Counseling Specific Populations | Addiction Counselor Exam Review Episode 20

Welcome to the Addiction Counselor Exam Review. This presentation is part of the Addiction Counselor certification training. Go to. Learn more about our specialty certificates structure starting at $149. Welcome everybody to today's presentation of the Addiction Counselor Exam Review. This is episode 20. Today we're going to be talking about working with specific populations and oh my gosh, there are so many specific populations that we can choose from and I can't possibly cover them all in an hour that we're going to be talking today. But we're going to hit some of the highlights that are really identified in the Addiction Counselor exam review guide that you can get from your state board or from icnrc. So we're going to look at some specific population considerations. We need to recognize that aspects of the client's identity may influence the client's substance using behavior, their responsiveness to treatment and the recovery process. So if clients are from a different race or ethnicity or have cognitive difficulties, that's going to influence their process. We're also going to find out later in this presentation that gender also has a significant impact on the types of treatment that are effective, how drugs affect the body, etc. So factors we're going to talk about little bit today include race and ethnicity, but we're also going to talk about age, sexual orientation and the presence of co occurring disorders, including trauma. It is really important to recognize that from a trauma informed perspective, the expectation is that most people have experienced trauma at some point in their lives, which is currently probably still impacting them. So a trauma informed approach is almost always a safe approach to use. And it's kind of better to be safe than sorry, I would rather use a trauma informed approach than, you know, not use one and find out that I accidentally re traumatized a client. Rather than placing a person in an established treatment slot, we're learning the importance of modifying and adapting services to meet individual client needs. And you know, where I used to work, it was a residential treatment facility and we had different programs. We had one for mothers and babies, 1:1 for veterans, one for adolescent boys, and one that was co educational. So those were all residential programs and they all had different, how shall I say, approaches that were tailored to sort of meet the needs of that particular population. But just because somebody is in a population doesn't mean that treatment for that population is actually appropriate for that person. Because all of us have multiple specific considerations. You know, I may be a woman obviously, and so that's going to potentially impact my drug use history and things that are effective with Me. But if I'm also a pregnant woman, then that adds on a whole other layer that we need to consider. SAMHSA has produced multiple publications called TIPS or Treatment Improvement Protocols that have dealt in depth with the treatment needs and recommended practices for specific types of disorders and populations. So I really recommend you go there and there's a link at the end of the presentation where you can go and review these tips and download them for free as PDFs. Most of them right now are not available for ordering as hard copy anymore, but you can at least still get them as PDFs. Substance abuse treatment programs typically report 50 to 75% of our clients have co occurring disorders. This is not a surprise. When somebody is in early recovery, they're probably going to experience depression or anxiety and then that doesn't even count for the people who have bipolar disorder or schizophrenia or something else. Whether the person had their mental health disorder before they came into treatment or it developed during the course of their addiction or during the course of their early recovery doesn't really matter. We have to address it. It's going to be really hard for somebody to clean and sober if they're anxious or depressed or, you know, having mood swings all over the place or in a fluoride psychotic episode. So we need to make sure to treat these things. Medical settings cite proportions of 20 to 50% of their clients have co occurring disorders. So even in the hospital or in primary care, doctors are saying, you know what, yeah, 20 to 50% of the people who come in here, not specialized addiction treatment, just general medical, have addictions in addition to mental health and potentially physical health issues. So co occurring disorders, dual disorders. There's been a lot of terms out there. Now we call them co occurring because dual implies two, and many times there are more than two diagnoses the person's dealing with. So we use the term co occurring. It means that multiple disorders are occurring at the same time. Co occurring disorders refers to co occurring substance use and mental disorders. So we're looking, you know, at the range of mental health issues. If they've got anxiety, ptsd, depression and addiction, okay, well that's four disorders that you're looking at trying to treat. They also, you know, people also have other physical disorders that may be going on like hepatitis or HIV or some of that stuff. And we want to make sure that we're encompassing that in the treatment plan. But when we're, when we talk about a co occurring capable treatment program, we're talking about a treatment program that addresses mental health and Addiction. A diagnosis of a co occurring disorder occurs when at least one disorder of each type can be established independent of the other. What does that mean? That means if the person is experiencing depression right now, we can diagnose the issue as independent from the substance use. It's not a side effect of withdrawal from the substance. It's not a side effect of intoxication from the substance. It's actually something else over here entirely. So that's when we have co occurring issues. So we want to rule out any depressive or anxiety symptoms or mood symptoms that are the result of intoxication or withdrawal. Review SAMHSA Tip 42 for more information on co occurring disorders. And you know, I'm getting ready to do a nine part series on SAMHSA TIP 42, so stay tuned for that if you know co occurring disorders is something that you feel like you're weak in preparing for your exam. Okay. One special population that is near and dear to my heart is the criminal justice population. I worked with them. This was my first job out of college. And a lot of times people who are in the criminal justice system have addictions. You know, that's not a surprise. But a lot of times they have addictions that have never been treated, either because they haven't sought help for them or because they couldn't afford it, or there's a whole myriad of reasons. But now they're in the system. And one thing that can be good, if you want to put it that way, about people who are in the criminal justice system is they have access to services and service providers often have teeth, if you want to put it that way, to encourage people to participate in treatment, we can offer them reduced, you know, if you work with the courts, a lot of times the courts will offer them reduced sentences for participating in treatment. They can get. They may have to go through treatment to get off probation. So there's a lot of different ways we can use contingencies when people are involved in the criminal justice system. For many people in need of substance abuse treatment, contact with the criminal justice system is the first acknowledgment of a need for treatment or an opportunity to receive services. Long standing patterns of poor coping skills, criminal values and beliefs, which we call criminogenic thinking. In other courses that we do on working with the criminal justice population, often a lack of education and minimal job skills may require an intensive treatment approach, particularly among offenders with a prolonged history of substance abuse and crime. When you're working with criminal justice offenders, you have your offenders who have One dui. That's generally not who we're talking about here. A lot of times when you're working with people in the criminal justice system, especially people who have a long history of incarceration, they have become institutionalized. They have adopted the values and the beliefs, if you will, of a criminal justice setting, those criminogenic values that are contrary to recovery. Many times they may not have the skills or tools or know how to survive in the outside world because they've spent so much of their adolescence and adulthood incarcerated that, you know, that's normal for them. They feel safe there. So these are things that we may need to look at addressing. We can't assume that, you know, every person who comes out of jail has the skills, tools, and abilities to function like you or I do, because they've had very different experiences. And remember, that's not for everybody in the criminal justice system. But that applies especially true for people who have been in jail or prison for a significant period of their life. Addiction professionals must be able to communicate effectively with judges who, you know, sometimes you'll have a sympathetic judge, sometimes you'll have a real hard nose. But you need to be able to hear the judge's point of view and effectively communicate to them what you think this person needs and what programs are available to help them get it. Because we don't want the judge thinking, oh, we're just trying to get this person a lighter sentence or exempt from charges or something. No, that's not what we're trying to do. But for example, we had a program that was called no Wrong Door, where people who were incarcerated were released early on what was called extended limits of confinement. Up to six months before their term ended. They stayed at our residential facility, and they went through treatment. We also had other programs where offenders would get out, or a month before they'd get out, they would be on extended limits of confinement. In our coed program, the benefit to that was we were able to help them ease that transition. You know, they had a lot of clean time theoretically under their belt, but they probably hadn't built up the skills and tools, and they certainly hadn't started addressing the criminogenic thinking while incarcerated. So we're able to start changing some of the thought patterns and behaviors when they got out. Sometimes judges would want to sentence somebody to treatment at the beginning of their sentence, and we would have to help the judge understand that that's counterproductive, because if they go in at the beginning, we're going to help this person make these Wonderful changes, but they're not sustainable in a prison or jail environment. So it's really, really important that we're able to get this person at the end of their sentence. We need to be able to communicate with probation officers. If you've got clients who are on probation and they suddenly test positive once, yes, the probation officer may have to put in a violation order, but we do need to communicate. We need to be able to communicate with probation officers what clients are going through. Most of the probation officers I worked with were really empathetic. You know, they didn't want to have to violate somebody because, you know, that was a lot of work for them and a lot of paperwork, and it's just not what they got in it for. You know, that wasn't their goal in life. So we were able to work with the probation officers to say, what is it this person needs in order to stay clean and sober and get off probation successfully? How can we work together so we can facilitate this process? Probation officers were generally more than happy to accommodate, whether that meant doing more home visits and urine screens or whatever it was. I never had a probation officer get all bristly and go, no, you know, if you can't do it, then tough tiddlywinks. They were really compassionate people in many cases. And we also need to be able to communicate with other criminal justice system personnel who are functioning as part of the community treatment team. This means law enforcement officers help them understand and identify early signs of addictive behaviors, help them provide early intervention and referrals when they go out on these calls and there's obviously a substance abuse problem. Help officers have resources to hand out. They can't spend 30 minutes doing case management. I'm not saying that, but we can help them be aware of resources and have a handout for people to make sure. We're trying to get people early intervention services before they actually do something that puts them in jail or lands them in the hospital or something else. Leaders in both criminal justice and treatment systems need to develop shared goals and clear systems of care for addicted offenders, both while they're incarcerated and after their release with the big problem with opiates right now. And this was a big issue back in the day when I was working at the clinic, because we would have people in our methadone clinic who would get arrested, and as soon as they would get arrested, the sheriff's office or who ran the jail at that point would discontinue their methadone, and they would go through a hardcore detox and it was pretty awful. And then they would send them out after their time was up and they would be not stabilized on any sort of psychotropic or medication assisted therapy when they got out, which set them up for relapse. So it was important that we had shared goals. What do we want to do? I mean, ideally we need cost containment, I get that. But we also need to make sure that we're providing the services these people need in order to not recidivate. We want to make sure they get out and hopefully don't come back. Another special population that we will work with a lot of are people with HIV and aids. HIV is most efficiently transmitted through the exposure of contaminated blood. Like sharing needles and certain sexual practices. Injection drug users represent the largest HIV infected substance abusing population in the US. Sexual contact, like I said, is another route of HIV transmission. But substance use treatment can play an important role in helping individuals reduce risk taking behavior. So let's think about it. When somebody is in active addiction, if they're using needles, if they're sharing needles, that's a risk. So if they're not using, if we're providing treatment, then we're keeping them from exposing themselves to potential needle transmission. Additionally, when people are in active addiction, they may engage in other behaviors in order to get the drugs they need or, or they may engage in other behaviors while they're under the influence that put them at high risk for HIV and aids. So again, substance use treatment keeps them from being in those situations, so it's preventative. HIV and aids, substance use disorders and mental disorders interact in a complex fashion, each acting as a potential catalyst or obstacle in the treatment of the other two. So let's talk about catalyst first. HIV and AIDS as it progresses can contribute to HIV related dementia, which is a mental health disorder. People who are experiencing grief loss, dementia associated with HIV may tend to self medicate more with substances so they can catalyze themselves. People who are abusing substances are putting a drain, a significant drain on their immune system which is going to speed up the rate that the HIV infection progresses. Same thing with mental disorders. A lot of times when people have significant mental health issues, they're not taking good care of themselves and they may even self medicate with substances. But even if they're not, if they're not taking good care of themselves because of their depression or their anxiety, they again, that stress as well as poor health habits are going to speed up the rate of the HIV infection so they can catalyze each other this way. And when people are On HIV and AIDS medication, they often don't feel well, which can contribute to a sense of depression and anxiety. Now they can also act as obstacles. And how is that? Some treatment programs are not set up to handle certain mental health issues. They're only set up to handle substance use. Some mental health programs are not set up to handle substance use issues. So if somebody has both, which we already learned is sort of the expectation, then they're going to have a harder time finding an appropriate placement. And if their HIV or AIDS condition is advanced enough where they're requiring significant medical care, that also may block them from access to certain treatment. Because a lot of residential level 3 facilities just don't have the medical staff to be equipped to handle that. When you're working with people who have HIV or aids, treatment goals include living substance free. Let's take away that stressor on the immune system. Let's take away that those risk factors for spreading HIV or getting something else that's going to contribute to HIV progression. Let's slow or halt the progression of the disease by ensuring the person has access to their antiretroviral medications and let's reduce risk taking behavior. So again, they are not spreading it and they're not contracting something else that could catalyze the disease. Treating HIV and AIDS is extremely complex. And that, I mean, we have courses on that@allce.com we're not going into that right now. But it's important to recognize that individuals with substance use disorders, whether or not they're HIV infected, are subject to higher rates of mental disorders than the rest of the population. So we have somebody with a substance use disorder or we know that it's likely they also have another mental health issue and they are at a higher risk of having HIV infection. So counseling is an important part of treatment. And I mean medical science has come so far and we're able to do so much in terms of prevention and taking care of the disease and slowing the progression of HIV, that counseling is becoming even more important to provide hope for people who are diagnosed that they can live a pretty normal life and they're not doomed to two or three years. It could be 20 or 30 years that they'll live with this disease. Risk reduction allows for a comprehensive approach to HIV and AIDS prevention which promotes changing the substance related and other such behaviors. So we do want to engage in risk reduction. If we're working with people who have substance use disorders, we want to ideally, you know, have avenues where they can engage in harm reduction practices such as clean Needle programs. So we're not promoting the issue. I mean, do we want to just hand out needles so people can inject? Well, no, but I would rather them if they're going to inject, if they're determined they're going to inject. I would rather them inject with a clean needle and not also contract AIDS than inject with a dirty needle and then have an opiate disorder as well as HIV or aids. That is the harm reduction philosophy. Not everybody embraces it, but it is a major part of risk reduction. We also want to encourage risk reduction in terms of making sure condoms and other things are available for people who may engage in higher risk behaviors. Substance use treatment programs can help reduce the spread of other bloodborne infections, including hepatitis B and C viruses. You know, all these bloodborne pathogens kind of start building on each other. So you know, when we're providing substance use treatment, we're also preventing the contraction and spread of hepatitis. Counselors need to be familiar with federal and state laws protecting information about clients substance use treatment as well as their HIV and AIDS related information. One thing that you'll find when you're going through the medical record is the HIV AIDS information is kept in a separate place from the assessment information because that is highly protected personal health information. Your assessment is going to be in another section and your progress notes are going to be in yet another section. Because when there is a subpoena for the records, the HIV and medical information as well as the progress notes are generally not covered unless the attorney or the judge puts that in the order. And CFR 42, part two talks a lot about special requirements for confidentiality. Another thing to realize before I move on to this next slide. In some states it is a felony to notify even if you have an identifiable person with whom the HIV infected client is engaging in high risk behaviors. Even if you know that they're, you know, having unprotected sex with their significant other or somebody and you have an identifiable victim. In many states it's a felony to notify that person. So you need to check with your attorneys as well as, you know, stay up to date on changes in state law about what you're allowed to report and who you have to report any HIV infection to. Alright, so physical and cognitive disabilities. This is our next special population. Now remember I said people with HIV can develop HIV related dementia, so they may have cognitive difficulties. You can have a female who is pregnant with HIV and HIV related dementia that you're treating. So she's like four different special Populations all wrapped into one. And I point that out to help you understand the different layers that make it imperative that we individualize treatment and not just say, okay, this is a female program or this is a pregnant program, or whatever. Okay, so physical and cognitive disabilities. People with physical and cognitive disabilities are more likely to have a substance use disorder and. And less likely to get effective treatment. We're going to talk about why that is in just a minute. 20% of persons with disabilities have a substance use disorder. These individuals are less likely to complete treatment because their physical attitudinal or communication barriers limit their treatment options or render their treatment experience unsatisfactory. Okay, so let's talk about examples. I worked with one client who had a tic disorder, and when he would get stressed, his tics would get really bad. When he was in group, he was stressed, so his tics were always really bad and he couldn't participate in group. I had another client who was minimally literate. So any of the activities that we participated in that involved a lot of reading, you know, he couldn't do without assistance, and he didn't want to ask for assistance. So we needed to be able to modify treatment to meet his needs. People who have dementia, cognitive issues, some physical issues, or who are. Or who are younger may not be able to sustain attention for the hour that group is going on. People who just came out of detox are not going to be able to sustain attention for the hour that group goes on. So we do need to be aware of specific issues related to people's physical and cognitive state. The Americans with Disabilities act states that both public and private facilities must be equally accessible. So if you're running a facility or you're working in a facility, you're going to work with people with disabilities, you need to be able to make reasonable accommodations. It's up to you, working with your legal team and your directors to identify what is considered a reasonable accommodation. But interpreters definitely are, you know, certain structural modifications definitely are. Certain modifications to the treatment program definitely are. So you really want to ask, what does this patient need in terms of treatment? What prevents him or her from being able to plug into our program as is, and how can we make modifications that make the most sense to make sure that he or she gets his needs met in our program? And a lot of times it's really not brain surgery. It's not that hard. For my client, who is minimally literate, instead of having him write his autobiography, which wasn't going to happen, he recorded it on A cassette tape recorder and then we transcribed it later. So there are options. Barriers to communication must be removed and discriminative policies and practices eliminated. We need to look at these things and really get input from the community if we need it, if we can't see the forest for the trees because it's our program, bring people in who have disabilities and say, what would be hard here? Accommodating people with coexisting disabilities in treatment for substance use disorders includes things such as adjusting counseling schedules. If people are on heavy duty medication, they may not be able to get up at 7 in the morning to be in group or they may need to take breaks throughout the day because the medication they're on is very, very severe. Sedating, especially like atypical antipsychotics and those sorts of things. Provide interpreters for people who are either deaf or hard of hearing, who are blind or who speak a different language. Suspend the no medication rules. Some treatment centers are not okay with certain medications. In ours it was opiates and benzos. However, when we started the program with the veterans and they were being seen medically by the va, we had to suspend that rule for that population and really look at our policies because many of them were on benzodiazepines and opiate based pain medications. And we need to overcome people's fears and ignorance, help them understand, you know, what's going on. If you've got somebody with Tourette's, if you've got somebody with a tic disorder, if you've got somebody with dementia, educate. If it's a residential facility, you may need to educate the other house members about, you know, how they can help that particular client. Definitely need to educate the staff about what that client will need in terms of additional supports. But we want to overcome their ignorance of about what causes it, if it's contagious, anything that could bring stigma to that person. People with disabilities are more likely to use substances in part because they experience unemployment, lack of recreational options, social isolation, homelessness, victimization and abuse more frequently than the general population. I have to say it again, and I will repeatedly say this when you're talking about any group of people, whether it's race, ethnicity, age, gender, whatever, there is nothing that applies to everybody in that group. But the research has found that some people with disabilities are more likely to experience these things, especially if they have significant disabilities or severe and persistent mental illness like schizophrenia. So we need to be aware of these issues because it's going to affect their treatment program. If they are socially Isolated, then do they have social anxiety, or are they not able to integrate, or do they not want to integrate with the programs that are available? If they are homeless, why are they homeless? Some people choose to be homeless. Some people are homeless because of their mental illness or because of job loss or financial reasons or whatever. But there is a subset of people who are homeless who are not mentally ill and they choose to live on the street. They don't want to have the responsibilities and weights of home ownership and all that other stuff. So we do need to be sensitive to why a person is experiencing these things. And if they need help with them, then obviously we need to provide linkages to help them. People who are deaf and identify with deaf culture will usually prefer specialized treatment programs. People with intellectual disabilities may find it easier to understand and participate in discussions with others with similar disabilities and may be more inclined to ask questions. People with dementia, for example, or people who are cognitively impaired in some way may need group to go a little bit more slowly. They may need a little bit more time for processing, and they may feel more comfortable opening up in a room full of peers who are, you know, processing at the same rate so they don't feel like they're holding up the group or they don't sense a resentment. Other disability conditions that may warrant some standalone services include traumatic brain injury, spinal cord injury, or severe or multiple disabilities. All right, I brought up women multiple times. Gender differences play a role in drug selection, drug use, and treatment patterns. The research has indicated that women and men tend to abuse different drugs and the effects of drugs are different for women and men. Women often use significantly more prescription drugs than men and are more vulnerable to certain drugs. Another issue, and partly because of our body composition and how it differs from men, women advance more rapidly from initial use to regular use to the first treatment episode, and we experience an effect called telescoping. You probably need to know that for your test. Telescoping is when we progress faster than men from initial use to alcohol and drug related consequences. Because the same amount of alcohol that a woman drinks and a man drink. We can drink the same amount of alcohol, but it will hit women harder or be more powerful in the female body, partly because we have more body fat and less muscle. And they have more muscle, but there's a lot of reasons for it. Women are more likely than men to have co occurring substance use and mental health disorders, including anxiety and major depression. Women's substance use problems are more stigmatized and less likely to be acknowledged than men's so let's think about that. We've got women who may have, may be pregnant or may have children. What does society say if they are in active addiction while they have children or they're pregnant? Society can be very, very judgmental. So it's important to understand that a lot of women may not acknowledge their problem or may not seek help for a variety of stigma and fear related factors. So issues impacting women, shame and stigma. You know, some women, it's not even the stigma from the community, but it's personal shame at being addicted. Physical and sexual abuse can keep them from seeking help. If they have been abused, they may feel like they're broken already, they may feel unworthy or they may be afraid to confront the traumas and they would prefer to stay numb for a while. Relationship issues, including fear of losing children, fear of losing a partner, or needing a partner's permission to obtain treatment. Some cultures are very family centric where an individual doesn't make a big decision like this on their own and they need their partner or their family's permission. Treatment issues include a lack of services for women, especially specialized services. There's a lot of co ed services, but there's not a lot of unique services for women. There's not a lot of unique meetings, support meetings just for women. Although there are more now than there used to be, there are often long waiting lists and lack of child care services. So since women are often the primary caregiver for children, if you do an assessment on a woman and it turns out that you know she would benefit from either iop, PHP or residential, one of the factors that may come up is what am I going to do with my kids? I don't have anywhere for my kids to be if I'm in treatment from 6pm to 10pm or if I'm in residential. One thing that you can do as a treatment center is look at when school starts and you know, generally school starts somewhere between 7 and 9am depending on the grade level and have your IOP program start 30 minutes after that. That way the parents, the mom can drop the child off at school if they need to, or get, get them on the bus and then get to treatment. Participate in treatment while the child is in school, then be home in the evenings. Systematic issues include lack of financial resources, lack of clean and sober housing, lack of pregnancy and postpartum services, and poorly coordinated services. So I mean, women have a lot of issues, especially if they've got children to care for. So it's important to look at, you know, Again, what are the obstacles that are keeping any particular woman from seeking treatment and how can we facilitate that? Three primary types of services exist for women. There's clinical treatment, iop, php, residential, there's clinical support. So that's more once a week, counseling and case management. And then there's community support, which includes everything from child care and transportation to housing services, family strengthening, recovery support services, employment services, vocational and academic services. Now we've started to call this a recovery oriented system of care. Those community support services are all those ancillary or wraparound services that support the clinical progression. So it's important to identify what does this person need to engage in treatment, succeed in treatment and stay in recovery. Development of substance use disorders is often viewed as a disconnection for women. And I don't like this term, but evidently you need to know it. Treatment stresses the development and repair of connections to others, oneself, one's beliefs and one's culture. Okay, so connections to others. I'm not going to tell people who they need to be connected to. I want them to tell me who's their family. Who do you want to be connected with? Because we all need social support. But that social support may be different in recovery than it was in active addiction. I do want them to reconnect with themselves and figure out what they need and start learning to like themselves. I do want them to get in touch with their beliefs and figure out what's important to me and what do I stand for and where do I stand on issues. Then when it comes to culture, I mean people are generally have multiple cultures that they affiliate with. But it's important for the woman to identify, you know, what parts of that culture, of each culture that she embraces. Pregnant women substance use often creates or is accompanied by an array of social problems, including violence, child abuse, neglect and family dysfunction. So if you're working with a pregnant woman who is also abusing substances, we do need to be aware of the fact that there's a higher rate of family violence, abuse and neglect and family dysfunction. 5.4. About 5.5% of babies are born to illicit drug users. Substance abuse during pregnancy increases the risk of problems for both the mother and the fetus. Alcohol use during pregnancy can be really detrimental to the fetus and cause fetal alcohol spectrum disorders. But other substances can also be detrimental to the fetus. SAMHSA just put out an entire publication on working with pregnant substance abusing women. The March of Dimes website has detailed information about risks by the drug used. So you can, you know, get A real quick overview. Pregnancy creates a window of opportunity to enter treatment, become abstinent, quit smoking, eliminate risk taking behaviors, and lead a healthier life if the woman is motivated to do so. Not everybody finds out they're pregnant and is like overjoyed and says, okay, I need to stop doing everything. You know, we need to get empathize with the woman and understand where she is at in terms of, you know, what does it mean if she becomes abstinent? What does it mean if she starts leading a healthier life? You know, she may be living on the street, you know, living with her pimp and has nowhere to go, doesn't have any family resources. You know, the idea of, you know, I'm pregnant now, I need to turn my life around, may not even be something she can even conceptualize how to make it happen. So that's important for us to help provide options. And if she wants to embrace those options, wonderful. But we do need to understand that that's huge for some people. Additional specialized treatment needs to include improving nutrition, child care, financial support, and identification and treatment of infectious diseases, both in women and their infants. Another population that we want to think about are older adults. Nearly 1 in 5 have mental health and substance abuse conditions. That's sad. Depressive disorders and dementia related behavioral and psychiatric symptoms are the most prevalent. But substance use is a significant problem as well. So you notice I said depressive and dementia related behavioral symptoms and psychiatric symptoms. They may not meet the full criteria for diagnosis of major depressive disorder or dementia, but those symptoms that go along with it may be prevalent and may be prevalent enough to be caught to be a reason for intervention. Age alters the way people metabolize alcohol and drugs. And this is something that I'm one of my soapboxes that I get on because as people age, it takes their liver longer to clear some of these drugs. So things like benzodiazepines can build up to toxic levels really quickly. Opiates can build up to toxic levels really quickly. You know, not only does age, and I learned about this in a different presentation I was doing, but ethnicity can also alter the metabolism of drugs. But since we're talking about older adults will stay with age right now. So it's important to recognize that, you know, the amount that a 20 year old could drink or use and not experience significant problems may be very different than the amount that a 70 year old could drink or use. Issues that trigger symptoms in older adults can include losses that frequently occur in old age, loss of a spouse, loss of Friends, loss of physical or mental capacities. It can get really frustrating. I know my stepfather right now just recently had back surgery. He used to play golf every single day and now he has to walk with a walker and that's devastating to him. So there are certain things that we do need to recognize that happen that older adults may have to grieve and deal with. It's important to differentiate between major depression and grief in the person with significant losses, but that's often difficult. And they've removed the bereavement exception in the DSM 5 for diagnosis of major depression. So you can have bereavement and depression at the same time, but you treat them a little bit differently. You know, obviously the we want to look at what's the underlying issue that is prompting these symptoms. Cognitive, functional and sensory impairments may complicate detection and diagnosis of mental health and substance use issues. As people get older, they may not hear as well. So we may not know if they just didn't hear us or if they didn't understand us. We may not know if they are losing their balance because of sensory issues or because they're intoxicated. Oh, and going back to metabolism of drugs. When people who are older take benzodiazepines, they are at a much higher risk of falls. So you know, it's really important to be aware of specific prescribing guidelines for the geriatric population because not all older adults go to geriatric specialists. So you know, you may see something and you know, need to refer to your in house doc to talk to their doc or whatever, adolescents. So let's go to the other end of the spectrum. The National Institute on Drug Abuse has recently published a version of the Principles of Adolescent Substance Use Disorder Treatment, a research based guide. So you can look at that if you go to the NIDA website, which I'm going to give you in a minute and look at that publication. You can learn a lot about treating adolescents, but we want to remember that adolescent brains are still developing. Up until about the age of 25, our brains are still developing, especially that impulse control area, exposure to neurochemical changes and health consequences associated with addictive behaviors appear to cause more significant and long lasting brain changes for adolescents. So everything's kind of mushy in there. If you want to think of it that way. That's not actually how it happens, but you know, for lack of a better metaphor. So when adolescents expose themselves to addictive behaviors, for example, and their brain is flooded with dopamine, or they expose themselves and their brain is flooded with certain drugs, it causes more lasting changes. So, you know, think about cement. You know, when you have cement, it takes a while to set up. And if you pour water on it after it's set up, you know it's gonna get wet, but it'll eventually dry out. If you pour water in the cement before it has set up, then you're gonna have very weak cement that kind of crumbles. And the same sort of thing can happen with adolescents. We may see greater brain damage, if you will, from addictive behaviors. And you notice I keep saying addictive behaviors and not just substance use. They found that pornography has a much more intense impact on the adolescent brain than on the adult brain. So even addictive behaviors like pornography and gambling can be much more damaging and highly addictive to the adolescent. It's important to remember that adolescents are often in a very tumultuous life stage. I mean, 17, 18, they are graduating high school. They are starting to be expected to be adults. They're ending their childhood, which some of them fight tooth and nail, others embrace wholeheartedly. They're starting to develop their identity and try to figure out who they are and, and what they want and what they think. And a lot of them are leaving home for the first time. So they're having to be responsible and start adulting. And this is, you know, overwhelming. Adulting can be overwhelming for adults who've been doing it for 20 years. It's really overwhelming for the adolescent who's doing it for the first time. So we do need to be sensitive to some of the issues that they may be facing when they go off to college. For example, a lot of adolescents leave home and go far away to college, so they're leaving their entire support system behind and they're having to make new friends at college, which can be exciting, but again, it can also be overwhelming. Other special needs that we didn't talk about, we talked a little bit about trauma informed care. Do remember that the expectation is that people have been exposed to trauma. So approaching treatment, whether you use cognitive, behavioral or humanistic or experiential or whatever it is, but approaching treatment from a trauma informed perspective is definitely the best way to go about it. So it's important to be aware of trauma informed practices and take a hard look at some of the practices that your agency currently uses that may be re traumatizing to some people. The other special needs issue that we didn't talk about are non abstaining addictive behaviors. Shopping, for example, people can't say, well, I'm never going to shop again. I mean, you have to grocery shop. You have to. There are certain types of shopping you have to do to be independent. People who have eating disorders or who binge on foods, who have a food addiction, if you want to put it that way, even though it's not in the dsm, there are addictive properties to eating. You can't say, I'm never going to eat again. That's just not possible. And while you can say I will never have sex again because there are some people who take a vow of abstinence, most people choose not to do that. So sex is another one of those addictive behaviors that people may present for treatment that they can't completely abstain. So it's important to know how to tailor treatment programs to help people who have issues, compulsive behaviors that they can't completely abstain from. Just like it's vital to be aware of the special needs of persons from different races and ethnicities, it's also vital to recognize that there are other factors that require specialized skills. Gender and age differences themselves produce a range of special issues that need to be considered in prevention. You know, prevention, preventing a 16 year old from using substances is going to probably be different than preventing a 46 year old from using substances. They have different life issues going on. They're developmentally different, they've got a lot of different issues. Assessment will be different for different genders and ages because like I said, drugs impact women differently than men. Drugs impact adolescents and older adults differently than middle aged people. Engagement will be different. You'll use a different approach when you're engaging and developing rapport with someone who is 65 versus someone who's 15 or 25. Treatment setting recommendations are going to be unique based on gender and age. Some people will prefer a gender specific treatment program. Some people, you know, a pregnant woman may need to be in a pregnancy and postpartum program. We need to consider this. We also need to consider, like I brought up earlier, that if the person who is often a woman who has primary caregiving responsibilities is enrolling in treatment, she may not be able to participate in certain programs because of a lack of child care. And we need to consider treatment approaches. Not every approach is appropriate for every person. If they've got cognitive issues, then they may have difficulty reading, writing, paying attention for an hour straight in group, etc. So we do need to look at the approaches that we use and modify those approaches to meet the specific needs of the individual. Okay, as promised there are more resources. If you heard some of this and you're like, oh, I need to brush up on that, you can go to our YouTube channel@allce.com YouTube and I have videos on there about working with adolescents, about working with older adults, about working with pregnant and postpartum women in the perinatal period, as they call it, and about cultural competence. And SAMHSA has a wonderful tip on working with cultural competence that you can also download from store.samhsa.gov and then to download that publication on adolescence that I told you about from the National Institute of drug abuse, Nida, you go to drugabuse.gov publications okay, thank you for joining me today and I'll see you next Wednesday for episode 21 all of us at all ceus wish you great success on your exam. Once you're certified or licensed, please Remember to visit all CEUs for all of your continuing education needs. We offer unlimited CEUs for $59 for addiction and mental health counselors, social workers, and marriage and family therapists. If you're still thinking about becoming an addiction counselor or all CEUs offers the training you need in three formats online multimedia, self study, self study, plus live webinars or Face to Face weekend intensives, which meet one weekend per month for 12 months. We can even present a training series at your facility. Just email supportlce.com go to allce.com acer that's allceus.com acer to learn more.