 Test, test, test. Okay. Hi, and welcome to the presentation by allcews.com. Today we're going to be discussing risk factors for co-occurring disorders. Over the next hour, we're going to define risk factors, identify risk factors for addiction and mental health issues in the following domains. Individual, peer, family, work, school, and community, and discuss similarities and differences between risk factors for each disorder. So what are risk factors? They're actually those characteristics affiliated with persons who are mentally or physically ill. These are things that make it more likely for someone to develop or worsen a condition that they already have or that they could get. That makes no sense. It considers the individual, peers, work, school environment, and the community. So remember, co-occurring disorders are the expectation, not the exception. So whether we are talking about did mental health issues predate the addiction or did the addiction predate the mental health issues, either way, it doesn't really matter. By the time they get to treatment, they've probably got both and we have to deal with both. If you deal with only one, you're going to end up with someone who's in a high risk of relapse. If you take away the addiction, the behaviors that are helping them to survive for right now, the mental health issues will likely not do so well because they don't have any other effective coping skills. If you leave the addiction alone and treat the mental health issues, yes, you might have someone who is functioning a little bit better. They may be engaging in the addictive behavior a little bit less, but we know that the power of that dopamine reward system is strong and the addiction, the addictive behaviors are still going to be there. So people are going to go back to this and while they're still engaging in this behavior and flooding their brain with happy chemicals basically, they're creating an imbalance. So they're not going to be able to fully recover from their mental health issues until the addictive behaviors are stopped. We have to remember that the addictive behaviors, again, are motivated by the time someone has developed a full-fledged addiction, not only by trying to escape the pain of whatever is going on in their life, but also the reward of the dopamine system and the feelings of pleasure, happiness, contentment, relaxation, whatever it is that they get from their addiction. So individual risk factors. Lack of accurate information on the prevalence and risks of use. So there are a lot of people out there who think everyone fill in the blank, everyone smokes pot, everyone drinks, everyone takes pain medication, whatever they think, or they think it's a lot more likely than it really is. Or they don't realize the high risk of use, whether it be the risk of getting caught and having legal problems or the risk of addiction because of kind of monkeying with their brain chemicals. So we need to help make sure people have accurate information on not only how much people are actually using this drug, this behavior, but also what are the risks? How likely is it for people to become addicted to this behavior? Perfect example is internet porn. A lot of people will say, well, everybody looks at porn, and that's not true. There is a certain prevalence out there, but our brains were never wired for never ending novelty, so the risks of use are actually quite high. When we look at genetic vulnerability, some people may be more reactive to certain drugs, certain addictive behaviors. Some people may have a depressed or highly anxious predisposition, if you will. They may have already been depressed or anxious, so when they start using, they feel normal. And it's this feeling of normality that makes them want to come back and continue using. So therein, we're looking at genetic or biological vulnerabilities. Pre-existing mental health issues, whether it be depression, anxiety, or difficulty with socialization, difficulty forming social relationships, all of these can lead to mental health issues that are, I don't want to say ameliorated, but seem to be fixed or helped out when someone engages in their addictive behavior. Now, when we look at it, we understand that it's all of facade. The person is either self-medicating or they are using the drug or the addictive behavior in order to relax enough to engage socially. So we need to help them develop the skills so they can do it without the addictive behavior, which takes us to poor coping skills. People with mental health issues, as well as people with addictions, tend to have poor coping skills, whether it be because they'd never developed them very well or because the coping skills they have are just completely overwhelmed by whatever's going on in their life right now. It depends. One thing we know is they're not able to deal with life on life's terms for one reason or another, whether it's causing a mental health issue, an addiction, or both. We need to help them figure out, find exceptions. When you are feeling okay, I'm not even going to say happy. When you're feeling okay, what is different? How are you coping? What things do you do to help yourself feel better? We can build off those. Use their strengths. Try to reinvent the wheel and say, okay, let me teach you this whole new skill. Ask them what's worked in the past. Build off of that. That will also give you an idea about what new skills might be integrated well because of their prior learning history. And lack of involvement with positive peers. We know that in depression, anxiety, and addiction, and stress management, for that matter. Positive peers or dysfunctional peers tend to make things worse. And positive, pro-social, healthy, supportive peers tend to make things better. They model healthy coping skills. They are able to set adequate emotional and physical boundaries. It's a wonderful thing. Poor health-related behaviors. In an addiction, people don't really care about eating right and getting enough sleep and all that kind of stuff. They want to feel better. They want to feel normal or they want to feel numb. But that's their priority, not figuring out whether they're getting enough protein. Poor health-related behaviors can lead to or compound mental health issues because we're not giving the body the building blocks it needs to make the neurotransmitters. It needs to function and keep that homeostatic balance going on in the brain. And we're also not giving them the energy that they need and the proper nutrition that they need for their body to rebuild. Whether it's mental health or addiction, both depression, anxiety, and addiction take its toll on the body, not just the brain chemicals. But when your heart is beating half again as fast as it should, when you're shaking all the time, you're burning through calories, you're burning through energy. The body needs time to rest and recover. Inability to self-soothe and self-regulate. In mental health issues, we see this a lot. But also in addiction, a lot of times the addiction itself is used to help the person self-soothe or self-regulate. With individual risk factors, we want to look at the person as a whole and we want to ask them, what is it that you are willing to work on? If we could do one thing right now to help you start feeling better tomorrow, what area would it be in? Do you want to look at coping skills? Do you want to look at developing healthier relationships? Do you want to work on your mental health issues? Do you want to work on nutrition and sleep and all that kind of stuff? What is it that you're willing to do right now? People are not going to be willing, most of the time, to do, actually, quote, whatever it takes. And we don't want them to try to change six things at once because we're setting them up to fail. No more than one or two major changes and maybe a third minor change at one time. Just let them master a couple of skills because we know that if they start having success, that will improve their self-esteem, that will improve their sense of empowerment and work against that hopelessness and hopelessness. But also, if we give them these successes, the positive effects not only of whatever it is that they're working on, but also just succeeding are going to have ripple effects, positive effects in all other areas of their life. You don't need to try to just tear it all down and start from scratch. Start making small changes. In both mental health issues and addiction, we see people have a lack of information on positive health behaviors. And I've harped on this before, and I'll harp on it again. Unfortunately, a lot of times we present information in ways that are not helpful for the average person who is dealing with mental health issues or addiction issues, and maybe not even for the average person, period. Most adult learning best practices say when you teach somebody something, especially an adult who has 16 things going on at once, we need to give it to them in bite size pieces. We need to make it applicable to them. It has to be useful, so bite-sized and useful and frequent. So we teach something, and what are the spots, oh, golly, the little commercial things that provide public service announcements. Thank you. Those are a perfect length. 30 seconds to a minute and a half to give somebody a little bit of information that helps them see why is this information that I'm getting ready to hear important to me. They get the technique or the tool or the information that's important to them, and then they get a summary that helps them take it back and go, this is why this is important, and this is how you can apply it. We need to answer, you know, the basic questions. Who is it important for? What is it going to do for me? Why do I care? How do I do it? And, you know, what can I expect? We can also do this by handouts. You know, it would be great if there were little handouts that people could get every single day or little snippets they could get on their phone through push notifications every day. Someone has to be willing to sign up for the push notifications, but that is one thing you can do is give somebody a tidbit every day. Low self-esteem is prevalent in mental health and addictive issues. They don't feel good about who they are. They never learn to be proud of themselves for who they are. And there's a lot of reasons for that. You know, it may never have been there, or they may have just been figuratively or literally beaten down so many times. They just gave up, which also goes to a lack of confidence. Remember, hopelessness and helplessness underlie depression, underlie anxiety, and underlie addiction. So if we can give somebody a sense of hope and a sense of empowerment that can do attitude, we're going to help them on their way. And I take it back to the Serenity Prayer. Now, whether you want to use it as a prayer or a saying or whatever it is that works for you, grant me the Serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. How many times do you have a patient in your office that is getting exhausted, emotionally drained, physically drained, trying to change things that they can't change? It's like leaning up against a building with their shoulder and trying to move it 10 feet to the right. It ain't going to happen. That is not something that they can do. So we need to help them figure out what things can they change? And how can they do it? And then what are they going to do about the things they can't change? If they really want that building moved, what are they going to do about it? And if it can't be moved, how are they going to deal with it, either let it go or change their approach to whatever it is that makes them want to move the building? People need to realize that a lot of their sense of helplessness and hopelessness comes from trying to change the unchangeable, instead of focusing on what they can change. See, that's a snippet that they can use right there. Peers, reinforcement of negative norms and expectations within a peer group. We get our idea about what, quote, everyone does from our peer group. If you're hanging out with a peer group where everyone does smoke pot and everyone does shoot heroin and everyone does fill in the blank, then you're going to get the sense that everyone does do that. I'll give you an example. Social networking can have its positives. And I've got friends in multiple places. I enjoy chatting with them. But I am not a night owl. I like to go to bed between 8 30 and 9 30. That's when I like to go to bed. I like to get up between 5 and 6. But I like to go to bed between 8 30 and 9 30. And for the longest time, I didn't realize how many people did that. I thought I was just an old fogey going to bed at 8 30 at night. And as I've started to talk with people that are in my age group and outside of my immediate social circle, I realize how much more common it is for people to actually go to bed at what I consider a reasonable hour. So it's these norms and expectations that you see within your peer group that you automatically expect are what's going on outside in the macro system. Peers that think alcohol, drug use, porn use, any sort of addictive behavior is cool. Now there are people. I spend the majority of my career working with people in the military and law enforcement. These guys are adrenaline junkies. And they really thrive on spontaneity and they thrive on risk, that rush they get. So why am I bringing that up? Because you can get addicted to adrenaline. You can start doing things in order to get that rush. And if you're not constantly getting that high level of stimulation, some people start to get really, really antsy. So if you think and the peers in your peer group think that certain behaviors are cool, then those are the certain behaviors that you're probably going to reproduce more often than not. Inappropriate sexual activity among peers and ties to deviant peers or gang involvement, mafia involvement, obviously. If you're hanging out with people who are still actively in their, if you want to say, their criminal mind, if they're actively working criminal behaviors, whether it be youth or adults, then it's probably going to be a high risk factor for addiction. You're setting yourself up. You're putting yourself in situations that are more risky. Now, does that mean you have to cut all ties with peers? Maybe it's somebody you grew up with since third grade and your best friends, but they happen to be dealing drugs. That's a decision that everybody has to make on their own. And if the patient themselves is not addicted to drugs and they want to still hang out with their best friend from third grade who happens to be dealing, there have to be certain boundaries set in order to make sure that the person who is not addicted maintains healthy physical, emotional boundaries and is not put in risky situations by hanging out with this person. It is possible for deviant peers to not be deviant 100% of the time. It's a balancing act. Bullying and hazing leads to a lot of mental health issues. And we're seeing that even more, oh my gosh, we're seeing that so much more with, again, social networking, because we have something called internet inhibition, where people will say things online that they would never dream of saying to your face. There is a lot of misinterpretation and miscommunication online. People take things, sometimes they take things personally that shouldn't be taken personally. And sometimes they take things personally that were meant to be personal, but had no business being said at all. So we look at bullying and hazing, and even in our current political debates and everything, people are just being hateful to one another. So the question is, how do we help youth and adults for that matter? Deal with this. Let it roll off their back like water off a duck. It's easier said than done. Part of this is making sure that the individual has a strong sense of self, a strong self-esteem, and strong, healthy peers. So they're not relying on validation from anyone and everyone, which takes us to lack of acceptance. A lot of people who have depression, anxiety, addiction issues have issues with needing people to approve of them, because they're not OK being who they are and just period. They need and they want people to validate them, people to tell them they're OK, people to respect them, people to want to be around them. Now, is it wrong to want people to be around you? No. However, if you have to have that in order to feel OK, then you're setting yourself up for a very risky situation. Family, family conflict is common in both addiction and mental health issues. We see this in the addicted family when we talk about the different roles in the addicted family, the hero, the mascot, the scapegoat. There are a lot of different roles that people take on in order to try to survive the addicted family. At a certain point, most of those roles fail to meet people's individual needs. So they start feeling isolated. They start feeling not accepted. Watching family conflict all the time is also just exhausting. However, part of it is cultural. And it's important to understand that some families and some cultures tend to be a bit louder and more argumentative, if you will. Oh, everybody loves Raymond. It was a sitcom that was on some years back. And the two of them fought like cats and dogs constantly. I mean, they were constantly bickering about something or another. You could tell that they loved each other, but they were constantly bickering. Now, is that kind of family conflict going to set someone up to be at risk for addiction and mental health issues? You could argue whether that is or not. Obviously, family conflict, where people are throwing things, telling each other how worthless they are and how they hate each other, that's a whole different level. So it's important to look at the degree of family conflict and what underlies all of it. Some people just like to debate. They like to argue. Some people go into the field of law because they just like to argue. Family history of addiction or mental health issues predisposes people to addiction and mental health issues, whether it be from genetics or social learning or both. In meshed or detached relationships, common to both addiction and mental health issues. If especially if the parents are all up in the child's business or completely emotionally detached, the child has difficulty with acceptance. If the relationships are in meshed, then they feel like they have to be whatever the parent tells them they are supposed to be and they have to feel the way the parent tells them they're supposed to feel. And they feel very controlled, like they can't breathe. They're being puppeted, like marionettes. In the detached relationship, the child often feels unaccepted and unappreciated because the parents just not stinking there. They may be there in body, but they don't pay any attention to the children. So it's important to recognize that there's a healthy level of boundaries and as children grow older, obviously they need more space to go out and try things, but they need to be able to come home and know that there's going to be somebody there to provide them emotional support. And lack of parental awareness. If parents are just checked out, then mental health and addiction issues can develop and flourish before they're even really noticed. It's important that parents be aware. And it's also important in adult relationships, you know, to be aware of whether it's your friend or your spouse or whatever, because a lot of times as outsiders, we can notice things before somebody else does. The same thing works in reverse when someone starts taking antidepressants or going to therapy or making changes. A lot of times the other people, the people in the person's immediate social circle will see the positive changes before the person really feels them. And then, you know, if you point them out, the person may go, you know, you're right. I actually have slept six solid hours for the past week and I'm feeling a little bit better. Encouraging people to be mindful and take an inventory of how they feel. And awareness when somebody starts feeling not so hot. I mean, we talk about relapse prevention and part of relapse prevention is understanding that the relapse happens long before the person becomes clinically depressed or picks up or uses their addiction again. The relapse starts happening long before that and they kind of white-knuckle it and try to hang on until everything just gets overwhelming and it all crashes. Work in school. It's so important to have clear expectations about what is supposed to happen for mental health and to prevent addiction issues. Think about working in an environment where you are overworked, there's little positive reinforcement, rapid unpredictable change, destructive communication styles and an inability to resolve grievances, okay? So think about this. You go to work, you know you're gonna have more to do than you could possibly get done. You know that if anybody opens their mouth, it's just gonna be to complain or to gripe at you. And you don't know from one minute to the next exactly what's gonna happen. You may be transferred, you may be pink-slipped, policies may change, it's just constant ebb and flow. There's no structure and there's no standard. I'm a structured person that drives me absolutely bonkers when things are constantly changing. And then destructive communication where the only thing that is ever said is you shouldn't have or you need to explain to me why you did this, that and the other. It's very punitive, very condescending, very authoritarian. Compound that with the inability to actually stand up for yourself or say, hey, y'all thought I'd take a look at this because morale's going in the crapper, productivity's in the crapper and things are getting bad really fast. So what's the opposite of that or how can we prevent it? We can't necessarily prevent overwork because sometimes there just is a lot to be done. Provide positive reinforcement as often as possible. Try to always make sure that people feel like they have a voice and even if their suggestions are not viable, help them understand why. That was one of the things I would harp on in residential treatment. If my staff was gonna tell the patients that they couldn't do something or that something had to change, they needed to be able to answer the question why. And if a client asked why, they had every right to an answer, not just because I'm the therapist or because that's the way it is. There needs to be a legitimate explanation for why. In treatment, again, patients were already under enough stress. So changing things up and deviating from the schedule threw a lot of people into a tailspin. This rapid unpredictable change, it was important for us as a staff, even if things were changing unpredictably in the agency, it was important for us as a staff to try to shield the patients from that because that's not their thing. Even if it is going to affect them in one way or another, we need to make sure that we present it to them in a cohesive fashion and make the transition as smooth as possible. It's important whether it's at work, at school or in treatment, that we maximize the number of people that succeed. Let's just think about being in treatment, for example. If you're in treatment and there's 30 people in your cohort and 17 of them either leave AMA or are kicked out of the program or relapse or whatever, that's not setting up a good proportion for me to go, hey, this program's gonna work for me because I'm seeing everybody around me fall. Same thing is true at work and at school. It's important that people see, that children see, that workers see, that there is the possibility for success. There is the possibility for longevity. There is the possibility for promotion. And a lot of people have that. If you have a work environment, pardon me, where people don't ever stay more than 18 months to two years, that communicates something about the environment. It communicates that it's a really high stress environment that people wanna get the heck out of as soon as they can, which tells me that it is hard on people's mental health and can lead to some addiction issues and some need to try to numb out some stress. And then environmentally, if addictive behaviors, activities, substances are readily available and affordable, it's gonna be a lot easier for people to access them than if they're not. So if someone is in crisis, if someone is struggling, if someone is in pain, if they're stressed out, whatever word you wanna use, and alcohol is not readily available, they'll probably find something else. If alcohol is readily available, they're gonna choose whatever's the easiest thing to access. The norms need to be clear and discourage use, discourage addictive behaviors. We need to ensure that the climate, and I'm talking about the environment in the house, in the neighborhood, as well as the community, is not depressed. I can tell you I did a week-long seminar in Detroit, Michigan. And Detroit, Michigan has some of the most beautiful architecture I've ever seen, but unfortunately right now the entire city is just impoverished and that beautiful architecture is abandoned and has graffiti on it, and there's just scores of people who are homeless, out of work, depressed, which doesn't set, when you go through that environment, it doesn't say, hey, this is a great place to be. It says, hey, I wanna get out of here as soon as possible. That doesn't create a great situation for mental health issues. If the climate is depressed, if there's a high cost of living, if there's lack of adequate safe housing, people are not engaged with one another, you can see how this feeling would not only discourage healthy relationships, but it's just depressing to look around and see how far things have fallen and how powerless you are to change it. Strong social institutions are also impossible, I'm not impossible, are important, in order to prevent addiction, mental health issues, mentoring programs, Boys and Girls Clubs, social support services, access to medical care, access to mental health care. So often, people have access to mental health care, I'm sorry, medical care, but they can't get mental health care. There are free clinics that'll help you get antibiotics, that'll help you get your shots, that'll help you get this, that, and the other, but when it comes to mental health care, which can't be taken care of in one shot 15 minutes, it's just not available. So encouraging the development of strong social institutions, encouraging the development of programs that provide free low-cost mental health counseling is really important, not only to prevent addiction, but also mental health issues. So where do we start? I mean, I've identified a lot of problems, where do we start? We need to educate parents about child development, developmental needs, and effective parenting to produce much healthier children, which we need to do it again, in bite-sized pieces, and in a way where parents don't feel like we're saying, you don't know what you're doing. There's a lot of us who are more than happy to say, our kid didn't come with a manual, I have no idea what I'm doing, but I wanna learn. There's also a lot of parents who would take offense to that, so how do we sneak it in there in little bite-sized tidbits, kind of like I sneak spinach into my kid's food? Whoops. Public service announcements, I know I keep saying that. At the bottom of receipts, if you wanna do that, push notifications, pop up ads that show up in Facebook, anywhere people are where they might see something, and I can tell you, on social networking, Instagram, Pinterest, Facebook, if something has a picture, and a few words, is actually a lot more powerful to most people, because they'll look at it, than something that's a half a page of text. So creating situations for our clients, maybe on your website or in your app for your organization, or even on your own Instagram feed that people can subscribe to, that have those snippets of information, those tidbits. Little five, 10-minute videos about, okay, is your kid doing this? Well, here's how we can help. Is your child having difficulty, your infant having difficulty getting to sleep? Here's how to help your child develop healthy sleep habits. Small snippets, nothing too complex all at once. People can watch multiple videos in a row if it's a complex topic, give them one piece at a time. YouTube is also excellent for that. There are a lot of places people go on the internet willingly, and if there's something they can learn, then great. Teachers, more effective teacher education to assist them in guiding children in early problem identification, self-soothing, emotional regulation, and transitioning from that egocentric all-or-nothing thinking to abstract thought. Now, I'm thinking more preschool, childcare, those sorts of things. Helping preschool teachers and childcare teachers understand not only Piaget's theories, which, you know, great, wonderful. Erickson's theory is great, wonderful. But if you can't take that and apply it to something useful to actually help the child develop, it's kind of useless. We need to translate theory to practice. How do we do that? Role modeling. Again, small little snippets for teachers, maybe at the beginning of every day, they have a little handout about a new technique or some information about how to handle a current problem going on with the children or a child in their particular, in their particular school. For example, when my daughter was in Montessori, there was one little boy who was going through a really rough period and would act out and bite people. So how do you handle a child who's acting out and biting people? Helping the teachers understand, okay, what may be going on with him? How can he better learn to cope with this? Because, I mean, he was three. It's not like you can sit down and talk to him like he was 13. So providing snippets in places where teachers, parents can get the information. Not requiring people to sit through hour-long seminars or even hour-long videos online. In the community, provide a variety of opportunities for youth of all ages and interests to get involved. Not just the little kids. When my children were little, there were a myriad of places that we could go, parks and what have you. And they would be amused for hours. Once they got past eight and weren't quite adults yet, there were a lot fewer things in the community for them to get involved with except for extracurricular activities. It's important that children have a place to go. Even if it's not extracurricular in the town I grew up in, way back in the olden days. Every Friday night, there was a church that opened up its basement for youth to come and hang out. There was a DJ, there were games, there were things that you could do. But it was a place where youth under 18 could go and be safe and allegedly away from alcohol, drugs and other things. I'm sure alcohol, drugs and other things made it onto the property at some point. But most of the time it wasn't. That definitely wasn't a prominent feature of the Friday Hangouts. Provide opportunities for positive youth recreation. Monitor media messages and enhance those that encourage positive health maintenance behaviors like exercise, nutrition and positive self-evaluation. Okay, so here's my next little soapbox. They're sometimes commercials and there was one for brownie bites and I can't remember what company made it. Sort of irrelevant. But the tagline was brownie bites for when you just need a hug. I'm like, no, no, no, no, no, no, no. Brownies are not hugs. We do not eat to replace our need for human contact. That's not a message that I want to see portrayed and ingrained in my children's mind. I want them to recognize when they need a hug, when they need social support versus when they're hungry. There's a very big difference. Exercise, it doesn't have to be 30 minutes on the treadmill. It doesn't have to be something that is grueling. It can be taking your dog out for a walk. I would love to see some more behaviors or some more messages in the media about how exercise is just getting up and moving. It doesn't have to be playing basketball. It doesn't have to be going to the gym. You can just go outside, walk around, garden. Anything that moves your body is technically exercise. Would I love to see people in their target training zone 20 minutes, three times a week? Sure, I would love that. But I'm being realistic. Our society is not really motivated for that right now. Let's get people outside. Let's get people moving around and at least breathing. And we'll move from there. Nutrition, think about the last two days when you were watching TV, if you watch TV that has commercials. What kind of messages that you saw? I can remember a commercial for Jack in the Box. I can remember a commercial for Hardys. I can remember a commercial for Pizza Hut. Yeah, no healthy nutrition was actually advertised. So what kind of message does that send to people? And messages about positive self-evaluation. We are trying to do that a little bit more, but I think the media has gone from one extreme of having really thin, wave-like models to the other extreme of highlighting people who are not only curvy, but to the point of being unhealthy. And I think there's a medium, a midline in there, where we should encourage people to maintain their health behaviors. Is it good if people who are thin or people who are overweight are happy with themselves? Yes, that's a great message. I would like to see us communicating to youth that we don't have to go to extremes on everything. So mental health problems can cause addictive behaviors and addictive behaviors can cause mental health problems. To prevent one, we need to prevent them both. There are a lot of overlapping risk factors, a lot of overlapping protective factors. It really takes me back to Maslow's hierarchy. I mean, let's get back to basics. Make sure people have basic health needs met. They're getting enough sleep. Our adequate health behaviors make sure that they are feeling safe, not only physically, but safe in their own head and safe when they get online from verbal attacks. We can be our own worst critics and people tend to lash themselves with wet noodles for forever. So if we can teach people how to make their head a safe place and be able to choose what sentiments and what people they let rent space in their head, I think we're 50% of the way there. And then you've got a happy person who knows what they're worth, who's willing to let go some of the stuff that is just irrelevant, forming relationships and developing self-esteem. Hey, go figure. So if you've watched this presentation and participated for CEUs, log into the classroom at allceuse.com and take the quiz. If you've watched this presentation and participated and want CEUs, purchase access to the quiz and certificate at allceuse.com. This presentation was recorded as part of a live interactive webinar. If you're watching it on replay, please remember that you can contact Dr. Snipes on her personal chat page at HTTPS, colon slash slash purechat.me slash qtvx.