 Welcome to the presentation on models and theories of addiction, the socio-ecological theory. Over the next hour, we're going to define the socio-ecological model, apply this model to addiction, explore different variables that create this model, and discuss how this framework can be used in the prevention and the treatment of co-occurring disorders. The socio-ecological model was designed to try to explain human behavior as the interaction between individual and five different environmental systems. The key here is the interaction between. It's not just a one-way, the environment doesn't just act on the person, the person also acts on the environment and changes what they may be encountering. The five environmental systems are the microsystem, mesosystem, exosystem, macrosystem, and chronosystem, which we will talk about in the next few slides. So let's take a look at the model. I've put the visual representation right here. The individual is at the core of the model. His or her, sex, age, health, just general characteristics of the person are this foundational center dot. The individual exists within a microsystem. The microsystem are those people and systems that the person encounters on a daily basis, but those systems and those people may not encounter larger systems. So we're talking about basically the people that the person encounters roughly every day. So we want to look at family, peers, school, church, or religious institution, or recreational activities and health services. So in this person's microsystem, if you want to think about it in terms of like a map, you have the individual, which is your house, and the microsystem, which might be your city or your town. We're not talking the county yet. We're just talking this small little area that has the greatest amount of influence on what may be going on with the individual. And likewise, the individual has a lot of impact on this microsystem. So let's think about this for a minute, and we're going to really look at it piece by piece as we go through. If the individual is relatively healthy, let's say we start with someone who is relatively healthy, relatively functional, and they're immersed in a microsystem that is dysfunctional. There's a lot of violence and crime at school. The teachers are burnt out, don't really want to be there. There aren't very many recreational activities and opportunities outside the family in this particular town. The family is replete with people who are struggling with addictions or mental health issues or both. And the peers, there's not a whole lot to do since there aren't a lot of recreational activities except for maybe hang out and use. This sort of describes a couple of the counties that I used to work in. So you take a person who normally wouldn't, they don't have a whole lot of personal predisposition toward addiction or mental health issues. But if you put them in a situation where they're exposed to a lot of risk factors on a daily or almost daily basis, you can see how those things might impact the individual. Now the individual can make a choice about who they hang out with, if there are choices to be had, or they can extract themselves from that microsystem. Which when we go into recovery, we talk about changing people, places, and things. We're talking about adjusting that microsystem to create one that is supportive of recovery and wellness behaviors. The mesosystem is the interconnection between microsystems. So how does the family interconnect with the school, if at all? How does the family interact with peers, if at all? How does the family interact with health and wellness services? So is there family engagement in the youths or the individual's life? Is there some interweaving? Or are these microsystems sort of operating in isolation? They're impacting one another, but they're not positively involved. The relationship between the child's peers and the family can have a big impact. And I say child, because when we talk about the socio-ecological model, oftentimes we're looking at the development of an individual over time. But this can be true of anyone. Think about when you went to college and your entire microsystem, for the most part, really changed almost overnight. You went from having curfew and living under mom and dad's roof, all the structure of high school, all that sort of stuff, the friends that you always knew to, you know, for me, I went to school five hours away from where I lived. So everything changed. I was kind of like a fish out of water or a butterfly spreading its wings, depending on how you want to look at it. So how did I impact my environment? Well, when I went to college, I chose my peers. I chose my recreational activities. And those things reciprocally interacted upon me. You know, you choose healthy behaviors, then that's probably going to be reinforced in your life. You choose unhealthy behaviors. That's probably going to be reinforced. School, you know, obviously I went from high school to college, and that was a big change, trying to adapt to the different rules, the different structure of school. Looking at how school interacted with my peers, who was skipping class, it was going to class, those variables played a big part in it. So you can see how you change your micro system. You can really change the course of someone's development. Now, does that mean we have to take someone who is struggling with addictions or mental health issues and completely transplant them? No, it might make it easier for them, but it is not likely to actually be something that is doable. So we have to look at helping the micro system or helping them alter their micro system, instead of letting the micro system bring them back to where they were before treatment. See what I'm saying here? You know, you can't change your family. You were born into that family. So the person can either choose to go back to the same dysfunctional family patterns that were there, or they can choose to react a different way, which will probably impact how the family reacts with them. So these are our first two systems. And remember, there's five. So this is a complicated, complicated theory. It does do a better job than just about any of the other things that we looked at at trying to account for the multiple reciprocal variables that are involved in the development of depression, anxiety, addiction. The exo system involves links between a social setting in which the individual does not have an active role and the individual's immediate context. So the exo system is like your spouse's work or social services, mass media, local politics. You may not have an active role in it on a day-to-day basis or even, you know, on a once a week basis, but it does have an impact on you, your neighbors. If you live in a neighborhood that has a homeowner's association, this is one of those exo systems. You may not have an active role in that on a regular basis, but it does impact how you keep your yard, how you paint your house, how you do all kinds of things. The exo system is important because it sets a tone in a community. It sets ground rules. And when we start talking next week about risk and protective factors, we're really going to hone in on the fact that neighborhood disorganization and lack of a sense of connection to the neighborhood and to the community are huge risk factors because people turn a blind eye and they don't develop social supports within the community. So we'll move on to macro system, which are the attitudes and ideologies of the culture. Describes the culture in general that the person exists in, American culture, for example. We can look at it on a slightly smaller scale such as socioeconomic status, but we're looking at how is this person surviving within the larger culture, not just their community, not just their county, not just their state, but on a bigger level as a human being. How are they interacting and interfacing and the chrono system. Now, this one's kind of interesting because you've got to think we're thinking tangible sort of systems right now as they get bigger and bigger and bigger. The chrono system involves all the events and transitions over the life course as well as social historical things. For example, my life was going along and I decided to go to college. So that was an event and a transition in my life. I got married. That was an event and transition in my life. I had a child. That was a big event and big transition. My child, you know, I hadn't had children. So I was under the foolish thought that I would work on my dissertation while he would sleep. He didn't sleep ever. The poor little guy had gastric reflux so, you know, it wasn't his fault, but for the first three months that he was home, he would sleep for 15 minutes at a time, which means I would sleep for 15 minutes at a time. So a lot changed as a result of my micro system changing. I had to become more flexible. I had to change the way I did things a little bit as a result of this new little person in my life. Deaths, moves, job changes. Emptiness syndrome. All of these major changes that sort of shake up the way you do things need to be considered in the chronic system. The other things that we need to consider are diagnoses. If you get a diagnosis of heart disease or kidney disease or something that may impact the way you interact with the environment and other people, it's going to be important to consider that. Now the CDC uses a four-level socio-ecological model to better address addiction. This model considers the interplay between the individual, the relationships, the community, and societal factors. So this is sort of a very, very simplified version of what we were talking about in Bronfenbrenner's model. The model suggests that in order to prevent addiction, mental health issues, it's necessary to act across multiple levels of the model at the same time. So let's think about this practically. Does that make sense? Do we need to act? Can we expect recovery if we just provide treatment to the individual and affect nothing else in the world? Chances are, no. I haven't seen people experience a lot of success when all we're doing is working with them. What we need to look at is what things in their environment can we help them work on? I mean, a lot of our clients come to treatment and they are in treatment by themselves, if you will. It's not a family treatment. It is Jim Bob coming to try to start feeling better. But Jim Bob probably is coming out of some sort of dysfunctional micro system. We don't know what's going on, but we know that since he has been behaving and acting with certain behaviors, that has probably created or influenced the micro system. So we need to look at what is it that we can help Jim Bob change in his micro system that can help him embrace recovery and wellness behaviors. We want to look at the family, peers, health behaviors. Those are kind of the three big ones. This approach is more likely to sustain prevention efforts over time than any single intervention. So instead of just saying, all right, Jim Bob, I want you to figure out, I want you to learn how to change your thinking and use the ABCs of REBT and everything will be wonderful. Well, Jim Bob can do that, but it is not going to be a panacea, and over time, its ineffectiveness will start wearing down his desire to use it, his motivation to use it, and he'll probably fall back into old behaviors. What we need to remember, and this comes from systems theory, is that a system wants to maintain homeostasis. It wants to maintain balance, and if it forms balance around dysfunction, then when you take somebody who has changed and plop them back into a balanced dysfunctional system, it's going to become unbalanced. So either the person has to change and revert to dysfunctionality, or the system has to change and revert or move on to recovery. So individual factors, we want to look at biological and personal history factors that increase the likelihood of addiction or mental health disorders. We're going to look at risk and protective factors. We're going to look at family history of addiction. We're going to look at the family environment, and remember when we talked about theory of addiction, we're going to look at what social learning influences from that micro system may have increased the likelihood that this person may choose addictive behaviors and or may experience mental health issues. Now people don't choose mental health issues. They may learn dysfunctional thinking patterns that contribute to depression and anxiety. They may be exposed to a micro system that is very, very stressful and promotes depression and anxiety instead of health and wellness. But people don't wake up in the morning and go, you know, I think I'd really like to be depressed today. Now people don't say they really want to be an addict today, but they may wake up and say, you know, I'd really like to get high today. So there's a little bit of a difference here, not a whole lot, but it is important to recognize that there's a lot in that micro system that can be adjusted. And just like if you've ever, you know, I'm one of those people I can't stand to have strings and if I have a string that is hanging off the shirt, I will pull it. Now when you pull a string, unfortunately I found out over and over again that it generally doesn't just snap. It starts to unravel the whole shirt or the whole sweater or the whole hemline. We can use that analogy in a positive way and think to ourselves, well, if we help Jim Bob create one positive environment, if we pull one positive string in that micro system, guess what? It's probably, it is going to have a reciprocal effect on the environment. It's going to have a positive one. If he stops being stressed out and negative and using all these cognitive distortions, people are going to observe that. People are going to notice that and it may lower the stress in that system. I'm not saying people are going to observe it and go, I want to be just like Bob. I'm going to do the ABCs. I'd like to think that, but it's not going to happen. Any change you make in a system is probably going to have similar reciprocal effects throughout the system. So little small changes will produce little small changes for the better or for the worse. We don't need to build, try to build Rome in a day. Let's just start with trying to get the site level before we even start pouring the foundation. We want to look at preexisting mental health issues. Maybe Jim Bob has been struggling with depression or anxiety since he was knee-high to a grasshopper. If that's true, there are probably, because of those reactive neurological pathways, he probably has developed some inaccurate thought patterns or cognitive distortions or whatever you want to call them. Because when you're little, especially when you're knee-high to a grasshopper, kids think in all or nothing terms. They're not able to think in shades of gray until they develop further along. So if things stressed him out, then he may have internalized these things and figured that those things always and forever would stress him out. We can help him start changing his black and white thinking. That's not changing how he thinks about, you know, and thinks all day long about everything. We're just encouraging him to notice his black and white thinking and change it to something that's less dichotomous. Encourage him to look for exceptions. Anyhow, I digressed. Individual factors, so these preexisting mental health issues may set him up to be more likely to develop worse mental health issues, other mental health issues or addiction issues. Does it mean he will? No, by no means. But it does pose a risk factor. Chronic pain is another individual factor, whether it's fibromyalgia we're dealing with or, you know, maybe Jim Bob played football in high school and blew out his ACL and now he has knee problems or back problems. We all know somebody who has a football injury and they're 45 years old and still talking about it. I have to believe that still causes them chronic pain or they wouldn't talk about it. So the impact of chronic pain is one that we really need to not dismiss. What is painful for one person may not be a big deal for another, but if it's painful for somebody, then it's going to affect their attitude. It's going to affect their stress tolerance. It's going to affect their mood. It's going to affect possibly their sleep, which will also affect their attitude mood concentration. You see how this is, you know, reciprocal changes. So we need to address the chronic pain. We need to look at it and say, okay, this may be a risk factor for you, you know, having some other issues. People who have chronic pain also tend to be more likely to develop depression. Why? Well, if you're in pain all the time, there's that sense of hopelessness and helplessness. You wake up and you're like, oh, everything hurts. Those of us who are blessed with not being in chronic pain all the time, we've had injuries. We've had things that have happened and you wake up in the morning and I'm getting over a shoulder injury right now and I wake up in the morning and I'm like, oh, it still hurts today. And it frustrates me because I can't do the things I want to do. I can't do the things I feel I should do. And we know should's a nasty word. That wears on a person after a while if their chronic pain is enduring. So hopelessness, helplessness, preexisting mental health issues, chronic pain, which may also impact sleep as well as mood and low self-esteem. If the person didn't develop a healthy self-esteem when they were growing up, they are at a greater risk. It is a risk factor for the development of addiction and mental health disorders. So you can see how there are a few things that we can key in on during our assessment. Is this all of the individual factors? No means, but it's a start. Biological and personal history factors increase the likelihood of addiction or mental health disorders. Some other factors that we want to look at are age, education, income, substance use, or history of abuse. So what do I mean? What is overwhelming, exhausting, depressing, terrifying to a five-year-old is going to be different than what is overwhelming, terrifying, exhausting to a 25-year-old. Because developmentally, we've had more experiences. We've developed more coping skills. We can handle things differently. And cognitively, we're just more advanced, if you will. Education, sometimes knowing is half the battle. So once people develop the ability to do research as a double-edged sword now with the internet, but someone with a higher educational level typically rationalizes, looks for answers, does research, instead of just going, oh my gosh, I don't know what to do. If the person has substance use currently or a history, we want to look at that because that will impact how they're dealing with life on life's terms. And do they have a history of abuse? There have been studies that have shown that a history of abuse and neglect while the person grew up may cause brain changes, changes in the development of the child and adolescent brain. We need to consider all these factors. And there's a whole set of classes that I do want on PTSD that we can look at and talk about some of those things. But it definitely influences how people look at their environment. Now think about this. If a child grew up in a household where there was a lot of domestic violence and they were in another situation, maybe five years later, they're in another situation and across the room they see somebody that looks kind of angry talking with large movements. What is their interpretation probably going to be? I grew up in a household where we were loud all the time and we use big gestures. If you've watched any of my videos, you know I gesture constantly. I'm not angry. That's just how I talk. But the way I interpret that situation, that person standing over there, I figure they're probably recounting something to the person they're talking to. A person who grew up in an environment that had a lot of violence may start to feel anxious and want to extract themselves from the situation, fearing that that person that is speaking with big gestures is angry. So you can see how prior experiences affect our interpretation of what we see. They affect our interpretation of our environment where one person may see it as perfectly safe, another person may feel threatened. Prevention strategies are designed to promote attitudes, beliefs and behaviors that ultimately provide the person with healthy coping skills and awareness of positive health behaviors and the ability to effectively communicate. We need to help them change the way they think. We need to help them change the way they take care of themselves because we know there's a connection between the mind and body and we need to help people effectively communicate their needs, wants and desires to those around them, creating a micro-system that is more supportive of what they need. Specific approaches may include education and life skills training. The relationship, the second level that we need to look at, examines close relationships that may increase the risk of experimenting with high-risk behaviors. Peers, family, neighbors. A person's closest social circle, their peers, partners and family members influence their behavior and contribute to their range of experiences. So if you grew up in a household, my household was rather protective and as such, I'm forty-some years old, I still don't know how to ride a bike because my mom didn't want me out riding a bike. I never had one, never learned how. That influenced who I interacted with. I mean, I couldn't go out and ride bikes with the people in the neighborhood because I didn't have one. So we want to look at what is the social circle? What are the peers, partners and family members modeling? What are they outright teaching? And what are they trying to achieve in their life? Risk factors include a lack of family involvement. If Jimmy can come home from school and nobody even notices exactly when he comes home, he goes up to his room, shuts the door, comes down long enough to grab a plate, goes back up to his room, goes to sleep, gets up the next morning, leaves for school before anybody notices. That's a much different environment than a family where Jimmy comes home, you know, maybe mom and dad are at work, but he calls mom and dad or sends him an email and says, hey, I'm home. They say, how was your day? He says, fine. Then he goes up to his room, plays video games, comes down, eats dinner with the family. Now, you know, and that looks different for everybody, but I'm kind of giving you two extremes. Dinner with the family does his chores, does his homework at the dinner table or at the computer in the living room and then may go to bed. Very different levels of family involvement, very different levels of family influence. The first version, Jimmy's basically avoiding his family and not going to be influenced very much at all by what they are doing. When I hear that, I'm wondering what he's trying to avoid. What's the benefit of not hanging out with the family? Makes me look at what's going on with the family that is so comforting. A lot of times when we have youth and adolescents in treatment, we can't go, oh well it's not you, it's your family. That is a dysfunctional bunch. So we have to figure out how to help the patient deal with it. But understanding what this lack of family involvement looks like and why it is there. And the why it is there is so important. If it is more harmful for Jimmy to be involved with the family, then we don't want to have as one of our treatment recommendations you'll eat dinner with the family every night and spend two hours with them. That might make him want to pull his own hair out. Other risk factors in the relationships are parents or siblings with mental health problems or addictions. Not only because that says there may be a genetic predisposition, but also because it says that there's an environment where someone is struggling for one reason or another. That puts stress on the rest of the family. That can be exhausting to the rest of the family. That person with mental health problems or addiction may also be modeling unhealthy behaviors. So when we think about social learning, we think about what this neutral child is exposed to. What are they learning? What are they experiencing? And what is the impact for that child of these other people and their family? And peer pressure. Well, that goes without saying. So I'm not going to be labored the peer pressure issue. We know that that's a big issue. So what do we do about it? Strategies for prevention may include parenting or family focused prevention programs. We tried to run some of those when I ran the facility in Florida and we had some limited success. But a lot of times parents couldn't or wouldn't a lot of times couldn't commit to, say, 16 week programs. So how can we take these programs and make them so they're accessible? If you're going to provide them, they have to be accessible and they have to be tolerable. If it's one of, you know, think back to when you were in grade school and I think you know, a lot of us still remember those videos. They were actually still on the on the movie reel that were from like 1940 and you would just sit there and listen to the narrator and go, oh my gosh, this is laughable. Okay, those are not going to work. We need to make something that is engaging, that's practical, that's meaningful to the parent. We don't want to talk about a bunch of meta concepts, you know, like we're doing now. Because it doesn't matter to them. They want to know what's the problem? What's the solution? How can I implement it? And it needs to be presented, like I said, in a way that is accessible to them. You know, if they're working an hourly job, they can't just take off to come, you know, participate in a program because they're going to lose money and a lot of times they need that money to do things like buy food. Mentoring and peer programs, those are wonderful if you can get them going. Because it encourages youth to hang around with pro-social youth. And this also includes like after-school activities and church programs, community recreation programs, drama clubs. The idea here is we want the relationships to help improve the person's self-esteem, foster problem-solving skills and promote healthy relationships. Teach them how to communicate. Teach them how to interpret verbal and nonverbal communication. Teach them to identify what it is about themself. That's really awesome. Then we move on to the community. We want to identify characteristics of settings in which social relationships occur which are associated with developing addictive or behaviors or mental health problems, such as schools, workplaces and neighborhoods. So let's start with schools. If drugs are available, that's a problem. If there is a lot of violence, peer pressure, bullying, lack of ability of teachers to monitor what's going on, all of those things set schools to be a problematic place. Now you can't have schools, it is possible to have schools where teachers teach and they're able to supervise and deal with things. That is on the school, the township and the parents that are involved to figure out how to make that work because we do expect a lot out of our teachers now. Workplaces. If parents are going to workplaces that are burnout work environments, stressful workplaces, they don't know if they'll have a job tomorrow, they're getting paid minimum wage. There's a lot of things that make work stressful or dysfunctional. Anything that is going to create a situation where a person can feel helpless, hopeless, stressed out, or need to escape, we need to address those things. We need them to feel hopeful, empowered, not as stressed out, you know, able to handle the things they can change and let go of the things they can't. And we want them to generally feel happy. I may not want to go to school, I may not want to go to work, but generally it's not something that I'm like, oh my gosh, don't make me do this again. Most days you want people to enjoy or at least not dislike going to where they work or go to school. And then the neighborhood, if there is low community involvement, if people are moving in and out all the time, that's a risk factor. When people are in the same community for a while, in the same neighborhood, you get to know the cars, you get to know the people. So there are less risk factors for interlopers coming in. There are less risk factors for things to get out of control in the community where bad elements have integrated, where people are committing crimes and car burglaries and all that kind of stuff. People watch each other's back when there's community connection. Neighborhoods that aren't safe, neighborhoods where there's a lot of drug activity, those are things that are going to be problematic. Prevention strategies at the community are typically designed to impact the social and physical environment by reducing isolation. Get people to come out of their apartments, come out of their houses, meet their neighbors and say hey, you know, I know that you work nights or you work days so you can watch out for one another. Improving economic and housing opportunities. If people are not struggling to survive and they've got a roof over their head, think Maslow's hierarchy. Get those basic biological needs met and people are going to do a whole lot better than if they are hungry, homeless, sick and exhausted. Improve the climate, processes and policies within the community, school and workplace settings. This is those meta concepts again. We want people to feel comfortable in their community. We want people to be proud of their community and we want people to feel supported by their community school and workplace. So we don't want an environment where people are just waiting for the other shooter drop or they're expecting to get thrown under the bus every time they turn around. We want to encourage a climate where law enforcement works with the community. It's a partnership, not an adversarial relationship. And societally, the broad societal factors that help create a climate in which addiction is encouraged or inhibited. So we're talking about mass media. We're talking about the internet mass media. Other societal factors include policies that encourage recovery and health like health policies. Do people have health insurance? Do people have access to get what they need in terms of health care? Preventive health care. And can they get enough nutritious food? Economic policies that encourage recovery and health care. Even things like can food stamps be used to buy cigarettes. That's one of those things that we need to look at. Educational policies. We want people to feel like successes at school and at work. We want them to feel like they have opportunities. We want them to have hope and empowerment. That's what the educational systems designed to do. Help them figure out who they are, what they want, and feel like they have the world by the tail. And social policies that encourage recovery and health. Many communities I guess this is true of the southern communities. I haven't lived up north very much, have a lot of policies and activities. A lot of parks. A lot of 5K runs, half marathons, health related behaviors, open farmers markets. Things within the community that encourage people to eat healthfully, exercise, get out, know one another. And just generally care about one another. Prevention strategies at the societal level are typically aimed to reducing the availability of addictive substances. If we get rid of the addictive substances, that would be great. Because then we can stop this whole dopamine overload thing. Reality is we may be able to get rid of some of the illicit substances, but that doesn't take away the behavioral addictions and that doesn't take away alcohol and some other things. This is only a partial solution. Increase availability of treatment. So people who are currently starting to struggle can get into treatment before it becomes a big huge issue. The other thing we want to do is really look at putting prevention strategies in place early on in the school systems in pediatric clinics. Helping parents learn how to teach their children how to cope with life on life's terms. Because we don't think about it. When my son was a little poor thing, I talk about him all the time in these things. He was a micro-premie. He had a physical therapist and an occupational therapist for several months after he came home and passed that gastric reflux thing. The occupational therapist would come to our house and would work with him 3 days a week and some of the things I just assumed he knew how to do. He didn't know how to do. Now, and you've got to remember I've already taken developmental psychology. I'm working on my doctorate and I don't realize that he doesn't understand he can stick his hand into a clear glass bowl to retrieve a necklace. We are not given an instruction manual for building self-esteem for helping people develop positive coping skills. And unfortunately these are things that are not taught very well. And my little soapbox, I think if we did a better job of teaching those things early on we could set people up for success and able to deal with some other issues as they come up. We can also help people learn more effective coping skills. But a lot of grown-ups don't have effective coping skills. So how can they teach them if they don't have them? And we want to alter media portrayal and societal attitudes toward addictive behaviors. Right now it's just another one of those things on the internet or on the news or on the this or that about who's going to treatment. It's almost a fad whereas we're not really focusing on the devastation that clinical depression, generalized anxiety, PTSD and addiction can cause. And those are only a few. I mean there's a whole DSM full of diagnoses that create quote clinically significant distress. We need to start taking these things seriously. So the bio-socio-ecological model they threw in the bio to take into account the individual factors that the person is born with. Identifies how the individual impacts and is impacted by not only his own characteristics but also those of family, peers, community and culture. Prevention can take the form of preventing the problem, preventing worsening of the problem or preventing associated fallout from the problem. So we can prevent the addiction all together or if somebody starts to develop an addiction we can keep them from getting worse. We don't want the addiction to get worse and we don't want them to develop multiple addictions and we want to prevent associated fallout. We don't want them to also on top of the addictive behaviors develop some significant mental health issues, financial difficulties, homelessness, yada yada yada. So there are multiple levels of prevention. We're not going to necessarily be able to get in there before the problem starts all together. We need to get in wherever we can and work backwards from there. Any change in the system will have an effect on all other parts of the system. If it's a good change, it'll likely have good changes. If it's a bad change, it's going to likely have bad changes so we need to pay attention to what's going on and it can be a small, small thing. We don't need to make these huge sweeping readjustments. Addressing addictive behaviors requires a multi-pronged approach looking at the individual, family, community, and society. If you have watched and participated in this program for CEUs, log into the classroom at allceuse.com and you can take the quiz. If you've watched and participated and want CEUs but have not yet registered, you can purchase access to the quiz and certificate at allceuse.com slash live-interactive dash webinars. This presentation was recorded as part of a live interactive webinar. If you're watching it on replay, please remember you can always contact Dr. Snipes on her personal chat page, purechat.me slash qtvx.