Systems, Stigma, and Substance Use: Where Prevention Begins

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Welcome to this edition of Psychology Explained by Dr.
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Curtis Peterson, who is trying to bring psychology
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alive for us all. All right,
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when we start looking at the different layers we need to take
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into account when individuals
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come in contact with different systems that
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can help them slow their use.
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Again, we're talking about people who are at
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that point that if it goes on much longer,
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it will kind of go over into the disorder category
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and become a full substance abuse addiction.
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Okay. And so when we look at many of these places,
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we often can look at it in the healthcare setting, the school
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setting, I can't remember who
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mentioned even the work setting. So what
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is kind of some of the necessary things that could be put in
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place in order to make
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it so individuals are more comfortable and more self-efficacious,
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have that self-efficacy that they can change? Okay.
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And of course, we can look at this from a
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systems approach. I think any of my students
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in here that are my social work
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crew, this kind of thing looks pretty
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familiar. So we can look at things like immediate
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encounters. So that's a patient at the clinic or a clinician And
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things such as language, language tone, privacy time,
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all of those things at that immediate contact level
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matter. But if we just stop there,
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we miss a larger picture such as who are the care
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team when we encounter someone who may have substance
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use issues? What community partners or who do I have in
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my organization that can help respond
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or deliver services. So when
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we talk about this, we talk about the physician,
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psychologists, social workers, pharmacists, and peers.
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Now, there's not very many, if you think
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of the primary care doctor place,
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there's not very many organizations that have
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all of these in one place. I think here in Tucson,
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I can think of the El Rio system,
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but beyond that, maybe the Banner system,
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but not many clinics really have this full
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second circle. So, it's about creating community partners.
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The organization itself, its scheduling rules,
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staffing, billing, electronic records,
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making them easily understandable and easily accessible.
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On the community level, if we're looking at community level at the prevention
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end, it's just not putting flyers on posts or PSAs
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on TV. We have to look closely at the
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ability for transportation and mobility.
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When treatment access and treatment capacity for
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those individuals who really need more
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intense intervention at the beginning phases of addiction.
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We also have to look at local norms. I mean, what is
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the attitude towards substance use?
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And then recovery support systems that
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really are there at the community level
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and accessible at the community level.
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And then beyond that, we have then the policy environment
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where a lot of our public health individuals really look. So this
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is consent rules, insurance coverage,
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prescribing regulations, all of those things that can
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then come down to the immediate level and
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assist the clinician in the center with
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being able to secure things like privacy.
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Okay, and then at the last level,
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and many of you kind of have
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alluded to this, is the life course context,
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is the developmental stage and age that they're
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at, their identity, culture, and prior institutional
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experience are all very important.
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And we have, we have talked about this, that most prevention programs
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occur at the child and adolescent level.
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At the child and adolescent level, maybe some in the
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young adulthood or emerging adulthood, But there
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seems to be a large need or a lack
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of when we get into adulthood and even later
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adulthood, where we actually are seeing
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higher and higher rates of substance use,
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substance abuse, and substance disorder.
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So while it's, it's good that we
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have these things for the youth, We're not actually focusing
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on the high-need population within
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our culture. And what does that look like?
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It's not the same to deliver a program
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to an adolescent than it is to a 50-year-old, for example.
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And as this kind of says, healthcare has reached
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legitimacy and clinical capacity,
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but contact alone is not prevention. A question asked,
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Without privacy produces silence. Okay.
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So I do want to talk a little bit about health psychology design
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intervention across healthcare systems. Um,
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I actually teach health psychology once in a while
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for, for another university, and it is really
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about looking at, um,
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healthcare and treatment
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and all of those and prevention from a
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psychological perspective. And it
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gives a helpful framework
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when we're looking at what should we do with all these
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systems and whatnot. So, in the next module,
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we're going to look at research and policy.
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So, we're gonna look at how do we develop a program that
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then we can say works, not based on the number
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of participants who show up, but based upon
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the efficacy of whatever program or
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system change we put in place.
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Okay, and it does
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policy analysis, and what it tries to do is address structural
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barriers to access. Okay, on the community,
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this is partnerships with schools, pharmacies, and recovery organizations
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to make care responsible— responsive to
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local conditions. So this is saying, what are the
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systems in the community? Are they communicating together?
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And how is
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it kind of on that kind of cultural level, How,
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what are the attitudes behind individuals who
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use substances? And if necessary,
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what are some ways that those attitudes and beliefs can be
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changed or influenced?
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And then on the organizational level, this is of course looking at
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workflow, referral pathways, measurements,
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staff training to make sure that it turns isolated
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practice into a reliable routine method
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of care. Again, one of the things that we've talked,
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I think we've talked about in this class is predictability
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is really important, especially when individuals who
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have substance use issues
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live in a constant chaotic or
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environmentally deprived situation,
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may have other issues, legal issues or
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relationship issues. And one
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thing that can help bring them closer to
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where they want to be is having somewhere they
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can go that is predictable and it's consistent,
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that the level of care is always there every time
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the individual walks through the
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door, okay? Then the next level that
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is looked at in this field is what are known as clinical teams.
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This is consultation, shared formulations,
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communication, coaching, stigma reduction,
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and this is really to prevent contradictory or
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shaming messages. So, this is where
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the medical prevention— medical professional
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conveys what they do, how they conceptualize
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it. The treatment teams come in and say, this is
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what we look for, this is how we assess and treat.
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And then the preventionists are there saying, this is the
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way we should formulate this together to create a
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consistent message across the different
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systems, okay? And then
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the patient and the family, this is where we do, where they
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do brief assessments, motivational conversations,
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coping, sleep pain skills, collaborative safety planning.
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And really what we're trying to do at this level again is to reduce
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immediate risk and strengthen self-regulation. Okay,
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and so we'll go through each of these and kind
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of dismantle them. The video mentioned at
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this patient level that brief intervention technique,
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which we will look at, that really is trying to
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really kind of get to what are the core things that the
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person needs to have in place to then
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start that healing process.
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So, what we're trying to do, the video mentioned
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the biopsychosocial model and then the ecological identity
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model. And I'll express
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this just like the video did. The biopsychosocial is kind of
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the gold standard in the field of counseling,
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psychology, the medical field,
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within areas of social work, within areas
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of addiction treatment.
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And if you can kind of guess, it kind of maps
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the biological, psychological, and social influences that
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are contributing to either a person's diabetes
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or a person's addictions.
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Okay. And it does a— and, you know, if we do go through
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these processes and look at the person more of this holistic way,
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it has very specific value.
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However, the thing that the biopsychosocial
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model kind of stops at is locating
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those influences within a nested ecological
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system and developmental timeline. What's meant by that is
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we can understand the social influences on the individual,
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the psychological and the biological,
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but if we don't know what the person is experiencing
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when they're at the clinic versus
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when they're at home versus when they're at school,
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we can be missing a whole bundle of information
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where that the biopsychosocial model may not
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capture. Um, and the basic
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idea behind this is, is that we behave differently based
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on the ecological condition we're in, or the environment,
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situation, place, and whatnot. And, you know,
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to put this simply, I'm assuming I'm
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assuming I can't see you because this is Zoom. I'm not
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on campus today, so I can't see my 2 on-campus students.
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But I'm assuming that if I was watching you take this class,
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you're acting much different than if you were at
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a party somewhere.
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Um, I wish this class was a party. But the point
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being is we act differently and we can express different things,
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but it's dependent upon the situation, place,
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location, people around us.
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And so in the, in the case of Roger,
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for example, you know, we could identify his social
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influences, right, between his family, school,
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and peers. His psychological
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influences, his anxiety and not being able to sleep,
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and his biological issues,
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the need to use that substance to
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manage his symptomology.
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And so even he sees that, yes, based on
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that, I need help. Okay.
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But him willing and able to seek
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that help and be open for that help really
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depends on the situation that he is in.
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Okay, and that's the EIM extension.
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So this goes to how does the person understand the situation?
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This examines things like cognitions, emotions,
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and behaviors. And then we need
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to include examining how their identity is being appraised,
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The threat of losing belonging,
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or in the issues that centered around
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rejection. Do they feel safe? And do they feel this
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is a credible situation? And when I say credible,
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we usually go to the doctor, right? And we say, okay,
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the doctor is the expert. He has, he or
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she or them have credibility
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because they've gone through medical school, they've practiced
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for a long time. But the credibility comes in the whole
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entire system, meaning how did the receptionist
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respond and act? How did the nurse respond and
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act? And all of those have to provide levels
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of credibility in order for someone to feel like
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they can be open, okay?
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Why might action be difficult? Again, in the biopsychosocial
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model, we're gonna look, we'll look at symptoms, skills, and stressors,
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and social barriers. But then on the prevention end,
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on the extension end, we need to see
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what are the ecological costs, what are the cross
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pressures, the messages they're receiving from different people
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in their life. And again, what that video went to,
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realistic choice isn't necessarily,
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I can't handle my substance use,
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therefore I need help. When we talk about realistic
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choice, this situation is
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going to stigmatize me, or it may,
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it's treating me like poorly, or I
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might lose some of my identity and people around
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me. And so to preserve those things,
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the realistic choice in that situation is
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to deny my substance use, as the
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video kind of took us through.
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And then we look at what changes behavior. So this combines biological,
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behavioral, and social interventions. Again, I use diabetes
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as a good example. So the diabetic takes their
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medication, they change their eating
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habits behaviorally, and hopefully maybe start exercising
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more. And in social situations,
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they may not eat to avoid— they might not
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eat to avoid social interactions.
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Emotional type of eating tends to center around social interactions.
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And so we look at all those things, but then we need to
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look again from a prevention perspective, is the
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changes in conditions, meanings, and costs of
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a protective action. Okay,
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meaning what does it mean if I have to stop using
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substance And even though it
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may be fake, it may be not
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good for me, what does that mean if I need to
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stop hanging around people who validate
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me? And when I'm around them, they think I'm cool or
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that I'm funny or I'm this or that.
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What does it mean to give up that in order to
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not use my substance or lower the risk
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of me using a substance. Okay,
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so all of these kinds of things need to be taken
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into consideration.
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And we'll end with this part right here for today.
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Is the other thing that we need to kind of keep
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in mind is this isn't a linear thing that a person,
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if they're feel safe, they feel secure, they feel like
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they can maintain their identity and
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who they are, they'll go to the next step to admitting
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to what their problem is, to the next step
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to an intervention, and so on. This is more of a
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circular thing, okay? So we start with the
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ecological condition. Where is the conversation
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going to happen? Who is present and what are the rules
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that exist? So again, that's where we go to mainly
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the healthcare setting is that this is a
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place where more than likely someone will,
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can have a conversation that they feel
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like they're getting, they're excessively using substances
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and they're starting to not be able to function without it. The healthcare
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location is one of the ultimate places where that conversation
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can happen. So in that, we have
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to consider who's having those conversations and
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who's gonna be there and what rules protect
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me or not. And then we need to step
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2 where we go through identity appraisal. What does the encounter say
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about who I am? And how a clinician sees
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me. And so this
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is where we kind of state, if I admit this,
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how are they going to respond? Are they going to go,
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going to do the whole individual willpower,
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you can do it BS? Or are they
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going to be there and be supportive and not force
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me to all of a sudden be
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someone that I'm not? Okay. And then the regulatory
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signals. Does this evoke a threat of shame,
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trust, curiosity, or belonging?
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What are the cross pressures? So when we talk about cross pressure,
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this is where we're getting mixed signals from different
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parts of our social system. So, for example,
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in the treatment setting,
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a relapse is seen as— in
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the cognitive behavioral therapy relapse,
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a relapse is not seen as a failure.
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It is seen as a misjudgment
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or a a mistake or something.
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It's something that is repairable.
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Okay. But in certain
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religious communities, not all, but in certain religious
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communities, a relapse would be something that you sinned.
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You need to go ask for forgiveness. You did something bad.
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You're a bad person. So now let's say the person is going
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through treatment. They're receiving cross-pressure
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from 2 different ways of thinking about
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their relapse. Okay, that cross-pressure
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then can create identity appraisal,
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identity alignment issues, and they
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might drop the relapse prevention because it
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doesn't align with their religious belief. Or they
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might give up that identity about themselves
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in their spirituality and faith and
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go with the relapse prevention technique.
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So there's gonna be a loss in that kind of situation either
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way. And so how do we as communities
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and systems reduce that potential?
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Okay, and this is where we get into calibration
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and behavior. Does the person disclose, minimize, or avoid, or try
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a new action? And then this is where the feedback come
24:03.981 --> 24:07.642
in. How does the system respond? What does that teach the
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person about future help-seeking? Because again,
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if we do it wrong, they're simply not gonna go and
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get help when they need it. If we do it right,
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they'll have more trust. They can retain who they are as
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an individual and get help. Okay.
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All right. I think that was a
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little bit of overload for today. So when
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we come back on Thursday, we'll talk about things like non-compliance
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and adherence. And continue this conversation.
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But I'm going to stop my sharing and stop.
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Thank you for joining us for this Psychology Explained.
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I hope you'll join us in later episodes where we can— we'll continue
24:59.388 --> 25:02.713
to investigate the human mind and psychology.