The Behavioral Corner 

Hi, and welcome. I'm Steve Martorano. And this is the Behavioral Corner; you're invited to hang with us, as we've discussed the ways we live today, the choices we make, the things we do, and how they affect our health and wellbeing. So you're on the corner, the Behavioral Corner, please hang around a while. 

Steve Martorano 

And let me welcome you guys to the Behavioral Corner. And happy new year if I haven't said that or not. There's never been a year more eagerly anticipated than 2021, for all the obvious reasons. And certainly, we're, you know, among that group bye bye 2020. And who knows, things gotta get better nothing. We're really grateful to have the time with our guests because it's a very, very busy time in the field of behavioral health. As you can imagine, Tom Longenecker has been a guest on the program, at least once before, he's a great resource to talk about his field he is now we love and I'll get you it'll explain to you is now I met him when he was primarily a when Retreat Behavioral Health, which is our underwriter was primarily and exclusively a substance abuse and treatment facility. And now it's expanded to include the wide range of things we refer to as behavioral health. The side that handles the mental health piece of that is under the umbrella of Synergy Health Programs, and Tom is one of the I guess the track leaders that handle that right time. Is that how it works?

Tom Longenecker 

I'm I'm a clinical specialist. And then we have five primary therapists who are working in two different tracks. And so I'm a resource for all of them.

Steve Martorano 

Yeah, let's talk a little bit about this because some people are a little confused when Retreat who as I said, as our partner were a renowned substance abuse treatment facility. And they expanded beyond that to include mental health issues, it was kind of a distinction, but not much of a change. Because in the field of substance abuse, you always dealt with mental health issues, which are commonly referred to as co-occurring disorders. Now, of course, it's possible under a behavioral health model to separate you don't have to go get mental health issues, singularly as a result of your substance abuse. So you're dealing with both kinds of patients?

Tom Longenecker 

So some of our patients purely have a mental health diagnosis, with no substance abuse diagnosis, others of our patients will have co-occurring, and we're able to try to address both of those at the same time. Whereas in our other programs, some of our patients there have purely a substance abuse disorder, diagnosis, and some will have substance abuse alongside with maybe a secondary mental health concern.

Steve Martorano 

you know, when the purely mental health diagnosis side so that people understand Retreats Behavioral Health programs, you are not a psych hospital. So what does that mean? And who do you see?

Tom Longenecker 

Okay, so you know, the higher-level care would be an acute unit, which is going to be noted by lock words, oftentimes a short stay, we would be a stepper. So below that were our patients, once they're through initial three-day isolation, which is COVID related, it's not related to mental health or otherwise, they've grown the campus. Now they might have supervision, they might have a one on one aid, depending upon what their safety concerns are. But unlike a higher level of care, there are no lock words there. The doors to the rooms are not locked, they're able to again, go to the calf, walk up the hill, go to the clinical rooms...

Steve Martorano 

So, clearly at the...

Tom Longenecker 

...gym, play volleyball. So it's just like the rest of the camps, which is somewhat unique in that field. I think there are only two don't quote me on this. I think one of the only two programs in the Commonwealth that have that kind of care.

Steve Martorano 

Everybody they're under a diagnosis of mental health diagnosis is a voluntary patient, they're there because they're looking to get help. So in that regard, you see lots of your garden variety stuff. I mean, you know, from anxiety and depression, what are some of the other things that we might deal with?

Tom Longenecker 

Certainly, depression, and it's all many forms is something we see very, very regularly as well as anxiety and its different forms. We will also see some of what we in the past called access to dimensions which would be borderline personality for bipolar disorders. We also deal with some people who are coming in in the schizoaffective dimensions of schizophrenia and its whole family of a cluster of the dimensions like about that with hallucination, delusion, suicidality is a very significant piece in terms of, we are the next step for a good number of people who have been in dire straits not long before coming here. They might have had a brief stopover at an acute care location, and then becoming to us for more for a longer period of time for care and to be doing some therapeutic work. So that would be very significant. 

Steve Martorano 

All of that, as well as the substance abuse issues, have been, of course, monumentally impacted by this virus. Like every other aspect of our lives, it should come as no surprise that the number of overdoses has skyrocketed in the past year, and skyrocketed is the word here. As I say, it should not be surprising, but it is nonetheless shocking. The numbers I see from the latest CDC estimates, between June of 2019 and May of 2020, 1230 people have died from drug overdoses. That's a massacre far more than dying automobile accidents. And just to give you a finer example of this, in the city of San Francisco, more people have died of drug overdoses than from COVID. Some of this is a result of just a sort of unfortunate path, substance abusers are on particularly when they're dealing with something like fentanyl. But in what other ways have this pandemic exacerbated the problem of substance abuse?

Tom Longenecker 

Well, first, it's played out in several ways. I mean, I'm quite aware of people that we've worked within the past, who actually was able to pull together recovery and time and sobriety. And then they find themselves in not so much in March, but April, May, June, very isolated, they might have been furloughed or lost their job. And one of the key things there is so many of the stories were that they were no longer in the face to face relationships with people in the rooms and the 12-step programs, other places in the recovery community. And so you get a combination of isolation, on its many different kinds of levels, particularly isolation, from the very resources that were a part of what provided me the strength to get through. Can you add to that loss of a job or a tremendous amount of time in my hands that I don't know what to do with, you know, some of our relationships are maintained, because we have certain kinds of connection and certain kinds of distance. And, you know, I think many people can recognize when people have been in quarantine together, sometimes we know each other too. Well, you know, and, but it raises those tensions and stressors there. And, and then you add to that, again, some of the other resources that I've relied upon simply are not available to me in the same ways they work. That's one piece of people who were actually making recovery work. They were doing what they needed to do, and suddenly, we're in a very different world, and the things I relied upon to swim against the current are not available to me in the ways that I've become accustomed to them.

Steve Martorano 

Are you seeing your patients face to face? Are you still doing that? Are you doing everything? 

Tom Longenecker 

Yeah, yeah, well, here on the hill, this is inpatient. So our staff, including myself, have been here, for the most part since March. Time, so I've been here besides them in a standard kind of days off. I've been here throughout that time, outpatient programs have been primarily telehealth in via zoom

Steve Martorano 

Tom is referring to the two facilities that anchor retreat here in the northeast Pennsylvania area, or in Ephrata. And down the road in Akron. One is the outpatient, as Tom said, in the hill, is the residential community was on the issue about the other side. I spoke to Jack Sodak, who heads up Synergy for you guys and has been running the outpatient plenty. Have you had a lot of any experience at all with telemedicine and is it helpful?

Tom Longenecker 

I do have been doing some zoom work. I would say it's certainly better than nothing. That's one way to look at it. I think it's a challenge. Personally,, I'm not very technologically adept. So I think it's a challenge in terms of how I am accustomed to working with groups and working with individuals. So there's just a personal professional challenge for me in terms of having retooled, I think that actually, I would say that it's been surprisingly better than I thought it might have been. I just came out of having some decent group work across the last couple of weeks with groups that I was working with via zoom. And I think they actually developed beyond my initial expectations and some of my own hesitancies.

Steve Martorano 

Because you know, because if you have great experience of being as they used to say, in the rooms and any You don't even have to have that kind of a background, you understand that in any setting when you're face to face with one or more people. There's a whole lot of communication that goes on, it's nonverbal. And you can only pick that up if you're in the room, people's postures, their hands, what they're doing with their bodies, they move, and that's all removed. How do you overcome that?

Tom Longenecker 

Well, actually, you actually make an interesting point because now when I am face to face with patients, and people I'm working with that we're all masked, I'm missing a tremendous amount of just this subtle communications that are just hidden from me now. So when I'm actually on zoom, I've seen more of a person's person's face. So no matter. So it's an odd situation across the board, whether we're in face to face or whether we're on zoom, I think probably one of the things that is beneficial about-face to face is not just what happens face to face. But the things that happen afterward, after the group convene, after it departs, rather, you know, for people who go to the rooms, it's going out for coffee, it's, it's all the other things that happen around that. Even on the hill, where we're much more stylized and formalized. It's the conversations that occur after the group breaks. And the other kinds of ways that people who've been in it can go and they keep talking about or they keep working through some of what happened there. Now that can continue here on the hill. Whereas I think that can be more limited when people are living independently in their houses. And the only connection is virtually the only connection is via zoom.

Steve Martorano 

Why is that carry over from out of the formal sessions into the more informal setting important? Why is that carry over important do you think?

Tom Longenecker 

We are wired to be sociable to be connected. And we can make a distinction between being sociable and connected. One of the key understandings of what's going on with addiction and compulsion is its disconnection. So part of the healing is a deep connection. And so there are other very informal ways of simply being part of with depth in places where I know myself as somehow important to this thing that we're part of, and it's outside of the realm of condemnation, not necessarily outside the realm of judgment, outside the realm of my worth is, so I think there's a big piece of that. And again, you know, neurologically, somebody who's in early recovery, is going through a time period where their brain is starved for pleasure. Whatever substance they were using was provided to some degree, something that the body interpreted as pleasurable. And we take that away from somebody during abstinence. And so we're going to go through a time period where the body's natural reserves of endorphin, and serotonin are not up to production levels, they're there, they're still quite depleted. And so physical touch the skin to skin contact, that's what they teach new parents these days, lots of skin to skin contact with your baby, okay, that that's bonds, and provides a tremendous amount of contact and a tremendous amount of pleasure.

Steve Martorano 

All of which is being cut off. 

Tom Longenecker 

You know, we talked about, you know, sex makes people happy. But really, the thing that actually really sponsored happiness is actual skin to skin contact, which doesn't necessarily need to be sexual, to provide some of that knowledge. And that's a key piece. But again, that sense of being connectable is something that provides pleasure so that it allows the brain starts to be less depleted. And let's really start.

Steve Martorano 

And in terms of surfy, it's always occurred to me that this carry over from the formal structure of say, a group, to the social aspects of after the group is beneficial, because it seems to me anyway, that the person in treatment gets to appreciate as a process, not confined to Well, here's my therapist, and let's sit down and do this thing here. Now I've done that. But when it's outside, when you have the cigarette or the cup of coffee, or in the dorm at night, then it becomes not what you're doing but who you are. You're working on your sobriety.

Tom Longenecker 

And again, it's into that kind of integration is just another kind of connection, right? It's kind of seniors together.

Steve Martorano 

Right. Yeah. And again, you know, this virus has just disturbed the universe in so many ways. Do you worry that Lee and 81,000 people overdosing? There's a lot of reasons for that. One of which would occur to me is that people overdose, it's because they aren't getting to treatment fast enough or in time, you worry that people who ought to be seeking treatment, both for mental health issues and for substance abuse issues, are reluctant to do that set against the backdrop of a virus? 

Tom Longenecker 

I'm certain that that's partly the case. I mean, we start off with, and I'm not quite clear on this at the minute statistics on this, but relatively only about a quarter of the population that should or could be seeking. substance abuse treatment is actually seeking substance abuse trigger for a variety of reasons. So we've already got a really a minority of people seeking that, who really should or could be, add to that, you know, the stigma of seeking treatment. Add to that, concerns about being an institution where, rightly or wrongly, we suspect that we could be more susceptible to COVID add to that concerns about insurance, who's going to cover those costs, he's gonna help me with those costs. Add to that, also, I think the implications are, trauma tends to be the gateway drug for most much addiction. And look at some of the events that go on to this prolonged period that we've been going through as a country. And we have cultural trauma. People lose jobs, people are unable to maintain their rent or their mortgage, and family relationships become much tenser, economic concerns become heightened. And then you add to that, that 81,000 deaths of people think about that, in terms of who are the children who are left be cared for by grandparents are the spouses, significant others, the extension of the family, and that adds to that whole level of how we experience something we get stuck in, it leaves its mark deep in us, and we remain stuck there. There's something that does not get resolved.

Steve Martorano 

81,000 deaths create, not a ripple, but a tsunami of effects. You know, emanating out from that it's just incredibly this year, in ongoing opioid and substance abuse epidemic, which got swept away of course, the in the wake of a COVID. Tom Longenecker with this. Tom is a clinical specialist with synergy health programs. They are a part of a retreat, behavioral health. And he's talking to us about what he does in the mental health field as well as substance abuse. And we're going to pick up on something brand new to me an article I read in the New York Times last week that Tom's going to try to enlighten us upon, we're on the Corner...The Behavioral Corner.

Synergy Health Programs 

Studies show that 2020 has negatively affected the mental health of millions of Americans. That is my app retreat, we work to provide comprehensive mental health programming through our Synergy Health Programs. To learn more about Synergy and the comprehensive mental and behavioral health services we offer. Call us today at 855-802-6600.

Steve Martorano 

Tom, so I sent you an article in anticipation of asking you about this, because I thought well, how about this idea? The article begins with a fellow that says that Stephen Kelly had been addicted to crack cocaine for 32 years, when he tried a different kind of treatment last year was so basically in the concept that he was skeptical, what would happen is he would go to a clinic twice a week provide a urine sample. And if he was clean, free of drugs, he would then draw a slip of paper -- it sounds like a game show doesn't it -- he would draw a slip of paper out of a fishbowl and it would contain half messages. You know sort of encouragement. "Good job." "Way to go." The other half were vouchers for -- ready for this -- money. Cold hard cash. Moolah. Yeah, that's right. They were paying people not to abuse, whatever substance they were abusing. The whole thing is controversial, to say the least very experimental, I think, and referred to as "contingency management." Tom, I'm always suspicious of really jargony names for things, it makes me feel like they're, you know, hide something. What was your impression of this?

Tom Longenecker 

I think in some ways, what they're working out of is, is a form of operant conditioning. So operant conditioning is, it's an attempt to reinforce or punish up behavior. Okay, so if I have to go to my probation officer, and I provide clean urine, showing no sign of using, I don't really get a reward other than I don't go back to jail, I don't go I don't violate my probation. If I go and provide hot urine or, you know, the probation officer might violate, I might have to have more legal issues, okay. Or, for instance, our dog, I don't allow our dog to come on the carpet, in our front room. And, you know, her options are to be praised for not going on the carpet. But the other part is she desires to be on the carpet because she's closer to the people she wants to be close to his or her options are, am I going to get scolded and told to go off the carpet? Or do I get praised? And so what operant conditioning is, is trying to relate behavior to an outcome. And so at some level, what they're trying to do is really, on the coin, clean time, ongoing abstinence, gets a potential reward. And I think in some things, it's a, you don't know what the reward will be. I think in some other programs, I'm under the impression that the reward gets higher each time. So maybe the first reward is $5, then 10 and 15. I'm not really sure how they always work that, but either way, the potential is, I get rewarded for abstinence. And so relating the behavior abstinence, or at least being able to show absence with some kind of pleasurable reward.

Steve Martorano 

If something like this is going to get a foothold in the treatment of substance abuse, the good old USA would be the place where, you know, money doesn't talk, it swears. I mean, that's how we keep score in this culture. Who has the most money, who has the most toys, so I guess it would make sense here, I'm confused about this sword, I understand it. Look, the techniques you just described, are pretty much the way most conscientious parents raise their kids. It's as simple as that. You know, you want to watch the movie, do your homework first, you want to go play, cut the lawn, I mean, stuff like that, and the denial that stuff we understand about that. But with regard to substance abuse, can the reward no matter what it is, be so powerful, that it cuts off the craving for a drug, like heroin? I mean, can it work like that? 

Tom Longenecker 

I don't know that I can answer that with authority.

Steve Martorano 

What's your suspicion?

Tom Longenecker 

My suspicion is that if we look at this as one piece of an array of different interventions, particularly an early recovery, and remember that in early recovery, the brain is starved. And so some kind of reward is almost necessary. So for some people that reward is I go to a meeting, and I'm surrounded by love and affirmation, and we go out and smoke cigarettes and go to friendlies and eat ice cream later on, or whatever, whatever they're doing. Hmm. And that for some people is a strong, strong reward. What I'm deeply craving some kind of pleasure. And it's even difficult to have some kind of pleasure. So I think we need to realize how that might function more acutely or, more significantly, particularly for people in early recovery. Just recognizing just how starved the neurology the neurological basis is. I think that you know, certainly, it can work in some ways, in terms of actually challenging actual craving. I know in the article you provided me they were highlighting this, particularly for methamphetamine, and cocaine dependence. As opposed to opiate or alcohol. tenancies, partly because we have medicines, we have pharmacological means to address some degree of craving with opiates, and alcohol, We have Naltrexone. We have Vivitrol, we have, you know, some of those means to address those. Whereas I'm not aware of an awful lot that we have that can really truly address, really, what is a parasympathetic craving for amphetamine, of some form.

Steve Martorano 

And so people understand this, this is not your garden variety, treatment. And in fact, most insurance companies want more data, more research, before they're going to pick up the tab on this kind of contingency management. But interestingly enough, it's being done in our area at the VA hospital in Philadelphia, they are trying this out with the voucher program Look, like I think most of you professionals in it, if it works, good. Let's give it a try. I mean, M.A.T., which is medication-assisted treatment, as you just mentioned, was for the longest time thought to be something antithetical to treating this now it's not that's changed. Who knows if this could work? But there are legal considerations to consider. I guess, in some places, you're not supposed to pay people to not use drugs, right? That's illegal.

Tom Longenecker 

Yeah. I'll play the kind of advocate for this for a second. No, but we also give bonuses for performance at work. Sure, people get paid to do surveys, in education, we have a certain kind of rewards. I mean, that's actually again, had to go back to parenting. There's some kind of rewards that we give. I know that for people with mental retardation or on the Asperger spectrum, that there is some kind of rewards that are built into the systems to behavior. homelessness and substance abuse are two areas that we, I suspect that we're very reluctant to reward for doing the things that we think you should do anyway.

Steve Martorano 

It's it's fascinating. I mean, we use words like a reward. And then when you attach money to it is a very clear idea forms in your head and what we're really, really not talking about how much money you're giving people a sense of an affirmation, you've done something worthwhile. Here, this will remind you of that, and you'll keep doing it. I mean, I've always thought that one of the great reinforcers for people in sobriety is the accumulation of time, the longer you're sober, the more you want to make that a bigger number, how many deaths weigh the days and years count.

Tom Longenecker 

And statistically, the longer period of time people have been absent, tends to predict the longer time people have accidents.

Steve Martorano 

Yes, exactly, exactly.

Tom Longenecker 

The same thing, the longer time people have in treatment exponentially per day, we see that it tends to be predictive of more time in essence,

Steve Martorano 

I knew you'd shed light on this for us. It's it was fascinated by that. We're going to find out more about that. There's some unbelievable stuff out there about technology and I read about apps that now we'll do saliva tests on the phone somehow or another and, and be rewarded right through your phone. So It's an amazing read. Let me ask you, but I'm gonna let you back your very busy schedule, I'm sure. One day COVID will be gone, not would. And we will get back to whatever the normal is then now, at that point, I'm guessing, though that even if COVID were to be eradicated tomorrow, what you're about the work you're doing is not going to go diminish.

Tom Longenecker 

I'm, I'm positive that. Yeah. Luckily, there are other jobs I can do if we've ever fallen into that world. Luckily, there are other things I can do.

Steve Martorano 

I guess my question is, are we just on the cusp of a real sort of mental health crisis? Or are we in a mental health crisis?

Tom Longenecker 

I think we've been in a mental health crisis. And in a substance abuse crisis for quite a long time, it was exacerbated in the last half-year or more. I'm curious, in terms of seeing what the after-effects are again, yeah, referring back to the 81,000 deaths is turned into a massacre, in terms of how that plays out in the lives of people who are the witnesses and standby. And I've seen this and it these people have been important in their lives, I'm expected to see the tsunami of that effect. And it's just because this is a tragedy, this is tragic. 

Steve Martorano 

And grief has been delayed. 

Tom Longenecker 

Grief has been delayed, just even the kind of the communal means of a funeral, which is a very simple way of marking that transition that change. Well, this has been removed from us in terms of viscerally, you know, so many funerals are now either not occurring, or they are occurring again, fortunately, there's a lot that can be done virtually, but we are still missing some of that basic, connecting with one another.

Steve Martorano 

Tom, thanks so much out for people who might hear this and are, you know, cut off isolated, struggling? What should they do, they can't sit there and expect this to go away, they have to be a little they call the family to the what do they do?

Tom Longenecker 

There are always interventions if people can always call upon interventionists and others if this is something that you're recognizing for yourself. So many people say I waited too long, I thought that depression would get go away, or one of the problems with depression is I just don't have the energy to make the move. And, or, or my anxiety gets in the way or I'm just waiting for the right time to make the move. Things are never the right time, I want to deal with my drinking, or I want to deal with this problem I've got, I recognize it's a problem. I just need to wait or I can do it without making the shift to leave my home, leave my apartment, leave my family takes off. However much time I needed to really become part of a bubble and address it. Those kinds of reasons are constant, no matter if we're in the middle of a pandemic or not. But one of the things I hear over and over again is I should have done this earlier. Because if people see the result, one of the great rewards I see over and over again, for people who really invest themselves is that quickly, they find this is like lifeblood. And so that's rewarding. In itself. I suspect that there's a lot of things we could do that would draw upon contingent management in certain different ways of being more overt about providing certain kinds of rewards. But one of those is simply the rewards of recovery, which is not without its trials, but not without the tribulations, not without difficulties.

Steve Martorano 

Yeah, there's a great expression that's applicable. Living Well is the best revenge. It's also the best plan. Tom Longenecker clinical specialist, Synergy Health Programs. Thanks so much for the work you do and for the time you give to us. We really appreciate it, Tom.

Tom Longenecker 

Thank you, Steve. Thank you for what you're doing.

Steve Martorano 

Hey, guys, thank you for hanging on the Corner with us. Don't forget to follow us on Facebook, Instagram, follow us in a cab on a bike like us. Never in my life if I had to ask people to like me because it never did any good. But like us, you know that the whole thing and look for us here on the Behavioral Corner. Take care, everybody.

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