Recently, an intern working in collaboration with WCCI, Brittney Craven, sat down (virtually) with Christa Capua, Clinical Supervisor and Chief Operating Officer at Stepping Stone of Boone. She spoke with us on the importance of understanding trauma and the role it plays in addiction, breaking down the stigma, and understanding personal growth.
Brittney: Would you mind introducing yourself and explaining your role in the community?
Christa: My name is Christa Capua and I am formerly the Clinical Director of Stepping Stone. I’m currently the Clinical Supervisor and COO. David Brumfield, our Program Director, and I have been running Stepping Stone for well over a decade. Stepping Stone is a medically assisted treatment (MAT) program. My role has shifted over the years. As a clinical director, I was seeing patients every day and overseeing direct patient care. Nowadays, my role is more as the title implies, supervisory. I supervise our team of therapists as we've grown quite a bit and I do a lot of work in the community with outreach and educating people about addiction and medically assisted treatment.
Brittney: For those who are unfamiliar with Stepping Stone and the services you provide, can you touch briefly on that for us?
Christa: Stepping Stone was begun in 2009 with the idea that medically assisted treatment (MAT) could be done better than what we had seen oftentimes in the field prior. Medically assisted treatment, in short, ideally is the use of medications alongside therapy and wrap-around services. So that's essentially our model. I think one of the negative views sometimes people have of MAT is that it's basically just the medication and that's really all that's happening in treatment but within the model of Stepping Stone we're using our medications as just one of the tools alongside therapy and wraparound services. Broadly speaking, MAT is using Methadone and Buprenorphine primarily. Those are two medications that are very very helpful and effective in blocking withdrawal symptoms, helping to block people's cravings to use, and also blocking their ability to get high. If they're stable on their medication and they attempt to take an opiate on top of it, they shouldn't feel it. It's a great way of curbing those behaviors medically while we're working on the root causes and the trauma through therapy and wraparound services, trying to help stabilize their lives.
Brittney: I didn’t realize all that the medically assisted treatment did as far as the medical side of it.
Christa: Yeah, a lot of people don't and that's why I’m passionate about education and outreach.
Brittney: Can you share with us a bit about your background and trauma work and then a second part to that, how did Stepping Stone come to be? What needs did you see in the community?
Christa: I would say really the sort of formative experience for me in starting to gain an understanding of trauma, as well as, understanding the way we manage people with trauma and how that can impact their trajectory happened to me when I was in graduate school. I was working on my master’s degree in Miami and doing my practicum and internship hours split between two sites. At that time my goal was to work with women and adolescents. Those were the population I was focused on. I would spend half my days at a private, lovely, beautiful treatment center for teenage girls and adolescent females with eating disorders. The center was pretty expensive to attend their program. The treatment was great and not surprisingly the girls whose families could afford to send them there were generally of high socioeconomic status. Then I’d go from there to a youth shelter that was run by social services. That service was for females, mostly adolescents but there were children too, who had been removed from their home for sexual abuse. They were essentially put there while the system figured out what to do next. Sometimes the girls were there long term and sometimes they'd be in and out pretty quickly. The point being it was really striking moving between these two environments. The trauma histories on these two populations of females were very similar. There’s a lot of research that shows sexual abuse correlates with the development of eating disorders. I saw a lot of similar childhood trauma but the primary difference between the outcome for these girls was money and the quality of their treatment quite frankly. Seeing that disparity early on was a good thing because it let me go into the field with that understanding. Years later, when Stepping Stone was getting started, David and I had a lot of conversations about what our treatment model would look like and so we talked a lot about that disparity and how medically assisted treatment is affordable and private inpatient treatment for any sort of addiction is exorbitantly expensive. If someone can afford to do inpatient treatment that's fantastic and that's considered the gold standard, but it's just not realistic for most people. Medically assisted treatment is also outpatient treatment so it lets people continue to work. A lot of people can't take 30, 60, 90 days off and leave their families or leave a job for that period of time. They're going to lose their job if they do that, so MAT allows people to keep working and stay at home while they receive treatment. The goal from Stepping Stone’s infancy was that we would bring that higher level of care, quality therapy, quality support, and engagement with the community to this very affordable form of treatment.
Brittney: I have a follow-up question that’s more for my personal knowledge ~ how do you deal with the frustration of seeing such disparity? Any advice there?
Christa: I would say that I’m the happiest angry person you know. I have a passion for social justice and there are a lot of areas where work needs to be done. I personally try to use that in focusing on systemic change and advocating for people with addictions and the accompanying issues in our community. It's the energy that propels me forward
Brittney: You touched a little on the trauma and the impact of ACEs but what would you like others to know about trauma and ACEs and the role that it plays in addiction?
Christa: Over the past 12 years, I’ve done hundreds and hundreds of intake interviews where we're trying to gather, in a shorter amount of time, as much background information on this new patient as possible. Of course, addiction affects all types of people for all types of reasons. That being said, over and over and over I see the same triad of circumstances with so many of our patients coming in for treatment. That triad is poverty, a family history of addiction, and trauma. With a family history of addiction, there’s sort of an inherent ACE within that. If the child has grown up in a home with someone who's an addict, that's often traumatic. The third part of that triad is trauma independent of that so often our patients have physical abuse, emotional abuse, and/or sexual abuse in their childhood histories and often violent or traumatic experiences that have come out of their addictive behavior. Essentially addiction work is trauma work. You can't really separate them.
Brittney: Right. What would you like others to know about trauma and how it plays a role in providing addiction services or the work that you do?
Christa: I think what I’d like people to know is that it's important to get away from binary thinking when it comes to trauma and addiction. What I mean by that is we're kind of taught growing up that drugs are bad and that by extension people who use drugs are bad. We have this binary of good guys and bad guys and that's pretty pervasive in our culture. If someone's committing violent acts and hurting other people that's not what I’m talking about but when we're talking about addiction and the behaviors that go along with that, what I see in our patients is someone doing what they think they need to do to survive on a day-to-day basis. If we can view the person not as good or bad but as a person in trauma trying to survive, that will shift our view of the person rapidly from someone to keep our distance from, to be afraid of, or in a place of judgment about, but rather to consider what this person needs to be stable so that they won't feel they have to steal, trespass, buy and sell drugs, and/or engage in sex work. Rather than viewing it as bad or good, I view it from a place of ‘okay what do we need to do to help stabilize this person’?
Brittney: You've kind of touched on the next question already, which is, can you share with us about how to change the stigma around addiction. Can you touch on the language as well because I know some people are hesitant about using terms such as addiction and the term methadone clinic is not necessarily the most positive connotation so could you talk a little bit about the stigma around speaking about addiction and treatment?
Christa: For me, we typically use the terms opiate use disorder or substance use disorder to talk about someone with an addiction. It's become a sort of an unconscious thing to just say it's a MAT program rather than a methadone clinic. We need to be viewing behaviors through the lens of trauma. It's also important that people view addiction through the lens of “the disease model’ and so addiction is considered a medical issue so it often does require medical treatment, in addition to mental health treatment. It’s not that the person is bad or weak. When people are able to start viewing it that way, It becomes a lot more difficult to divide it into that binary of good and bad and move to a more hopeful - and helpful - viewpoint.
Brittney: What's your favorite aspect of the work that you do in working with individuals healing from addiction and trauma?
Christa: Definitely getting to that AHA! moment with somebody when they make that connection between their behaviors, their triggers, and their trauma and realizing that they can make a shift in their response. I have two tools that I use when I am working directly with a patient but these really apply to anybody and anything. The two primary tools that I refer back to in working with someone... The first one is what I call the stock ticker. This is a helpful way to view anything in terms of our development as human beings. When you're watching the news and they're doing the financial forecast and they're talking about a company, let's say Coca-Cola. They talk about their profits and losses and they'll show that stock ticker of the ups and downs. Hopefully with a company that is growing the trajectory will be upright but it is never a straight line up. That simply doesn't exist. That's not how growth works. Let's call the starting point intake. Even when a patient’s not necessarily feeling that they're growing or changing, as long as they're coming in each day and sitting down with their counselors, that is growth. This brings us to another piece on bias and resilience that I think is important. In terms of community bias and coming to understand addiction in our community a little bit better, a question I often get from family members and people in law enforcement is “how long is this going to take”. That's a valid question but it's not one that can be easily answered for several reasons. First off, it typically takes a person five to seven attempts at treatment before they find stability and so these drops in the graph can represent anything from you've had a bad day to a relapse. For the purposes of working with my patients, when they relapse, which happens, it’s a part of that process of developing new resiliency skills. I hope that a person can enter treatment and never use again. That's great and it does happen but typically you're going to have some of these ups and downs before a person gets really stable. The part of the graph that displays an upward line is them working full-time, they haven't used in a really long time, etc. so when a person relapses and we're talking about it in treatment, I try to bring them back and say “okay you used and you're feeling terrible about it. You feel guilty. You're not feeling good physically but did you go back here (to the intake/starting point of the graph)? If you stayed in treatment, that's awesome. Even if you left and came back in, that's awesome. We can build on that. “Have you re-engaged with every single behavior without any insight into it?” And usually they say no and I ask,“well did you come back into treatment and did you get back on track?” “Yeah” “Well then your growth is still upward” and it's really important to view working through trauma, which is what working through addiction is, through that lens. When someone is willing to start viewing their setbacks as part of that growth process, they're always going to be able to build on that and that's a resiliency skill. I draw this for every single patient and we talk about it. It's my little visual prop and I give it to them. Is it gonna end up in the trash? Maybe, but sometimes, more than you might think, people will say “I keep this on my refrigerator” or “I keep it next to my bed because it reminds me that I didn't go back to my rock bottom”. My other analogy is the brick house. I’ll ask you Brittney and I’ll pretend you're a patient of mine. How do you build a brick house?
Brittney: You start with the foundation I assume. Gather materials and start there?
Christa: You're heading in the right direction. In the addict’s mind, with someone who's experienced a lot of trauma, they may not have the tools that you and I have to navigate the world. They're going to kind of just dump a pile of bricks down and call it a house. so what I talk about in therapy a lot is every day you build that house one brick at a time. It's essentially another way of saying ‘one day at a time.’ So every time I ask them to identify their bricks. Bricks can be acts of self-care and/or better choices. If today you stayed hydrated, you ate a banana instead of going to McDonald’s, you didn't use anything, you came into treatment, and you went to work, that's five bricks that you put down to build your house. The house is your recovery. No one can take that away from you. Relapsing can't take that away from you. Every time you're making these positive steps forward, you are building. Those are the primary types of resiliency skills we use at Stepping Stone.
Brittney: Would you like to share any more about defining resilience or what it means to you?
Christa: One thing I think is really good for folks to think of is stepping outside of their own model of what success is and allowing that success looks different for different people. Recovery looks different for everyone. One example of that is if somebody finds success in their recovery through 12-step meetings, that's awesome. If they find success going to an inpatient recovery treatment program, that's awesome. Don't look down on MAT if that's a person's path towards stability and success just because it's not the one you might have chosen. Are you familiar with Maslow's Hierarchy of Needs?
Brittney: Yes.
*For any reader who would like information regarding Maslow’s Hierarchy of Needs, you can find more information here.
Christa: It's ideal to get up to the very top of self-actualization and spiritual development but that's not realistic for a lot of people or they might get up there for a little bit and then come back. I mean that's the human struggle and so one thing this circles back to is the “how long will it take” question. There are so many factors that determine that. Let's talk about patient A and patient B as a hypothetical example. Patient A is an Appalachian State student, which we have. We have probably more college-age patients than most people might realize. This patient is going to school. They've still maintained school, they've got friends, they've got family, they obviously have some degree of socioeconomic status to be able to access education, so they've got this series of support systems. They probably haven't been using long relative to other patients that we see. Their level of use is not so advanced that their health has been greatly impacted and the other consequences of long-term addiction have probably not taken hold yet. So a person entering treatment at that point has, to be honest, probably an easier path towards recovery in front of them and a more straightforward path up to that top of Maslow’s Hierarchy of Need. Now Patient B is coming into treatment for the first time at 50 years of age. They've been intermittently homeless, for decades possibly. They've been in and out of prison for decades possibly. They've developed, say, hepatitis or other health conditions related to their addiction. That's a very different case. Patient A really started maybe midway up on Maslow’s Hierarchy, while Patient B is down closer to the base. They don't have secure housing, they don't have the security of their body, mind, or spirit so that's going to be a much longer path and there's nothing wrong with that. That's one of the biggest points to make.
Brittney: Yeah, so how can we learn more about the work that you do and the resources you're connected with?
Christa: People are certainly always welcome to check out ourwebsite which is primarily directed at potential patients who are interested in coming in. I love talking to people, as you can tell, about these issues so I would love to talk to anyone who is willing to talk to me. I’ve gone out and visited lots of community agencies and groups and I’m always happy to do that either remotely or in-person to answer any questions. People are welcome to set up a time to visit our center if they like. We are here and we are available.
Brittney: Anything else you would like to share as we wrap up?
Christa: Just that I appreciate what WCCI is doing. We’re in a place of gratitude towards you guys.
Brittney: Well, thank you for being willing to share. I know this is a topic that, as you said, is definitely a need in Watauga County.
Special thanks to Christa Capua and Stepping Stone of Boone, our Partnering Sponsor for the upcoming 2021 WCCI Virtual Conference: "Community is the Solution!". We are grateful for the work they do and the compassion they continuously spread in our community.
Registration for the Conference can be found at https://www.wataugacci.org/2021-conference.html
References:
Mcleod, S. (2020, December 29). Maslow's hierarchy of needs. https://www.simplypsychology.o...aslow.html#gsc.tab=0.
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