ATTC's Pearls of Wisdom: Training & Trainer Evolution – COVID’s Lasting Impact

 By Paul Warren, LMSW, Research Project Director at the New York State Psychiatric Institute

The COVID-19 pandemic forced and expedited the use of technology to provide services, training, and technical assistance (TA) on an unprecedented scale across the globe, in all professions. From our present vantage point, trainers and TA Providers may wonder “Will SUD workforce training and TA ever go back to the way it was before COVID?”

I predict, “No”. End of story. Next question. All kidding aside, I believe the answer is still “There is no going back.”

As challenging as these adjustments in training and TA delivery have been, and despite the attrition of experienced trainers, the intentional and skilled use of technology has extended our reach, increased availability and, dare I be so bold as to suggest, more effectively prepared and supported the SUD workforce through training and TA interventions.

Let us now transition from broad forces to granular experience and application.

As with in-person training, on-line training platforms like Zoom and others succeed or fail based on a Trainers’ ability to engage participants in the learning environment. A robust grounding in Adult Learning principles is essential in contexts and in building and maintaining engagement on-line requires significant adjustments on the part of the trainer.

Pearl One - the “training” begins before the “training” starts – also applicable to on-line TA provision. For in-person training, I often arrive an hour or at the very least 30 minutes prior to its start. Yes, to set up and manage logistics, and more importantly to build engagement. I’ve sincerely grown to enjoy on-line training because I’ve adjusted to achieve comparable levels of participation and engagement. I enter the virtual classroom/meeting space prior to the start time, I greet people as they enter, use their names, invite them to unmute and ask them questions about their real and virtual backgrounds. I express my sincere curiosity and extend a genuine welcome.

 

All of this “engagement” intentionally occurs prior to launching into logistics or any training content. Of course, the time is greatly condensed. Prior to opening the on-line classroom, I send waiting-room messages, affirming their early presence and extending welcome. Practically speaking, the classroom opens five-minutes prior to the official start, and I also use the first five-minutes to continue to build engagement and set a tone for the Learning Community Conversation.

Pearl Two – Consider facilitating Learning Community Conversations (LCC). “What’s in a name?” you may ask. I believe a lot! Especially if, in your role as Trainer/Facilitator, you truly respect the experience and needs of Adult Learners.

As I’m building engagement and setting the tone in the five minutes before and after the official start time, I’m planting the Learning Community Conversation seeds. I’ve seen these seeds consistently flower during many training sessions. Adult Learners have a lot to offer, they want to talk, and they want to be heard. Establishing ground rules is essential to making sure that the LCC remains safe, inclusive, and forward moving. The “Language Matters” slide is an excellent visual anchor for the LCC. A related tip focuses on the intentional use of reflections and summaries by Trainers/Facilitators. As during the provision of direct client services, Adult Learners also want/need to be heard. Trainers can continue to build engagement by taking the extra moment invested in reflecting or summarizing what a participant risks to offer during the LCC.

Pearl Three - In real estate, it’s “Location, Location, Location”, in on-line training it’s “Duration, Duration, Duration”. Zoom time and in-person time are not the same. “Zoom Fatigue” is real. I’ve experimented with duration within the bounds of deliverables needs. Ideally, when possible, I don’t conduct on-line training or TA sessions that go beyond three hours. Clearly this is an individual call based on many variables. What I can anecdotally share is that I’ve found great benefit in putting several days between Part One (first three-hours) and Part Two (second three-hours).

Many years ago, in another life I learned a very valuable lesson that I’ve applied in this context, “less is more”. I find it highly applicable when considering duration and amount of content to include in an on-line training. Ultimately it comes down to intentional utilization of the duration, methods and approaches that will best illuminate the content and provide Adult Learners with opportunities to explore, adopt and implement.

It's likely that training and TA provision will never return to the way it was before COVID. Trainers and Technical Assistance providers have an opportunity to responsively devise ways to engage, establish synergistic Learning Community Conversations and to compose educational interventions that maximize the means of the moment. These intentional adjustments and the openness to flex holds great promise for a strong Substance Use Disorder workforce.

ATTC’s Pearls of Wisdom: Innovative partnerships + hard work help tackle stimulant use in the Western U.S. & beyond

By: Beth A. Rutkowski, MPH, co-director, Pacific Southwest ATTC

I’ll never forget the first time we met Tom Donohoe back in spring 2004. Tom is a colleague from the UCLA Department of Family Medicine and Director of the LA Region of the HRSA-funded Pacific AIDS Education and Training Center (PAETC). UCLA Integrated Substance Abuse Programs had become the administrative home of the Pacific Southwest ATTC (PSATTC) in 2002, and many potential community partners were requesting meetings with us to see how we could collaborate and share PSATTC resources.

But Tom Donohoe was different. He said he had resources to share with us, and he meant it. This initial meeting marked the beginning of a nearly 20-year collaboration that has impacted thousands of HIV and SUD clinicians throughout Region 9 and beyond.

Tom Freese and I had been conducting dozens and dozens of trainings on methamphetamine throughout Region 9 (and beyond) and had established a recurring educational series called the California Addiction Training and Education Series (CATES). The first several rounds of CATES trainings focused on the many different facets of methamphetamine use. We had more material than we knew what to do with, and we were constantly updating our training slides to make sure we were teaching others the latest science-based information for providing services to people who used methamphetamine.

Similar to the PSATTC, the PAETC had been working to develop training curricula and resources on the topic, and when Tom Donohoe received supplemental funding through the PAETC to work on the U.S./Mexico border, he immediately contacted us to help conduct needs assessments and deliver trainings. The first series we co-sponsored was “HIV, Methamphetamine, and Women along the U.S.-Mexico Border.”

A few years after the PAETC and PSATTC initiated the U.S./Mexico Border Training Series, we were encouraged to expand our partnership to encompass the other Region 9 Federal Training Centers, including the Curry International Tuberculosis Center, California STD/HIV Prevention Training Center, and Cardea Services. The resulting product was the development and delivery of multiple one- and two-day training events focused on the treatment of HIV, STDs, TB, Hepatitis C, family planning, and substance use. Each event also featured simultaneous English/Spanish translation. All were held along the U.S./Mexico Border in California, Arizona, and New Mexico. In each of these endeavors, the focus was on the provision of high quality, up-to-date data, and best practices on how to treat people with HIV, TB, STIs, and substance use. We made a lot of amazing friends along the process, and trained hundreds of clinicians.

Traveling and training with the PAETC and PSATTC faculty not only improved our respective knowledge of substance use disorders and HIV, but it helped us all sharpen our skills as trainers and content developers. We were cross training each other as much as the bi-national participants who came to our trainings. In addition, the four-city tour of the border was fun. Often, the events that most shape us as trainers are learning and having fun with other experts in our respective priority areas. One of the most impactful results was the development of a “Methamphetamine TIP sheet” for HIV clinicians. The tip sheet has been revised a few times over the years, and is one of the most downloaded products from the AETC National Resource Center website.

Flash forward to 2019, when the ATTC Network received a request from SAMHSA leadership to establish a national workgroup on stimulants. While so much recent attention had been focused on the opioid epidemic that was killing Americans at record rates, drug poisoning deaths related to cocaine and methamphetamine were on the rise, as well. It was only natural for me and Tom Freese to volunteer to co-chair the newly established work group, and we were lucky to have Jeanne Pulvermacher agree to be our third co-chair. Little did we know in fall 2019 that a global pandemic was on the horizon that would challenge us to adapt our in-progress curriculum development efforts and pivot to create a national product that would be immediately useful to the SUD treatment and Recovery workforce and not sit on a shelf in someone’s office waiting for the return to in-person training.

The Stimulant 101 National Core Curriculum is a comprehensive set of training materials focused on the latest evidence related to the impact of stimulants on brain and behavior and best practice approaches for effective treatment and recovery. More than 50 ATTC-affiliated trainers participated in a modified training of trainers process in summer 2020, and to this day, these trainers are delivering the curriculum around the country. The National Core Curriculum features the following components:

• Daylong Face-to-Face Curriculum (with a fully articulated Trainer Guide & Reference List)
• Three-Hour Live Virtual Overview
• 70-minute Keynote Presentation
• Seven Supplemental Video Modules and Reference Lists
• Considerations for Families in the Child Welfare System Affected by Stimulant Use
• Gender Differences and Stimulant Use
• Methamphetamine Use and HIV among Men Who Have Sex with Men
• Polysubstance Use among Stimulant Users
• Overview of Recovery and Recovery Supports
• Stimulant Use in Rural and Remote Areas
• Stimulants and HIV
• Three Video Cultural Modules and Reference Lists
• Stimulant Use among African Americans
• Stimulant Use among the Latinx Population
• Stimulant Use among the American Indian and Alaska Native Population

The stimulant-focused work that we’ve had the privilege and honor of conducting through the PSATTC, and by extension, through our partnership with the PAETC represents one of the most challenging and fulfilling experiences of my career. This experience has taught me that you should never say no when someone new reaches out to you with an idea to collaborate, because who knows, that initial conversation can blossom into a decades long innovative partnership, with a lot of hard work making a huge difference in the quality of training/TA services provided to the community-at-large.

NIATx in New Places: Building Capacity for Effective School-Based Suicide Prevention

 By: Maureen Fitzgerald and Sarah McMinn

Sarah McMinn, LCSW, joined the Great Lakes MHTTC team in 2018 to lead the School-Based Mental Health Supplement. In her previous work as clinical program manager for a Colorado agency, Sarah had worked with homeless families and mental health clinicians. She had also helped launch a family and child clinical program at the agency’s early childhood education center. Sarah grew up in Madison, Wisconsin, and earned her undergraduate and graduate degrees at UW–Madison. The school-based mental health program manager position was an ideal match for Sarah's skills and background, with the bonus of being based at her alma mater. 

During the first year of the supplement, Sarah’s work focused on training and promoting school-based mental health across the Great Lakes region (HHS Region 5: IL, IN, MI, MN, OH, and WI) and launching the best practice modules developed by the MHTTC Network. In addition, Sarah organized a suicide prevention learning collaborative with suicide prevention expert Tandra Rutledge. 

“School-based mental health gained additional attention as a national issue in spring 2020 with the advent of COVID as school-based mental health providers struggled to meet their students’ needs,” comments Sarah. “We recognized that schools have a lot of resources and information on suicide prevention but lacked a concrete set of guidelines on how and where to start implementing those policies and procedures.”

The NIATx model offered a potential solution to meet this need. “We recognized that NIATx could provide a simple framework to help guide school districts that needed to update and implement their suicide prevention policies.”  

Identifying gaps

Sarah and Tandra, with assistance from NIATx coaches Scott Gatzke and Mat Roosa, developed an intensive learning collaborative that was structured around the NIATx Change Leader Academy (CLA). Schools and school districts applied to participate in the initial learning collaborative, and it was so successful that it has been repeated with a new cohort.

“To date, we have worked with 28 school districts across two cohorts embedding the NIATx CLA into intensive technical assistance efforts,” says Sarah.

Two NIATx tools that helped participating schools immediately were the walk-through and rapid-cycle PDSA testing.  

“For a lot of our schools, doing the walk-through as an eye-opener,” adds Sarah.

“The walk-through allowed schools to determine how new staff were introduced to, trained on, and kept updated on current suicide prevention policies and procedures at the school,” explains Sarah. “It allowed them to find the gaps in knowledge and training that needed to be addressed to have fully available and implemented suicide prevention strategies.

For example, one school did a walk-through as a new employee was called upon to help a student expressing suicidal ideation. The change team went through the process step-by-step to identify the resources a person would need and who they would need to contact to get the whole picture of what's required to appropriately respond to a student in crisis. The walk-through helped identify where additional training and directive was needed so that both current and new staff were better prepared.

The NIATx flowcharting tool helped another school’s change team identify the need to create a suicide crisis team. “They used flowcharting to determine what needs to happen from start to finish to create safety for the student, the provider, and the school," says Sarah. "This exercise also identified gaps in school staffing that community stakeholders could fill. As a result, they're now drafting a manual for prevention, intervention, and postvention."

NIATx: Easily adaptable to school settings

The school-based NIATx CLAs identified three areas where change teams can focus their efforts: 

• Increasing staff awareness of the district suicide prevention protocol 
• Increasing the use of a universal screener 
• Increasing number of staff trained in suicide prevention training (QPR, ACT, ASIST, etc.)

In addition, the CLAs have demonstrated how the NIATx approach can benefit school settings.

“Educators, student support staff, and school administrators are busy. They often have little time to commit to projects outside of immediate student needs and educational requirements. Furthermore, they often must weave through heavy bureaucracy to make significant changes. The NIATx process gives education teams the opportunity to identify a problem and try small, measurable changes quickly so they can support students efficiently. It also gives them data to show leaders that small changes building upon one another are necessary, important, and have the potential to create significant change.”

About the trainers

Sarah McMinn, LCSW is a program manager for the Great Lakes MHTTC in Madison, WI, part of a national network of SAMHSA technical assistance centers. She is responsible for coordinating training and TA to enhance the implementation of school-based mental health programming. Previously, Sarah was a therapist, clinical supervisor, and program manager working with homeless families and developing mental health services at an ECE and after-school program. She holds an MSW from UW-Madison.

Tandra M. Rutledge is a mental health and suicide prevention educator, advocate, and consultant. She is currently the Director of Healthcare Systems Initiatives for Project 2025, a national initiative of the American Foundation of Suicide Prevention to reduce the suicide rate by 20% by the year 2025. Tandra provides subject matter expertise on the Great  Lakes MHTTC school-based suicide prevention intensive technical assistance and has helped pilot the school-based NIATx Change Leader Academies.

ATTC's Pearls of Wisdom: Driving Integrated Knowledge Transfer and Implementation Via Collaboration

 By Oscar Morgan, Central East ATTC

Since joining the Addiction Technology Transfer Center (ATTC) Network in 2001, the Central East ATTC has endeavored to provide training and technical assistance (T/TA) that includes promoting gender, racial, sexual orientation equity, and cultural considerations. In addition to influencing people's experiences in the behavioral health system, these diverse identity markers also contribute to understanding the value of each individual.

We provide T/TA on evidence-based and promising practices for prevention, treatment, and recovery support services to substance misuse professionals and others in HHS Region 3 (Delaware, Maryland, Pennsylvania, Virginia, West Virginia, and the District of Columbia) according to identified regional needs. We use proven technology transfer strategies and practices to heighten awareness, disseminate information and promote the adoption and implementation of evidence-based practices that address substance use/misuse in real-time.

Methods include: 

• skills-based training; 
• targeted and intensive technical assistance; 
• development of handouts, guides, and toolkits; and 
• both virtual and in-person training.

Our center serves as a resource to collect, store, disseminate, and implement substance misuse disorders evidenced-based practices that emphasize a public health approach. The bedrock of our T/TA is the recognition that recovery is a process involving person-centered care, which improves health, and wellness resulting in an individual’s ability to thrive in communities of their choice. Our T/TA approach also recognizes the multi-faceted nature of substance misuse and the myriad of individual, social and environmental factors that influence substance misuse.

Throughout our history, we have prioritized collaboration as a crucial component of our mission to strengthen the capability, skills, and knowledge of professionals in substance use disorder treatment and recovery as well as the public health workforce as a whole in HHS Region 3. We engage with researchers, subject matter experts, behavioral health professionals and organizations, state and local behavioral health authorities, universities, consumers, peers, families, veterans and members of the military, community coalitions, social service groups, faith-based organizations, ethnic-minority-specific organizations, LGBTQ+ serving organizations, and other stakeholders.

A unique collaboration for our Center is with the Mid-AtlanticTraining Collaborative for Health and Human Services (MATCHHS), managed by the Office of Regional Operations- Region III. MATCHHS is composed of the HHS-Region 3-funded training and technical assistance centers with complementary missions. The Central East ATTC role within this collaborative is to ensure that the needs of people with substance misuse, substance use disorder or other behavioral health disorders are addressed in every health and human service setting through the implementation of evidence-based practices.

MATCHHS works to strengthen the capabilities of the public health workforce to support delivering high-quality services throughout our region. Collectively, we employ evidence-based and promising practices and data-informed solutions that focus on the adverse interactions between social conditions and diseases.  This fosters a better understanding of substance misuse prevention, treatment, and recovery.

Together, we work to reimagine, transform, and sustain health and human service systems in an equitable manner so that the needs of individuals with substance misuse and/or other behavioral health disorders in our region are met. Under the integration of behavioral health care into the public health system, we have trained over 8,100 providers.

About the author:

Oscar Morgan has more than 35 years of experience working with state behavioral health systems, organizations, and treatment practitioners. He has dedicated his work to strengthening their capacity,  skills, and knowledge in providing integrated culturally and linguistically competent behavioral health prevention, treatment, and recovery support services for children, youth, and adults who have and/or at-risk of developing serious emotional disturbances/serious mental illnesses and co-occurring substance use disorders. He is the project director of the HHS Region 3, Mental Health Technology Transfer Center, Prevention Technology Transfer Center, and the executive director of The Danya Institute, Silver Spring, MD.  Mr. Morgan is a former mental health commissioner for the state of Maryland. He has held senior-level management positions in a variety of state and national behavioral health organizations.  He obtained his Bachelors of Arts degree from the University of Colorado Boulder and Master’s Degree in Health Care Services Administration from George Washington University, Washington, D.C. 

Reckoning harm reduction with Twelve Step recovery: Who’s “in the room(s)”?

By Kim Gannon and Emily Pasman, guest authors

Twelve Step programs are ubiquitous in the US substance use disorder (SUD) treatment landscape. For many, they provide a powerful forum of life transformation, fulfillment, and purpose. We are two such people: two statistically rare cases (Dodes & Dodes, 2015) who have successfully found long-term recovery from SUD via Twelve Step participation. While we have benefitted personally from these programs, we cannot ignore the lives they put in jeopardy by stigmatizing people who use medications for opioid use disorder (MOUD) and harm reduction strategies. Without large-scale structural and cultural change, Twelve Step communities will continue to harm those they intend to help.

To bring awareness to this tension, we recently authored a commentary entitled Knowing or not knowing: Living as harm reductionists in Twelve Step recovery in the Journal of Substance Use and Addiction Treatment. In it, we begin by describing our journey from drug use to Twelve Step meetings, often called “the rooms” by attendees. Then, we outline our path to embracing harm reduction and non-abstinence recovery pathways. Some of what brought us to harm reduction was academic; we immersed ourselves during graduate school in the overwhelming literature supporting harm reduction over abstinence-only modalities (Barnett et al., 2020; Paquette et al., 2022; Wakeman et al., 2020). Some, however, was much more personal: dozens of our friends and community members have died of overdose in the past few years alone. Beyond grief, rage, and gratitude for our own lives, these experiences have provoked deep reflection and interrogation of our own biases and those of the communities we are a part of.

Editor's note: The authors of this guest post were interviewed by our colleagues at the Peer Recovery Center of Excellence for the April 2023 episode of the "Recovery Talk" podcast. We invite you to listen to that conversation here. 

As graduate students in public health and social work, we frequently find ourselves in dialogue about power and privilege. When wrestling with the way institutions exert influence, we are presented with a common question: “Who’s in the room?” Who are the voices that are heard, privileged, and acted upon in decision-making circles? Historically, the answer is us. Even in 2023, abstinence is still perceived as the “right” (or only) way to recover from SUD, and those who can attain it are elevated in social, clinical, and political circles. We wrote this piece, however, to bring attention to those who are not “in the room(s)”: those kept out due to stigma, and those who died from gatekeeping in the very communities that saved our lives.

To be part of the solution, we offer several suggestions. Individual Twelve Step members can work to deconstruct their own biases and to vocalize their support for non-abstinence pathways in meetings, including by directing people who use MOUD and harm reduction to supportive people and groups. At the meeting level, groups can adopt policies that proactively state support for other pathways in a reading at the beginning of meetings, similar to the Alcoholics Anonymous “safety card” (Alcoholics Anonymous, 2022). Moreover, clinicians can clearly communicate the risks and benefits of Twelve Step participation to their clients, as well as offer themselves as a resource to help navigate messages from “the rooms” that may not support clients’ goals. However, without policy change – including removal of meeting attendance requirements from criminal-legal and treatment settings, changes to Twelve Step literature, and oversight to hold groups accountable for harmful messages they spread – these changes will not suffice.

Harm reduction philosophy promotes the inherent worth and dignity of the individual, regardless of their drug use. Twelve Step philosophy aims to be of maximum service to others, particularly those suffering from SUD. These philosophies are more than compatible, and combined they can be unstoppable. But we cannot achieve this unity without a major reckoning within Twelve Step communities. And as people lucky enough to be “in the room(s),” we must dedicate our lives to making it happen.

References

Alcoholics Anonymous. (2022). Safety card for A. A. groups. https://www.aa.org/safety-card-aa-groups.

Barnett, M. L., Barry, C., Beetham, T., Carnevale, J. T., Feinstein, E., Frank, R. G., de la Gueronniere, G., Haffajee, R. L., Kennedy-Hendricks, A., Humphreys, K., Magan, G., McLellan, A. T., Mitchell, M. M., Oster, R., Patrick, S. W., Richter, L., Samuels, P. N., Sherry, T. B., Stein, B. D., … Vuolo, L. (2020). Evidence based strategies for abatement of harms from the opioid epidemic. Washington, DC: Legal Action Center.

Dodes, L., & Dodes, Z. (2015). The sober truth: Debunking the bad science behind 12-step programs and the rehab industry. Beacon Press.

Paquette, C. E., Daughters, S. B., & Witkiewitz, K. (2022). Expanding the continuum of substance use disorder treatment: Nonabstinence approaches. Clinical Psychology Review, 91, 102110. https://doi.org/10.1016/j.cpr.2021.102110

Wakeman, S. E., Larochelle, M. R., Ameli, O., Chaisson, C. E., McPheeters, J. T., Crown, W. H., Azocar, F., & Sanghavi, D. M. (2020). Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Network Open, 3(2), e1920622. https://doi.org/10.1001/jamanetworkopen.2019.20622