Hello, and welcome. I'm Dr. Amy Cohen, Program Director for SMI Advisor and a Clinical Psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Integrating Cultural Competence into Evidence-Based Practices with Individuals with Co-Occurring Disorders. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians and has also been approved for one CE credit for psychologists. Credit for participating in today's webinar will be available until January 3rd, 2021. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. And now, I'd like to introduce you to the faculty for today's webinar, Mark Sanders. Mark Sanders is a licensed clinical social worker and a certified alcohol and other drugs of addiction counselor. He is an international speaker, trainer, and consultant in the behavioral health field whose work has reached thousands throughout the U.S., Europe, Canada, Caribbean, and British Isles. He has received numerous awards, including a Lifetime Achievement Award from the Illinois Addiction Counselor Certification Board and the Barbara Bacon Award for outstanding contributions to the social work profession as an alumni of the Loyola University of Chicago. Mark, thank you so much for leading today's webinar. And thank you very much, Amy. And I also like to thank the APA and SAMHSA for sponsoring the event. Let us begin. Okay, so about three years ago, I was flying in from Arizona to Chicago where I live, and I was sitting next to a man with six Purple Hearts. How do you earn a Purple Heart? I'm glad you asked, bravery. You see, I met people before that had one Purple Heart, but six. He was a World War II veteran about 90 years old. In other words, for three and a half hours, I'm sitting next to the bravest human being I ever met in my life. He says, Mark, what do you do? I said, I'm a social worker. I teach college. My students are social workers. I've taught psychologists, psychiatrists, recovery support specialists. And he told me to tell you, thank you for your service. I read a book called Good to Great, and the author says that you can tell what's most important to a society by its tallest buildings. You see, 100 years ago, the tallest buildings were churches. Today, the tallest buildings are Fortune 500 companies and Fortune 100 companies. But no society is great, the author said, just because they have tall buildings and Fortune 500 companies and Fortune 100 companies. A society is great when they have great social workers, great counselors, great psychologists, great psychiatrists, recovery support specialists, people like you who help others for a living. So if you're sitting in a room anywhere near a mirror, I ask you to look at yourself in the mirror and repeat these words to yourself. This is your lucky day. You're looking at greatness. Why don't you take a moment and claim that? So I'm in my 38th year as a substance abuse counselor certified, a co-occurring disorder specialist. And people ask me, how have you done this work for 38 years? The answer is recovery. So I share with you a quick story. So years ago, I was counseling a group of teenage girls who had co-occurring disorders. All of them had traumatic stress disorder, and all of these girls were using drugs in order to medicate their traumatic stress. So between these seven girls, they had seven days of recovery. In other words, the only recovery those girls had was that day. And I heard that in the residential facility where they were receiving services, there was a 19-year-old emerging adult woman walking around the same building with three years of recovery. So I selflessly thought what you would have thought. We needed her in this group so that her recovery could rub off on them. I've learned in my 38 years that recovery is contagious. So I called a therapist and asked, can she be in our group? No, she's doing fine all by herself. I called a second time, can she join our group? No, she's doing fine all by herself. And I asked a third time, maybe there's something magical about three. Her therapist says, yes, she can be in the group. Turns out she wasn't doing fine. She came to her first group and said, I was going to relapse today. Our timing was impeccable. The second group she attended, she says, Mark, I want to be a social worker. I want to help girls. And I said, you can be a social worker. You can help girls. She came back the following week and said that when I said she could be a social worker, she said, I cried all week. She said, I had four therapists before. I told them all I wanted to be a social worker and not one of them said you can do it. And I told her, there's only two things to qualify a person to do the work that you do. You're either an expert, meaning that you went to school and you studied it, or you took APA workshops, or you're a witness, you've lived it. She was a witness. She lived it. As a girl, she was abused by her uncle. She was a witness. And after I said, you can be a social worker, you can help girls. She was in community college and she declared that major social work. She received an associate's degree in social work. Then she went to the university, got a bachelor's degree in social work. In March of 2018, she asked me to come to the agency and said she had a surprise for me. And when I showed up, she was wearing a sweatshirt from one of the most prestigious universities in the world. And she showed me a letter where that university honored her with $50,000 in scholarship money towards her master's degree in social work. June 15, 2019, I attended the graduation ceremony where she walked across the stage and she received a master's degree in social work. It's been those types of experiences that have kept me doing this work this many years. And in addition, as our topic today is on integrating cultural competence into evidence-based practices, I also have a 25-year history of facilitating workshops on cultural competence. So today we marry the two. And then throughout our presentation, our short time together, periodically, I'll share a story with you. Let me tell you why. I've been a 30-year college educator and my former students come up to me and they don't remember the facts, but they always remember the story. And what I discovered is that if somehow you can connect the story to a fact, then people can also remember the facts. So by definition, a co-occurring disorder is two coexisting disorders independent of each other, but yet interacting with each other. Each is characterized by denial ambivalence and is treatable. When mental illness and substance use disorders coexist, both should be considered primary and treatment of both is needed. Sometimes people wonder where should you start if a person has a dual diagnosis? There's only one place to start, where the client lets you. That is the only place where you can start. So by definition, cultural competence is the ability to substantially understand, communicate with people from different backgrounds, different cultures. Cultural humility is a lifelong process in which one first learns to increase their awareness of their own culture, their biases, assumptions, and stereotypes, and then challenge their beliefs when they interact with the beliefs of others. Cultural humility in action involves seeking knowledge about various cultures. And as you seek that knowledge, having an openness to new ideas and contradictory information. See because cultural humility is a lifelong process and because when you're striving for cultural humility that you're acknowledging that you don't know everything about another culture, I'm believing that cultural humility is a more realistic goal than cultural competence. You see, cultural competence makes us an assumption. That assumption is that once you've acquired a certain amount of knowledge, you have arrived. And I am convinced after 25 years of doing presentations on cultural competence, that you can read 300 books on Chinese culture. And there will still be some things about Chinese culture that you wouldn't understand. So Laura Brown said, in this era of evidence-based practices with addictions, mental illness, and co-occurring disorders, few of any models have been intentional about integrating or incorporating cultural competence into the model. Let us check. We are in an era of evidence-based practices. Many of you have learned evidence-based practices. Can you think of one or two evidence-based practices that have been intentional about incorporating cultural competence into the model? If you can think of one or two, please put your response in chat. While you chat, I can think of one. The Native American communities have an evidence-based practice called the seven teachings of the grandfather. You see, as their culture was stripped away, they lost their culture and they were vulnerable to alcoholism, the highest rate in the world. That evidence-based practice brings them back to the early teachings of their culture. And do you see anything, Amy, in chat? Nobody's writing anything in questions, folks. That's exactly what I mean, is that few of these models have incorporated cultural competence in the model. So Dr. Stephen Bacon says that techniques alone have no therapeutic value of and in themselves. They are only valuable if the client finds it credible and you have a good relationship. So you can spend millions, thousands of dollars learning CBT, EMDR, acceptance and commitment therapy. And according to Dr. Bacon, these techniques have no therapeutic value unless the client perceives it as credible and you have a good relationship. According to Dr. Bacon, psychotherapy is a process driven by beliefs, expectations, and suggestions. Charisma and believability is what makes some counselors, some therapists more effective than others in engaging clients and facilitating change. So let's take a moment and let's talk about what does he mean by charisma? And I'll give you a list of four things that are considered charismatic. Empathy is charisma. Clients want to know that they're understood. Trustworthiness is charisma. Again, if clients don't trust us, why would they trust the technique? And since we're talking about culture and there's tension between various groups all over the country, sometimes empathy is a challenge, if I haven't walked in your shoes. And number two, if there's mistrust between various individuals based on culture outside of the therapy office, then there can be mistrust in the therapy office as well. Genuine enthusiasm is charisma. Genuine enthusiasm. How about this? A deeply held belief in the capacity for clients to change and grow is charisma. So after my client asked me how did I know she could get an MSW and why did she believe me? She wanted to know why did I believe you when you told me I could get that MSW? I didn't give her the answer, but I'm going to give it to you. She believed me because I'm a trauma survivor. You know, Dr. John Breer from USC in California says that helping professionals, recovery support specialists, case managers, case workers, counselors, psychologists, that we experienced more trauma in childhood than any other profession. But your brilliance is that you've taken the trauma that you've experienced in your lifetime and you've turned it into empathy and compassion and you use that to help others. You see, why does she believe me? Tell you a quick story. Be my therapist for a moment. My mother left my father when I was in third grade and she married a man that was heroin addicted who would beat her physically in front of the kids and then she would beat us or children in front of each other. When I was a junior in high school, my father went to Stateville Penitentiary on possession of marijuana, pounds of marijuana with a plan to distribute. In 1986, the year I became a social worker, my father was found dead in the closet at work, smoking a drug of his choice, cocaine. And in 2001, my first child died and I survived all of that. So what I was thinking was that if I survived all of that, of course she can get that MSW. You see, I don't have an opinion as to whether or not you should disclose information to clients about yourself. But I do think what I said is true, that you have a history of trauma and you've endured that. The fact that you've endured that is what gives you empathy. And when clients are more likely to believe you because they don't even know why, because you've overcome so much. If therapists do not understand their own diverse identities, and we all have diverse identities, gender identity, racial identity, religious identity, cultural identity. If therapists do not understand their own identities, examine their own isms, racism, ageism, homophobia, and do not strive to practice cultural humility and not learn from counter-transference reactions. Modern analysts believe that counter-transference reactions, when we have negative reactions towards our clients, especially where there are cultural differences, it's actually a gift because it reminds us of more information that we need to learn. If we don't do this work, no training in evidence-based practices like motivational interviewing, EMDR, DBT, or prolonged exposure therapy would allow us to do our best work with clients. Our unresolved work can get in the way. So I have some questions here just for you to think about, and you can look at these at your leisure time and just take a look at how you were raised and how you grew up and how that influences how you approach the work that you're doing with clients, if you take a moment to glance at these. So we're going to take a moment before we get into, we'll take a look at three evidence-based practices and how to integrate culture within those practices. We first want to take a moment and talk about the 10 characteristics of effective culturally competent counselors. The first one is that the counselor moves beyond first impressions. You know, research says that people start having opinions about others and making impressions of others within seconds of meeting the other person. And sometimes when people have impressions of the other, they tend to hold on to those impressions sometimes for dear life. Why? Because who wants to be wrong? The question is, when you meet with a client for the first session, how long does it take for the client to have an opinion about you? At what point in meeting you the first time does the counselor know, the client know, whether or not they're willing to see you a second time? It happens quickly. And we also have first impressions of clients. As a matter of fact, we can make first impressions before we even meet the client just based upon their diagnosis or the documentation that we receive before we meet the client. So particularly in cross-cultural situations, it's really important to move beyond first impressions because sometimes first impressions can be based in stereotypes. And one way that I know to move past first impressions is number two, to focus on client strengths. You see, we are too often in our field using what I call a deficit model, a pathology model. Even from the first question we ask clients, I was part of the social worker to ask clients at the first session, what brought you here? But that question, what brought you here really is how did you mess up your life? And somewhere before that first session ends, I'm expected to make a diagnosis. So I'm looking for pathology. What if we ask questions like, what's right with you? Like, what do you do well? You know, lots of the clients that we work with that have co-occurring disorders have bouts of homelessness. Doesn't it take a certain amount of strength to be able to live with years with homelessness without a job? How about sleeping in the winter in New York, homeless without a job with mental illness or Chicago homeless without a job? How about the strength that it takes and the savviness to survive off of a social security check? Or how about the strength that it takes to like survive active addiction without money to support your habit? What skills did you have that enabled you to survive so much? That's a trauma question. And when I look at that question, I think about my, I think about my grandmother. You know, my father died smoking crack cocaine, May 29th, 1986. My father, my grandfather, my father's father died of a heart attack a few months after his son died. I think he died of a broken heart. My grandmother responds to the death of her immediate family by having a stroke. It was somatic. We think she never walked again. She didn't eat much. She lost a ton of weight. She was bedridden. She never walked again. And a decade later, my grandmother died. And the plan was for me and my siblings to plan her funeral. How are we going to do that? Because when she was alive, my grandmother did all the planning. She fed the whole neighborhood, the world's greatest cook. How are we going to plan a funeral? My brother went into the house and found her Bible and said, turn to the section called the 23rd Psalm and you'll know exactly what to do. And the 23rd Psalm was a part of the Bible that my grandmother recited when she felt stressed. We turned to that section, a bunch of pieces of paper fell on the ground. We picked them up and put them in order. These were notes written by my grandmother. They were difficult to read because we believe she wrote those notes laying upside down in her bed. One note read at my funeral, I want to wear my hair the way I wore it in the 1930s. We did the best we could. Another note said, at my funeral, I want to wear a white dress and a red rose. We accommodated that request perfectly. One note said, I want Sister Sarah to sing Amazing Grace at my funeral. That song has never been sung more beautiful. One note said, ask Reverend Emmett to preach my eulogy. He did well. One note said, would you ask Deacon Jones to speak at my funeral? I know he's shy, ask him anyway. The deacon went up with his head down and he said some nice words about my grandmother. Her final note said, I would like for all five of my grandkids to speak at my funeral. We all spoke. Well, after the funeral, there was a burial and I'm in the limousine and it hit me. Even though my grandmother looked so frail and helpless the last decade of her life, she was powerful beyond measure. She was so powerful, she was able to plan her own funeral. Never looked at people the same sense. You know, Goethe said nobody rises to low expectations. He went on to say, see a person for who they are, they only become worse. See them for who they could be, they become who they should be. How have you been able to endure so much? What do you like to do in your leisure time? We asked the man that question, African-American male court mandated, 70 years old, been using heroin for 50 years. I don't like to talk about it. He didn't want to be there. But then we asked him, what do you like to do in your leisure time? I don't talk about it much, but I'll tell you. He says, I play the drums in my leisure time. He says, have you ever heard of Miles Davis? I said, certainly. He says, when Miles Davis would come to town, I was his local drummer. Would you like to see an album cover where I was listed as Miles Davis' drummer? And he brought the cover to the next session and he was transformed before my very eyes. From a 50-year heroin user only to a jazz great. What are the best three moments you can recall in your life? You see, that question suggests that maybe the client had a life before mental illness, before addiction, before homelessness, before co-occurring disorders. What's the best thing you ever made happen? You know, the obvious signs of schizophrenia show up in a young adulthood. That strength-based question suggests that maybe the client made things happen that preceded their mental illness. And by the way, there are so many communities of color where people are viewed negatively. Strength-based intake questions help me build rapport in cross-cultural counseling relationships. My students have asked me if I could ask clients one question, what would it be? If I could ask clients one question, what would it be? And it wouldn't be what brought you here, it'd be this next question. What is your previous life suffering preparing you to do with the rest of your life? What that question means, like the next one, what have you learned from what you've gone through? Whatever the client has gone through, it wasn't for naught, especially if it can prepare them for something else. We are talking about the 10 characteristics of culturally competent counselors. And the third is the counselor's aware of his or her own biases and works to allow them not to interfere with their work with clients. Self-talk helps here. The counselor allows the client to be the teacher about their culture. This sets up an egalitarian relationship. People work best in egalitarian relationships. The counselor deals with microaggressions. We're defining microaggressions as direct and indirect, conscious or unconscious, insults, slights, and discriminatory messages. In other words, you can be having a session with clients using EMDR or CBT, and all of a sudden, you say something that's insulting, the client backs up and crosses their arms and they look angry. You have to put the model aside and attend to that. One of the things that Dr. Kenneth Hardy told Irvin Yalom's grandson is that when you've offended a client, the last thing you want to do is start explaining yourself and justifying what you said. What you must first do is find out how your words negatively impacted the clients to understand it. And then there's one more thing that helps with microaggressions. When I was a senior in high school, I participated in a sport called cross country. We ran three-mile races in the woods in November with shorts on. That was a strange sport. And I had a teammate that was Cuban, and my Cuban teammate was the best runner on the team. And he invited me to live when he and his family, my senior year in high school. So he and I can get up every morning at 5 a.m. to run five miles. Sound like fun? I agreed to live with him for two reasons. One, his mother, my Cuban friend's mother, resembles my grandmother. My grandmother was my heart. Number two, his mother, she could really cook like my grandma. I said, okay, I'll stay. Now, his mother didn't speak a word of English, and every night she would cook these elaborate Cuban meals. Without saying a word to me, she would always sit the food directly in front of me, and then she would always sit directly across from me, elbows resting on the table, smiling. I knew the smile meant I expect you to eat every drop of the food on the plate. I'd eat the food, she'd smile, go to bed, wake up in the morning, run five miles, where she always greeted me at the door with a smile, and there she'd be in the kitchen where she always fixed the warm breakfast, and while I ate the breakfast, she would sit across from me smiling. I knew the smile meant eat every drop. I've been in contact with my Cuban friend, we consider each other to be brothers, for 40 years. And he said to me for 40 years, my mother asked more about you than all my other friends. What about your friends from Cuba? She asked more about you than she knew my friends from Cuba. And she's always on my mind. Every Mother's Day, I bring her the largest bouquet of flowers. About 10 years ago, my friend's brother, who was 35 years old, had a brain tumor. And before I could make it to the hospital to visit the brother, the brother died. And five days later, they had the funeral. And I brought my wife to the funeral chapel for support. As soon as I walked in the chapel, the mother who was sitting in the front row, she spotted me in the back and said in Spanish, his family sit in the front row. Family is one of the few words I understand in Spanish, is sat in the front row. That night as I was driving home, I was crying hysterically, I was so angry with myself because I'd never learned to speak Spanish. And all I was thinking is that I learned to speak Spanish, I could have shared with the mother how I felt about the fact that she had just lost her son, that maybe I could help her with her grief. Next day was the burial. My mother was standing next to me crying and a voice came into my head and the voice said, say something to her. Just say something. So I reached over and gave her a hug and I whispered in her ear, the first words I'd ever said to her in my life. I said to her, I love you. And she said to me, I love you too. That was the first time we'd ever spoke. So I'm driving home, I'm feeling a little better. My wife looks at me and says, you know, you and your friend's mother have a very peculiar way of communicating with each other. But what you have is the purest form of communication. It's not about words, it's about heart. You connect at the level of heart. You went to graduate school, paid all that money. Most of the books that we read about helping clients, the purpose of the book is they put something in our head so that we can reach the client's head. Where we really connect with another is in the heart. The essence of connecting is a loving, a caring heart. We must protect that organ of our body if we are to engage clients, especially in cross-cultural situations. You know, the human heart is the one thing that I know that's stronger than biases, assumptions, and stereotypes and allow microaggressions to be forgiven. You ever notice that when we offend someone, their first question is, where's your heart? They want to know if it was intentional or not. The counselor works effectively across cultures. The counselor advocates for clients. We could talk all day about that, but some of our clients experience discrimination. My professor said to me years ago, you can't be at your best unless you're willing to get yourself fired. And that means fighting for clients. You know, he also said that sometimes if all we're doing is individual therapy, we might be actually being more hurtful than harmful because our clients are sometimes oppressed by systems out there that let's advocate. The counselor views counter-transference reactions as a gift, the opportunity to learn more about another's culture. The counselor strives for cultural humility, and finally, the counselor integrates cultural competence into evidence-based practices. So let's talk about that. Integrating cultural competence into evidence-based practices with individuals with co-occurring disorders. And, you know, Scott Miller, psychologist Scott Miller and Barry Duncan, they talk about the differences between evidence-based practices and practice-based evidence. Usually with evidence-based practices, somebody developed a model, and then they had researchers study the model. But my good friend, Dr. Joe Rosenfeld, said that whenever you study an evidence-based practice, your first question should be, who did the research on the model? Because he says often when people develop a practice, they're the ones that hire the research to prove that it's effective. And then number two, he said, the second question we should ask is evidence-based compared to what? Because sometimes the fine print is evidence-based compared to like someone sitting on the waiting list or business as usual. And in the case of addictions treatment, and I can speak on that after 38 years, business as usual was never all that effective. So the way practice-based evidence is different from an evidence-based practice is that with practice-based evidence, all the evidence as to what you're doing, whether or not it's effective comes directly from the client. Scott Miller said, Barry Duncan said, client feedback about your effectiveness may be more important than your supervisor's feedback about your effectiveness. In other words, your supervisor can watch you work with clients through a one-way mirror and conclude that you walk on clinical air. Your supervisor might say that you put the C in counselor before you came along. Everyone else was just counselor. All of that praise. And if the client doesn't come back, it doesn't matter very much. So they changed the name from practice-based evidence to feedback-informed treatment. And it's in the SAMHSA Registry of Evidence-Based Practices. It was based on a mega study where they found that there are four factors that lead to client engagement. The clinical model, counselor hopefulness, the therapeutic relationship we establish with clients, and then client factors being things that lie within the clients. We don't have a ton of time to talk about this, but let me just say this to you at this time. The research says that the clinical model accounts for about 15% of the engagement process. However, so the models are about equal in effectiveness, but every counselor using the model is not equal in their effectiveness. Some of you engage clients better than others. Counselor hopefulness, the mega study said, accounts for 15% of the engagement process. Hold on to your hat. Don't throw anything at me at this screen. The relationship that we establish with clients accounts for 30% of the engagement process. That mega study indicated that the most important factor, 40%, in our ability to engage clients in counseling are client factors. That will be the things that lie within the client. There are two ways you might consider that to be the truth. Number one, with all of your knowledge, the only way you can engage somebody in therapy is if they let you. And number two, just like so many of us have histories of trauma, so do our clients. And the research talks about something that's called extra therapeutic factors, things that clients can bring to bear on their own recovery, like success prior to the presenting problem, resilience, cultural strengths. The client has schizophrenia plus alcoholism, but how they recover, people love them. They participated in family therapy sessions and supported them through their recovery. Extra therapeutic factors includes employability, a good education. Did you know that as education increases, there's some research called, it's called helping clients develop recovery capital, like educational recovery capital. And as education increases, the chance of recovery increases and the chance of relapse drops. Vocational skills, hope for the future, leadership skills, clients can bring this all to bear on their recovery. What it means, particularly in cross-cultural situations, if we are doing cross-cultural counseling, we want to make sure the client has a voice in an ideal world. Each of us would like to be the master of more than one approach so that clients can pick and choose what they want. That's one of the more, the greater safeguards to make sure that the client has a voice. Faith, spirituality, extended family orientation, sometimes to bring that to bear on their transformation. So feedback informed treatment uses what's called the client rating skill, where you meet with the client at the end of each session, you have them to rate the quality of the session, drawing a vertical line through the horizontal line, and they give you feedback and you make changes accordingly. And what they've learned through their research is that when you incorporate client feedback, they're more likely to come back to the next session, the next session, and the next session. Some studies indicate that client, 50% of clients miss their second outpatient session. Again, I can master DPT, but if I can't get clients to attend more than one session, it doesn't matter what I know. They've discovered through their research that incorporating client feedback helps with engagement. Here's another way of getting feedback, asking clients questions at the end of sessions. How was the session today? What worked? What didn't work? What would you like to see different in the next session? My colleague, Matthew Sell, I'm going to ask clients these questions. What questions do you think I've avoided asking you that are important for me to ask you? What do I need to know that would make you believe that we were more on the same page and have faith in my ability to help you? What do you think I am missing that will make a big difference in your situation? And because we're talking about the incorporation of culture, there's also some ways that we can get cultural feedback, asking questions like, how do you view this problem from your cultural perspective? From your cultural lens, what causes this problem? And from your cultural perspective, how do you think the problem should be addressed? This is a good way to allow clients to have input into the work that we do together. The use of motivational incentives, also in the SAMHSA Registry of Evidence-Based Practices. Let me give you a scenario and see if you can find chat because I want to know how you answer this question. Pretend that you're stranded on a desert island and they're going to rescue you. If you're stranded on a desert island, you can have only one piece of candy while you're on the island. What piece of candy would you want to have with you while you waited to be rescued? Would you put that in chat? I'm curious. One piece of candy, you're on an island, waiting to be rescued. And Amy, do you see any responses? Come on, folks. Oh, one person said, I'm not in... Wait, I've got... Wait, they're writing. They're writing. I'm not into... I'm ready. One says, I'm not into sweets, then I've got a Mounds Bar, Jolly Ranchers, Snickers, Smarties covered with chocolate, peppermint hard candy, Lifesavers. You know, Amy, if we could see their eyes while they talk about this question, the candy, some of them, their eyes would be so big, look like they just smoked crack cocaine, where candy gets people going, but not everybody's into candy, is the first person responded. There was a doctor that worked with heroin users. And he started offering his clients a piece of candy at the end of session. So he wondered what would happen if he offered every other client, every other client, a piece of candy at the end of sessions. And what he discovered is that those who received the candy were more likely to come back to the next session. So he wrote an article. And someone from NIDA read the article, and they funded him to do a study where they would offer every other client their favorite piece of candy. They discovered that those clients that received candy were more likely to come back than the rest. And while they were there, they would get the opportunity to address, you know, how do you recover from heroin? You know, I did an educational group every Friday in one of the three greatest cities in the world, Paris, Rome, and Gary, Indiana. I drive every Friday from Chicago to Gary, Indiana. And they have put a women's treatment center right there in public housing, mostly African American women. They actually brought the treatment to the women. And as you know, most of these women had a co-occurring condition because the great majority of women, according to the research, that are addicted to drugs were either sexually abused as girls or sexually assaulted as women. And the first day I showed up on a Friday to do this educational group, one of the women, one of the clients reached for a bottle of water, and the staff took the bottle of water out of her hand. Said, we don't give clients bottles of water. That pissed me off. It bothered me. So I took matters into my own hands. Every Friday before I went out to Gary, Indiana, I would buy water, orange juice, and donuts from Dunkin Donuts. Attendance tripled on Fridays. Women started coming to me saying, I don't know why, but when I go to bed on Thursday night, I find myself dreaming about donuts. Donuts was bringing them to the groups. And then I learned about an evidence-based practice called the fishbowl technique. I'm going to take a moment to talk about that. And I witnessed and was a part of a group using the fishbowl technique with men of color who I considered to be quadruple challenged. All of these men were HIV positive. They all had a psychiatric diagnosis. They all had a substance use disorder, and they were constantly threatening poverty because their only source of employment or money was SSI. So if they smoked crack one day, they might not be able to pay their rent. They were quadruple challenged. And the program heard about the fishbowl technique. SAMHSA has some writings about the fishbowl technique. And every time clients come to group, they get to draw a raffle ticket from the fishbowl and win some prizes. They call those incentives. And there are 250 raffle tickets in the fishbowl. So let me talk with you about the value of each. 125 of those raffle tickets read, congratulations for coming to the group today. Keep up the good work. Meaning that in that group, there's a 50% chance that you will not win anything that day. However, her clients, because of the stigma of HIV addiction and mental illness, no one's clapped for them in years. So when a client would draw that particular card, the rest of the group would clap for them and they would smile. 50 raffle tickets out of 250 reads, congratulations for coming to the group today. You won a small prize and the value of the small prize is $5. 50 raffle tickets read, congratulations for coming to the group today. You won a medium prize. The value is $10. 24 raffle tickets. Congratulations for coming to the group today. You win a large prize, $15 to $20. One raffle ticket out of 250, you win the grand prize of flat screen TV. All of the prizes sit on the table and in the group room. What's her attendance like? Standing room only. Because people want those prizes. Now some of you are thinking, I'm not going to pay clients to do what they should be doing anyway except in that program. Back then all the prizes were donated by Walmart, Kmart, Sears, and church groups. They were all free. And how did they justify that? Because if you can keep these men coming back to the group and learning more, you decrease the chance that they'll wind up in the criminal justice system. And in places like Chicago, it costs about $35,000 a year to incarcerate an adult, disproportionately individuals with mental illness, substance use disorders, et cetera. Now, in one group, NIDA showed up and they filmed the fishbowl technique. And a crack user actually won the fishbowl technique that day and they filmed it. Now, what do you think that he did with the flat screen TV? They followed up six months later. Some of you are thinking, maybe he sold it for crack. He actually donated it back to the program. And the reason that he donated it back to the program was because he was in recovery for one year. And what the science says, what the research says is that when these incentives are most reinforcing is when a person is like, stop using drugs for 90 days. But once you're in recovery for a year, a new incentive kicked in called gratitude. So then I became curious. This was so effective. I shifted to working with African-American and Latino Hispanic adolescents who had traumatic stress disorder from gun violence in Chicago, and they were medicating it with the use of drugs. So they had legitimate co-occurring disorders. Counseling wasn't their idea. Some of them were on probation and mandated. I wondered what would happen if we introduced the fishbowl technique. And what we learned is that who people are culturally and what's important to them culturally should determine the incentives that you use. In other words, what inspires a person who's homeless and an adult to come to a group might be different with adolescents. So we had all of these things for them, Nike jerseys, Nike shoes, Cubs baseball hats the year the Cubs won the World Series, Yankee caps, even in Chicago, they like Yankee caps, all things Jordan, $5 gift cards to Target and 7-Eleven. Those were actually the prize rewards because the program was located directly across the street from a Target and a 7-Eleven convenience store. So they can leave the group and go right over to Target and 7-Eleven. We had zero resistance because the young people says, you know what? I'll come for the things. I don't have a problem. And then we use an evidence-based curriculum like the matrix model and the manualized cannabis use study model to actually help them figure out how to avoid using drugs, but using the incentives that were important to them to actually get them in those spaces. So let's talk about group psychotherapy. You know, the father, the grandfather of group psychotherapy is Irvin Yalom. You know, Irvin Yalom is a group psychotherapy, of course, like what Freud is to like psychotherapy in the early years of Freud. And Yalom's research indicates that there are certain factors that are most important in the early phases of a group. If you are to build cohesion, what his research indicates is that group cohesion is evidence-based. So in the early phases of group clients need universality means you need to know that you're not alone and you need hope. And the way you come to learn that you're not alone is through the stories that group members share with each other. If you are using a curriculum, an evidence-based curriculum in your group, doing group therapy, our recommendation is that make sure those exercises do not get in the way of the stories that members share with each other, especially in the beginning, because they need hope. They need to know that they're not alone. In the middle phases of a group, they need to feel close to each other. And the way you get towards cohesion is through the stories that members share. So, I'm going to tell you a little story about a boy named Mike who played a little league baseball on a team known as the Cougars. And Mike came down with a rare illness, cancer actually, requiring him to have chemotherapy, radiation treatment, he lost his hair. And he was embarrassed to go to the next Cougars baseball game because at the beginning of each game, the team would line up along the third baseline. They'd take off their hats and place their hats over their heart. And they would sing the national anthem. He was afraid that everyone would laugh at him when they saw that he had no hair. His father talked him into going to the next Cougars baseball game. And sure enough, the team lined up along the third baseline. And right before Mike took off his hat, all 25 of his Cougar teammates took off their hats first. And he saw they all shaved off their hair. And they looked at him and said, once a Cougar, always a Cougar. That when you're connected to cohesiveness, you make progress. Stories first, it brings you close. Then Yalom said, in the final stages, the third stage of group therapy, people need to express their feelings and unload their secrets. They trust each other now. So in this third stage, they can start to talk about those secrets. And then they come to learn from each other. They learn things like how my behavior distances me from you, how my behavior affects you, how you see me. They're less defensive. And so they can take in feedback better. Hidden talents and blind spots. Here's the question. So what happens then to group cohesion when you have multicultural membership? Social worker Larry Davis did some research where he talked about racial balance in groups. And he mentioned four important terms. If you have a pen, would you work along with me? I think you'll appreciate his research. He says, in various groups, you have different group members. The actual minority is defined as the group that has the fewest members present. The group that has the fewest members present. So there were a group with like 10 men and one woman. The woman would be the actual minority. The actual majority is the group with the most members present. Now the definitions will get kind of interesting. The psychological minority is the group that feels the least comfort based upon their numbers in the group. The group that feels the least comfort based upon their numbers in the group. Then the psychological majority is the group that feels the most comfort based upon their numbers in the group. And what he talked about is of these four subsets of group members, which would you expect to have the most early group dropouts? You're correct. The psychological minority. When people don't feel comfortable, they're more likely to drop out. Our job is to help everyone feel comfortable. His research also said that minority group members and majority group members have a different conceptualization of when a group is racially balanced. Minority group members are more likely to feel that a group is balanced when it's numerically even. 10 minority, 10 majority, it's balanced. Majority group members are more likely to feel that it's balanced, and therefore I'm comfortable as a member of the majority, when it mirrors the percentage of majority and minority where they live and where they work. So let's say a majority group members living in a community that's 80% majority and 20% minority in a therapy group, if there were 10 group members, and eight of them were majority and two were minority, most of the majority would say it's balanced. Why the difference? Think about it. In the real world outside of group therapy, people in minority groups, communities of color, tend to get more practice going into communities where they're in the minority, those communities where most of the jobs are, so they get more practice. The majority tend to get less practice in going into settings where they're in minority. So with that increased practice comes more comfort. And when I was reading his research, I was leading therapy groups with men called occurring disorders groups. What I noticed was that in my group, so there were like eight white males in the group and like two African American males, the white males would do most of the talking. And then the minute like three or four of the white males left the group, and two or three black men were added, then the black males would do most of the talking. Then I started noticing things like, if there were one Latino Hispanic in the group, often he wouldn't talk much. Then as soon as second or third was added, then they would talk even more in English and Spanish. I was noticing how people were talking in the group based upon race and their numbers in the group. So here's what's important. As the group therapist, you are the bridge. You have to be available to all. It's important early on to help those in the psychological minority feel more comfortable. And sometimes all that means is an occasional smile, a head nod and a glance, until they can get comfortable with the group. It's important to avoid tokenism, there's too much pressure on one person. I know with the adolescent males I work with, when you're gonna have girls in the group when there's at least two or three girls, too much pressure on one. Especially when you think about the percentage of girls who've experienced trauma at the hands of males. Be aware of how issues occurring in the larger society is affecting group process and be willing to talk about it. Like I'm not leading a group right now, but I really wonder what's the impact of police shootings on unarmed African Americans on trust in groups without multicultural membership. We should talk about it. I remember leading groups when the OJ verdict came in. White members were sitting on one side, black members on the other side, Latino members said they felt in the middle. Primarily all we had to do was talk about it. What we were seeing on television and how it was impacting relationships within our groups. So Amy, we wanna see at this time, are there any questions? I do not have any questions right now, but people should write in. I know that one person wrote in earlier, a little delayed response to one of your questions and said, Dr. Steven Kniffley has a manualized treatment on racial trauma and the black community, last name K-N-I-F-F-L-E-Y. So she was just giving that tip. That's excellent. Can you spell the name again? Yeah, first name is Steven, S-T-E-V-E-N, last name K-N-I-F-F-L-E-Y, has a manualized treatment on racial trauma and the black community. Perfect, thank you. So sometimes people are a little nervous to ask the first question. Who has a second question? We wanna hear from you. And while you think about questions, I have a question for you and you can put your response in chat. What I've learned over the years, and we've been together for such a short amount of time, it's not so much anything I teach, but it's more about the action that you take. So my question is, what's the action you're gonna take? Amy, can you still hear me? Hear you, no problem. Okay, so what's the action you're gonna take when this webinar is over as a result of the time that we spent together today? What's the action? So one person wrote in and said, do you have suggestions for facilitating these types of discussion with staff? Yes, you know, somewhere in, of course, you know, somewhere, so safety is really important, right? And somewhere in this webinar, I talked about these questions that individuals can ask themselves to develop more cultural humility, to see where they come from. I facilitated such discussions with staff. And the way you set the stage is that you, I tell people that we were all born innocent. There's all this racial tension in the world. And people try to get even through what they teach their kids about other people's kids. And we also live often in segregated ways and segregated spaces. And so sometimes when you're 25, 30 years old, and you wanna have these discussions, it's uncomfortable. So I always set the stage by saying, we're all innocent and we believe what we believe. We were taught certain things and which you give each other permission to make mistakes. And not have that perfect knowledge about these subject matters. And we have these discussions. You know, I work with one organization, they started having these discussions once a month. They were really struggling diversifying the staff. And the more comfortable they got with these discussions, the more diverse their staff became. To the point where their staff started to resemble the clients they were serving. So three people have written in what they're gonna do in response to what you said before. Oh, actually four, maybe four. I'm gonna go through a couple of them and then I'll let you know. So one person said, I'm gonna use feedback informed treatment approach. Another person said, I'm gonna review the slides to reinforce your presentation. Another person said, share information and slides with the team. See if there are providers that need support in this area. Another one, here's a really good one. I'm changing my initial questions of engagement. Yes. Another person said, I'm gonna utilize your strength-based questions into my intake at an inpatient mental hospital. We definitely in all capitals, overly focus on deficits with our population. Yeah, it's called grad school. Amy, I have one more little brief story for the group and then I'll turn it over to you. Sounds good. All right. So I imagine that some of you have seen like the sitcom, Monk. Monk is a walking DSM-5. In obsessive compulsive disorder, fear of heights, germs, dark rooms. He fears everything, yet he's the world's greatest private eye. I watched two episodes of Monk. The first episode I watched Monk was on the plane. He hadn't flown since he was nine years old. He's shaking in the air. He's so nervous. He's sitting near a salesman. When the plane landed, the salesman demanded his business card back. Luckily, Monk has his assistant, the world's greatest assistant. Everyone in the world can lose an assistant like Monk's assistant. The world thinks he's strange. She really understands Monk. Second episode, his brother called. The assistant answered the phone. Monk, you never told me you had a brother. Hang up. I haven't seen my brother in seven years. I haven't talked to my brother in seven years. Hang up. He'll stop calling. Three weeks went by and the brother never stopped calling. Finally, he called again. He said, there's an emergency. I need to see my brother Monk right away. And she dragged Monk over to his brother's house. And as soon as she met Monk's brother, she felt like she understood Monk better. The brother had a psychiatric condition called agoraphobia, the fear of the marketplace. He hadn't been outside in seven years. No wonder Monk hadn't seen his brother. The door was open. And being the charming person that she was, the assistant was leading the brother outside for the first time in seven years. And as soon as he saw daylight, he backed up and said, I can't go out there. And she whispered, you don't know this. But your brother Monk, he's scared all the time too. What does he have that you don't? And the brother looked at her and said, he has you and I don't. He has you. What separates the clients that you work with from the ones that you don't is the fact that the clients that you work with, they have you and that's a big deal. So in a seminar attended years ago by Dr. Carl Bell, a prominent African-American psychiatrist, he was asked whether or not psychoanalysis developed by Sigmund Freud in Vienna was culturally competent. And Dr. Bell stated, all clinical models are culturally competent in the hands of a culturally competent therapist. That's the big biography list, reference sources. That's how you reach me. If you're wondering why I have an AOL email address, I still have abandonment issues, that's why. Thank you so very much. Now turn things over to Amy. Thank you. Oh, Mark. Okay, thank you so much. It was such a great talk and I loved the story-based presentation. I'm going to ask some more questions in just a second. I wanna take a moment to let our audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download our app now at smiadvisor.org forward slash app. So if you have more questions, send them in. I've got a few more here for you, Mark. We have a couple, I can ask a couple of them. So one person said, what's the best way you found to work through your own feelings regarding current events when they differ from what the majority of the group feels when you're facilitating a group? What an important question like all the rest. So I'm a believer in like, you know, there are things that happen that really frustrate me, get me angry, et cetera. And I feel like that audiences that I work with and clients that I've worked with shouldn't have to own my anger, right? So what I found to be helpful is, you know, I have a handful of African American males that do the same work that I do. So periodically, we talk about what we're seeing and what we're experiencing. And we're able to work through it together so that when we're in groups, they don't have to be punished by our experiences. And I also likewise, you know, lately we've been talking a lot about implicit bias. We've been talking about privilege. I always encourage people to have, who feel like they experience privilege to get together with others who also feel like they experience privilege and work through it together. So I think we all need that type of a group, a supportive group, others who have similar experiences that we can work together on whatever those issues are, whatever those challenges are. Terrific, people are writing in that they have felt really moved by your talk today and that it was really good. And then just on the funny side, someone did admit that they also had an AOL account and that there's no shame in that. Yeah, you know what's interesting about that? You know, AOL, you know, you get all of those pop-ups, you know, people proposing marriages, it's not real, wanting to give you millions of dollars, but still, still hit. Terrific. So I don't have any more questions. So let me move through the last few points I wanted to make to the audience. If you have any follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health, Addiction, and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to select Next in the activity window to advance and complete the remaining course components, including an attendance attestation and a program evaluation. You must complete all course components before you will be able to claim credit. Please join us next week on December 11th, 2020, as Heather Gotham from Stanford University and the Network Coordinating Office of the Mental Health Technology Transfer Center presents How Implementation Science Can Help Solve Longstanding and New Challenges in Behavioral Health Service Delivery for Persons with Serious Mental Illness. Again, this free webinar will be December 11th, 2020 at noon Eastern time. Thank you so much, Mark, for your presentation today, and thank you all in the audience for joining us and participating. Until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question, and it is completely confidential and free to use. This service is available to you This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions. 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webinar

Dr. Amy Cohen

cultural competence

evidence-based practices

co-occurring disorders

feedback informed treatment

client engagement

cultural perspectives

group therapy

support systems