Monthly Archives: February 2016

Substance Use Treatment

I’ve been trying to write about the problems with substance use treatment in the US since I quit the field in November but haven’t been able to. I’ve been so burnt out from the topic that I even removed songs about drug and alcohol use from my MP3 list. Before I got a job at an outpatient substance use clinic about four years ago, I never had any interest in the subject. I was never interested in trying illegal drugs. I’ve never even smoked a cigarette. I have the occasional drink, but always stop at one drink per evening, and the only time I deliberately tried to get drunk was during my bachelorette party, and I really didn’t succeed because I didn’t like the feeling of being buzzed and stopped there.

The only history of substance use disorder in my family is my great-grandfather, who I never met.My parents don’t drink, not for moral reasons but because my dad, the pickiest eater of all time, just can’t stand the taste of alcohol. Aside from contending with asthma attacks triggered by second hand smoke, substance use did not affect me or my family growing up. Because of this, all of those contentious political questions about substance use that get everyone else so fired up didn’t interest me. As opinionated as I am, I didn’t have any opinions about legalization or 12 steps groups. I didn’t know enough or care enough to have an opinion about them.

Four years later, and I maintain that all of the issues are more complex than either side makes them out to be. But one thing I believe most people can agree on is the state of substance use treatment in the US is in shambles. NPR had an article about it today that just barely touched the tip of the iceberg.

So what do we need to do to improve substance use treatment in this country?

  1. Ditch the 12 Step Model and move to more evidence based techniques. OK, Alcoholics Anonymous and Narcotics Anonymous works very well for some people, but it does not work for the majority of people with substance use problems. Further, there are several aspects of these programs that conflict with modern findings about substance use and are dangerous for people in recovery. For a complete break down, see The Sober Truth.
  2. Primarily, the people providing treatment are LCDCs. LCDCs are poorly trained and tend to be in recovery themselves. I am an LPC and went to school for 6 years, have a Masters, and can treat the whole mental health spectrum. An LCDC goes to school for two years post high school at most (some with just a high school degree are grandfathered in, and the ones who tend to work in jails just have a certificate). They can only treat substance use, yet as substance use tends to be co-morbid with other disorders and, face it, substance use IS mental health, there’s a lot they can’t address. Further, counseling is more than just listening and giving advice (in fact, if your counselor is giving you advice I’d recommend finding a new counselor). And the sessions lead by and LCDC that I’ve set in on were not counseling. Some were cringe worthy. And further, a lot, but not all, LCDCs have serious mental problems themselves. There was one I was training when I was about to go on maternity leave in a week, and I had to tell my boss there was no way I could leave my clients with her. The least harmless thing she did was, when I gave her a list of referrals that I give to clients for case management purposes, she went to live at one of the women’s shelters listed. Knowing that we send clients there. Can you imagine going to live at a shelter and finding your counselor living there?
  3. As the NPR article addressed, the pay is poor. Especially for what the counselors have to deal with. People who go to substance use treatment are often forced into it. In our case, most of our clients have had their children removed by Child Protective Services. So we’re dealing with people feeling a lot of grief and shame because they lost their children AND who are in withdrawal. Some people come in very eager to cooperate and put their best face forward. Others, I can’t begin to describe the depths of their anger. Maintaining your cool and helping them to defuse that anger is draining. $40,000 a year does not begin cover the mental toil this takes on a person after awhile.
  4. The burn out. I was aware I was burnt out, but I wasn’t aware of just how bad it was until I got away from working there. And in my case I will say my boss did a lot to help us manage burn out. It’s why I lasted there as long as I did. We had work retreats about once a year. Last year, though, the Monday after my work retreat I spent an evening on the phone with a suicidal client who would not tell me her location (I did successfully talk her down). All of the relaxation I got from the retreat was undone by that Monday and I was even worse than before I went on the retreat. Suicide calls are emotionally draining and extremely anxiety provoking for counselors because we’re put into a confidentiality trap (if we break confidentiality and call the police, we could be sued successfully and lose our license, but if we don’t call the police and they kill themselves, then we can also be sued successfully and lose our license). Add to it that I, like most counselors I know, struggle with anxiety, it put me in a real bad spot. Really I think there needs to be a counselor contracted with clinics that counselors who work there can go to free of charge. The other thing my boss wanted to do but she could never get the staff to do it was have a counselor rotate among the staff so the counselors could have a break to develop curricula or do research or something else, but have a break from working with clients while still doing work vital to the company. I think having these role changes would have helped. And here’s the thing, having counselors who are energized and clear headed helps the clients. So it is vital the make sure the counselors are kept emotionally healthy.
  5. Increase the length of stay for people in treatment. It takes time for the brain to heal from substance use. Outpatient programs are about three months long. When a person stops using drugs, one of the times they are most likely to relapse is three months after getting clean. See a problem? Further, a lot of the times the problems a person coming in for treatment faces are so complex it’s going to take a lot more than three months to fix.
  6. Get as much of the family in treatment as possible. When one member of the family has a problem, the whole family has that problem. A lot of times I would feel like I put a fish in the bag, taught it some nice coping skills, and then threw it back in with the sharks. People with substance use disorders tend to come from families who have problems with substance use. Very few of them are willing to say good bye to their family forever or to tell them they can’t use drugs around them. So that individual completes treatment, and most of the time I think they genuinely believe they will be strong enough not to use around their family, and then BOOM, they’re back in treatment.
  7. Evidence based treatment, evidence based treatment, evidence based treatment. This means cognitive behavioral therapy. This means accepting that medication may be useful for some people rather than treating that medication as another addiction. However, it also means not going the opposite extreme and expecting to give a pill as a solution to every problem (as I said above, the reality is more complex than any side would maintain). Here’s what we do know, though. Addiction is not about will power. There is a biological competent. There are maladaptive thought patterns. A person’s environment plays a strong role in whether or not they will relapse. Good treatment needs to take all of those factors into consideration.

OK, that’s all I can do about this topic today. May be in another three months I’ll write more.

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Learning Through Play, What a Revolutionary Concept!

Last Wednesday was the last day I took Buddy to his old school. They told me it was no longer acceptable for him to come to school with his clothes on backwards. I also know they’ve been punishing him with time outs for toileting accidents, something that EVERY book on autism I’ve read has said not to do. Once that started happening I noticed a change in Buddy. He stopped wanting to go to school. I wonder if they got on to him for coming to school with his clothes on backwards because last Weds he was very withdrawn. But since he can’t talk to me all I have is speculation.

Thursday morning he was extremely reluctant to go to school. It’s usually not an issue. Unlike a lot of kids with autism, Buddy likes getting out of the house. I asked him if he wanted to go to school and he said “no.” In the past when I’ve asked he’d repeat, “school” which for him is a way of saying yes.

I took him to a playground instead. There were several other little boys Buddy’s age there, and he surprised me by joining in their game of Power Rangers. One of the mothers there had worked as a physical therapist at his old school and recognized him and she commented on what a good job he was going with the other boys. As we left I felt he benefited far more from those hours at the park than he would have at school. And that play? He wasn’t getting at school. But it’s the type of play he needs.

Friday I took the kids to visit my grandparents. And on Saturday when my parents came to visit, they found that Buddy had come out of the shell he had been in for the past few months, ever since they started the time outs at school.

Monday we started his new school. When I picked him up, he proudly showed me the truck he was playing with. His case manager said he’d done well and he won a game of musical chairs. Today when I went to pick him up I saw his therapist engaging him in a long, back and forth verbal sequence (five turns). This is something they were able to do in two days with him that his school was not able to do in five months of being with him! In fact, his school had no idea how to engage him. They asked me once, and when I told them (find what he is interested in, play with him, and gradually bring him into your world) they dismissed me as being permissive and went back to doing what doesn’t work.

And Buddy just seems happier now. And we’re seeing more engagement from him. While driving home today with Buddy and Sissy in the back seat we got stopped by a train. Buddy pointed at it and looked at Sissy and said, “Look, Sissy! A train!” I rarely hear him talk to her expect at night when he says, “Night night, Sissy, love you.”

At home we were watching “Mary Poppins” and when Mary Poppins did her long twirl during the “Step in Time” sequence he got excited. I started wondering out loud if any of us could twirl as long as she could and gave it a try. After I tried, Buddy tried. Here’s the thing, Buddy rarely imitates what he sees on tv. But as the show went on he started dancing more and imitating the movements. Later as I was doing dishes he started singing “Old MacDonald.”

I don’t think his new school has wrought a miracle so much as I think his old one was really stressing him out. And what I want to emphasize was that he was in pre-school. Pre-school was stressing him out. And further, is was inhabiting his growth when it should have been encouraging it.

And here’s the thing, it’s not just parents of children with autism experiencing this. Kids today are more anxious and at younger ages.Sensory processing disorders are on the rise. We have become so focused with academic success that we have set our expectations for our pre-schoolers way too high. Kids in pre-k are not wired to sit down for hours. They are not wired to know how to read or to do arithmetic. Our society got this insane notion that if we teach things to children at a younger age they will be smarter. But what happens is that we are teaching our children skills they are not developmentally ready for. Some children, boys especially, can’t learn to read before they are seven! But if you expect that child to learn to read at 4, well, of course they are going to get frustrated with school. When you expect a pre-school to sit still for hours, well, he’s going to get frustrated when he can’t do it.

And here’s where it ends up. Children’s mental hospitals. I did my practicum in one. I saw kids as young as four given ADHD medication so they could sit still for long periods of time. Here’s the thing, you give a kid who had ADHD medication, and he will calm down. If you give a kid who does not have ADHD medication, he will become irritable. When this happens, rather than saying the kid does not have ADHD, what tends to happen is it is viewed as that child has depression that the ADHD was masking, so they’re given an antidepressant. And then when the child has the symptoms from the depression medication, they’re given a third medicine. Some kids get up to 18 medications so they can sit still. At the age of four.

A disclaimer, I do not feel all medication is evil. While I was working there I also saw kids with schizophrenia. They definitely needed medication to be lucid at best, or to at least control their outbursts at worse (the prognosis for childhood schizophrenia is not good). However, for things like ADHD, I feel that medication should be used as a LAST resort when behavioral options have been tried and failed. But too often it’s used first.

Something else to point out, the children’s hospital I was in did not have a playground. I did not learn about sensory processing disorders until I had graduated, but looking back, I realize that a lot of those kids likely had undiagnosed SPDs and would have benefited more from physical therapy and play as opposed to Adderral and Abilify.

Which is all a long winded way of getting to my basic point, when the expectations we place on children are too high, normal behavior become pathologized. When a four year old is expected to sit still for hours, not being able to sets that four year old on the path to being labeled ADHD. When a five year old can’t read, she is set on the path of thinking she is too stupid to learn.When we stress the importance of achieving a high score on a test above all else, we set our kids up for anxiety disorders.

In the two days Buddy has been at this new school, I have already seen good progress. He spends his days learning through play. On the note they send home they have play activity after play activity they have engaged him in. At his old school they did a lot of work sheets and art projects, both of which are not age appropriate for a pre-school. My son has made more progress with play activities than he has with five months of work sheets. And it frustrates me to no end that we have someone gotten so obsessed with academic achievement that the idea of children learning through play is revolutionary, and finding places that provide it are so exceedingly difficult.

These Little Things

It’s Buddy’s last week in public school. On Monday he starts a program specifically for children with autism. And after today, I’m thinking it’s coming not a moment too soon. And the matter is so small it should be inconsequential, but it isn’t.

I want to encourage Buddy’s independence as much as possible. He’s five. Sissy is not yet 2 and I still have to take care of a lot of things for her, such as dressing her. Buddy can dress himself. One of the things that drives me crazy about the school dress codes is that if I give him a shirt with Jack Skellington or Olaf on it, he will get in his shirt, pants and shoes in five minutes flat. But if I give him a plain polo shirt that the school requires, even in his favorite color, it’s more of a pulling teeth experience to get him to dress himself. But he’s five, he’s able to do it, so I find ways to coax him into it (usually if I set them out at breakfast he’ll put them on as part of a routine, but then there are days when he doesn’t).

I’ve always had an issue with school uniforms. Way to promote conformity and stifle individuality! But as a parent, I find them even more irksome because it is so much easier to get Buddy to dress himself when he really wants to wear what I set out.

The second part of this is that Buddy does not care if his clothes are on backwards. Well, he cares if his shirts that have characters he likes on them are on backwards. He will turn those around himself. Not the polos. He will even button them up in the back.

One thing I firmly believe as a parent is that you have to choose your battles. Running in the street? Yes, that’s a battle I will fight. Even though Buddy does not want to, I make him hold my hand when we are in a parking lot or crossing the street. That is a battle I will fight. Wearing his shirt forward? Not so much. He’s not hurting himself. He’s not hurting anyone else. The person it affects most is him. I know some people worry about teasing, but given my own experience with being bullied, bullies will use ANY excuse to bully another child. If they aren’t going to bully him for his clothes, they’ll bully him for the strange way he talks. If not that, then they might bully him because he’s biracial. Buddy is NOT responsible for the bullies’ behavior. The parent of that bully or the teacher has a responsibility to tell that kid that bullying is not okay and to knock it off. In my mind, use it as a learning opportunity for kids to promote tolerance. Some kids like their shirts forwards, others backwards, but it really doesn’t matter.

If I try to coax Buddy into turning his shirt around he gets upset. Trust me, we’re quickly on the road to a tantrum if I push the issue. To me, it’s not worth the battle. He dressed himself, which is what I wanted. Him dressing himself makes my life easier. Me fighting with him over which way his shirt is facing does not. I’d much rather spend time having positive interactions with him than arguing with him over something that is of no consequence to anyone!

The school has sent notes commenting several times that they had him turn his shirt the right way and he didn’t protest with them. This does not surprise me too much. Like a lot of kids with autism, it takes Buddy a while to be comfortable telling people what he wants. In strange places he’s less likely to protest stuff that he will at home, where he feels more secure and comfortable (and unlike a lot of kids with autism he rarely tantrums in public). So he’s more likely to protest something with me than he is his teacher in a place that is not as comfortable for him.

Today they sent a note saying he needs to come to school with his shirt facing forward. Of course, they pointed out that he doesn’t protest with them so it shouldn’t be an issue at home.

Fine. Come live my life for one day. Come see what battles you’ll fight then. Just dismiss my experiences with my son, who I live with every day. Come, tell me I’m doing it all wrong. Come, tell me I should create a power struggle over something so small and insignificant as a matter of which direction his shirt is facing. Come, tell me I should fight with him over that as opposed to spending that time doing something we enjoy together because, for whatever reason, it is so vitally important that his shirt faces the right way.

It bugs me because it is such a small matter. He’s five. No one is going to be harmed if his shirt is facing the wrong way. And this is just a beautiful example in my mind of how school policies can just make life at home that much more miserable for parents and kids who have disabilities, or even kids who do not, and are more focused on appearances than actually creating environments that are kid friendly and conducive to learning. My mom fought this battle with my sister. Though my sister is not autistic, she has sensory processing issues and as a child especially was extremely sensitive to touch. The seams on her clothes were extremely painful for her as a result, and she preferred to wear her pjs and her clothes inside out. My mom had to fight with the school for this to be allowed. But how they would expect a 6 year old to learn anything when she is in physical pain because of the seams on her clothes is beyond me. If a kid learns best wearing pajamas, why is it such a battle to get the schools to let them learn in pajamas?

And for the record, my sister now wears regular clothes and outgrew a lot of her sensitivities. And she’s now getting her Ph.D., is well adjusted, and lives independently. This is not mollycoddling and spoiling. This is about schools having rules that are not realistic for children. This is about promoting policies that make them kid friendly and creating environments that are conducive to learning. For small kids, this means being comfortable. To me, this means focusing less on what our kids are wearing and more on what they are doing.

And no, I am not going to pick a battle with Buddy over this. As of now I’m just repeating the mantra, “two more days, two more day.”

A Place for Buddy

We just got back from touring an autism treatment program for Buddy, and we’re very optimistic and excited. Ever since I became concerned about autism with Buddy I’ve had a hard time finding a place that seems to understand autism which has been a source of frustration (there’s nothing worse than being scared there’s a problem, having people tell you he’s behind but will grow out of it and not to worry), and I think we finally have.

Things I like about their program.

  1. 1:1 teacher/student ratio. At Buddy’s current school there are a lot of kids and not a lot of teachers, and a child with autism needs A LOT of engagement and really need to be shadowed constantly.
  2. 50% of the time is one on one, the rest is with the other students.
  3. There’s a playground across the street owned by the Boys & Girls Town that they have a contract to use, and Buddy can play there with them while being shadowed by a therapist who can help him learn to play with other children (this has been the hardest thing for me. Sometimes he plays very well with other children, sometimes he wants to but just can’t break the ice and it’s so hard to watch).
  4. No worksheets. Everything is natural, play based learning. We evolved to learn through play, not worksheets, and finding a place in my area that does not focus on worksheet drills and focuses on learning through play has been exceedingly difficult. Play IS the mechanism by which children learn.
  5. They have a gross motor therapy room with a ball pit. Buddy saw that and jumped right in and did not want to leave! So yeah, Buddy liked it there a lot! I explained that he is sensory seeking and they actually knew what I meant and understood the other autism lingo.
  6. They did not give me that condescending false hope that he will start talking and acting like a typically developing child in abut a month. Everything was realistic. I feel like they actually understand autism.
  7. Once a month they will either meet me or my husband in the home to check out concerns, progress, and to work on issues in the home to help Andy and I improve how we interact with him, and also to help Sissy learn how to interact with him. As a therapist I strongly believe that when one person in the family has a problem, the whole family has that problem, and the actions that each person in that family performs or fails to perform either makes the problem better or worse. So even though Sissy is not yet two, she’s affected by having a sibling with autism and also needs support. So I like that the whole family is going to be included.
  8. It’s more hours during the week than what he currently has, and it’s year round. So not more of this getting him in a schedule and it getting messed up by summer or Christmas break.

So Andy and I are very happy with what we saw and Buddy really liked playing there. We think this will be a good place for him and that he can grow and thrive there. They did not promise me a miracle, everything was realistic, and they accepted his autism behaviors as autism behaviors and not being defiant or manipulative.

Of course, until we meet our very high deductible, we’re going to be paying through the nose for this. This is one of those instance where I want to emphasize that a person’s financial resources matter. Person A with a child like Buddy who can afford the therapy will get it and see their child progress. Person B with a child like Buddy who can’t would have to settle for what the school offers, and considering all of the labeling of his behavior in pre-school, frankly that would put that kid on the path to juvenile delinquency. The thing is I have worked with people less fortunate and seen how their children are punished by the school system for having autism. But that’s the subject of another blog.

For now we’re just overjoyed to get Buddy into this program and out of the schools. End of February!

Why Modern Parenting is So Hard

I’m currently reading The World Until Yesterday: What Can We Learn From Traditional Societies? by Jared Diamond. It’s a look at modern hunter gatherer and traditional small farming communities and explores how they structure their lives. Diamond takes pains not to romanticize these societies, he draws attention to the bad as well as the good (for example, infanticide, either deliberately or through neglect). While reading the chapter on parenting in traditional societies, I was really struck by how different things are in the US where I lived from the societies that humans evolved in and were more acclimated to.

In hunter-gatherer societies, the care of children is spread out among the whole tribe. While mom is the primary caregiver, dad, grandparents, aunts, and uncles are all readily available to help if mom needs a break or is busy doing something else. A new infant is frequently passed from caregiver to caregiver. Considering how intensive caring for a new infant is, this must be a tremendous help to a new mother!

Considering in the US, childcare is highly concentrated in the hands of the parents, particularly the mother, I think it’s little wonder women are struggling with postpartum depression and feeling overwhelmed by caring for their children. We live in houses separated from other people in our neighborhoods, not to mention separated from our families. This may have been the society we built, but it was not the society we evolved in.

The other thing that struck me was the notion of egalitarianism for children in hunter-gatherer societies. For an adult to impose his or her will on a child is considered a grievous offense. Physical punishment is seldom or never used while it is permissible for children to hit their parents (they are expected to grow out of it at a certain age). Children in hunter-gatherer societies are left to play with dangerous objects such as knives and near fires. Adults in those societies tend to have burn scars.

I tend to hold egalitarian views even for my children. They are little people, trying to figure out this world, and I have to show respect to them. In general, I only try to intervene with them when they are going to hurt someone else or hurt themselves.

I also believe that the less I intervene, the better. For instance, if Buddy puts his clothes on backwards, which he often does, I don’t make him turn them around. Either he’ll do it himself (which he’s started to) or he’ll ask me for help (if they ask for help I’ll give it). If he doesn’t want to wear his jacket I don’t press the issue, but I’ll carry one in our hiking bag. If he gets cold enough he will ask for it. If he hits a difficult part of the hiking trail I give him time to figure it out for himself. Same with Sissy, who sometimes takes five minutes to buckle herself in her car seat, but she does it herself (and yes, I check to make sure everything is tight and properly done). In general I try not to impede on their autonomy.

One day my kids are going to be adults, and I do not want to be doing everything for them at that time. So I give them as much responsibility as possible so they learn to take care of themselves. I’m the anti-helicopter parent.

And it’s the hurting themselves is where a lot of the hang ups come in.

In theory, I like a lot of the ideas of the Free-Range Parenting movement. Despite what we see on the news, child abductions are rare. And I would love to let my son, who is five, go and play in the woods on his own like I did when I was five.

Here’s the thing. When I went in the woods when I was five, I lived on an Air Force base and went into the woods with about 5-8 other children. This being an Air Force base, all of our parents knew each other, and further, security was extremely tight. If one of us children fell or was hurt, we would usually divide ourselves, one into a group of children who would wait with the wounded child and the second being the group that went to get a parent.

And it was the same in hunter-gatherer societies. Everyone knew everyone, children played in large groups, and the adults would watch over each other’s kids.

In the US, our society is no longer set up like that.

I rarely see my neighbors, even though the ones who live right next to us have about seven kids whose ages overlap with mine (they come from a culture where men and women who are not married are not allowed to socialize, if I see the father he does not acknowledge me, though the few times I’ve talked to his wife she was really nice). Yet with our big houses, our multitude of indoor entertainment, we just somehow never make it outside to see our neighbors. And while we don’t use the garage for parking our cars (we let our cat in the garage) plenty of other neighbors do, so you don’t even see them entering and leaving their house!

Further, as often as I use the park by my house, I am strangely an anomaly in my neighborhood. Most people with small kids do not regularly walk down there with them. It’s either an infrequent occurrence or they drive down. I have had yet to find another family that is at that park as often as we are. Further, when I take my kids to the trails by the creek, I am for the most part the only parent doing it. Occasionally a frisbee golfer will have a kid in tow.

By and large, I don’t worry about a stranger kidnapping my kids. I worry about an off roader running them over. Or one of them falling in a cactus patch. Or finding a poisonous snake. Or falling in the creek and getting caught  by a strong current and drowning. Or tripping and spraining their ankle. Heck, when I was pregnant with Sissy I was walking my dog and found a mountain lion walking up ahead of me on those trails. Um, me and my 65 pound German Shepherd promptly turned around and headed home.

And while some societies are structured so that children are monitored even if not by people who are their parents, the society I live in is not! If I sent Buddy to play in the woods by himself and anything happened, it’s likely that no one would be there to witness it and get help. Heck, sometimes I get to a certain part of the woods and think about how hard it would be to give an ambulance directions to where we are if there is an emergency and wonder how reckless it is to go alone with two small children into the woods even though I always take my phone with me. In truth while we never get more than 2000 feet from the main park with the playgrounds, the woods is thick enough and there are enough hills and crevices that no one would know what is happening in some of the places we trudge through, especially now that I’m going into places the off roaders have not encroached on.

While there are a lot of benefits about our modern society, I think something we lost along the way is community with the people we live close in proximity to. My close relationships are not with people who live in the neighborhood. The drawback is the burdens of raising children fall solely on me and my husband. Our neighbors are not going to look out for them. They will not go into the woods with a group of neighborhood kids to watch each other’s backs. Somehow we lost that social support.

And that’s why I think parenting is so stressful in this modern age. We evolved in a society where it took a village to raise a child. We don’t have that anymore.