Women with Substance Use Disorders

Transcription

1 Women with Substance Use Disorders Anne Helene Skinstad, PhD Behavioral Health is Essential to Health Prevention Works Treatment is Effective People Recover American Indian & Alaska Native Behavioral Health Webinar Series This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT). For more information on the ATTC Network, visit: attcnetwork.org To find your regional center, visit: attcnetwork.org/findregcenter.asp For more information on the National American Indian & Alaska Native ATTC, visit: attcnetwork.org/americanindian, or call

2 Upcoming webinars from the National American Indian & Alaska Native ATTC Mental and Behavioral Health Considerations for Native Transgender People presented by: Michaela Grey, MPH Diné Clinical Supervision with Cultural Considerations presented by: Robert Rohret, MPH, and Sean A. Bear, BA, Meskwaki Tribal Nation Clinical Evaluation: Treatment Planning presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe Referral, Service Coordination, & Documentation presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe For more information about our webinar series, contact Kate Thrams at or Continuing Education Hours (CEH) Webinar Follow-Up CEHs are available upon request for $15 per session. This session has been approved for 1.0 CEH s by: NAADAC: The National American Indian & Alaska Native ATTC is a NAADAC (The Association for Addiction Professionals) certified educational provider, and this webinar has been pre-approved for 1.0 CEH. To obtain CEHs for this session, submit a CEH Request Form and payment to the National AI & AN ATTC. A request form is available for download in the Files pod in the webinar screen. If you choose to download a file, a new tab will be opened in your browser, and you will have to click on the webinar window to return to view the webinar. Participants are responsible for submitting state specific requests under the guidelines of their individual state. Presentation handouts: A handout of this slideshow presentation is also available by download. If you are unable to download the documents from the webinar, please contact Kate Thrams at kate-thrams@uiowa.edu or

3 Webinar Follow-Up Evaluation: SAMHSA s GPRA This webinar is provided by the National American Indian & Alaska Native ATTC, a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT), and is evaluated in accordance with the Government Performance and Results Act (GPRA). Participation in our evaluation lets SAMHSA know: How many people attended our webinar How satisfied you are with our webinar How useful our webinars are to you Immediately following this webinar, you will be redirected to a customer satisfaction survey. Please take a few minutes to give us your feedback on this webinar.. You can skip any questions that you do not want to answer, and your participation in this survey is voluntary. Through the use of a coding system, your responses will be kept confidential and it will not be possible to link your responses to you. We appreciate your response and look forward to hearing from you. Participation instructions: To alternate between full screen mode, please click on the full screen button on the top right of the presentation pod. (It looks like 4 arrows pointing out) To ask questions or share comments, please type them into the Q&A pod and hit Enter. Adobe Connect Overview 3

4 Adobe Connect Overview Please note: The webinar system records participant attention time. If you have other windows open and active, or have the webinar minimized, the system will deem you as inattentive, which may be reflected in the number of CEHs received. Disclaimer Please note: The National American Indian & Alaska Native Addiction Technology Transfer Center is supported by a grant from SAMHSA The content of this publication does not necessarily reflect the views or policies of SAMHSA or the Department of Health and Human Services (HHS). 4

5 Today s Speaker Anne Helene Skinstad, PhD, is a clinical psychologist who has worked with women with substance use disorders for many years. Through her work both in Norway and the US, her commitment to human rights, always strong, has grown stronger. She has also worked with the Native American Tribal communities in the upper Midwest since 1998 and now American Indian and Alaska Native treatment providers across the country to enhance their skills in providing evidence-based and experience-based treatment, with a special eye on the fact that this population has a right, by law, to receive culturally informed behavioral treatment. Through her work with Native American Tribal communities, Dr. Skinstad has learned the best and most innovative solutions are developed by the communities themselves and often a return to traditions. Women with Substance Use Disorders: What Do We Know and How Can We Help them? Anne Helene Skinstad, PhD Program Director: National American Indian and Alaska Native ATTC Co-Director: Center of Excellence on Racial and Ethnic Minority Young Men Who have Sex with Men and Other LGBT Populations (YMSM+LGBT) Clinical Associate Professor, Department of Community and Behavioral Health, University of Iowa College of Public Health Behavioral Health is Essential to Health Prevention Works Treatment is Effective People Recover 5

6 Overview of the Presentation Stigma: Once-upon-a-time Culture around drinking Standards for light moderate and heavy drinking Prevalence data Adolescents Adult women and women of childbearing age Older women Sexual minority women Co occurring disorders Etiology Prevention Early intervention Employee assistance programs (EAP) Treatment Assessment issues Treatment approaches New directions Once-upon-a-time 6

7 Once upon a Time... Stigma Treatment of substance use disorders (SUDs) in women has been burdened by a history of stigmatization of women with substance use disorders. For many years, clinicians believed there were few differences between men s and women s treatment needs. Research on women with SUDs has been hampered by the inclusion of too few women in treatment and too few in research samples (Nathan & Skinstad, 1987). Views on Drinking by Women in Diverse Cultures The way we treat women with SUDs in the US and Europe is not necessarily the way women are treated in other parts of the world. Cultural differences Other cultures may not view substance use disorders as we do. More or less stigma associated with substance use in women Level of assimilation influence drinking patterns Traditional Living bicultural living assimilated living 7

8 History of Drinking by Women Historically, women have a lower alcohol consumption rate than men. Talmud (about 200 AC): One cup of wine is good for women Two cups of wine are demeaning Three cups of wine make her behave like an immoral women, and Four cups of wine makes her lose all self-respect and shame Once upon a Time (Cont.) Evolving treatment approaches for women from 1960 to the present (Grella, 2008): 1960s - Generic treatment Men s needs were the model for how women s needs were to be understood. 1970s - Gender differences A focus on biological, psychosocial and parenting issues 1980s - Gender specific Separate treatment facilities, special groups or services, child-care or child live-in 1990s-2000s - Gender responsive Trauma informed, strength based, relational theory 2010 and beyond - Gender and Culturally informed treatment (Skinstad, 2015) 8

9 Standards for light, moderate and heavy drinking by women Moderate and Heavy Drinking Binge drinking (Wechsler s 1993 definition): For women: four or more drinks in one sitting For men: five or more drinks in one sitting Moderate drinking by women: 4 9 drinks per week Heavy drinking by women: 10 or more drinks per week 9

10 Alcohol Equivalencies and Drinking = = = 1 glass of wine 4 oz. of table wine 12% alcohol by volume 4 x 0.12 = 0.48 oz. of ethyl alcohol per serving 1 can or bottle of beer 12 oz. of beer 4% alcohol by volume 12 x 0.04 = 0.48 oz. of ethyl alcohol per serving 1 shot glass with distilled spirits 1.25 oz. of whiskey or other hard liquor 40% alcohol by volume or 80 proof 1.25 x 0.40 = 0.50 oz. of ethyl alcohol per serving 1 bottle of wine cooler 12 oz. of wine cooler 4% alcohol by volume 4 x 0.12 = 0.48 oz. of ethyl alcohol per serving Prevalence of substance use disorders across the lifespan 10

11 Lifespan Issues in Substance Use Adolescence Early onset use of alcohol (before 13 years of age) is significantly more often reported in boys (34.2%) than in girls (24.2%). This gender difference has decreased in recent years. Early onset predicts later dependence on alcohol in both boys and girls. High novelty-seeking behavior in boys predicts early onset alcohol abuse Sexual abuse in childhood is the strongest predictor of chronicity and dependence in girls. Lifespan Issues in Substance Use (Cont.) Adolescence (cont.) Physical changes, hormonal changes, neurological changes affect substance use. Pre-frontal cortex is involved in goal-directed behavior and emotional processing. The amygdala also undergoes major changes during adolescence. It mediates emotional reactions and response to stress. The hippocampus controls learning and memory; it shows shrinkage in adolescents with alcohol use disorders. Maturation in girls is associated with depression, low self-esteem, and increased risk taking. Early maturation put some girls at risk Adolescent girls perceive events as more stressful than boys. Adolescents show a changed sensitivity and tolerance to alcohol. Chronic alcohol and drug use in adolescents can disrupt developmental changes in hormone levels in both males and females. 11

12 Lifespan Issues in Substance Use (Cont.) Prevalence of alcohol use in women of child-bearing age: Moderate drinking by women National average: 15% Heavy drinking by women National Average: 5.5% Native women: Difficult to estimate level of drinking Important to remember: Large percentage of Native women are abstinenent from alcohol Lifespan Issues in Substance Use (Cont.) Adult women and women of childbearing age Worldwide prevalence: Men generally consume more alcohol than women; these consumption rates vary from culture to culture. Marriage and aging reduce drinking by women and men. Depression predicts increases in drinking by women but not by men. Illicit substance abuse in expectant mothers, including cocaine, heroin, marijuana, stimulants, hallucinogens, and non-medical use of prescription medication: Prevalence 1.9% 12

13 Lifespan Issues in Substance Use (Cont.) Older women: 65 years and older Prevalence of problem drinking among older adults: from 1 to 15% Prevalence of problem drinking among older women: from 1 to 8% Prescription drug use in older women on the rise Rates of illicit drug use among older women are low. Low prevalence of recreational drug use Higher rates of drug use for medical reasons Lifespan Issues in Substance Use (Cont.) Older women: 65 years and older (cont.) Tolerance for alcohol decreases with age. Older women increased sensitivity to alcohol and a higher risk for alcohol problems. Older women heightened response to over-the-counter and prescription medications. Use and misuse of alcohol and medication is especially risky for older women. Older women More likely to be prescribed benzodiazepine, barbiturates, and antidepressants. 13

14 Lifespan Issues in Substance Use (Cont.) Older women: 65 years and older (cont.) Risks of drinking by women by consumption level Low risk drinking: Fewer than 7 drinks a week At-risk drinking: More than 1 drink a day Risk factors for alcohol use in older women Regularly use of alcohol will lead to 2.2 times more likely to have impairment in activities of daily living. Increased rate of depression; combining anti-depressants and alcohol is risky. More research is needed to better understand the health consequences of different alcohol use patterns in women. Lesbian and bisexual women Sexual minority women 14

15 Sexual Minority Women and Behavioral Health Issues Mental health issues reported by lesbian women as compared to heterosexual women: Punitive and traumatic reactions in childhood more often predispose to mental health and substance use issues. Sexual orientation is associated with higher level of emotional stress. Lesbian women report more depression, phobias, and PTSD. Lesbian and bisexual women consult their primary care physicians more often about mental health disorders. However, they usually do not want to discuss sexual orientation with their primary care physician. Lesbian women who are out of the closet are 2 to 2.5 times more likely to experience suicidal ideation Lesbian women who are not out of the closet are more likely to attempt suicide. The coming out process needs to be taken very seriously by providers. Providers need to offer resources and support to clients in the coming out process Some Ways to Help Sexual Minority Women Suggestions on the individual level: Address possible victimization issues. Address the coming out process. Address resources and supportive networks: chosen family as compared to family of origin Be sensitive to their needs for privacy. Suggestions on an agency level, to make the agency LGBT-affirming Address physical surroundings. Address procedures. Choose LGBT-sensitive assessment, prevention and treatment approaches. Provide cultural sensitivity training for staff. Work with collaborators to ensure they provide LGBT affirming services. 15

16 Native LGBTQ/Two-Spirit Holistic Health Challenges Sexual Abuse Trauma Alcohol & Substance abuse Ostracized Disowned from family HIV/AIDS dx Mental Spiritual Emotional Physical Homophobia Discrimination Shame Homelessness Intimate Partner Violence Clinic distrust Suicide Violence Minority Stress Chronic Illness Distrust of Authority 16

17 HIV/AIDS: AI/AN men and women had the highest percentages of HIV acquisition through injection drug use (IDU) or IDU related behavior 18.6% men and 28.9% women Rate of new infections per 100,000 in 2012: 9.9 AI/AN The number of people diagnosed with HIV increased between 2011 and 2012: 20.6% - AI/AN * This is the largest percent increases of new HIV infections among all reported races and ethnicities CDC, 2012 Transmission Categories Among American Indian/Alaskan Native Males Living with HIV, 2012* 15, 8% 16, 9% 19, 10% MSM MSM/IDU IDU Heterosexual 132, 73% *These charts contain data through the end of 2012 is from CDC s latest surveillance report (2012) containing data from 50 states and 6 dependent areas. 17

18 Transmission Categories Among American Indian/Alaskan Native Females Living with HIV, 2012* 13, 29% Heterosexual IDU 32, 71% *These charts contain data through the end of 2012 is from CDC s latest surveillance report (2012) containing data from 50 states and 6 dependent areas. Co-occurring disorders in women 18

19 Co-occurring Addictive Disorders Alcohol dependent women often experience cooccurring other substance dependence. The most frequently abused substances in addition to alcohol include: Illicit substances Marijuana Stimulants Opioids Prescription drug abuse Benzodiazepines Barbiturates Opiates Co-occurring Mental Health Disorders Women with substance dependence have a significantly higher prevalence of mental health disorders Anxiety disorders Post traumatic stress disorders Phobic disorders Mood disorders Major depression Dysthymic disorder Bipolar disorder 19

20 Co-occurring Physical Disorders Telescopic development of substance use disorders in women More rapid development of substance dependence than men. Women metabolize alcohol differently and more slowly than men. Women achieve higher blood alcohol concentrations over shorter periods of time than men. Because of differences in the metabolism of alcohol, the consequences of abuse are more severe for women than for men. Higher prevalence of liver disorders than men. Co-occurring Physical Disorders in (Cont.) Higher prevalence of osteoporosis in women with SUD than women without SUD. Higher prevalence of certain forms of cancer than among non-abusing women. Breast cancer Cancers of the oral pathways, throat and neck Cancer of the digestive tract Dental care for substance abusing women is typically limited Especially among methamphetamine-abusing women 20

21 Co-occuring Physical Disorders (Cont.) Change in weight dependent on substance of abuse Reproductive Health issues Sterility Menstrual disturbances Amenorrhea (absence of menstrual cycle) Early natural menopause Moderate use of alcohol has a positive effect on estrogen levels in post-menopausal women Early aging Fetal Alcohol Spectrum Disorder (FASD) Native Americans have some of the highest rates of fetal alcohol spectrum disorders in the Nation. Among some tribes, the rates are as high as 1.5 to 2.5 per 1,000 live births. Issues that influence women s tendency to drink during pregnancy and the development of FASD in the child are: Oppression, Displacement, and loss of self-determination. Trauma. Poverty and inadequate access to health care 21

22 Etiology Socio-economic Issues AI & AN populations have some of the highest prevalence of substance abuse/dependence in the country State/ regional differences and tribal difference in prevalence of substance use disorder Community characteristics High prevalence of abuse Violent communities Family issues Dysfunctional family situation Domestic violence 22

23 Antecedents of Substance Abuse in Women Antecedents of alcohol and substance abuse: Genetic predisposition Transmission of genetic risk factors across genders is less strong than within genders Environmental factors Mother s drinking pattern is often modeled by her daughter. Close relationship to a sibling with a substance use disorder is a risk factor. Sexual and physical abuse are the strongest predictors of early onset and chronic substance dependence in women. Change in roles, or loss thereof, increases women s abuse of substances. What do we know about Women who Abuse Substances? Childhood Adolescence Young Adulthood Antecedents to substance abuse in women (Gomberg s model 1984) Biological/ genetic Personality Socio-cultural Drinking/drug behavior Positive family history Irritability, tantrums, nervousness SES, neighborhood, region, family norms Of parents, sibs, relatives Menses, pregnancies Impulse control problem School, peers, religious group Early use of alcohol, marijuana, nicotine Metabolism of alcohol/gynecological and obstetrical events Depression, inadequate coping mechanisms Availability, user who is a significant other Social contexts of drug/alcohol use 23

24 Prevention Prevention Programs for Women Recent CASA at Columbia University NYC study conclusion: Unisex prevention programs do not work for women. Selective prevention programs: Focused on adolescent girls at high risk because they were victims of sexual or physical abuse. Indicated prevention programs: Focused on girls who are starting to develop problems with substances. 24

25 What Kind of Selective Prevention Programs do they Receive? Pregnant women: Prevent the development of FASD Prevent use of tobacco products during pregnancy Prevent use of illicit substance use Parent and family programs Visiting nurse program Parenting skills program Cradle Rockers Partners in Parenting Families and Schools Together On What should Prevention Programs Focus? Female adolescents and women with psychiatric disorders: Depression, anxiety disorders, PTSD Women who abuse tobacco or alcohol, or have drug use disorders Girls with substance-abusing mothers Skill-based prevention programs Enhance problem solving skills Enhance self-esteem Prevention programs at work: Employee Assistance Programs (EAP) 25

26 With Whom will She Discuss her Concerns? Primary care physician Medicine men/women/clergy or spiritual leader Anonymous phone lines, such as a crisis hotline Early Intervention 26

27 Early Intervention Primary care, less stigmatizing Motivational interviewing, Non-confrontational approach Screening, using screening tools normed for women Advice and feedback of gender-specific information on alcoholrelated risks should be incorporated into brief interventions. Referral, if necessary Older women respond quite well to intervention in primary care Emergency rooms and the use of teachable moments Post rape victims or victims of assaults/domestic violence Women who have attempted suicide. Women who are depressed Early Intervention Home visiting nurse programs (Dr. Olds) First time mothers Low income mothers Over two years Feeling overwhelmed Results Enhanced mothering skills. Enhanced problem-solving skills. Significantly reduced mothers use of substances over two years. Children older than 12 years, used fewer substances and were less likely to report feelings of depression and anxiety 27

28 Peer Support programs Paraprofessionals deliver home visit intervention with American Indian teen mothers and their children Four tribal communities in the south west High rates of substance abuse (84%) High rates of depressive symptoms (32%) Drop out of school (57%) Residential instability (51%) Greater knowledge of parenting Parental locus of control Intervention Family Spirit Intervention and optimal standard care compared with optimal standard of care alone Family Spirit Interventionist, family health educators Delivered lessons in the teen s home Evaluated over a 36 month period Positive results both for teen mother and her child 28

29 Results Fewer depressive symptoms Lower past month use of marijuana and illicit drugs Children in the intervention group were better adjusted in school and in the home Employee Assistance Programs (EAP) EAP programs: Programs offered in tribal casinos Less stigmatizing for women Easier to combine with work and family Use of prevention programs in the workplace should focus on: Health promotion Social health promotion (team awareness training) Brief intervention Changing work environment 29

30 Assessment and Treatment Assessment Issues Attitudes toward assessment of substance use disorders in women Nonjudgmental attitude Assessment strategies need to be gender sensitive, as well as affirming for lesbian/bisexual identified women. Assessment strategies need to be sensitive to the culture the woman comes from. To-Be-For-Others Women often have not had time to think about themselves, so focusing on their own needs may be a challenge for them. 30

31 Assessment Issues (continued) Assessment strategies need to be focused on sensitivity towards the traumas the women have experienced. Assessment strategies need to be focused on the woman s strength. Assessment strategies also need to focus on the woman s stress level and how she chooses to cope with stress Assessor needs to: Respect and support her dignity Expect not to get all information the first time asked Expect to find co-occurring mental health issues Expect to find concerns for her children or dependent others Assessment Issues (continued) Screening tools for women, developed for pregnant women TWEAK T-ACE Addiction severity index Adapted for use with women Adapted for us with AI & AN Screening, Brief Intervention and Referral (SBIRT) Screening and Brief Intervention (SBI) 31

32 Treatment of behavioral health disorders in native women Treatment of AI & AN Women Content of treatment Understand the process of substance abuse and mental health issues Understand chronic disease like SUD and MH Reduce feelings of shame Enhance self-esteem Trauma informed care Relapse prevention in combination with mindfulness training Lifestyle modification/ Healthy Living Feeling empathy from the staff Parenting 32

33 Empirically supported treatment Psycho-social treatments: Motivational Interviewing Motivational Enhancement Therapy Motivational Incentive Therapy Cognitive Behavioral interventions Social skills training Developing social skills and assertiveness Relapse prevention Community Reinforcement treatment Assist with family, job related and legal problems, social clubs (buddies system) with alternatives to drinking, use of antabuse Behavioral marital therapy: Ïmproving the relationship and resolving marital conflicts and problems Treatment (con.) Gender sensitive substance abuse treatment services crucial for positive treatment outcome Structure: Feeling safe in gender specific programs Access to transportation Supportive family/significant others Single-gender group treatment Single-gender treatment program 33

34 Treatment Issues Multidimensional Stages of Change Model (Brown et al. 2000) Steps of change model, influencing the woman s ability to enter into treatment: Background and demographics Readiness to change domestic violence situation Readiness to change sex risk behaviors Readiness to change substance abuse behaviors Readiness to deal with emotional problems Treatment Issues (Cont.) Brown et al (2000) Women do not have a generalized readiness to change but they have multiple needs and pressures that they need to consider. Immediacy readiness to change in some areas and not in others (safety and saliency). Motivation to change is dependent on how well the provider is able to work with the woman s immediate needs before she enters treatment. 34

35 Therapeutic Strategies in Working with Women Fingeld-Connett, Bloom, & Johnson (2012) Metasynthetic approach; identified therapeutic strategies for helping homeless women: Use of careful assessment Show a caring attitude. Personalized structure and control Development of interpersonal trust Instilling hope Targeted use of psychotherapeutic agents and counseling. Comprehensive Approach to Treatment of Women Comprehensive approach, including case management, important for success in treating women. Recovery oriented care Use of peer support specialists Focus on her immediate issues. Wellness perspective for her and her family Consider mental and physical health Consider nutritional issues Consider exercise Treatment of nicotine addiction Women s subjective rating of nicotine addiction is significantly higher than men's. Women need support to quit smoking, through psycho-social treatment, nicotine replacement, anti-depressants. 35

36 Comprehensive Approach to Treatment of Women (Cont.) Family and definition of family Chosen family as compared to family of origin Partners as opposed to husband Cultural issues Spiritual issues Native American women s spiritual needs Engage with spiritual leaders in the community Emirically supported pharmacological treatments Nicotine Dependence: Nicotine patch, Bupropin Women: Nicotine patch and SSRIs Alcohol Dependence: Oral disulfiram (antabuse) Selective Seretonine Reuptake Inhibitors (SSRI) Buspirone Acamprosate Opioid Antagonists: Naltraxone, Nalmefene 36

37 Other emirically supported pharmacological treatments (O Brian & McKay, 2000) Cocaine Antidepressants, Tricyclic antidepressants Methamphetamine None to date Opiates Methadone Maintainance Buprenorphine (partial opiat agonists) Naltraxone Nalaxone for acute opiod intoxication/overdose SAMHSA publication 37

38 Other SAMHSA Publications Treatment Improvement Protocols (TIPs) TIP 42: Substance Abuse Treatment for Persons with Cooccurring Disorders TIP 51: Substance Abuse treatment: Addressing Specific Needs of Women TIP 53: Managing Chronic Pain in Patients with or in Recovery from Substance Use Disorders TIP 57: Trauma Informed Care in Behavioral Health Services TIP 58: Address Fetal Alcohol Spectrum Disorders (FASD) New Directions? 38

39 Healthy Women: Healthy Lives - Overview of the Sessions Science of substance abuse Wellness 2a and 2b Recreation and hobbies Food and nutrition Physical activities and fitness Sexuality Mental health Social support networks Parenting Childrens health issues Sustaining a healthy lifestyle Relapse prevention Healthy Women Healthy Lives Developed an addendum to the curriculum explaining implementation with NA women w/ Substance use disorder Recovery Oriented Care is at the core of this curriculum Mental and Physical Health Diet and nutrition Exercise 39

40 Hand-in Hand Psycho-educational group program for women with co-occurring disorders Implements an integrated treatment approach 13 week program includes the following: Introductory Session Communication Skills Family Relationships Mental Health Promotion Substance Abuse Continuum Post Traumatic Stress Disorder (PTSD) Depression Bipolar Disorder Schizophrenia Eating Disorders Relapse Prevention Anxiety Grief Acknowledgements Kate Thrams, BA Research Support Coordinator and Graphic Designer Jenny Gringer Richards. MSW Coordinator of Evaluation and Curriculum Development National American Indian and Alaska Native ATTC 40

41 Contact information Anne Helene Skinstad, Ph.D. Associate Professor: Department of Community and Behavioral Health Program Director: National American Indian and Alaska Native ATTC Co-Program Director: Center of Excellence in Racial and Ethnic Minority YMSM and Other LGBT Populations University of Iowa College of Public Health Can I answer your questions? 41

42 Questions and Discussion Please type your questions or comments for the presenter in the Q&A pod at this time Follow-up Within the next 24 hours, you will receive an from the National AI & AN ATTC which will include: Link to the recording of this webinar Link to the survey in case you were unable to access it Handouts of the presentation CEH request form We appreciate your participation in our survey, it should take you no more than 10 minutes to complete, and lets SAMHSA know: How many people attended our webinar How satisfied you are with our webinar How useful our webinars are to you 42

43 Upcoming webinars from the National American Indian & Alaska Native ATTC Mental and Behavioral Health Considerations for Native Transgender People presented by: Michaela Grey, MPH Diné Clinical Supervision with Cultural Considerations presented by: Robert Rohret, MPH, and Sean A. Bear, BA, Meskwaki Tribal Nation Clinical Evaluation: Treatment Planning presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe Referral, Service Coordination, & Documentation presented by: Dee Le Beau-Hein, MS, Cheyenne River Sioux Tribe For more information about our webinar series, contact Kate Thrams at or Thank you for taking time out of your very important work to ensure quality service through education in collaboration with the persons you serve Behavioral Health is Essential to Health Prevention Works Treatment is Effective People Recover 43