A noted expert on substance use disorder within the disability community, Elspeth Slayter joins The Conversation to talk about best practices and emerging questions. Her Impact article discusses how treatment systems often fail to serve people with intellectual and/or developmental disabilities despite evidence that they may experience more profound consequences. On the show, she shares her enthusiasm that the topic seems to be gaining traction in the addiction and disability fields.

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Janet Stewart

Welcome to Impact the Conversation, a podcast of the University of Minnesota's Institute on Community Integration. It brings you strategies and stories advancing the inclusion of people with disabilities. Our guests are the authors of impact, our long running magazine that bridges the research to practice gap with professional and personal reflections on what matters most in disability equity today. I'm your host, Janet Stewart.

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Janet Stewart

Today we're talking with Elspeth Slayter, professor emeritus in the School of Social Work at Salem State University in Massachusetts. Doctor Slater's body of work includes extensive disability services research related to addictions. Her predictable training was supported in part by the National Institute on Alcohol ISM and Alcohol Abuse. Earlier in her career, she practiced as a forensic social worker in a number of court settings.

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Janet Stewart

She brings an equity lens to addiction work and advocates often for acknowledging the dignity of risk. In this work. Her article for the new issue of impact lays out a clinical intervention she conducted that was designed to build confidence and skills for people with intellectual or other developmental disabilities to decline alcohol and other drugs. Doctor Slater, welcome. It's great to be with you today to talk about this work.

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Elspeth Slayter

Thank you. I'm honored to be here.

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Janet Stewart

Yeah, yeah. So can we start with this intervention? You did? When was it, and what did we learn from it?

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Elspeth Slayter

Sure. Well, I want to start by saying, that this work was led by doctor Mark Capuccino, who's at Harvard and McLean hospital. We were both interested in, a study that was done a number of years ago by McGillicuddy and Blaine that looked at something called refusal skills development. And it was targeted to the community with intellectual and developmental disabilities, and basically used role playing and sort of mentoring, modeling, to help people engage in really self-determination in situations where there is dignity of risk around the use of alcohol and drugs.

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Elspeth Slayter

And, so we were interested in this study, both interested in this study. And Mark had already done some work in this area. He's a clinician that specializes in addiction treatment. I had always done, clinical case management. With this population in both, forensic settings, meaning child protection settings, parents involved with that system, and also in adult criminal defense, people coming in to their involvement.

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Elspeth Slayter

So we we had this shared interest and Mark had access to the clinical population. He has led this work. Basically, building on the McGillicuddy and Blaine study and, what exists in the literature? A ten session treatment program was developed, 45 minute, sessions, with the goal of looking at people's capacity to, engage in a redirect if they wish to do so around alcohol or drug use.

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Elspeth Slayter

Pretest and post-test, looking at, a couple of different variables, and we found that, this was effective at helping people to engage in refusal of, use of alcohol or drugs. And, there, there various different types of strategies that we worked on. They were strategies that, we developed based on work that Mark found, from the James Stanfield Company, which does, creates curricula for adolescents around alcohol and drug use prevention.

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Elspeth Slayter

And, so using that, material which was targeted to that particular developmental stage, seemed appropriate. So, for example, Mark worked was folks around role playing, situation where someone is saying offered, a drink, maybe they don't want to drink. So they are modeling or they're working towards, saying no and getting out of the situation.

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Elspeth Slayter

That's one scenario. So it's sort of, learning to engage in a particular rote interaction. That one can come back to and pull it out of their tool chest. Another one might be something like, no, I'd rather not have a drink. I'd rather go to the movies. Would you like to go with me and then go if the person doesn't want to go on?

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Elspeth Slayter

So there were various strategies that people, were offered, and practice during the course of the ten sessions, and practice. The goal was to practice to automaticity.

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Janet Stewart

Now, I know you've done a lot of work in the area of dignity of risk, and I think that is so crucial in this discussion because we're talking about adults who can make choices themselves for substances that they may want to partake in. And it just has seemed really important to you and your work to bring in, guardrails around this so that, you know, we're not harkening back to the Nancy Reagan era of just saying, oh, you know, where we are.

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Janet Stewart

How did you build in some, some nuance to this to make sure that not only in your study, people were given responses that really reflect what they wanted, but how do we, you know, as we learn from that study and and incorporate the people that with disabilities that we work with, how do we bring that element to the work?

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Elspeth Slayter

Yeah, I think that's the million dollar question. And I'm really excited that you're asking that question, because I've been waiting for 20 years for people to start really wrestling with that particular question. So let me contextualize the question. Just just a little bit more, part of why the dignity of risk is so important is that the traditional approaches to treating someone for an addiction problem, should it develop.

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Elspeth Slayter

Right. Is, that the standard methods that we have, in, in the addiction treatment sector, which are generally cognitive behavioral therapy, there's challenges there in terms of people with intellectual disabilities and developmental disabilities around acquiescence bias, things like that. So there's there's this but there's this worry that I've always had watching folks as a clinical case manager going through, assessment and treatment, that there's acquiescence going on that that harms the clinician and things like that.

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Elspeth Slayter

So I'm coming at it a step in because I think that's an important piece. There's there's if we back up and we say, you know, should people have access to alcohol and drugs? I think any community member should, with supports. And that's true for everybody regardless of IBD status. Right. But the problem becomes, if you do offer someone the dignity of risk to go and have a beer at the bar after work, or a glass of wine with dinner, or, use a CBD gummy.

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Elspeth Slayter

We're seeing a lot of this in the field. Those are normative behaviors. And yet when there is potentially increased, potential, for negative consequences for this population, the degree of risk gets really sticky. And then when you add to that, the treatment piece, you've got a problem because you don't necessarily know what works with this population very well.

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Elspeth Slayter

And that's where the field has been stuck for a great deal of time. So, when I heard about Mark's work and we began to collaborate on in a variety of different ways, this was a conversation that we had a lot as in, Mark, you know, you're talking about using cognitive behavioral therapy modified for folks based on a different developmental stage, which is great.

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Elspeth Slayter

He focuses a lot on the here and now, as opposed to using abstract concepts. That's great. You're talking about motivational interviewing, where we engage people, help them focus, help them evoke their goals and help them plan towards the goals. But to what extent is all of that potentially trampling on dignity of risk? Given that acquiescence bias, that is, you know, if we think about just a standard motivational interviewing question that a clinician or, case manager might ask, because this is a tool that doesn't necessarily just need to be used by clinicians.

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Elspeth Slayter

We might say something like, what might be some good things about making this change? That's a nice open ended question, right? And so when working with this population, we don't want to be leading in this way. So eliciting that individual view, is super important. So, so yeah, so there's so many facets to thinking about dignity of risk and how it interacts with the fact that we've had a dearth of information about what to do with this population.

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Elspeth Slayter

But I don't think that should stop us from supporting our people to have normative community experiences. And I know that's controversial, in many settings. And I've been a consultant in settings where I've said that and, you know, that that hasn't necessarily gone over well. If you think about, shared living, facilities and organizations that run those, you know, group home, shared living facilities, you know, they're thinking about risk management, right?

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Elspeth Slayter

And rightly so. And how do you balance that dignity of risk? Which we say we're so committed to with the fact that our institutions have this risk management as well. So that's and really options, but also same, same issue for clinicians.

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Janet Stewart

And, and isn't it really two families as well because they have so much invested in not, you know, having their family member harmed.

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Elspeth Slayter

So right. And that people have tried to block folks, even with normative behavior. I was just consulting on a case where, an individual who had, parents with limited, guardianship status around health wanted to block that person from using, marijuana gummies, to, to fall asleep at night. In, in conjunction with, with a clinician.

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Elspeth Slayter

And so this is this is the medical marijuana thing is popping up all over the place. And I'm working on a project about that. But, but this is a huge issue with families. There's and I think that any family, regardless of whether someone has it or not, there's this want to protect, there's this need to protect, and there's this impulse to protect.

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Elspeth Slayter

And of course, we know with folks with A.D.D., we've had decades of knowing that we have to do better and not necessarily completely protecting people from learning in normative community spaces.

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Janet Stewart

And you mentioned the gummies and, you know, with marijuana legalization going on across the country. Do you think that there that this is really going to be a big spike in, in issues related to addiction with this?

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Elspeth Slayter

I don't know if it's going to be a spike in addiction. And this is based on anecdotal evidence, but let me tell you a little bit about what I've been involved with. So I do some consulting with the start group at the University of New Hampshire. And they provide services to clinicians all around the country. They have monthly meetings with ID clinicians, around behavioral health concerns.

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Elspeth Slayter

And so I've been in a couple of times to, to meet with them and brainstorm with them and provide them with information about the evidence base. And we are just hearing marijuana, marijuana, marijuana gummies, CBD constantly. And so we did an anecdotal, non population based, survey of the people that participate. And well, they start did it, not me.

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Elspeth Slayter

And they said, you know what, what are the issues? How much are you seeing this? And they're seeing a spike, a significant spike in use of these legal materials, which I think we're seeing around the country. But it's harder to say with respect to addiction because we're not necessarily measuring that, scientifically. And of course, it's anecdotal.

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Elspeth Slayter

So we really need to do some more work in this area. This is also exacerbated by the problem of not having screening and assessment tools that are validated for folks with IBD. We know that that population has traditionally been excluded from those kinds of studies because they are seen as biasing the sample. But that, leads to a, back door problem of not having the kinds of tools we need desperately to assess what's going on with this population side.

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Elspeth Slayter

No. So I couldn't say, that there's been a spike in addiction around, marijuana. I wouldn't be surprised if we're heading in that direction, but I think we need to help our the families. We need to help the individuals. We need to help the clinicians. We need to help the staff, to remember that if something is legal, people with ID have every right to use it.

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Elspeth Slayter

But we need that circle of supports, to guide from the side, you know, and, and help people to make decisions and deal with consequences and things like that.

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Janet Stewart

And you mentioned in your article that there seems to be, now a surge of interest in talking about this as a field. Do you think the the addition of marijuana is driving that, or. I think you pointed to some other, potential reasons for for why there does seem to be a surge of interest in this.

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Janet Stewart

Now, what what do you think?

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Elspeth Slayter

That's an interesting connection you make about, marijuana. I mean, I suppose, the the embrace of legal marijuana is changing the narrative in so many ways for all segments of the population. That perhaps that that is a factor. I've really wrestled with why this is happening again. I've, I've waited 20 years for people to pay more attention to this.

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Elspeth Slayter

I mean, that's a whole other story. I, I do think, that we're getting better with community inclusion. We're, we're wrestling with the harder issues more maybe all these decades of working towards that. Maybe it's coming to fruition and looking at the harder issues, I call it the sex and drugs and rock and roll issues.

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Elspeth Slayter

Of community inclusion as opposed to where do I live? What do I wear, you know, whose party am I going to? Where am I going to work? So maybe we're getting to that good place in thinking about community inclusion. I also think from a research perspective, that perhaps we're paying a little bit more attention to external validity or generalizability in addiction treatment research.

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Elspeth Slayter

And we see that primarily in, I think, the fantastic expansion of research around, mental health treatment for folks with intellectual and developmental disabilities. I mean, I've talked to a number of I mean, there's nad the, there's wonderful work being done out there. So I think, there's a critical mass of work around psychotherapy, various aspects of psych or modalities and psychotherapy, for this population.

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Elspeth Slayter

So maybe now we're starting to sort of trend over towards addiction treatment as well. I will just add that I'd really like to see more participation of individuals with intellectual disabilities. In that research in terms of amenability to the interventions, applicability, etc.. But that's that's sort of a side note just to just to get a little bit of, empowerment oriented work in there.

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Janet Stewart

Yeah. And and what do you think about some programs have, successfully used people with IDD in their, in their investigations, in their, in their programs. But oftentimes to get the sample size, they'll take anyone with IDD without any experience in addiction. Is that useful at all?

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Elspeth Slayter

It's something I mean, it's it's definitely not ideal, but I mean, we've been doing this incrementally for decades, right? So I think a little is better than not. I'm sure some people would disagree with me on that.

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Janet Stewart

Well, getting to your. Yeah. And but getting to your point though about everything taking so long and it is pretty egregious when you look at, you know, how old is the Ada and you know, the, you know, sort of the, the equity in that it just from a health care standpoint of, of, you know, getting treatment. But we heard and putting together this issue that a lot of families encounter treatment specialists who sort of throw up their hands even today and say they aren't equipped to, to treat people with IDD.

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Janet Stewart

Is that just another convenient excuse for dumping patients? You know, it it there's such a crisis in getting mental health treatment, other kinds of treatments. Is there something to that, you know, and, and, you know, is it is it really less difficult than what they sort of make it out to be or do they have a point and we just need more training?

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Janet Stewart

I don't know, where do you come down on that?

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Elspeth Slayter

Well, for 30 years I've been seeing the same story, sitting with clients, trying to get them into treatment. We don't work with people like that here. We don't want to turn off our normal clients by having someone with an intellectual disability in this session. We don't know. It doesn't work. They drop out. I've been hearing this the for 30 years.

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Elspeth Slayter

I still hear it when I get calls from people in consultations to assist them in what's going on. I mostly get those calls from the disability service sector. Rarely do I get calls from the addiction treatment sector saying what to do, but those calls are starting to increase, which is which is wonderful. So is that a cop out?

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Elspeth Slayter

Yes, that's a cop out. That's about ableism, but it's also about the lack of the evidence base. However, now we're starting to move beyond these scads of articles. We have the document, the problem in the population, towards actually some, some indication of what to do. So I do think training is a big piece of it. Training is absolutely necessary.

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Elspeth Slayter

And we have information to share in those trainings. And I've been doing those, and getting calls all the time to do it. I can't keep up with it. But if we don't have people look at their ableism around who should be in treatment, around who should be allowed to have the opportunity to, take a gummy half a drink, you know, or have had that opportunity.

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Elspeth Slayter

It's not going to work. We need anti ableism, anti-Zionism should work just as much as we need people to get up to speed on what we've been finding and the evidence base. We're just coming out with, a scoping review that looks at all of the evidence based, from screening to assessment to prevention to treatment of addiction.

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Elspeth Slayter

And, folks with ideas. And we our goal was to really get that out there, both to the disability side of the equation so they can cross train the addiction side and to get it out to the addiction side, so they can see what's there. So I hope that answers the question.

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Janet Stewart

Yeah. And what is that work? Is that something that's out and available now?

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Elspeth Slayter

It's under it's under review right now, but great. The last review was just for grammatical, stuff. So I'm hopeful that it will be published soon.

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Janet Stewart

Wonderful. That's great news. So at the end of your article in impact, you talked about sort of posing this question of, you know, a lot of what we've done so far is sort of adapting curricula for the wider population to people with intellectual disability. For example, do you have a suspicion that people with ID, just fundamentally need a different approach, not just translating it?

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Janet Stewart

Well, I don't know. What do you think?

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Elspeth Slayter

I think we should ask them. And that gets to your issue of sample size. We had such a hard time, recruiting for Mark's, clinical work. We ended up with 30 folks, but it took, years of of getting people in the room. So part of the problem in terms of bringing people together is, is locating them, and locating folks that are willing, just speak openly in that way.

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Elspeth Slayter

And then managing acquiescence bias. I think you'd have to take a triangulated approach. You want individuals in the room to talk about their experience, what they think works, what doesn't, what something else might look like. Is it possible to vision? I would like to think so. I think you get collaterals in the room. One of the things we found, in our scoping review, is that a number of studies are starting to use a support person, in sessions.

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Elspeth Slayter

And this seems to assist, with positive outcomes. After the intervention and so I'd also want to hear from the collaterals, the family members, the girlfriends and boyfriends and partners, the staff people, things like that. I think we need all hands on deck. And I love your idea. I think it's a very empowering idea.

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Janet Stewart

Great. So we're about at time, but is there anything I haven't asked that you think is really important to bring out in that intersection of addiction and disability?

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Elspeth Slayter

I think you've asked, the key questions. I just want to highlight again that our addiction treatment service provider community needs to look at the ableism piece. As you pointed out, the Americans with Disabilities Act, how many decades have we had it? I see regular violations of access to, addiction treatment for folks with intellectual and developmental disabilities.

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Elspeth Slayter

Based on the consultations that I do, I hear it all the time. And so, honestly, to some extent, I think maybe if someone starts a lawsuit that'll help things, we've seen how that's gone before. And that's unfortunate to say. But I hope that, the folks that listen to this who are on the ground in the IT sector, make friends with folks in the addiction sector, create that personal connection, do informal cross-training.

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Elspeth Slayter

Here's how we get comfortable working with a person with ideas. So often the addiction treatment providers say, I don't know how to talk to someone like this. They're uncomfortable. That's able ism. That's also just, you know, not knowing the population. Get to know the population. Learn how to do better for our people. So those are some other thoughts.

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Janet Stewart

Doctor Slater, it's been so great talking with you about this. I really appreciate both you writing the article for impact and sharing a little bit more detail here with us today. Thank you so much.

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Elspeth Slayter

You're welcome. Thank you for the work you're doing.

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Janet Stewart

Thanks for joining the conversation. If you'd like to reproduce all or part of this podcast, please email pub at UMD. You.

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Pete McCauley

Our show is co-produced at the University of Minnesota's Institute on Community Integration by Impact Managing editor Janet Stewart, and AISI media producer Pete McCauley. Skyler Mihajlov is our editor. Graphic designers are Connie Burkhart and Sarah Curtner. For more information on the Institute and all of our products and projects, please visit Eisai Dot NZ. You.