In this episode we’ll be looking deep into the impact trauma has on families and how it can span generations. We have guest Ward Blanchard, the Chief Executive Officer of The Blanchard Institute joining us to talk about how vital it is that the whole family system be active in the treatment process. Following our discussion with Ward, we have Alexis Crook from Landmark Recovery of Louisville speaking to the importance of the American Society of Addiction Medicine (ASAM) Criteria and how its used to ensure and measure the success of an addiction program.
Welcome to Recovery Radio by Landmark Recovery with your host, Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields, and help navigate the road to recovery.
Now, here’s the host of Recovery Radio, Zach Crouch.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.
In this episode we’ll be talking about trauma, families, and addiction. We’ll be looking deeper into the impact trauma makes on families and generations. We have guest Ward Blanchard who has a Masters in Business Administration as well as he is a licensed Marriage and Family Therapist. He’s also the Chief Executive Officer of the Blanchard Institute joining us to talk about family systems and trauma.
Let me just make sure, Ward. Did I get that right? Are you a licensed Marriage and Family Therapist?
Ward: There is analphabet soup after my name and a licensed Clinical Addiction Specialist and yes, together with $2.50 that will get you a Starbucks, but yes that’s the appropriate way I guess.
Zach: I love it. Welcome to the show, sir. We’re really grateful to have you on speaking with us today.
Ward: Yes. Thank you so much for having me, Zach. It’s something near and dear to my heart so each time I get a chance to have a conversation about it I really jump at the chance.
Zach: Fantastic. Tell the audience a little bit about your background. Can you tell me a little bit more also about Blanchard Institute?
Ward: Sure. Thank you. I’m a small town Eastern North Carolina guy who actually was born on a five-mile by 12-mile island and lived in what you would think of like Mayberry, Andy Griffith scenario most of my life. I worked and really took to community and neighborhood in sort of ways that the kids and I were very…
Zach: Takes a village, yes.
Ward: Yes. It does take a village and I’ve had the fortunate opportunity to grow up in a situation like that where there wasn’t much as what we would think of as direct substance abuse or violence and neglect in the home. I was very fortunate I had to grow up that way. Through high schools, some of the kids they loved to hate me in high school, sort of that Freddie Prinze, Jr. type where you’re getting sports and the accolades and the hunk and all that superficial age and that sort of thought you were invincible.
At 18 years old I experienced a sort of trauma. It was a medical trauma. I was on my way to college to play sports and in 1999 received Athlete of the Year from North Carolina. Two weeks later I couldn’t get out of bed because I came down with this illness that they didn’t know what it was. Within six months I’m breathing out of a trachea and oxygen tank. They gave me a couple of years to live. My life dramatically changes from an 18-year-old…
Zach: I’d say so. Yes.
Ward: My world just shifted dramatically and that was very traumatic, not only for a young 18-year-old but for my family system. Fortunately we had some of the resources in many ways through navigating a medical trauma experience and 80 trauma operations. I was able to make it through it.
Zach: Wow! 80, 80 operations.
Ward: It took quite a few to put Humpty Dumpty back together again.
Ward: It was a little visual, too because I had a trachea and an oxygen tank. It wasn’t something that I could hide.
Ward: It was very visible. I was still able to go to school, went to Chapel Hill with 22,000 kids but I was the only one on a trachea and oxygen tank so it was very lonely for me.
Zach: Yes, yes.
Ward: Fortunately I made it through that, but then that was right at the epicenter of the late 1990’s, early 2000’s when that pain medicine was then promoted, and pain was fifth the vital sign. Oxytocin wasn’t addictive.
Zach: Here’s some very loose medical research to define their cause for that, right? Yes.
Ward: I would say loose is a very generous way to describe that. I got prescribed lots of it and got sort of…that absolutely took away the physical pain, but it took away that emotional pain that I had been burying deep since I was 18. A sort of addiction took off as it always does. Through a series of a few dark years got worse and other substances and in and out in my early 20’s. It wasn’t until my family just really leaned in to the family system approach, a family recovery approach that became the change agent itself that I’ve started to get healthier.
At the moment that happened and I was placed in a [Inaudible][05:57]I knew right then that I wasn’t going to go back to Eastern North Carolina where I belonged in the Behavioral Health field, the recovery space. I didn’t want anybody to go through what my family went through. We had all the resources in the world and couldn’t find appropriate help that understood true diagnosis for trauma or some of the unique individualized elements that we know that are part of the recovery treatment now.
I threw myself into the Behavioral avenue career and that was 15 years ago. I went back and got my MFT and my and all those letters and stuff and just really had been passionate about helping families and treatment and human services ever since then.
Zach: I love it. Not to belabor the point or the topic, what was it exactly at 18 years of age that happened? Was it just some sort of you said medical thing but did they find out? Did the doctors diagnose what was it?
Ward: It really happened all in a flash, Zach. It was very, in that essence as we talk about trauma can be one main event or a series of events. I remember the day. It was Friday the 13th, August 1999. I had been sick for about a month because I was still playing sports and very, very active. I woke up one morning and my breathing was very labored and pain all over my body. They discovered that I developed a really rare auto-immune disease where my body recognizes cartilage as foreign bodies and it attacks cartilage.
Literally the day before I was supposed to report to my first day, freshman year at freshman’s Chapel Hill. I was diagnosed with this condition. We were at the Mayo Clinic at Rochester, Minnesota. My parents were at two adjoining hotel rooms. I was in one room and they were in the other and it was midnight. I could hear them crying on the other side of the wall and I could hear what they were saying to each other. At 18 years old, I’m never going to let them see me cry.
I just started burying that trauma experience. That underlying current got into the soul as what we know then you can try some of this is what drove my addictions and my help for a number of years. It really did a number in my family until we started to learn how to heal and get proper treatment.
Zach: Got it. Wow. You brought up a good point. Some people might experience a death, somebody might get shot, the obvious abuse, sexual, mental, emotional, physical, etc.; what would you define though as trauma beyond even those examples?
Ward: Sure. That’s a great question. How do you put a definition or a box around trauma? You can’t. It’s really an individual event. It can be a series of events or a set of circumstances where individuals or groups of people experience very emotional, physical, distressing events. It is very much individualized per person. What is traumatic for one person is not necessarily traumatic for another.
Ward: One of the biggest things I try to help families understand, too that trauma doesn’t have to be that lightning bolt that would wound, that gunshot or death by a thousand cuts. Families, I’m learning how their like with my parents for instance they experienced a medical trauma where their child had a trachea and an oxygen tank and could barely breathe.
Ask those parents out there listening to this if you experienced that, how many nights’ sleep, good night sleep would you get with your child in the house which can’t breathe and whether it’s going to stop or slightest variation puts you on constant alert. That medical trauma that I under directly had its ripple effect to my family system.
Zach: Yes. Absolutely. You bring up family and I’m thinking, too of spouses, parents, even professionals. There’s a term. It’s called caregiver stress. Can you tell us a little bit more about what, to the audience what that exactly refers to?
Ward: Yes, absolutely. Caregiver stress is something that whether you’re a professional or a nurse or whether you’re involved with one or a family member and you’re taking care of somebody with a progressive or chronic illness. It’s really unique.
A progressive or chronic illness doesn’t have to be addiction. It can be cancer where people get overwhelmed and exhausted and drained. Sometimes it’s physical exhaustion because they’re up all night taking care of loved ones or in some of the most emotionally and exhausting role that emotional and spiritual exhaustion because they’re trying to be strong for their loved one.
Ward: One of the antidotes I give as a key to my active addiction example of caregiver stress when it got to be its worst, my mother called my house every morning at 6:30 AM. I thought she was just being the overbearing helicopter mom that she still is.
Zach: Right, right, right.
Ward: When I got to this process I found out she was just calling to see if I was alive.
Ward: She had valid reason to worry if I was alive. It wasn’t a hyperbolic reaction just where my addiction had gone, how severe it was where I was running and playing around. She had valid reason to wonder day in and day out, hour to hour if I was actually alive.
Ward: I pose this question to people that other scenario other than having a loved one deployed to war and I’m not comparing war and addiction. I’m just comparing what the loved ones
Zach: Addiction can be a war, but right. Yes.
Ward: Very much so, it can be a war. What other scenario other than having a loved one deployed to war where a family member has valid reason day in and day out to have mortality level stress and anxiety worry about their loved one.
Zach: I can’t think of anything.
Ward: That is where I see death by a thousand cuts. That’s extremely traumatic for families and it affects their bodies physically, emotionally. They’re washed out. Their affects them the same way. It’s a parallel process between them. That’s caregiver stress that caregivers feel in every dynamic of their life it impacts.
Zach: We’re in the business, at least I’ve been with Landmark Recovery for quite some time now and we treat both the patients and the families that come through. We have basically a 40 to 60-hour curriculum, so to speak that families go through while their patients come in our care. In your perspective, what would you say are some of the requirements for treating both patients and families? What do you see as being important?
Ward: Absolutely. I think there’s, really taking a look at where we are in our 21st century as far as the addiction epidemic that’s out there is we know it’s not awareness anymore because you can’t turn on the channel and not hear about the epidemic. It’s what’s keeping families and patients from walking in the door and what’s keeping them from picking up that thousand-pound weight…
There’s still a significant stigma, a significant amount of shame and shame-based trauma that come with getting help. Despite depression being the leading cause of medical disability worldwide, we still think we’re alone and nobody understands.
The first thing that is really required to provide that safe, secure space because it’s a primal need. It’s not a psychologist’s buy-out. We want to feel safe, secured, connected, and trust. Empathy is the best way. The two most powerful words you could say to somebody when they’re suffering is, “Me, too.”
Ward: “Me, too.” It’s a lot different than sympathy because a lot of times people want the silver lining and say, “It’s not that bad,” or say something that puts a silver lining around it. That’s for the person who is trying to figure out what to say. It’s not the individual who is suffering because they don’t need your silver lining. They just need you to validate, to listen, and just to provide that empathy, understanding.
Brene Brown, he says that you put shame with secrets sirens and judgment. You douse it with empathy and shame starts to heal and becomes resilience.
Zach: Yes. Yes, I love a YouTube video of a cartoon. There were some giraffe or something like that that fell in like a hole. The bear looks down. I guess a lack of empathy would be like, “Man, that sucks down there.”
Ward: Yes. “You want a sandwich?”
Zach: Right. The other, I guess the empathy piece is when the bear goes down and maybe it was a girl that fell in the hole or something like that but the bear goes down there and it was like sitting with the girl and just says, “You want to go up together?” I think you’re absolutely right. Empathy is won, you mentioned I think at some point as I was reading over some of your websites, you mentioned I think perspective shift is another one, too, right?
Ward: Yes. Absolutely, I think. That’s really important to them to recognize especially families like we understand that in the industry like you just spoke of that you guys have a significant family curriculum and understand when I say parallel process and we have a lot of resources and agents that sail the ship to help out our identified patient that makes them feel not alone but with family.
Family systems, we don’t. It’s very shaming language that we use, whether it’s saying you’re co-dependent or you’re enabling. It’s really a lack of vernacular we use. Some of it is saying descriptions that we’re back in the 1980’s. Here we are 40 years later using the same language when what these families really need to hear is “You’re resilient,” or even being in this chair “You’re a trauma survivor,” that “It’s traumatic going through addiction. It’s traumatic.”
Loving somebody in addiction and the behaviors that you developed may be unhealthy, but there’s a reason for is your brain. The chronic stress and anxiety when we go through it it’s just our brain chemistry. It teaches our brain that it exists in a chronic threatening state.
The importance of perspective shift is if you think about human beings, whether the stress or anxiety, whether it’s real or perceived can be a big difference, but the difference inside the body is arbitrary. If you perceive stress, whether it’s perceived or real you still feel it. It doesn’t matter if it’s there or not.
Ward: If there are people in the room but you shut off the lights [Inaudible][19:02]somebody’s going to freak out. That perception is what matters and so your body still responds to it.
Zach: Don’t you think it’s incredible, too or that unless those pieces are healed inside folks, even things that happen, a 60, 70-year-old person sitting there with you in front of you talking about these things, this is stuff that happened when they were maybe eight, nine, ten years old then it’s still, still has a profound effect on them today, right?
Zach: That’s incredible.
Ward: Exactly. I had one of my mentors tell me that’s because there’s no time in the emotional world. If we were walking down the street and you punch me in the face and then I didn’t see you for two years and I didn’t work through it, all of a sudden I walk in to you and it will be like, “Aargh!”
Ward: That would feel like you hit me yesterday.
Ward: That’s why addressing that underlying current in getting to that root cause is so important. In treating mental health and substance abuse disorder issues people get tunnel vision on the chemical consumption. It’s like that’s the easiest part to stop and that’s all we needed, prison should work. Treating that trauma is important.
Zach: Yes. Yes, I know. I was thinking, too just about how the, I think the book The Body Keeps the Score by Bessel van der Kolk highlights a lot of this stuff very well especially their pieces around trauma and how it impacts the brain.
You mentioned also I think when we’re kind of communicating before through e-mail that one of the most frequent lectures that you get called around to do is something called The Neuro Architecture of Family Systems and Trauma and how all humans are chemically dependent. My question to you is why do you think it’s such a popular sought-after topic? What’s covered in that particular lecture?
Ward: I think that it’s such a popular and sought-after topic is because nowadays which the addiction epidemic and mental health epidemic is out of control. There’s not one person walking around in our country today that isn’t directly affected somehow by this.
On top of that, we now know that trauma is so prevalent in our society and just rarely talked about when we say one of five Americans, this is from Bessel van der Kolk’s book: one of five Americans sexually molested as a child, one of four beaten by a parent, one of three couples engage in physical violence.
The topic starts to resonate with so many people that they connect with it and it provides an element of validation. It provides what we talked about that empathy and so I’m called around especially in the field of recovery because we know trauma and substance abuse disorders and processed behaviors are so connected with trauma. We need more evidence-based. We need more empathetic ways of teaching families other than saying, “You’re co-dependent.” [Inaudible][22:25]
They need more support. They need to be shown that perspective shift that they’re not bad parents or bad spouses; that they need to be resilient and they can be the change agent in helping their loved one get help and they can have significant influence. They’ve got PTSD and if they treat this properly you can actually elevate yourself to a higher level of functioning and that post-traumatic growth. There’s a lot of hope out there and that requires that perspective shift.
Zach: You pointed out that a lot of research is proving that this treatment, this progression of healing from trauma can actually, and I didn’t know this before but increase the amount of gray matter in our brain. For our listeners gray matter is important because it contains most of the brain’s neural cells so the gray matter includes regions of the brain that include muscular control, sensory perception, seeing, hearing, etc., memory, emotions, whatever, decision-making.
I don’t think I’ve ever heard this before, but that’s amazing news. Is this similar to neuroplasticity? Is that kind of the same piece or is it even more?
Ward: It is an element of that because when you’re talking about neuroplasticity in the brain is sort of healing and re-wiring its pathways. You can grow so much from trauma from the neuroscience perspective, but it’s also the human being perspective that naturally we’re just attracted to those people who show such courage. That’s why there are little sayings like “Suffering brings wisdom.”
Once you’ve been wounded deeply, allow God to use you greatly. It’s because there’s so much power in somebody’s healing and that’s what we’re attracted to. We’re not attracted to those people who are constant victims and playing everybody else.
When we talk about somebody going through trauma, they’ve got such a shamed face. They really think they’re not worthy and their self-esteem is low. When you show to them it’s not their fault and here is what’s going on. There is a path out of this.
Once you lean on to that, that is comfort and it really starts to do the work that develops those resilience skills, encouragement skills. You become sort of a change agent on fire. People are drawn to you. You really elevate yourself to a higher level of functioning.
What I tell families is, “Go and do this.” Everybody walks through trials and tribulations and pain. We get wisdom in pleasures keeping our conscience but shout in our pain. We have a choice to lean in to it and do the work.
Zach: Yes. That’s a good word, lean in to. Right.
Zach: Yes. Absolutely. I was thinking about the words that you used there. You’re very familiar with the treatment industry in general and I think you bring up some valid points. We operate in a space, the treatment industry where all models of treatment are still utilized. As you pointed out, there’s a lot of shaming and language like addict, alcoholic, co-dependent, etc. We often shame the one suffering with those labels.
My question is why hasn’t the treatment industry and even those professionals involved evolved? Why haven’t they taken into account these practices versus maybe other areas to help that would certainly evolve?
Ward: That is a million-dollar question. I think there’s two parts to that, Zach. [Inaudible][26:38]There’s actually a study that shows that in all of health care wants clinical trials to have proven a certain procedure or modality to be the way like the way you need to treat a certain…that it takes 17 years for that modality to be adapted by 51 percent of the medical community.
Ward: 17 years. That’s in health care in general. I think if you did look at addiction treatment, we are such a young part of the health care field. It’s really in the 1970’s, 1980’s we became prominent. There’s so much personal crossover that people feel so passionate and it’s so emotionally-charged. It’s nice to have that personal connection; I could say that ability to empathize.
Sometimes that personal connection skews objectivity. They feel so passionate about it that they say, “The way that I did it is the way.” I think that throws up some barriers to us which is now getting so outrageous. The evidence that we have versus some of the models that are still being used that worked 30, 40 years ago.
They were great back then but we’ve made so much advance and I don’t think your patients and families deserve to have them treated with the reverence of how deadly this disease is.
Zach: I think that’s a wonderful word — reverence because you’re right. Each person that does walk in front of us and needs treatment is going to be different. They’re going to have similarities but there’s always going to be a unique sort of twist to the person that’s sitting in front of us and to have that reverence, I guess to honor the other person and then their story in that way really can go a long way.
People using their own recovery as a methodology sort of to speak to treat others is yes, it doesn’t work for most people. The other piece that you brought up around will it take I would say as a culture to battle the shame and the silence that surrounds trauma for so many people. I’d love for Brene Brown to be in every city or every family or whatever but that’s not possible. What do you think on a practical level we as family members, members of a community do to battle that shame and that silence?
Ward: I think that’s where you find a solution. Zach, I have to thank you for asking it that way. The Blanchard Institute is and IP. It’s a community-based organization. We do a lot of community and go and talk to schools. They want to identify what will come up, identify strategies.
I can do that. I can teach you how to identify strategies and stuff but the solution is in the system. The long-term solution is in the system. It’s not exclusive to people who struggle with substance abuse and mental illness. They don’t have and we don’t have a monopoly on spiritual bankruptcy. It’s a human being quality.
The first thing I like people to understand is the epidemic of addiction that’s what’s ravaging the country. That’s also the reason why all adults demographic in the society is the most addicted is the most medicated in depth adult cohort ever.
It’s all of what is vague. It’s all avoiding that question of shame and the way that people get through this is the depressing and connected within their own family because if you look at it now the society’s blowing up about where you grew up or what age. Zach, I didn’t have active shoes or training when I was in high school.
Zach: No, no.
Ward: I didn’t have chronic stress, chronic anxiety at my fingertips with technology and you hear about what’s happening in Serbia and Afghanistan at the drop of my fingertips. It’s all the time that chronic stress, that chronic trauma and it’s just a lack of connection.
I tell parents and families, “I need you guys to text your loved one who is in the same house, sharing the same room or across the dinner table or if you have a difficult conversation, what I call a personal conversation that you need to have from an emotionally-connected place.” You send a text or write a novella. [Inaudible][31:24]There’s just a lot of disconnect. It’s a lack of connection.
The solution is being connected with your family and providing that safe space and the adults in the house modeling healthy behavior and valuing members of their family as individual that they are allowing them to be different. Really we all desire to be safe, secure, connected and have that trust.
Zach: Yes. We’re hard-wired, right? Yes.
Ward: Yes. That’s exactly right. We’re hard-wired, whether it’s Brene Brown with her information or whether it’s the Gottlieb Institute with his love lab. It all said [Inaudible][32:11]There’s a primal need.
Zach: Who was it? It was Bowlby with Attachment Theory that talked…that’s what we do. That’s what we’re made to do is attach.
Ward: The solution is in the system. The long-term solution to this epidemic is the emotional pain. It’s the real epidemic in America. That’s what’s driving adults being abused, medicated in-depth as it’s driving the addiction epidemic. The way to really find that solution is in the home early on and allow the parents to model healthy communication skills and provide a safe and secure connected environment. That’s where we’re going to find the solution.
Zach: Let’s talk about this for a second. What are the best treatment options then you recommend for helping this whole family heal?
Ward: I think in understanding sort of the treatment resources that I am one of those that I will sit on a soap box and say, “This is just like any other health care condition.” It is a health care crisis. A health care crisis like what happened to me when I was 18. Getting that trachea, it sucked. It was uncomfortable. It was inconvenient. It was costly. I was angry. I didn’t want it. I was forced to comply and get it. There’s nothing about it that’s fair.
That was a health care crisis so all those things that are negative and getting that treatment and getting that trachea was still the appropriate path to save my life. Some people think that they have to want it to get better. I’m like, “Nobody wants treatment.”
Zach: No. Nobody wants treatment. Nobody wants treatment.
Ward: That’s the first thing to sort of understand. The second thing is that this is also the only field that’s really ungoverned and unlicensed where when we have a sick family member it’s laid on the feet of that family. You Google’d WebMD. You figure out what treatment. There will be no other disease that will treat that way. You go to a medical professional. They do some sort of assessment, sort of understand where you are in the spectrum of your illness and assign and recommend to the treatment accordingly.
I think too often that doesn’t happen in our field. If we see somebody struggling with substances that it’s hard for families to realize that there’s no support or education out there in general health care community, that their loved one can exist on a spectrum and where you might tend to.
A 19-year-old dual diagnosis female is a whole lot different from where you’d send a 45-year-old female dual diagnosis. The care needs to be highly specialized, evidence-based. I really encourage families to do your advocacy and education, but also not live what you read in the Internet.
Ward: Find a professional that knows places and has vetted resources as they put you in the hands of treatment that does quality ethical work and actually provide the things they say they do on the website.
Zach: Yes. Yes. Yes. I appreciate all that. That’s a big reason why we started this program here in Louisville, Kentucky was that we wanted to provide solid trauma-focused evidence-based curricula for our patients. It focuses both the trauma and the substance abuse.
The Seeking Safety curriculum is what we base our whole group modality around and then the experiential therapies that go along: the art therapy, music therapy, gender-specific programming, those important pieces along with Smart Recovery, 12 Step Recovery. We even do Buddhist-based Refuge Recovery.
It just opens a lot of avenues for people. A lot of people who felt like before they didn’t have a place where they could come to and feel safe enough to talk about this stuff. I think that safety is one of the biggest things that drives people’s ability to walk through a lot of these trauma that they have been through.
Ward: No question. We speak the same language. At Blanchard Institute we have gender-specific out-patient EMDR therapy as our most utilized auxiliary service, family services that we provide. It is the cheap and safety trauma informed care that people that do it well and really maintain the human service element as priority of their mission and our mission as an institute. We all sort of speak the same language.
Unfortunately as I’m sure you know a very conservative guesstimate, I would say may one out of ten resources really effectively understanding, comprehensively provide support for trauma that would be my guess and I’ve worked around the country as a Clinical Interventionist for 15 years and have gone visiting all these places and they’re still very, very huge places that do comprehensive solid trauma-based care.
Zach: That will do in the work with Fidelity. Right. Absolutely.
Ward: Absolutely. Yes.
Zach: I wanted to touch on one more thing before we sort of wind down. It’s a fascinating, I don’t know idea, topic in this idea that you brought up in an e-mail that we’d shared. Basically it’s this idea that until we do a lot of the healing that needs to take place, you mentioned emotional pain being the greatest epidemic that’s going on; we will pass along this trauma on to generations. Not just in our family but as a culture.
I’d think that’s an important piece, this generational piece that we’re talking about. This is true with alcoholism and addiction. It gets passed on. It gets passed down. It’s a very interesting idea of passing along trauma.
Ward: I think you can see that as the more we learn about trauma and human behavior and passing along to generations or communities that tell people look or talk to somebody of Jewish heritage it’s very valid. It’s almost like the Holocaust happened to them. That trauma is passed down. It’s very valid, but also talk to the people in Louisiana. They experienced Katrina. That community has experienced the trauma and passed it along to their generation.
It’s just an example of human beings and family systems and how we crave that connection and how that impacts each other. This generation and generations to come will feel the effects of trauma until we start as the older generation because I love people make claims to or want to complain about the millennials and say, “These are the leaders of tomorrow.” You are the leader of today. There’s something about it.
Zach: That’s right. That’s right.
Ward: We can make generational change but it has to start with adults in the house.
Zach: Yes, absolutely. Ward, thank you man. I really, really do appreciate your time and for taking your time to come on the show today. If you’d like to learn more about what Ward Blanchard and the Blanchard Institute is doing, you can find them online at theblanchardinstitue.com.
If you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn about our substance abuse programs that are both saving lives and empowering families.
We have Alexis Crook, the Intake Clinician here at Landmark Recovery Louisville joining us to explain what the ASAM criteria is and its implications for addiction treatment.
Alexis, welcome to the show. We’re really glad to have you on speaking with us today.
Alexis: I’m happy to be here.
Zach: Before we get into the questions, I know that you serve as an Intake Clinician at Landmark Recovery. Can you also tell us a little bit about your background and what you studied, went to school for?
Alexis: Sure. I did my Bachelor’s Degrees in Biology and Psychology and then actually got a couple of Masters Degrees. I’ve been to dual programs with Social Work and African Studies. I actually did a Public Health Masters, too. My PhD is also with Interdisciplinary Studies and Public Health. I look at health and how it affects underserved and underrepresented populations. With my MSS study I actually got a CSW license so I act as a therapist as well.
Zach: Fantastic. You obviously have studied a lot and been in school for a little while. This topic of ASAM to clinicians andpeople in the field of addiction it’s a very useful tool to have. For anyone listening who doesn’t know what does ASAM stand for?
Alexis: ASAM is the American Society of Addiction Medicine. They’ve been around for a while. They were founded in 1954. It’s a professional society and their mission is kind of dedicated to increasing access and improving quality of addiction treatment. They provide a lot of education for medical professionals as well as the public, do a lot of research and prevention with regards to addiction. They basically try to educate the public that addictions are chronic disease and there is treatment.
Zach: Got it. Got it. Within this ASAM criteria there are several different dimensions, six as a matter of fact. Can you talk to the audience a little bit about what these six dimensions are and what do they measure?
Alexis: Absolutely. They put the six dimensions for the ASAM criteria. They’re kind of standardized treatment. They’re very widely-used. They kind of take a holistic approach to assess an individual because they believe in individualistic care. It’s kind of used to determine treatment. Those six dimensions, I’ll kind of name each one then I’ll go into a little more detail.
The six dimensions are acute intoxication and withdrawal potential is the first. The second is biomedical conditions and complications. The third is emotional, behavioral or cognitive conditions and complications. The fourth is readiness to change. The fifth is relapse, continued use or continued problem potential. The sixth is recovery environment.
Those are the six dimensions. We kind of rate each dimension on scales of zero to four. Zero would be none. One would be mild. Two would be moderate, three serious, and four severe. We use these dimensions to kind of assess, determine what the care for the individual is. I know I kind of said a mouthful so I’ll kind of talk about each one.
Zach: Good. Yes, yes, yes. Please.
Alexis: The first one acute intoxication, that’s where we get information on what the patient’s using, how much they’re using, how often and kind of get that history of use which is super important and what kind of treatment they need. With this dimension, too we also talk about detox and withdrawal symptoms.
Alexis: The detox and withdrawal usually last from probably about a couple of days to a couple of weeks after stopping. They’re mostly physical. That’s when we see people say they’re nauseous or they have some tremors or they have some chills or sweat, things like that. Those are mostly the actual physical symptoms that they go through for just a little bit. We also ask them about PAWS and PAWS stands for Post-Acute Withdrawal Syndrome.
Alexis: That is super important because these are symptoms that persist after the acute withdrawal has resolved.
Zach: After the physical symptoms have sort of worn off, right?
Alexis: Absolutely, yes. These are more, as you said kind of like psychological and mood-related. They happen exactly, like you said after the physical symptoms have worn off. Those are things like anxiety, irritability, insomnia, extreme cravings. These PAWS symptoms can last up to a year so they’re pretty serious. A lot of people relapse just because those PAWS symptoms are super severe so we do assess for that. Yes.
Zach: They can last for a long time. That’s a very long time in really anybody’s eyes, but I mean especially for someone who had depleted basically their dopamine in their brain and they aren’t able to experience any sort of pleasure, these normal sort of pleasures that you and I would experience, whether it be sleep, food, whatever it might be. That’s a long time in a person’s life.
Alexis: Yes. That’s kind of why we ask about the PAWS symptoms because a year is a long time after they feel better physically to have these ongoing psychological and mood kind of issue. Kind of like what you said, that’s a very long time. Oftentimes people will relapse even after they’re done with the acute withdrawal physical symptoms because the psychological symptoms are so distressing to them.
Zach: Right. Got it.
Alexis: We definitely look at those within this dimension. Another thing we look at the kind of last thing we look in that first dimension is their COWS or CIWA score.
Zach: Okay. What are those? COWS and CIWA.
Alexis: Yes. COWS is the Clinical Opiate Withdrawal Scale. Nursing will do this on patients that come in with opiate addictions like heroin, fentanyl, things like that, pain pills. They ask them, I think there are 11 items on the COWS. There are things like pulse rate, sweating, pupil size, joint ache. They will ask the patient to rate these items from zero to four.
That score kind of determines whether they’re mild to moderate or moderately severe, severe withdrawal. That kind of helps with people that are having really tough times with acute detoxing kind of it triggers like sometimes a medication protocol they’re forced to have if that makes sense.
Zach: Okay. Yes. Sure. It’s tools that we as professionals use to kind of gauge where the person is in the withdrawal process, right?
Alexis: Absolutely. Yes.
Zach: Okay. What’s the second dimension? What is that?
Alexis: The second dimension is the biomedical. That’s health concerns. Things we look at there, we ask the patient if they have any health concerns. Some examples will be like they’re diabetic and on insulin or they have hypertension and they feel like their blood pressure is high, Hep-C, things like that. We ask them if they have any concerns.
We look at medical issues. Have they been hospitalized? Are they diagnosed with anything? Any kind of like seizure history, head injury history, things like that? We also ask them about their sleep which is very important. How much sleep were they getting? Do they need medications to go to sleep? Do they have insomnia, things of that nature? This dimension we also ask about eating habits. How is their appetite? Do they have an eating disorder?
Other things we kind of go over is do they exercise regularly? Did they have a physical? Do they have a primary care doctor? Do they have any allergies? Are they on prescribed medication? We kind of hide all that back in just to see if medical issues would worsen if the patient relapses. An example of that would be like somebody that’s coming off alcohol they have hypertension and their blood pressure will skyrocket if they just go home and don’t continue with kind of like a medically-treated detox.
Zach: Moving on to the third dimension, what is that?
Alexis: That’s the kind of, I call that like the bigger picture. It’s the emotional, behavioral, and cognitive dimension. That’s where we ask patients kind of everything about their life. We get a developmental history. Did they have complications when they were born? Did they meet their milestones like walking and talking as a child? Any illnesses?
This dimension is also where we look at family history. Who raised them? How are their relationships with the family? Is there a history of mental illness or substance abuse in the family which is very important? We also look at like a social and spiritual history. Do they live with anyone? Married, have kids? Hobbies, religious preference, things like that.
We get a legal history and that as well talk about work and school and has substance abuse kind of interfered with that in any way? We kind of also get into the trauma history. Do they have any resolved trauma, unresolved trauma? Have they seen a therapist for that? This is where we have a couple of tools that we use to actually measure trauma that are objective. We use the ACEs and the MDI.
Zach: What is the MDI?
Alexis: The MDI is the Major Depression Inventory.
Zach: Got it. Okay.
Alexis: We ask, I think it’s 12 questions. We ask 12 questions. Have they felt like this in the last two weeks? For instance, have you felt bad in the last two weeks? It’s a one to five scale. The MDI is actually zero to 60. If a patient scores over 30, they’re considered to have severe depression.
Zach: Got it.
Alexis: That’s a good tool to use. ACES is the Adverse Childhood Experience. It’s zero to ten and there are ten questions that ask if they’ve experienced a certain type of trauma before the age of 18. We use those to kind of measure trauma and depression.
Zach: Got it.
Alexis: We also ask patients to self-rate their anxiety and depression from zero to ten. We ask if there’s any past mental health diagnosis in this dimension. Lastly we kind of ask safety questions. Do they have a history of being suicidal, homicidal, having any self-harm, audio-visual hallucinations? That truly gets into that.
Zach: The fourth dimension is one of my…it’s usually a pretty good sign on where a person is in terms of their readiness, right?
Zach: It’s called the readiness to change dimension. Talk a little bit about that.
Alexis: For the fourth dimension whoever is doing the assessment will kind of rate what stage of change the patient is in. Are they in pre-contemplation which means they’re not even sure that this is what they want to do? Are they in contemplation? Are they thinking about it? Are they in preparation? Are they preparing for this? Are they in the action stage which means they’re readily open to treatment in this case or maintenance?
We rate each of the patient’s stage on this dimension. It’s usually a pretty good indicator, like you said of where they are in the process. We also look at motivation. Internally and externally, what’s motivating this patient which usually kind of goes hand-in-hand with stage of change.
We also ask what do they want help with? Why are they here? A lot of times we deal with co-morbid mental health and substance abuse. A lot of people will talk about the mental health services they want in helping maintaining sobriety. That’s a pretty good indicator as well.
Alexis: The other things that we look at in this dimension are kind of like the relationship between use and negative consequences. Have there been negative consequences like jail, DUI’s, divorce, things like that? We look at that at that dimension as well.
Zach: In the fifth dimension we move on to kind of looking at the history of where the person is in exploring their relationship with relapse and continued use. Talk a little bit about that. Why is that important?
Alexis: This is a dimension that’s pretty important. Here we look at their longest period of sobriety. How long have they been sober and how did they achieve that? If there has been a past treatment history, whether that be they saw a therapist once a week in terms of out-patient, if they have been in-patient before, things like that?
We also kind of get a gauge of awareness of triggers. Do they know why they’re using? Are they aware that “If I go here, this is going to trigger me. It will cause me to relapse?” We also ask their cravings. Are they still craving drugs or alcohol? If so, what is that craving kind of on a one-to-ten scale?
The other couple of things we look at is there a relapse intervention plan in place? If there been one and kind of what happened? I think probably for me one of the most I guess important pieces of information in this dimension is what is the patient’s risk if they relapse? If the client treatment goes out today and relapse what do they risk? A job, children, marriage, family. I think it’s a very poignant question and sometimes it kind of spurs different responses from people.
Zach: I think that this dimension bleeds into the next dimension which you mentioned relapse. The sixth dimension is recovery and living environments. Talk about why that’s an important dimension to explore with the patient.
Alexis: Recovery is just so…I mean they’re all so important but recovery is particularly important because this is kind of going to measure how they’re going to do once they’re out of the facility, whether that be intensive out-patient or whether that be in-patient.
It looks at the housing. Do they have stable housing? Who they live with, if they live with a boyfriend, a friend, a girlfriend, a husband, a wife, a family? Are those family members sober and supportive? Are they going to go back to an environment where everybody is using in the house which is triggering?
We also look at employment. Is the person employed because a lot of times people we see don’t have any really sober hobbies? If they’re not employed and don’t have any hobbies they’re kind of idly sitting by. That cannot be a good thing. We do ask about sober hobbies. What do you like to do? Some people like to listen to music, to be in nature, things like that.
We ask about reliable transportation. That’s important because generally if someone is doing in-patient we like to step them down to out-patient which does require trips back and forth. We ask about are you on a bus line? Do you money for the cart? Do you have somebody that can take you? Do you have reliable transportation?
We also ask about children. If the person has children, is there child care set up? Is that going to be a stressor? Do they have custody of their kids? We go over legal issues again in this one because if someone is on probation or a parole that kind of adds another piece.
Zach: It sure does.
Alexis: Do they have community charges, court dates, things like that?
Alexis: The last thing really we look at in this category is do they have sober friends? What percentage of their friends use drugs and alcohol? How does this affect them? If they have a support group of friends but a hundred percent use drugs or alcohol then that becomes a problem because they don’t have any sober support.
Zach: Are treatment centers in Kentucky required to follow the ASAM criteria?
Alexis: For Kentucky, yes. The Kentucky government in 2012 made it that all health centers that do addiction or substance abuse to use the ASAM.
Alexis: Besides that, the MCO’s, the insurances require ASAM use to authorize any type of treatment, continuing treatment or discharge.
Alexis: What that means is that we have to use the ASAM and it also has to be updated if patients are in kind of a longer care in-patient facility because the insurance makes us do it to just offer us even to just continue treatment.
Zach: Got it. How have you seen these dimensions, the ASAM, how have you seen them positively impact the patient’s even in Louisville here in Kentucky at our facility?
Alexis: I think there’s a lot of ways I’ve seen it impact the patients positively here at Landmark in our facility at Louisville. I feel like it empowers patients. They’re able to kind of take an active part in their care. It’s not somebody just saying, “Hey. You used heroin yesterday so you need to spend 35 days in a facility.” They get to weigh in and answer the questions and be an active part in their care.
I’m a believer that when we engage patients in that way it makes their voice heard and ask them questions and make them active in their care, they’re more apt to A-trust us and B-follow our recommendation.
Alexis: It really makes patients kind of put their trust in us because we’re letting them know like, “Hey. This is why I’m asking you these questions,” and kind of leading them. It helps us be objective and not subjective. It helps us determine what level of care someone needs.
Alexis: For instance, Landmark we do IOP to the interest of our patients and we do in-patient. There have been times that patients are intensive out-patients and they’ve relapsed and we’ve been able to do ASAM. They’ve used and we’ve been able to get them like literally walk them over from IOP into in-patient because that’s what they needed and the ASAM allows us to justify that and get them the treatment that they need. I think that’s so very important.
Zach: Sure it is.
Alexis: There’s not like a window to wait or anything like that. We can justify why they need that higher level of care and vice-versa. It’s also just a consistency thing. Like I said, it makes us be objective and it just lets us be consistent and putting patients in the appropriate level of care based on these criteria.
Another thing is it individualizes treatment which I really appreciate and I think the patients and clinicians and everybody can appreciate that. The individualized treatment is not we’re just saying, “Okay. You’re going to go to two groups today,” kind of lets them take charge of their treatment and understand that it is specifically for them and not just something that we just throw people into.
I guess there are a couple of other points. It allows a continuum of care so we do a lot of step downs as I mentioned. If someone completes our in-patient program, we’re able to just step them right down to individual out-patient because it will kind of be a shock to do in-patient for a little bit over a month and then just go back to your daily routine. We’re able to have that continuum of care and step people down to the appropriate care and we’re able to justify that and get them the care they need.
Zach: A hundred percent.
Alexis: It’s also holistic. We don’t just look at the use but we look at the biology, the psychology, the social and environmental factors.
Zach: They can’t really separate them all out and just focus on one and hope that everything is going to get better. You do really need to take the entire person into account, so to speak. You get a really thick description I think when you look at the ASAM criteria of who is sitting in front of you.
Alexis: Absolutely. Just reading over the six dimensions, you can really, like you said get a picture of who that person is and the areas where they might need some extra help and it’s a full picture. It’s not just this person is using this and has this trauma. We get their full picture and it’s very holistic which I appreciate. It’s not one-size-fits-all. It’s kind of patient-driven and individualized. It’s a very good tool to use to help people get where they need to go.
Zach: I love it. Alexis, I just want to say thank you so much. This has just been a wealth of information to hear from you. I appreciate the preparation that you took to take the time to get into this subject. There’s a lot there. Thanks for coming on the show today. I really appreciate you.
Alexis: No problem. Thanks for having me. I appreciate it so much.
Zach: If you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio wishing you well.
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