows that they already applied for insurance and then that just takes care of that problem.

So a lot of times people will hear like oh I wasn't able to get into treatment, there wasn't any funding for treatment, I can tell you right now where there's a will there's definitely a way when it comes to treatment. Whether it be through their private insurance, through Act 106, through private county funds, through scholarships, it's just a matter of linking that person to those services, and that can also be a barrier. So that's why calling that single county authority can usually be a very great tool. So that's the single county authority information.

So just very quickly, what is treatment? Because you get to hearing these terms thrown around quite a bit, and then I'm going to pass it on to Kelly so she can do her piece. When we're talking about treatment we're talking about anything from basically when the person decides they want care and they need to get that assessment, through all of these different levels of care. Detox is generally the first five to seven days of treatment, often it's assisted by medication, it's when they're actually going through withdrawal and kind of just getting the substance out of their system and that usually lasts five to seven days. Short term rehab is the first 21 to 28 days, it's kind of considered stabilization and just kind of getting the person on solid ground so they can return to their lives. Some individuals need to have long term rehab like long term rehab really is great for anybody but it's an additional 28 to 90 days and in patient to work on co-occurring disorders, life skills, whatever it is that they need.

The next step down from that is partial or partial with housing. All across Pennsylvania now, especially with private insurance we see partial with housing as a good alternative to residential mainly because insurance will cover it for longer periods of time. This is generally, there's two different styles, there's what's called the Florida model so to speak and that's partial with recovery housing attached to it. So the person is living in a house owned by the partial program or ran by the partial program, so they go to partial during the day from like nine to three and then they return back to a staffed house and they stay there, they don't go home. There's also partial programs that are like nine to three during the day but you're returning home at the end of the day and that usually can last anywhere from three to six weeks.

A halfway house is anywhere from a 45 to 90 day program generally and that is, it is a level of care, it's covered by insurance, they generally do not take private insurance in the state of Pennsylvania, they are generally funded by Medicaid or county funding. But it's a program where they have a counselor, they have groups, they have everything like that but they're also able to start going out to work, start reintegrating into the community, finding jobs, getting volunteer opportunities, whatever it is. It's a step between being in patient and being out on your own. From there often people go to IOP GOP and transitional programs. IOP programs, licensed by DDAP, have to be at least nine hours contact a week so usually it's like two to three nights a week or days a week where you have several groups, you have an individual counselor. From there you step down to GOP which is a similar model but shorter and then often they have a transitional group that can last anywhere from a few weeks to a year where you still go and meet for group each week.

Most treatment programs now are working to develop strong family programs, obviously we're really seeing the importance of having the family involved in treatment because this is a family disease it's not just the person who's sitting in rehab. So what we were seeing over time was people go to rehab and they're doing a lot of work on themselves but we're not working on how to incorporate their recovery with their family recovery. So there's a number of really great, whether it be ran by the treatment program or another group in the community. In the Philadelphia area PRO-ACT as an amazing free family program that helps

educate on addiction, on enabling, on what does it mean, how can we take care of our families through it? And that's a free program and a lot of areas have something like that. So educating and supporting the family is every bit as important as educating and supporting the person who's actually struggling with a substance use disorder.

In many areas there is ICM and case management services, much like the one that I run that's the Center of Excellence program, we do care coordination for opioid use disorder. But in that you basically have a person that's helping the person navigate everything that they need whether it be to get into treatment, to find a job, to find items for their household that they really need, anything like that and just kind of supporting their recovery. We have a big push now too for peer support, so CRS and CPS programs, so that's certified recovery specialist and certified peer specialist programs. And those are ranging the gamut from everything from just like somebody who kind of coaches you in your recovery to somebody who might be doing some level of care coordination for the person. But it's somebody who has the experience of addiction and mental health issues who have achieved their own recovery, their own path, and have gone through training programs to help them work with their peers to support them and help them get better.

So that's just kind of like, you get all these different terms sort of thrown at you when you're working with families struggling with substance use disorder, that's just like so you kind of have some familiarity of like what we're talking about when somebody's like oh I'm in a recovery house, oh I'm in a halfway house, oh I'm in this, oh I'm doing that, I need to go to detox, now I need to go to rehab. Like those are just the slight variations in each one and generally what's available in each county resembles that. So I'm going to turn it over to Kelly now so she can talk to the home visitor's piece.

Kelly Hicks: Okay, thank you very much Shannon. So hi everyone, so now I'm going to speak about home visitation and how home visitors such as parent educators can effectively work with parents who struggle with addiction. This could also be useful for grandparents or extended family that currently have custody of a child because the parent is struggling with substance abuse, to really kind of understand where certain deficits lie in parenting. So in order to address the specific needs of parents who struggle and have struggled with addiction, home visitors need to identify the areas of parents that are most affected by addiction. And once you have identified those areas, home visitors are then responsible for tailoring lessons to address specific deficits that exist due to addiction.

So as a home visitor it really is your responsibility to kind of take whatever curriculum you are working with and find a way to address the areas that are most affected. So when we talk about certain areas that are most affected, the effects on parenting due to substance abuse are mostly seen in the areas below. So empathetic parenting and meeting children's needs, routines, disciplines, and family roles. So in the next couple slide what I'm going to do is just take a closer look at those effects and how home visitors can address these when working with families we are serving who struggle with addiction.

So the first thing that we're going to talk about is empathy. So empathy is defined as the ability for one person to perceive the emotions needs and desires of another person. So the quote I think that is most common when you think about empathy is that in order to really understand someone you need to walk in their shoes. When we talk about empathy is regards to parenting, empathy is the parent's ability to perceive the needs emotions and desires of their children and respond in a positive way, keeping the welfare of the child in focus. So a parent can be aware of their child's needs, however because of their addiction they're not able to properly respond to those needs.

Tiedra Marshall: Hello?

Kelly Hicks: Hello?

Tiedra Marshall: Now we can hear you.

Kelly Hicks: Okay sorry about that.

Shannon Hays: Okay sorry about that.

Tiedra Marshall: Thank you.

Kelly Hicks: Okay so, oh where was I? All right, we're talking about empathy, so I'm sorry about that.

Shannon Hays: Yeah I apologize I was trying to be really slick and I messed up.

Kelly Hicks: All right so as a parent educator the first thing that you really need to do when we're talking about empathy and meeting needs is first define the needs of children. So what you want to do is address and define the needs of the children. So when we talk about needs of every human being on this planet whether you are five or 500, it's physical, emotional, social, spiritual, intellectual, and creative. Now I didn't put these in the right order but you want to think about them as the slices of life so if you switch that around it spells out slices. So those are the needs that every human being has and when we talk about dealing with parents and teaching them about those needs, you want to first again define those needs for the parent.

Once they're defined, you want to then educate the parent on the degree in which a parent is responsible for meeting the needs based on the child's age and ability. So basically what that means is how dependent the child is on the parent for meeting those needs. So obviously a two year old, the parent is pretty much their, they're highly dependent upon the parent for most of their needs being met. So for their social need, the parent is pretty much their social connection. A 12 year old is obviously going to fulfill that social need through peers and through different friendships in school. So that's what it means by really educating the parent on the degree in which a parent is responsible.

And then you want to just guide parents on the way in which they can effectively meet those needs. So if you think about the emotional need for a child, for every child, includes trust and consistency, a way in a which a parent can fulfill these needs for their child is in establishing daily routine. So that's going to move us down to, uh oh, okay thank you. So a routine is defined as a consistent way of doing something. So if you're looking at it in regards to parenting, a routine is defined as a consistent way of parenting that empowers children by building their sense of consistency, predictability, success, and that which in turn enhances their self concept and self esteem. So children thrive with consistency, having a routine will help make children feel more confident because they can start to participate in their own routine.

The problem comes in is a parent who struggles with addiction often has difficulty maintaining routines because of the inconsistencies in their own life. So what a home visitor or a parent educator could do in helping that parent is work on helping the parent establish routines. So you can have a routine in the areas of feeding, dressing, diapering obviously for the young infant, bath time and bed time and as the child gets older you can include a homework routine for the older child. All of these things will help set up a more consistent and structured home for the child which in turn will be beneficial to start to kind of build back that trust in the child in regards to the relationship with the parent but also trust in their home life.

So the next thing that we're going to talk about is discipline. So when we define discipline, the way that we define it is a set of guidelines a parent establishes in order to teach children the difference between right and wrong and also to ensure children are making good decisions. Most people when they hear the word discipline often think about punishment, that's the first word that pops in peoples' head is discipline equals punishment. And although punishment is a piece of discipline it is not everything, so you want to think about discipline in terms of guidance. So it's not just about consequences but also the rewards.

So most of the time when we work with parents who struggle with addiction, they often struggle with consistency in discipline and setting appropriate boundaries. It's sometimes just easier to give in and also it's also because sometimes of their own lack of boundaries. Many parents who struggled in the past have a sense of guilt and they mistakenly attribute consequences as being harsh so sometimes they feel like what they're doing is I'm making up for past mistakes by allowing children to do whatever they want without any consequences and we know that that can cause a whole host of problems. And then lastly, when we think about problems with discipline and it's about finding alternatives to corporal punishment. It can be difficult for those who struggle with addiction because of the inability to regulate their own emotions. So it can lead to inappropriate forms of discipline for a parent.

So what we want to do is as home visitors you should address the deficits by helping parents create family rules that apply to all family members, you want to identify appropriate rewards and punishment, you also want to make sure that you're illustrating the limitations of corporal punishment. So home visitors can

work with the family and create family rules, sitting down with the parents and the children and having everybody around to come up with a set of family rules is every important. Most children tend to buy in to family rules when they're a part of it because most people in general are more going to buy into something if something's not being imposed upon them. So that cooperation is very important when creating that family rules.

It's also really important in terms of the fact that a lot of times with there being inconsistencies with discipline in the past and so it gets a little blurry about what exactly is a rule and what isn't a rule or what is something that they're not supposed to do and they get a little confused about what is acceptable and what is not acceptable in the home because of not a clear cut structured discipline plan in the past. So when you are creating the family rules, this is giving them a visual, it's also giving them concrete examples of the things that they, the different areas that, or the different ways that you want your child to act.

So when creating family rules it's important to stress that all those who are involved in the child's life on a daily basis should be included because you want to make sure that again, it's that consistency, that with the creation of rules and consequences you're insuring consistency from one place to the next. So this can include anyone who takes an active parental role for the child such as separated parents, grandparents, aunts or uncles. You want to help parents create behavior charts addressing specific behaviors. But it's not enough just to sit with them and create the chart, it's also about as a home visitor or parent educator, going out and making sure they're utilizing the charts appropriately, that they're sticking by, not giving the sticker when the behavior presents itself or not giving in and just giving the sticker or just forgetting about it, having one week where they put it up and then it goes to the wayside. So you just really want to make sure that as a home visitor you're kind of helping the parents be consistent with addressing specific behaviors.

And then you want to identify rewards, praise, extra privileges, objects, and identify consequences which would be loss of privileges, grounding, timeout, restitution, and parental disappointment. So it's very important for a parent educator to make sure that they're giving parents concrete examples of a specific consequence to a specific situation. So for example, if your child comes home late for curfew, an appropriate consequence for that could be that the next day they lose their privilege to go out after school. You want to make sure that you're telling the parent to relate the consequence to the behavior. But again, a lot of parents don't have these concrete examples so that's why as a home visitor it's really important for you to come up with these concrete examples.

So now we're going to talk about family roles. So parentification is the process of role reversal whereby a child is obligated to act as a parent to their own parent. So often times with addiction parents will not have an appropriate outlet for daily stressors, a parent may use their child as their support system and then they're confiding in their child information that's not appropriate for the child to know and this can actually cause added anxiety and stress for the child. So as a home visitor the importance of addressing family roles is in that you need to kind of

make sure that you're dealing with the stress and helping parents find alternative outlets for those stressors in their lives so that they're not relying on their children for that stress relief, so they're not confiding in their children for that stress relief.

You also want to make sure that you're helping parents identify their support systems. As a home visitor it's really important for you to, often times you'll sit with a parent and they say I have no one in my life that can help me but when you start to talk to them you can start to pull out different people that seem to be a positive influence in their life. And it's important for you to help identify those people so that you can increase their support system so they do have another outlet to go to rather than confiding in their children.

So that's going to move us into resources for parents. So a lot of times for home visitors and parent educators you may be the consistent professional in someone's life in that you're coming to the home, you're with them an hour a week or whatever your program might be, so you are their connection. So it's really important that you are knowledgeable about the resources that are available to them. So you just want to make sure that you're really understanding the resources that are available in your county, knowing that where you can refer them to mental health services or parent support groups, food and diaper pantries, treatment centers, early intervention services, donation centers for safety equipment for children. These are all areas in which you should be knowledgeable as a home visitor of where you can kind of send somebody to seek help in these certain areas. So again, because you are the resource for a lot of these parents because you're in the home with them sometimes more than other professionals.

So I am done, so we're going to I guess turn it over to questions, so if you have any questions right now for myself or Shannon you could please just put them in the box and we'll try to answer them as they come through.

Tiedra Marshall: Thank you, Shannon we do have one question that's come in so far and that question is around the idea of developing a tolerance, how does that show itself in someone's behavior?

Shannon Hays: The main way it kind of shows itself is over time somebody needing to take more of whatever the substance is to get the same effect that they were getting. So say you're somebody who's struggling with alcohol use disorder and maybe you used to drink one beer and you would feel the effects from it but now to feel the same effects for it you need six or 12 beers. So over time you need a significantly higher amount of the substance to meet the needs of I guess the desire and the, I guess the need, whatever it is that they were getting out of using the substance to, like you need an increased amount basically.

Tiedra Marshall: Okay thank you. And how do you work alongside with family and treatment of a family member? What does that look like?

Shannon Hays: So those I believe kind of, I'm not sure I understand the question. I think it does kind of, like it's a very individualized thing by the family, like some families need

more or are open to more and some need connection to resources and then they want to take it from there. I think for the most part it's kind of presenting like what is available to the family and trying to help and then kind of seeing like what their needs are and what they're willing to participate in. I'm not sure if that answers the question or not.

Tiedra Marshall: I'm actually going to open the mic for the person who asked that question, so [inaudible 00:55:27]. Naomi are you there?

Naomi: Yes, sorry. I was asking, I sent another question, how would you support the family when I asked that, whatever treatment they're getting from whatever services is how do you work alongside with them so it doesn't go against what they're getting in their treatment?

Tiedra Marshall: Thank you.

Shannon Hays: I think like the most important thing would be just communication, communication with whoever the treatment provider is, communication with the family and keeping those lines open so that you're aware of what the actual treatment is that they're receiving and that there is like a planned conversation around like how you can continue to support that family while they're going through that. Like what does the family need? What does the treatment provider need from you? Because it's going to vary. If they're participating in IOP program versus if they're across the state in a residential facility, the needs are going to be very very different. So I think really just having that conversation with the family, with the provider, where everybody has some time to kind of talk about what they plan is so that everybody's kind of clear of expectations and roles.

Tiedra Marshall: Thank you. How would you address a family member who is enabling someone in their addiction?

Shannon Hays: I think that's a good place where if there's a family program for them to attend, can be very helpful and also see like what the treatment provider themselves offer. But that is one of the biggest things that kind of happens and people have to sort of be ready to recognize that in themselves. Because there's a big argument of okay well if I don't enable this is going to happen or I don't feel like I'm enabling I feel like I'm supporting. So education comes in there too of like what is enabling? What is hurting? What is helping? There's a lot of tools, like directing somebody to al-anon or nar-anon can be very helpful because then they work on those types of triggers and education. So kind of again goes back to like is the family actually enabling or are they just trying to keep the person alive? Like there's such a fine line there.

Now if it's something like every single time the person gets out of rehab they buy the person a car and set them up in an apartment and things like that, or if they're giving them money for their drugs, that's definite, clear cut enabling. If it's like I let him come over and fed him dinner, is that enabling or is that engaging supportive behavior? So that's another place where referring to a family program, referring to family therapy, seeing if the person's involved in treatment, if there's anything

available for the family there. And then really at the end of the day just education on what enabling looks like versus what support looks like and kind of looking at the family as a unit and it can be a very individualized thing.

Tiedra Marshall: Kelly do you have any suggestions for approaching the first visit with that parent after they return from recovery?

Kelly Hicks: I think that you just have to be sensitive to whatever they're going through, I don't think, let me clarify this, do you mean if it's the first visit that you have with the parent and they return from recovery? Or you've already been working with the parent and they've gone to treatment and have come back? That's a different question because it depends, because if you've already been working with the parent you've already established a relationship with them. So are you talking about like if you're working with someone and they go into treatment while you're working with them? Or it's the very first visit you're meeting with them and they have just gotten out of treatment?

Tiedra Marshall: I believe the person who asked the question is referring to if you've already had a relationship with them. But you know what, I think it's best if you address both because there could be people who are dealing with both situations.

Kelly Hicks: Okay. So for, I think that the first thing that you do is you congratulate them for completing treatment and if you have the relationship with them, I think it's important for them to know that you do understand how difficult it is and that you are, if you have a relationship with them you're proud of them for taking the steps to move forward. And then again, I think it's just kind of with parenting, it's knowing the areas that you need to address with that parent specifically. Fortunately we have an assessment that kind of identifies areas for us but you also know with substance abuse that these are certain areas that need to be affected. So it's again just going in, congratulating them, asking them if there's anything they need from you, but then going business as usual as far as continuing with whatever you're working on with them and the children.

Shannon Hays: I think additionally also kind of prepping the parent regardless if they're somebody you've been working with for a while or are new, to kind of keep their expectations kind of reasonable, like helping them realize it's going to be a rough path, like it's really great that they did treatment but the family wasn't necessarily in treatment with them. And that there's going to be great days, there's going to be hard days, and to kind of keep it sort of balanced. Like kind of know to expect that there's going to be some rough patches but that you're there to support them in that. Like if they hit a rough patch or the kids struggling, or whatever they need, that they have help like going forward. Like that just because they were done in treatment that the support's not ending.

Kelly Hicks: Exactly, and then also, and I think what Shannon said before, making sure that there was a conversation with the kids about what was going on with the parent. And yeah and again, making sure that they do know that congratulations, we're moving forward and then again, like Shannon said there's going to be difficulties but there is support out there for you if you do hit that patch.

Tiedra Marshall: Thank you, and Kelly, how do you handle a situation if let's say you go to a parent's home and the parent is visibly intoxicated during the visit, how do you handle that? How does your program handle that family's enrollment in your program? And I understand we're talking about parents that already have children who are born but what about prenatal clients as well, how do you, is there a difference in how you respond to prenatal parents or expectant parents versus parents who have children that are currently enrolled in a program?

Kelly Hicks: If someone is visibly intoxicated when I'm there, now 90 percent of our clients that we work with already have children and youth involvement, so that would be a phone call to children and youth and then if there are children present, then it would be a child line. But if the parent doesn't have custody of the children or if they're not in the home, then it would be again, that would be probably a call to children and youth if they have a caseworker. But we do get releases signed for everybody that's working with the family so if the parent is in therapy or is working with someone in COE or has again mental health or [inaudible 01:03:04], people that are supporting them outside of the home visiting program, we have releases signed for them so that could be a phone call for a therapist or something like that if the children aren't in the home and there's no children and youth involvement.

Tiedra Marshall: And is there a difference between how you work with expectant or prenatal families?

Kelly Hicks: Yeah if they're prenatal ...

Shannon Hays: So it kind of depends on the program. I think in Kelly's case the family support program that she works with, they're already, like we don't work necessarily with the prenatal individuals, there are case management programs for that. Depending on the situation, depending like if the person's in active addiction, there's absolutely, like they're considered a priority population in Pennsylvania for treatment and placement in treatment. So that would be, hopefully we'd be able to get that person into treatment and absolutely as quickly as possible. And then from there keep them engaged, so it's a little bit more of a, so that would kind of be, I don't want to say it's like a slightly different situation than Kelly faces in the program here. And then there's also some aspect of getting children and youth involved possibly, things like that, like it kind of depends on how the person's coming to us, what state they're in, what their needs are. And then finding, like really at the end of the day it comes down to connecting the person to the right resources.

Kelly Hicks: Exactly, that's what, yeah I think it's just, in that case if you're there with them, if they're going to be honest with you then it's about okay that's why it's important as a home visitor to have the resources available to you that you can kind of connect them with the appropriate people to help them in that situation.

Tiedra Marshall: Thank you. Are there any specific activities that you do with parents to address empathy that you've found to be effective?

Kelly Hicks: Oh yes, there is, I'm trying to think. So with empathy, we work with, I do a feelings game, it's actually, you can actually go online and download games. But we do, like if we're working with the parent and the children we do a feelings game, we talk about so that we can address, recognizing and understanding emotions, so having the parent understand, having the parent and the child interact and talk about the way that they feel and it's done through like a little fun activity. Now when we're talking about doing empathy lessons with the parent, we literally will sit and discuss recognizing and understanding feelings, we'll discuss what empathy looks like, we'll discuss how you meet your children's needs. So all of those things go into empathetic parenting and that's, the curriculum of nurturing parenting that we follow will have these specific lessons that are geared specifically to empathy. So again, meeting your children's needs and giving them examples of what that looks like at each age and stage of the child's life.

So how do you meet your child's social need? How do you meet your child's creative need? How do you meet your child's physical needs at each age and stage? And then also, just discussing the way in which they understand their own feelings, the way in which they express their feelings, the importance of expressing their feelings and modeling that behavior for children, the importance of being your child's model. So all of those lessons we do throughout the course of working with the parent and it's all based in this specific curriculum that we use.

Tiedra Marshall: So how might a parent educator or a family support professional identify a parent who has a deficit in empathetic parenting? What would that look like?

Kelly Hicks: So a child who, well obviously if you see that there's physical, that the child's not getting what it needs physically. If there's no structure or routine in the household, the child's going to bed at any time, there's no, that the child is, every time you come over is not, there's no interaction between parent and child, the child's kind of off by themselves playing with a toy by themselves and you don't see any of that interaction. You know that they don't have a specific bedtime, they eat whenever, they don't really, all those things are kind of clues that your parent is not meeting your child's needs. They may know what they need but they can't kind of, they can't respond in the way that they need to respond.

Tiedra Marshall: Okay. If you are working with a small child and they confide in you about what their parent or caregiver's going through, what are some appropriate child answers? You referenced that in your presentation, can you give us examples of maybe some responses that you've used when working with younger children?

Kelly Hicks: Okay so I was never in, because in most cases I'm with the child and the parent at all times, I never work with children alone the parent is always present because I am a parent educator. So can you, does that make sense? Like I would never have an opportunity where I would sit with a child one on one, that would be more of a therapy piece but I'm more education for the parent.

Tiedra Marshall: Okay, or maybe Shannon if you had maybe a colleague has shared an experience with you or in your communications with others maybe you've come across some examples?

Shannon Hays: I'm not sure exactly what you're looking for, I'm sorry.

Tiedra Marshall: I think what the participant is asking is there a specific language, I know you said like don't use technical terms, ensure that they have a voice, but if a child brings it to your attention and the parent doesn't, but if you've not had that experience then, and you can't elaborate that's okay. We have one final question, a participant wants to know where can they find resources on getting some clarification about the difference between helping and enabling as a home visitor?

Shannon Hays: I think probably the best thing to do, when I mentioned like contacting the local SCA, finding out specifically what family programs are in your area. The other thing that's always very helpful too is like if you go to SAMHSA website, like Hazelden's website, they've got a lot of really excellent resources for working with families and talking to families. If you Google like the SAMHSA Clearing House there's free publications on there that are appropriate either for giving to the child or to the family, but also like information for yourself just to kind of have as a reference. So if you're looking for just general literature, like that's always a really excellent resource. But then also to find out what family programs might be available in your actual area, contacting that local SCA because it varies greatly. Like I said like in this area in the Philadelphia Metropolitan area, we have the PRO-ACT family program and that covers Buck County, Montgomery County, Chester County, Delaware County, and Philadelphia County so it covers our little corner, but other counties have similar programs as well, that's just the one that I'm aware of.

So finding out, like I really can't say enough about the local single county authorities because they will be the expert on what's available for those counties in their area for family, for anybody else. So I guess that's what my answer would be.

Tiedra Marshall: Okay thank you. Well thank you both for your time, your expertise, and your experiences. We found it very helpful today for our participants and the work that they're doing so thank you again for your time.

Kelly Hicks: Thank you.

Shannon Hays: Thanks for having us.

Tiedra Marshall: So that brings us to the conclusion of today's webinar, thank you all for joining us today. The archive sessions will be at the parents teachers and children's trust fund websites within a week. When you receive the electronic evaluation via email please take a few minutes to complete it as your feedback does help us to offer professional development of the highest quality. Registration information on next month's webinar will be emailed soon, our topic and date is still, we're in the

process of determining those. So please remember that you can join the family support webinars in multiple ways including on mobile devices such as phone and tablets. Thank you again for joining us and this concludes today's webinar.

Shannon Hays: Thank you.

Kelly Hicks: Thank you very much.