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Treating Co-Occurring Disorders

October 14th, 2020
A woman learning about the treatment of co-occurring disorders

In this episode, Zach is first joined by Karl Shallowhorn, an Alcoholism and Substance Abuse Counselor with over 19 years experience. The two discuss how Karl became involved in the field of addiction recovery and his knowledge and personal experience with treating co-occuring disorders. The two also touch on the practice of motivational interviewing and it’s benefits as part of a recovery program. Following Karl, Zach is joined by Andrew Spiers, a licensed social worker and the Director of Training & Technical Assistance at Pathways to Housing, a non-profit working to end chronic homelessness for individuals with co-occurring disorders in Pennsylvania. The two discuss Andrew’s journey into working in the field of addiction recovery, and more specifically his work as Lead Therapist at RHD’s Morris Home, the only residential drug and alcohol rehabilitation program in the U.S. exclusively serving members of the transgender and gender non-conforming community.

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: Hello. 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.

We have guest Karl Shallowhorn joining us on the show today. Karl is a New York State-credentialed Alcoholism and Substance Abuse Counselor with over 19 years of professional experience in the field as well as being a mental health educator. He also has lived experience in long-term recovery from addiction; he’s got 32 years of sobriety as well as bipolar disorder.

Shallowhorn’s book, Working on Wellness: A Practical Guide to Mental Health is part self-help and part memoir.

Karl, appreciate you coming on the show today, man.

Karl: Thanks, Zach. I really appreciate the opportunity to be here.

Zach: Can you share a bit about your story and how you got involved in addiction recovery? What was that like for you?

Karl: Sure. Like I said, I’ve had 32 years but the story goes only beyond that for me. I was a college freshman in 1981 at Joe Morris Institute in Michigan. I was in my second semester. I’ve had a history of alcohol use in high school then when I got to college I began to use a lot of drugs, being away from home, a lot of stress.

In the middle of my second semester, I had a major psychotic episode which basically had me end up in a hospital being brought back to Buffalo which is where I live now and essentially I spent about seven years cycling in and out of Buffalo area mental health hospitals and institutions. It was during that time I received diagnosis of bipolar disorder type 1 with psychotic features and a co-occurring cannabis disorder.

Like I said, during that period of seven years it was rough. It was really a time when I was just lost and up to that time I was actually in counselling. It was interesting how at first it was even back in the day when I would meet with psychiatrists for nearly an hour. You can’t do that nowadays. Eventually, I ended up at Horizon Health Services which is a local service provider and it’s still around today.

After I’ve been with a couple of counselors, I end up with a therapist, a guy named Dick Hefron. Dick himself was in long-term recovery from alcohol addiction. Dick was one of these guys who really connected with me. I hadn’t really connected with anyone else before, but Dick kind of I guess went through that wall that many therapists had with sharing about themselves. He would share some of his experiences but that’s really what kind of hooked me.

After a while, I was still using but he kind of called me out one day. In fact, it was the middle of January and I’ll never forget the conversation we had. He basically said, “Karl, I’m going to give you three choices: either you go to rehab, you go to a 12-Step meeting or you end up back in the hospital.” Actually during that time, those seven years, I happened to graduate college somehow. I don’t know how but I graduated and I didn’t want to lose my job. I didn’t want to tell my boss I had a drug problem.

I definitely don’t want to go back to the hospital I thought to myself. [Inaudible][03:52] Two days later, January 15th, 1988 I went to my first AA meeting and I’ve been going ever since. That’s how it began for me. I realized at that point that I really liked recovery. With my first couple of years in the program I thought, “I think I like the concept. I really think I’d like to help people like I’ve been helped so much.”

I went to community college and just took off from there. I got my job in the field and had worked in it for a while.

Zach: The rest is history as they say, right?

Karl: Right, exactly right.

Zach: Yes, man. I want to go back because you brought up some interesting points with the first couple of things that you mentioned. You talked about being away from home. I think it’s especially significant because when you were talking about how this major psychotic episode kind of occurred, coincided with you leaving the house; when you look back now and I think that we all, for whatever reason, me included get into this field with a really burning desire to understand the history that led up to who we are right now, today even now.

Do you look back at that time? If you look back at the environment that you came from which was you had your house, your home, your family…high school for me, by the way was an incredible time. I had great friends, but when I left high school, when I left that environment of stability, it was really challenging, man. I was probably clinically depressed at that time. Do you have any similar experience with what I’m kind of talking about?

Karl: I think in my case, I’m an only child. I’m also adopted. I lived at home. I had everything a kid can want. I was very fortunate, very privileged in many ways to have a great family. Like you said, I went away and that’s when basically everything ran riot, so to speak.

One of the first experiences I had at college within my first week was going to a fraternity party where I was offered basically some hashish essentially. I’d never ever had smoked before. I just was hooked almost immediately. I said to myself, “Wow. This is great. I don’t have to get sick from drinking,” because that was like my pattern of course. I would get sick all the time by binge-drinking and that was my pattern.

I realized there’s another substance that I enjoyed but that’s really what kind of kicked in. I would even call home, ask for money, and things that my parents never even knew was going on, but like I said the stress at school which was enormous and then just that detachment from being home during that second semester I became, like I said psychotic and over a couple of weeks and things just really caved in on me.

Zach: It’s interesting. I used to counsel adolescents. When I was doing counseling with adolescents, one of the things that I used to tell them was it’s difficult to be part of something a lot of the times because there’s expectations from other people in a group, whether it’s whatever it is, whether it’s you be a certain way or you’re funny, you’re smart or whatever it is.

When you don’t have that sort of sense of, I would say sense of worth that alcohol, substances or whatever for a lot of people provide a way to belong. Now there’s a cost, but you don’t have to do much. You can just use with other people and you’re part of something. Did you find that at all to be true in your experience?

Karl: Totally. Without any hesitation, totally. That’s just so funny because that was my in. I realized that if I used…first of all, I had a couple of roommates. JMI had kind of an interesting thing where it was a coop program. You would go to school for two months and then you work for three months. My first experience was at school and then I also work but almost immediately yes, just like you said I fit in because I was able to go get high, whatever with people.

If anything, I kind of lost myself in that process of really becoming that person perhaps that I wanted to be. It was that identification with the drug culture that really kind of got me.

Zach: Yes, yes. As I mentioned in the intro, you’ve been in this field for quite a while, almost 20 years now. We’re going to talk about something that has been used tremendously to a tremendous effect in treating people with substance use disorder and that’s motivational interviewing and you know a lot about it.

Karl: Right.

Zach: Tell us about what that is though and how it is helpful for people in the recovery process.

Karl: Okay. Essentially, motivational interviewing was basically developed based on the stage of change model in the early 1990’s. Essentially, it’s kind of like a guiding style of communication that basically helps the client center between good listening and giving information to the client. It empowers people, which is a big part of how it works. For instance, if you have someone that is trying to understand where they’re at and maybe make a change it will empower them.

You have basically the same, but you can do it. It’s possible. It’s also collaborative which is also key because for many people therapy is about not being told what to do but feeling like you’re being told what to do. With motivational interviewing, it really is like a partnership between the therapist and the client or the clinician and the client where it’s almost like a give and take, kind of back and forth.

There’s this idea of ambivalence. Essentially, that’s kind of like when a person kind of weighs the pros and cons. We say that oftentimes people dealing with say, addiction disorders or co-occurring disorders are ambivalent. They feel like on one hand I like using substance; on the other hand, there are also some downsides.

In that process of motivational interviewing, we try to, as we say erase ambivalence or address ambivalence the way that the person realizes that there may be some downside and then there we kind of get into the point where we kind of hold on to that and then we move along to this idea of responding, reflecting and so forth. We use what’s called open-ended questions, affirmation of reflections with folks to be able to help them, kind of guide them through this process so that in the end they feel like they are in the driver’s seat.

The beautiful thing is that in motivational interviewing when done properly, it really is to say where the client feels like I’m getting to a place where I’m going from ‘I think I need to make a change’ to ‘I know I can make a change’. It’s going to take certain actions, but that’s also where the therapist comes in. They kind of work together to feel what is this process going to be, how do we do it, and what’s the plan going to be.

Zach: All right. I’m curious to hear your thoughts, too. As you were talking, Karl, I was thinking about this ambivalence piece that gosh, man to so many people that come into our facilities are there usually not because they want to be there because they maybe got the law underneath them. They’ve got a family member. They’ve got a job on the line, kids, whatever it is.

Interestingly enough, studies will show that whether someone’s coerced into treatment or they willingly go themselves, research will show that the outcomes for either of those two sub-groups are pretty much the same, meaning that your motivation going in is not as important as why you’re there and then on the backend when you leave.

I know that MI is really not a modality. It’s more of an intervention piece. I think what freaks people out today and for good reason is that the lethality of these substances that are out there are so great because what we’re seeing in our communities right here in Louisville at least is that most of the heroin that you’re seeing on the streets is fentanyl. Fentanyl is extremely deadly. Can MI really up the ante for people quick enough to get them into treatment so that they don’t have a negative outcome, leading up to death even?

Karl: I would say certainly it can help. What I mean when I say that is, like I said before, you’re talking about basically giving the person some tools and also giving the belief that they have the ability to make the change. It’s one thing to tell them you can do it, but if that person really understands based on maybe even some of the successes they’ve had in the past, using what occurred in the past – a difficult question to ask. Yes, you have a period of six months. How’d you do it?

That kind of thing and also just let them know that this whole thing here certainly takes a lot of work but you’ve got some ability and if anything, giving them some confidence that they can do it. That’s another thing that I think many times people lack when they’re dealing with addiction disorders is this confidence that they can actually be successful.

Zach: You say competence with a P or confidence with an F?

Karl: Confidence, yes with an F.

Zach: Okay.

Karl: Maybe also with a P, I think they kind of go…both actually, another dimension because just understanding, the competence; in other words, how to do it, how to facilitate the change, how to make the change. That’s where certainly that idea of education and teaching about addiction and teaching about where it comes from and how it develops and all those things along with, like I said the confidence of just enforcing the idea of hope even, just saying there’s hope in this whole equation here.

That’s also another essential thing that I think can come out of motivational interviewing.

Zach: Yes. Obviously the relationship between the therapist and the patient is a really important one. Can you tell us a little bit though about the relationship really between patients and their peers in treatment for folks living with co-occurring disorders?

Karl: I think it could be a double-edged sword. Like any other therapeutic setting, any set of a force sometimes people are there for good reasons. On one hand and it’s been my experience, too you might have person-to-person kind of group setting that might not be buying into the process, might not be even willing to go along; however, if the therapist is effective they can even use that as a tool to engage others, not to make that person an example of what not to do but there might be others who feel like ‘I do want to do this’.

The group can be very powerful. In other words, it’s almost like human behavior. If you have one person who’s going to stand up and say, “This is what I’ve done. This is what’s helped me,” you might be more likely to get others to say, “Wow. That actually might work.” The great thing is that a peer has the ability to speak out in a level that even a therapist may not be able to and that’s also powerful.

Like in my own story when I got involved in 12-Step recovery early on, I realized the value of, as you say the therapeutic value of one addict helping another — the idea that there’s no comparison to someone who’s walked in those shoes who’s lived through it and has been successful. In many programs, I ended up working in Horizon Services many years later. I was an Addiction Program Specialist.

In this program, I worked, for instance in a group of people with smoking addiction with co-occurring mental illness and in this group there were of course those who really were there because that kind of where they chose to be. It was a program called PROS, Personalized Recovery Oriented Services where it’s more self-directed where the groups go to, but still in the end they kind of went there because they thought, “I’ll work with the group. I really want to stop.” They were the ones that were really making a difference.

Zach: I appreciate all that. I was thinking as you were talking about group members back when I ran a group as an LMFT which I still am, but when I was running therapeutic groups you’re right, man. One of the most powerful things that somebody would say to a person struggling came from another group member typically most often an effected change for that person because it’s such an interesting dynamic.

It’s such a powerful dynamic having a solid good therapeutic group going especially ones that have been meeting for weeks, months, even years. I’m curious though. As a therapist, what did you find in maybe groups where maybe you have certain people in there and they have maybe sort of co-occurring disorders that really could be detrimental in a group? I’m thinking people with narcissistic traits and things like that.

How would you handle those kinds of people as a therapist if they’re in the group and you really are running a really solid group but you’ve got that one person or two persons in there who are really causing problems?

Karl: That’s always a challenge when you got that person in that kind of a setting. For one, I would never humiliate or call someone out or use them like I said, that bad seed. I would never do that. In fact if anything, I always try to treat everyone in the groups I work with, with respect and understanding where they’re coming from. Mind you, that person may be throwing all kinds of curveballs in the process or whatever you want to call.

I think what I would try to do is simply redirect. A lot of times it’s redirect what they’re talking about and bring it back to the focus of where the discussion is or what the other group members are talking about so as to really not make that person the center of the attention if anything because that’s what they want.

Zach: Yes, absolutely.

Karl: Narcissistic, they want to be center of the attention.

Zach: Absolutely.

Karl: Yes, yes. It’s really about bringing it back to “This is what we’re talking about today. Thank you, John. I appreciate that, but let’s talk about maybe what Joe had to say about his experience.” Once again, not to cut them off, not to make them feel like they’re less then, but really just redirecting it to a place where it’s most productive I guess you could say.

Zach: Yes. One of the sort of certifications that’s become really popular within the past couple of years, maybe even more is this one of being a certified peer specialist in a clinical setting. In addition to therapists and the patient’s fellow sort of members in a group, recovery group members even, what do you see as the value of that certified peer specialist certification in a clinical setting?

Karl: Let me give a bit of a background so folks can understand the context. Essentially peers and when you and I are talking about peers, that’s people with experience, a lot of them moved and came from the 1970’s from the health world where it was about advocacy, change around treatment, about human rights and things like that but it evolved.

It evolved and I think, I can’t remember exactly but it has to be about 20 years ago maybe where I think Georgia was the first state to certify peers in a setting where they would be seen on par with therapists and other clinicians. Basically, it’s more evolved now to a place where it’s more common. The advantage is, like I said before that lived experience piece that someone could say, “Look, I’ve been there and I’ve done it.”

However, as you and I know and maybe others know that for clinicians typically they don’t cross that wall, that invisible line of sharing personal lived experience. Peers are encouraged to do that. Peers are basically just encouraged to say, “This is what happened to me,” not to say it’s about them but saying shared experience so that the other person realizes first of all, we talked about hope; secondly, recovery is tough and third, here are some tools.

I’ve seen it work. It’s amazing how powerful, like I said that individual can be as part of a team. That’s the thing, too, Zach. We’re talking private team. It’s not just the peer is the star; it’s a team approach.

Zach: Yes. Yes and a hundred percent, man. I think that from what I can understand about this certification about certified peer specialist is that it gives some training. It gives some educational pieces that for folks who have gone on and gotten higher level, master’s level clinicians, you don’t necessarily need to go that route if you don’t want to go into that particular realm of therapeutic sort of expertise.

Karl: Absolutely. Yes, yes. If anything, to say the least you need a high school diploma. Now of course other people will say, “There’s no education there. What about the streets?” Some people learn more in the streets than many people have learned in college level of education in schooling, but it’s that lived experience, like I said that’s the value.

Now what happens though is that there are certifications, peer specialist certification programs for the mental field, addiction field and it’s a bona fide process that’s aligned. There are courses that people take, curricula. You have to do certain hours of work in the field before you…you get a provisional certification then you get a permanent certification, but it’s a process.

In other words, it’s not just saying you’re recovered for two years, you’re good. No, you have to go through a process to get that credential.

Zach: Good stuff. Karl, are there any co-occurring combinations specifically that need certified peer specialist support more than others?

Karl: That’s an interesting question. I think I would say not necessarily specific combinations, but I really think it’s about severity that we’re talking about here. I’m talking about approaching it from more of a person-centered kind of way, person-centered approach. For instance, obviously there are more serious disorders – schizophrenia, schizoid affect disorder, bipolar disorder, things like that.

Yes, certainly those are oftentimes major disorders that certainly could benefit from a peer intervention, but on the same respect you might have two people with a similar combination or say, severity in terms of say, the addiction disorder and it might be a different approach. It might be a different kind of way to intervene.

I would say, to me granted, yes there may be some combinations that would be more serious; obviously opioid use disorders are severe in many ways, even marijuana or cannabis rather, things like that or anxieties, but in the end, it’s about using peer as a tool to address these things so that they can hopefully learn from the experience of the other person.

What we’re talking about is being able to look at each person and say, “These are the circumstance. How much do you want to change?” In other words somebody can say, “How’s that working for you?”

Zach: Right.

Karl: Also say, “Yes. It has success. Maybe there were some things that worked here before,” or what you think might work and how we can make it work for you.

Zach: Fantastic, man. I’m curious to know and our listeners probably are, too. Where would they find more about your book or books? You’ve written a couple, right?

Karl: Yes, yes. Working on Wellness: A Practical Guide, both on Amazon. You can find that on Amazon. I just released the book called Leadership Through the Lens of the 12-Steps which is based on taking the principles of 12-Step recovery and translated them into leadership development. They’re virtually the same thing. I kind of took my recovery experience plus my experience of work being an administrator. I’m a graduate of the Health Fellowship program here locally.

I’ve had leadership opportunities that I kind of merged and I put into a document which is like a workbook which is very similar to my first book where it’s like a work guide and also to be used preferably with a mentor or coach; same concept as you find in 12-Step recovery that you go through it with someone. In other words, granted you could practice on your own but better yet with someone who may know you either professionally or even personally.

Zach: Excellent, man. Karl, thank you so much for coming on the show today. This has been an enlightening discussion. Thank you.

Karl: I appreciate it, Zach. Thanks for the opportunity to be here.

Zach: Listen, 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 saving lives and empowering families.

Until next week, I’m Zach Crouch with Landmark Recovery Radio.

Andrew Spiers

Zach: We have guest Andrew Spiers joining us on the show today. Andrew Spiers is a licensed clinical social worker who holds a Master of Social Service from Bryn Mawr College’s Graduate School of Social Work and Social Research. He’s the Director of Training and Technical Assistance at Pathways to Housing PA, a Philadelphia non-profit working to end chronic homelessness for individuals with co-occurring disorders.

Prior to that, he held the role of the Lead Therapist at RHD’s Morris Home, the only residential drug and alcohol rehab program in the US exclusively serving members of the transgender and gender non-conforming community.

Andrew, it’s a pleasure to have you on the show today.

Andrew: Yes. Thanks for having me, Zach. I’m happy to be here.

Zach: Tell us a little bit about your background. How’d you get involved in the field of addiction recovery?

Andrew: Sure. I kind of came to social work in general in sort of a backwards way. I actually studied poetry in undergrad at Pratt Institute of the Arts in Brooklyn New York. I spent the next few subsequent years playing music and touring. I was in my late 20’s and my mom started encouraging me to find a job that was going to offer me health insurance and I just sort of stumbled upon this position at an adolescent drug and alcohol rehab.

I had worked with teenagers prior to that as a guitar instructor off and on. I knew I really like hanging out with teenagers so I thought I’d give it a shot. That job really changed my life to where I became familiar with 12-Step recovery. I made friends with other folks that were in recovery and that led me to figuring out that I myself had a substance use issue that needed to be addressed, celebrated 11 years this past June. That’s just where I fell in love with social services.

Zach: It’s awesome, man. Congratulations on that.

Andrew: Thank you. Yes. I’ve had a lot of odd jobs over the years. I’ve supported myself financially in between tours but I usually got bored with them pretty quickly. When I started working with youth in the rehab, I realized that no two kids were the same and everyone came into treatment with a different set of skills and barriers. I worked there for about three years as a behavioral health technician and as supervisor.

I decided to go back to school for my masters so I could kind of continue on the path. Like you said, I went to Bryn Mawr College’s Graduate School of Social Work and Social Research. I had really great field placements as a student. My first year, I worked at Prevention Point Philadelphia helping with their syringe exchange program. I worked in their Suboxone clinic and helped at the drop-in center.

Later I worked with returning citizens at the Institute for Community Justice which is part of Philadelphia Fight, an HIV-AIDS service organization here in Philly. I learned a lot at those places about drug use and health and harm reduction, HIV criminalization laws and community-led advocacy efforts. When I graduated, I worked for a time at this program called the Trans Health Information Project.

It’s now called the Trans Equity Project. It’s a PR-led program based in West Philadelphia that helps connect trans folks to affirming medical and legal resources and we offer harm reduction PR-based counseling. I was there for a little while and then got asked to come on as a therapist at Morris Home which as far as we know is the only in-patient substance use treatment program in the country, possibly the world that is exclusively serving members of the trans community.

There are LBGTQ-focused rehabs but Morris Home which is run by Resources for Human Development through the national non-profit. Morris Home itself is only for transgender community, not for binary folks. I had not planned to take a therapy role ever really. It really felt like a once-in-a-lifetime opportunity. As a trans person in long-term recovery myself, getting to work in a program supporting other trans folks seeking the same thing is something I really want to do.

I didn’t have any trans role models in the rooms to look up to in my early recovery. I really wanted to help offer that to other folks. Obviously I’ve had many different life experiences in the folks that I was working with in regards to right privilege, the economic background and things like that, but the one commonality of having a treatment provider who can relate to understand some of the struggles around sexuality, your gender identity, your family acceptance and the way substance use plays into all of that I think is really important.

Zach: Sure thing, yes.

Andrew: Yes. I was in that role for about four years.

Zach: I want to just kind of interject because I’m curious. I got several questions. You began it sounds like, your work in working with the teenage population. Did your work with that population help to inform your work now with your current mix of people that you serve? If so, how?

Andrew: Sure. Now I work in an organization called Pathways to Housing PA and we are a homeless service organization that works with individuals with co-occurring disorders. I think that I feel like the trajectory of all of those jobs that I’ve had starting in adolescent in-patient rehab, working in a harm reduction program, working with folks who are returning from incarceration, and then working with trans folks in recovery really set me up perfectly for what I’m doing today.

A lot of work I do at Pathways advocate for folks of trans experience to get connected to housing and to help make sure that they’re getting the support they need when they’re here. I’ve done some LGBT competency trainings for the organization. We’ve seen a number of trans folks get connected to our services in recent years. I feel like having had the experiences in all of those other jobs really kind of led perfectly to that happening for us.

Zach: Sure. I’m curious to know also as it relates back to I would say the unique challenges that the LGBTQ population faces with regards to seeking out even services for substance use treatment. What do you think that, as you kind of have a unique view now of having been exposed to treatment and seeing the things that are done, are the things that the larger substance use disorder treatment community can do and do differently that would help better serve this population?

Andrew: I think that effective treatment for LGBTQ folks have to look at the whole picture, the whole person. We talk about holistic care a lot in treatment, but the thing I saw happening all the time at Morris Home was folks were turning to treatment because of unstable housing and how that would lead them back to using.

Like your first semester at social work school teaches you about Maslow’s Hierarchy of Needs and if you’re not satisfying those basic needs like shelter, safety and access to food and water, things like that then you can’t fulfill those higher needs about love and belonging and esteem and self-actualization. It’s pretty difficult for folks to achieve their recovery goals if they don’t know where they’re going to live next week or where the next meal is coming from.

Zach: Absolutely.

Andrew: Social workers always say that discharge planning starts at intake or discharge planning starts on day one but I think that’s extra true when you’re talking about marginalized folks who are at an increased risk already for homelessness, violence, trauma, family rejection, poverty, unemployment. All of those issues make it harder to stop using substances and the folks know that they’re going to return right back to the same situation they came from then what’s the motivation while they’re in treatment.

Zach: Are there different forms of addiction treatment or therapy modalities used to serve LGBT community?

Andrew: I don’t think that the forms of treatment or modalities are different necessarily but maybe the way that they’re utilized or implemented. There can be some considerations there more for users groups therapy on a daily basis. The individual therapy sessions there, narrative therapy, cognitive behavioral therapy, some dialectical behavioral therapy if that suits the individual. It’s tailored to the individual person.

A few years ago our staff was all trained in the Seeking Safety model which I know you’ve had Dr. Najavits on the program before.

Zach: Breakout.

Andrew: Yes. Present-focused therapy addressing substance use, symptoms of trauma concurrently I think is really huge for trans folks because you see higher rates of trauma in general and then we also have to consider community trauma on top of that. In Philadelphia alone, we’ve lost ten trans women of color to violence since 2002. In the US in 2020, I think the most recent number I’ve seen is 28 trans people lost their lives to violence.

We have folks in treatment that hear about a new death a couple of times a month and they wonder if that is in the future for them. The average life expectancy of a transgender woman of color is 35 years old.

Zach: Wow.

Andrew: It’s not just the drug use. It’s all of these things that are happening at the same time. I think trauma work is really, really important.

Zach: Andrew, I don’t know if you have any details or research to kind of help understand this, but are the rates of substance use disorder within the transgender population is it higher than even folks who are lesbian or gay?

Andrew: It’s hard because there’s not a lot of great research out there. In 2015, the National Center for Trans Equality did a survey, a national survey that has some good information there but I think it wasn’t even until…there’s a statistic. Let me see if I can find it.

Zach: Go ahead.

Andrew: SAMHSA didn’t even start tracking sexual minority status in any of their studies until very recently so it’s hard to compare. I know I have this somewhere.

Zach: Hope I’m not putting you on the spot there.

Andrew: I think you said you can edit it. I’m going to take my time and find you the actual statistic.

Zach: Yes.

Andrew: A-ha. Yes. Only since 2015 has any federally funded substance use research surveys included any information about sexual minorities in their data collection. We haven’t had a lot of time to even look at that information because no one was collecting it for a long time. We do know that trans folks report higher rates of homelessness, of suicidality, of family rejection, unemployment.

All of these things are compounded when you also take race into consideration. The challenges faced by a white transgender man are going to be very different than the challenges faced by a black transgender woman, for example. Yes.

Zach: I’m curious to hear from you. How do we begin to have this conversation with people that our trans…because I think that many people are just simply afraid that they’re going to say something wrong or something offensive like they’re not going to get the proper use of whatever, the pronouns, whatever it is. What individually and as a community can we do to move this sort of dialogue ahead?

Andrew: I think it starts with training honestly. You want to be in a position where you at least have a basic understanding of how to talk to people before they walk in the door because with any marginalized population you don’t want to be doing the learning when you first encounter somebody. People are coming to us for help then we don’t need to be asking for education in those initial contacts with people.

Organizations that are interested or able to meet the needs of trans folk treatment or LGBTQ folks in general, it starts with training and that means the entire organization — everyone from the CEO to the person at your front desk because if all of your clinicians are trans affirming and trans competent but the person is going to get mis-gendered by the receptionist they’re going to leave and they’re not going to come back.

Really making sure that everybody is on board and the training spaces are the places where you can ask those questions that you might feel a little awkward about. It’s really not actually that difficult. People get really worked up about how do I ask somebody what their pronouns are. You introduce yourself. You offer what your pronouns are and say, “What about you?” “Hey, I’m Andrew. I use he pronouns. How about you?”

If you’re talking to another trans person, they’re really, really going to appreciate that. If you’re talking to a CIS gender person and they don’t understand that question at all, you just keep it moving. It’s not that big of a deal because the impact it’s going to have on a trans person greatly outweighs the minor inconvenience of maybe a CIS gender person who doesn’t understand why you’re asking that.

Zach: Sure. As you mentioned, you work for RHD’s Morris Home which again, exclusively serves the transgender community. Talk to us a little bit more about what was that like and what you learned from that setting.

Andrew: Yes. Morris Home is one of the most amazing places in the world. I’m very convinced of that. About half the program’s staff are trans-identified themselves and come up in there from the very beginning. I believe they opened the doors in 2011 or 2012 in a neighborhood that didn’t even want the program there to begin with and they fought really hard to keep members safe and to create an atmosphere where people can really recover and thrive and heal.

They’re getting ready to move into a larger space and double their capacity in the next few months which is super exciting. The work is super challenging. You’re seeing folks coming in at a real disadvantage than what you might see in a privately-funded rehab. Most of the folks who come through the door do lack stable housing or income or family support, access to employment, access to serving medical care.

A lot of them had to leave treatment in the first place because of adverse experiences they’ve already had with treatment providers directly related to their gender identity presentation. There’s a lot of work to do. It’s not just therapy. There’s a lot of case management work that needs to happen for folks to get where they need to be.

Other social workers would hear that I carry a caseload of four to six people and thought my job must be so easy but they didn’t understand that for every one to two phone calls that they would make to refer a CIS gender person somewhere, I’d need to make ten to 12 phone calls to find a comparable resource that was also trans affirming for one of my clients.

Zach: Right.

Andrew: I can think of one instance in particular where one of my clients who is a trans woman in an abusive relationship with her boyfriend and I looked for weeks to find her a domestic violence support group. I couldn’t find a single one in Philadelphia that had included a trans woman in their groups before. They were open to it but they didn’t have the skills or the language. They didn’t know how to manage any issues that might come up, navigating the reactions of the CIS gender women in the group and things like that.

I can’t refer someone to a service that might potentially cause them more harm which meant that in addition to being a therapist I spend half my time going out in training other organizations on trans competency for free just so we could have somewhere to send people. Yes.

Zach: It sounds to me, at least with the RHD Morris Home that it really is kind of a safe place. That’s the words that come to my mind.

Andrew: Yes, that’s the idea. We recognize that folks have so much trauma that they’re bringing with them that we’re trying to combat that as much as possible and not reinforce any of that traumatization when they come into the house.

There’s a lot of opportunity for self-determination in the program for folks to decide what it is they’re going to work on to think about what housing is going to look like after, what locus do they want to engage in while they’re in treatment if that means reconnecting with family, finding volunteer work, getting a part-time job, getting a GED. There’s actually a whole cohort of clients right now who are all attending online GED courses together in the evenings which is really exciting.

We do see really great success rates especially now that Morris Home folks are getting connected to housing through the Journey of Hope Program as they leave and reintegrate into the communities and have that kind of support. Yes. It’s a challenging place to work but you become really aware of how all of the odds are stacked against trans folks, particularly trans folks of color but also really amazing to work with all of these really resilient and funny and brave and amazing people.

Zach: Have you found in your work with the trans population that they just feel more firm and free when they actually have started the process of trans, when they’ve gone down that road, when they’ve started down that road? I think the second part of that question for me would be once they have gone into male to female, whatever that now that they’re there and they don’t have a community it can be worse.

I don’t know. I’m not a transgender person so I’m trying to understand it I guess from someone who is and also with your work on the population.

Andrew: First part of your question, can you repeat the first part of your question?

Zach: Yes. I guess in your work with the population have you found that when they make the decision to go through with becoming transgender that they are just like a whole weight has been lifted off their shoulder like they just feel so much better because they’ve been wanting to do this for a long time?

I guess the question would be have you found that with the population that they needed some affirmation from someone to follow through with that or do you find that most people are just like ‘No. I’m doing this. I don’t care what anybody says. I’m doing it regardless.’

Andrew: I don’t think that the decision…I don’t think transitioning or being transgender is like a decision that anybody makes. It’s who people know that they are already inherently. A lot of what we see in the media we see this medical model, a medical narrative of trans people.

Zach: Right, right.

Andrew: The trans person that was born in the wrong body and has always known that they were supposed to be a different gender and they have to jump through all of these hoops in order to finally become who they think they really truly are on the inside.

Zach: Sure.

Andrew: That is definitely true for some people but it’s really not true for all trans folks. Transition can look very different for different people and it’s not always this smooth ‘I was born female and now I’m male and that’s it. It’s over.’

Zach: Right.

Andrew: Transition is a process that can last a person’s entire life. Sometimes that includes social transitions – changing your name and your pronouns, telling people in your life this is what I’d like you to call me. That might mean changing your hairstyle, changing the way you dress. There’s medical transition. That might be choosing to take hormones or choosing to have various gender affirming surgeries, but there’s no set process or order or requirements for any of that stuff.

I think having a treatment program that knows that, understands that and affirms that for people and that whatever your transition looks like is great and fine and you and we’re going to support it. Some trans folks choose to take hormones and some don’t. Some folks choose to have surgeries and others don’t, but having treatment providers and community that are going to use the name you want, use the pronouns you want, affirm who you are as a person no matter what you choose to do is the important part.

It’s the affirming and accepting and encouraging environment because there are lots of reasons why someone would choose to take a certain path over the other, but I think people’s general idea that it’s like you’re going from one gender to another and then it’s over is pretty inaccurate of most trans people’s experiences especially non-binary folks who don’t really identify as either male or female or somewhere in between or like a combination of the two.

I get that that can be very hard for people to wrap their head around but there’s a lot of work that goes into being a trans affirming provider. You can’t just take a one-hour training and think that you understand.

Zach: Right.

Andrew: It’s really something that you have to study and learn about and practice and take an actual look at your own gender identity development. Everybody has a gender identity.

Zach: Yes.

Andrew: Yes. It’s a process that you have to engage with.

Zach: Look, I appreciate that feedback. That’s I think just really helpful.

Andrew: Sure.

Zach: It’s good to know that. If people are curious about learning, are there books, podcasts, things like that that you recommend people to just sort of be on the up and up about this subject?

Andrew: An interesting question. I think one of the really great starter books is Gender Outlaw by Kate Bornstein. Other than that, starting with the basics you can just check out the National Center for Trans Equality. You can check out resources from PFLAG or from the Human Rights Coalition or there are lots of really amazing trans-led groups like the Trans Women of Color Collective. Yes, I can send you some more resources on that. I don’t know them all off the top of my head. Yes, there’s definitely tons of stuff on the internet.

Zach: Andrew, I really appreciate the work that you’re doing. Please keep up the good work. It’s been a pleasure having you on the show today.

Andrew: Yes. Thanks very much.

Zach: If you know someone struggling with an addiction and you’re 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.

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