CONNECTING TO

THE HEART OF THE MATTERTHE HEART OF THE MATTERMark Goheen, M.A.Clinical SpecialistClinical SpecialistMental Health & AddictionsFraser HealthFraser Health

Walking towards wellnessWalking towards wellness…

• What’s one thing that you could do more of, less of or different that would have a significant positive effect on

your wellness (physical, mental, social y (p y , ,and/or spiritual), yet for some reason you have delayed acting upon?y g p

• Reflect on what this might be and hold onto it for later- Thank Youonto it for later Thank You

What’s my agenda?What s my agenda?• I will offer some not so broadly publicized ways y p y

of looking at addiction that are based on ideas and evidence related to a “bigger picture”. I will take a “grist for the mill” approach (some g pp (evidence supported ideas to reflect on rather than absolute truth).

• Suggest some practical directions for how we• Suggest some practical directions for how we might respond at both the personal and community levels.R h i h d ll f ill i• Respect that, in the end, all of us will continue to act on our values and theories about the challenge of substance use in society.g y

What if…• no “technological” band-aid can remedy the

challenges of substance abuse and other forms of self harm in our communitiesof self-harm in our communities

• the matter is complicated and multi-layered.• how we define “the problem” is a key to how wehow we define the problem is a key to how we

can more effectively respond. It’s not just about “strategizing and doing” but developing the lens through which we see the problemlens through which we see the problem

• many of the strategies to “solve the problem” have not “solved the problem”, and in some

t dd d t th h ll (E Grespects added to the challenge (E.G. criminalized illness, funded organized crime, alienated those most vulnerable from help, gobbled-up valuable resources…)

Time for an exercise…Role A: Remember the first slide…share the significant

change that you could make, but have been putting off. Pay attention to your experience of the interviewPay attention to your experience of the interview.

Role B: Identify the change that the person could make but has been putting off. Your responsibility is to get a real commitment from the person to start making thecommitment from the person to start making the change happen tomorrow. Since their wellness is at stake (we’re not kidding around here!), please use pressure tactics, shaming, blaming, confronting, advice i i d j d t Agiving and judgments. As you are aware,

procrastinators tend to be in denial and are good at making excuses. Be careful to not buy into “their stuff”. Just because they say they’ll do it doesn’t meant thatJust because they say they ll do it, doesn t meant that they will. Watch for prematurely buying into “their promises” Good luck!

PAIR-UP…5 MINUTES IN EACH ROLE

Let’s de-briefLet s de brief

In respect to each of the roles:In respect to each of the roles:What was that like?Wh t th ht ti b dilWhat thoughts, emotions or even bodilysensations did you notice?

What does the research tell us…• Genetics have a strong influence on the quality of our brain functioning.

No one gets to choose the genes that they carry. In respect to substance abuse, studies typically demonstrate that genetics, in a population, contribute in the range of 20 – 50 % of the “cause” (Kendler et al, 2003).

• All behaviour, including substance use and mental illness symptoms, reflects brain function.

• The fact that we are legally and morally held to account for our behaviour does not change the fact that our unique brain function is something that we

t f ll t l (it’ t ll h i ”)cannot fully control (it’s not all our choice”)• The emphasis on why people use drugs overshadows perhaps a more

useful question: How is that some people have a great challenge in not using (stopping when it makes sense to do so).It th t i t l d t d h h• It appears that we can compassionately understand someone who has trouble stopping a non-threatening behaviour (E.G. hand washing compulsion, stuttering, obsession with organizing), but we tend to be challenged when the behaviour tugs at our values (E.G. addiction to sex, drugs gambling )drugs, gambling…).

• The use of Magnetic Resonance Imaging (MRI) and Positron Emission Topography) PET scan has extensively demonstrated systematic differences in brain function between those who appear to be functioning in health and those who struggle with mental health concerns (E.G. gg (depression, anxiety disorders, psychosis, substance misuse…).

What else does the research tells us ?us…?

• Childhood experiences are powerful determinants of well being. For example, children who witness or experience family violence are at much greater risk (Aversive Childhoodviolence are at much greater risk (Aversive Childhood Experiences studies).

• Health Consequences. Adults with a history of aversive childhood experiences are more likely to experience heart disease cancer lung disease and skeletal fractures Theydisease, cancer, lung disease, and skeletal fractures. They are also more likely to be obese, have diabetes, and engage in behaviors associated with poor health outcomes.

• Mental Health and Substance Abuse. The negative t t l di l Ad lt ith i hildh doutcomes are not only medical. Adults with aversive childhood

experiences are also more likely to be depressed, attempt suicide, have unintended pregnancies, and have personality disorders. Substance abuse problems and alcoholism are also

l t d ith ti hildh d icorrelated with negative childhood experiences.• Criminal Behaviour. Child abuse and neglect increase the

odds of delinquency and adult criminality by 40 percent. Abused children are more likely to be arrested later in life than ytheir non-abused peers, and commit more serious offenses.

For exampleFor example…

Persons who experience multiple AversivePersons who experience multiple Aversive Childhood Experiences (ACE’s), such as witnessing repeated family violence are 7-witnessing repeated family violence, are 7-to 10-fold more likely to develop addiction to drugs (compared to those whoaddiction to drugs (compared to those who have 0 ACE’s)(Dube et al, 2003)( , )

An attempt to focus the problem…(Durrand 1986)(Durrand, 1986)

“Two interrelated sets of factors predispose persons to addictions: an abnormal physiological resting state, and childhood experiences producing a deep sense ofand childhood experiences producing a deep sense of inadequacy.”

(Durrand, 1986)Two Questions:1. What factors lead to “abnormal physiological resting

states” (e g anxiety stress depression )?states” (e.g. anxiety, stress, depression…)?2. What factors lead to “deep sense of inadequacy”?

For example, The McCreary 2008 BC Ad l H l h SBC Adolescent Health Survey

Female (%) Male (%) Average (%)

Ph i l 19 14 16 5PhysicalAbuse

19 14 16.5

Sexual Abuse

13 3 8.0Abuse

For example, The McCreary 2008 BC Ad l H l h SBC Adolescent Health Survey

NotAbused(%)

Sexually &Physically

Increase

(%) Abused (%)

Poor 13 36 176%HealthBinge 20 49 145%gDrinkSuicidal 8 42 425%SuicidalIdeation

8 42 425%

What else…Understanding and responding to theseQuestions involves at least Q2 landscapes:

1. The lived histories and biological functioning of individuals. (E.G. genetics, nutrition; Aversive Childhood Experiences; underlying mental illness; childhood stressors; recent stressors such as losschildhood stressors; recent stressors such as loss, poverty, conflict…).

2 Th t t d h lth f i t2. The structure and health of our society.

Understanding and improving matters involves al l ti hi b t th tcomplex relationship between the two

The Roots of Addictioni F M k S iin Free Market Society (Alexander, 2001)

“Every society must cherish its defining beliefs. Therefore, y y git is only polite to overlook connections between free markets, dislocation, and addiction.”

“A realistic discussion must recognize that addiction isA realistic discussion must recognize that addiction is mass-produced in free market society, and that, therefore, society as well as individuals must change.”

“Addi ti i h f l lif t l hi h d“Addiction is a harmful lifestyle,…which more and more people in free market society are adopting as a desperate measure to prevent themselves from being

h d b l d di l ti ”crushed by severe, prolonged dislocation.”

The Roots of Addictionin Free Market Society

• How well does the structure, values and,activities of our society lead to all peopleexperiencing a sense of belonging, identityand worth?and worth?

• What if “real” prevention and responses fully took into account the importance of living in a society that valued belonging as primary?that valued belonging as primary?

• Healthy relationships, families, schools and communities place belonging as primary. Treating each person as sacred takes precedence overeach person as sacred takes precedence overpower, winning and material possessions?

• What might it look like to live in a community where this type of sacredness from cradle to grave wasthis type of sacredness from cradle to grave was the primary organizing value of the community (society)?

Some evidence from B.C.’s M C SMcCreary Survey

“ showed that building protective factors…showed that building protective factors such as family, school and cultural connectedness can assist even the mostconnectedness can assist even the most vulnerable youth to overcome negative experiences can assist young people toexperiences, can assist young people to make healthier choices and can contribute to more positive health outcomes for allto more positive health outcomes for all youth in BC.”

Evidence from B.C.’s McCreary Survey…some staggering food for thoughty gg g g

High (School)C t d

Low (School)C t dConnectedness

(interpreted %)Connectedness(interpreted %) Difference

Bi 5 76 1 420 %Binge Drinkingin last month

5 76 1,420 %

SuicidalIdeation

4 50 1,150 %

in past year

Poor/FairHealth

4 48 1,100 %Health

What might it look like to live in a community h th d f f dl twhere the sacredness of persons, from cradle to

grave, was the primary organizing value of the community (society)?community (society)?

What predictions might we make about:• The prevalence of violence and other

crimes?• The prevalence of addiction?• Problems associated with mental illness?• Physical health (heart disease, diabetes,

obesity…)?y )

Wait a minute here!Wait a minute here!A person’s addiction is society’s fault?

Idea: this leads to either/or lens that limits our understanding and responsesg p

• Again, the reality of substance abuse is complex because it is complex AND whatcomplex because it is complex AND what is the case for one person with a problem may not be true for anothermay not be true for another

• Allocation of blame is not part of the Landscape of SolutionsLandscape of Solutions

A proposed ideaA proposed idea…1. A variety of complex factors and interactions lead to an

entrenched relationship with substances (addiction). Many of these factors are beyond the person’s control (E.G. genetics that give rise to mental illness,control (E.G. genetics that give rise to mental illness, Aversive Childhood Experiences, one’s society…)

2. Given that much of what “causes” addiction is beyond ’ l i di id l d d ka person’s control, yet individuals can and do make

choices to move towards change (help).“You may not be responsible for being down but youYou may not be responsible for being down, but you

can make a choice to work at getting-up”

Where does this leave us?Where does this leave us?Two layers:y1. What directions will reduce the likelihood that

individuals in our society will develop a d i l i hi i h l h l d hdestructive relationship with alcohol and other drugs?

2 What can we do to support a person who has2. What can we do to support a person who has developed a destructive relationship with alcohol and other drugs move towards wellness? What helps people who “are down”, get-up?

What directions will reduce the likelihood that individuals in our society will develop a destructive d dua s ou soc ety de e op a dest uct erelationship with alcohol and other drugs?

This is about prevention. pRather than “educating kids about drugs”, which has little

effect on actual use (Tobler, 2000):• Work towards developing a community where all peopleWork towards developing a community where all people

have an opportunity to be sacred from cradle to grave.• This involves opportunities to learn about and experience

belonging (a social skill). Think healthy families, mentors,belonging (a social skill). Think healthy families, mentors, elders, “true” community centres…

• This can take place in families, schools, neighborhoods, sport teams, community projects, places of worship, work…p , y p j , p p,

• This can take place in all relationships: Police-Citizen; Parent-Child; Teacher-Student; Doctor-Patient…

• The scope of this (the lens of effective prevention) is beyondThe scope of this (the lens of effective prevention) is beyond this evening

What can we do to support a person who hasdeveloped destructive relationship with alcoholdeveloped destructive relationship with alcohol and other drugs move towardswellness (get-up)?

• This is about treatment (the horse is out of the barn).

• All “accepted” treatments help, none “magically cure”

• Treatment only helps if it a person is engaged with it.

• The primary challenge (apart from resources) is how do we help a person, who is challenged with addiction engage with help (motivation)?with addiction, engage with help (motivation)?

Time for an exercise…• Pair up as before.• Take turns in each role (a & b) for 5 minutes.a) Re identify the positive change that you have beena) Re-identify the positive change that you have been

thinking of making, but have put off.b) Interview the person exploring:1. How would this change affect their physical health?2. How would this change affect their emotional and

spiritual healthspiritual health3. How would this change affect how they see them self

(self-esteem?)4 Wh i th i lif ld b i t d b thi h d4. Who in their life would be impacted by this change and

how so?5. What support would they welcome towards creating pp y g

these changes?

Let’s de-briefLet s de brief…

In respect to each of the roles:In respect to each of the roles:What was that like?Wh t th ht ti b dilWhat thoughts, emotions or even bodilysensations did you notice?

One perspective (Miller et al, 2005) isOne perspective (Miller et al, 2005) is that “it’s primarily about motivation”

What is motivation?What is motivation?

Human Motivation has been intenselyresearchedresearched…

What is motivation?What is motivation?

Motivation is often viewed as being aboutMotivation is often viewed as being about willpower. As it turns out with human beings, things might not be that simple.

There are at least 3 main notes:1. Readyy2. Willing3. Able3 b eAnd perhaps a 4th:4 Worth it4. Worth it

What is motivation?What is motivation?

People move towards changePeople move towards change when they believe that they can, they desire the change, are ready to take action and feel thatready to take action and feel that they are worth (the change).

What is motivation?What is motivation?

Q: How we do we help peopleQ: How we do we help people move towards a place of hope, desire, worth and readiness?

A: Through relationships that areA: Through relationships that are characterized by walking alongside

How do we help once a person has b bb d b ddi i ?been grabbed by addiction?• At some level a simple process but not easy!At some level a simple process but not easy!• Listening, respect and understanding are

powerful, yet simple everyday acts of “being”p , y p y y g• To do so requires an acceptance of the person

and a faith in what can be possible in their life.p• May be challenging for family (in early stages)

as there rightly can be a good deal of emotional energy for members around trust and outstanding hurt (lies, thefts, broken promises…)

Create Change Opportunities• Non-judgmental relationships where there is regard

for the person’s hopes (to live one’s authentic values). Thi d t i i b i h t b tThis does not mean giving up on being honest about your perceptions, but it does mean letting of blaming.

• Range of treatment options, including harm reduction.Range of treatment options, including harm reduction.• Low-barriers (minimize hoops to jump through) at entry

points• Community as “referral source”. Family, friends, police,

teachers, clergy, coaches all can play a part in helping a person “get up”person get up

• Post-treatment resources that promote sacredness-belonging (safe housing, access to supports,

k/ l i i [ i i b k]work/volunteer opportunities [giving back]…