All right. Hello everyone, my name is Christina and I'm a librarian here at San Francisco Public Library. Welcome everyone. Find a good seat. Get settled. You're in for a treat tonight. I want to thank you all for joining us today. We're so happy to be here celebrating Filipino American History Month at the library. For us Filipinos, October is always a very exciting and very full time of year. How have you been celebrating Filipino American History Month? Go ahead and throw it in the chat. We'd love to hear if you've been at a library program or watched a film that you love or maybe even seen something in person. Please share. So throughout the month of October, we've been inviting you here to learn more about the unique history and contributions of our community through interactive workshops and demonstrations, book readings and more. So we invite you to check out our website. We have a dedicated webpage and in the chat, our trustee chat monitor will go ahead and share that with you. You can see the events that we've had, but also the great books that we have here available at the library, ebooks, physical books by Filipino, Filipino authors and illustrators and more. So definitely a wealth of resources about our community here. Before we start, I want to go ahead and acknowledge that here in San Francisco, we are on the unceded ancestral homeland of the Ramatush Aloni, who are the original inhabitants of the San Francisco Peninsula and they continue to live, work and play here today. As the indigenous stewards of this land and in accordance with their traditions, the Ramatush Aloni have never ceded, lost nor forgotten their responsibilities as caretakers of this place, as well as for all people who reside in their traditional territory. We wish to pay our respects as settlers by acknowledging the ancestors, elders and relatives of the Ramatush community and by affirming their sovereign rights as first peoples. We would like also like to say thank you to the friends of San Francisco Public Library, without their generous support, we simply could not bring programming like this to you. So find out more, look up friends of San Francisco Public Library and find out how you can also support public programming at the library. And without further ado, I want to introduce Tiff Marcello. If you're out there, give her some snaps, give her some claps. Tiff Marcello is a veteran U.S. Army nurse and holds a BS in nursing and a master's in public administration. Can I please give just like a huge shout out to all the Filipino and Filipino nurses in the world, because there are plenty, I know I have many in my own family, my Lola was a nurse, so thank you, thank you for the hard work that nurses do every day. But back to Tiff. Tiff believes and writes about the strength of families, the endurance of friendship, heartfelt romances and is inspired daily by her own military hero husband and four children. She hosts the stories to love podcast and is the USA Today bestselling author of in a book club far away. Once upon a sunset, the key to happily ever after and the journey to the heart series. And of course, the holiday switch, which we're here to discuss and learn all about today. And it is available immediately with your San Francisco Public Library card through as an ebook. So please give a warm applause and welcome to Tiff Marcello. Welcome, Tiff. Hi, everyone. This is Tiff. I am just so thrilled to be here. I wanted to thank the San Francisco Public Library for inviting me to come here today. This is so exciting because it is like coming home. I'm from Northern California, although we currently live in Kentucky. We are I'm military spouse. I was in the military too, but we've moved around all of my adult life. But coming to San Francisco is home for me just to let you all know. So I went to Sheridan Elementary School. I went to Hoover Middle School. And then I went to Lake Wilmerding High School until I was a sophomore. And then we moved up to the East Bay. And then I came back to San Francisco and went to the University of San Francisco for my undergrad in nursing. So it's so it is like coming full circle because I have written The Holiday Switch, which is a teen holiday novel with two Filipino-American main characters, which is so exciting. And it has all the trappings of the holiday season.  And then I'm going to read a passage. So this story is a first person point of view. And it is about Lila Santos. Lila is 18 years old and she is a senior in high school. And it's her very, very last winter break before she goes off to college. So she's really intent on making as much money as she can. And she works in this in called The Bookworm Inn, which this entire book is set in Holly, New York, which is an upstate New York. So it's really very much like a Christmas town. And she wants to earn as much money as she can. However, she finds out that her hours are being taken by the innkeeper's nephew, Teddy. And that sparks a rivalry between them. But when they switch phones, they realize that they have more things in common than what they had expected. So I'm going to read their meat cute. And in a book or in movies, a meat cute is when the two main characters meet for the first time. So this scene is just to set the scene is that Ms. Velasco, who is Lila's boss at The Bookworm Inn brings her into her office and wants to talk to her about her her employment for the winter. And this is all in Lila's point of view. Dread rises up inside me. You were going to talk to me about something? Yes, Teddy applied for a part-time seasonal position here before you sent your email. Oh, the shock of it leaves me speechless. I was fully prepared to give up my hours for KC, but not for this, Teddy. And no, there aren't my hours to give away, but the inn is like my second home.  I'm sorry, Lila. No, I get to understand, but if there's a chance here and there for extra hours, I'll take it. I force a smile and grit my teeth. Only the second half of that statement is true, but Ms. Velasco has always been kind, and she taught me everything I know about retail. She suffered through the first days when I had no idea how to talk to customers. She broke me out of my shell. I'll just have to make up the hours somehow with babysitting. Great. Thank you for understanding. Speaking of, Teddy is on his way here to drop off some of his stuff before he goes back for his last week of school. Her face lifts as another set of jingle bells rings out. Ah, here he is. She stands. A guy walks into the office. He's wearing a hoodie and comfy baggy knit pants with pristine white shoes. His skin is golden brown, and he has lush, wavy dark brown hair, which he pushes back with a hand. Tiny diamonds, said his earlobes. My jaw slackens. Oh, my. Teddy is not the little boy in the picture on Ms. Velasco's wall. Far from it, if I passed him on the street, Teddy would definitely turn my head. First, because he's Filipino, and there aren't many Filipino people in Holly. Second, he's cute. Cute in the sprouting way that bookboy friends are often described, with prominent dark eyebrows and steely brown eyes. He sets a duffel bag at his feet, and the clinking of several carabiners snapped into one of the straps momentarily catches my attention. Ms. Velasco hugs him. Anak, you look good. She squeezes his shoulders like she's trying to take him in. I know I am. Wow. Muscles. Hi, Tito Lu. He dips his head as if shy.  Lila, Ms. Velasco's voice, yanks me back, and it's only when I realize I was staring at Teddy. Yes, I'm sorry. I was looking at, yes, that's me. I'm Lila. One of Teddy's eyebrows lifts, and his lips curl into a grin. The kind of grin that says, you're interesting, but in a wearing a Halloween costume in December kind of way. My neck heats, and I inwardly groan. This feels like the world's most awkward meat cute. Ms. Velasco laughs. Exactly. Teddy, this is Lila Santos. Lila, this is Theodore, or Teddy Rivera, my nephew. He'll be working together. All of us will be working together. It's going to be such a special few weeks. Great. He nods, but doesn't say anything else. In the silence, his expression shifts minutely to what seems like weariness. I can't tell if he's being sarcastic or indifferent, but it sets off my penchant for hospitality. I want to douse this weirdness like snow over campfire. Welcome to the Bookworm Inn, home of Holiday by the Lake. I announce in perfect welcome pitch, like I'm a Holly tour guide volume eight out of 10. If you need anything at all, I'm here. Ms. Velasco claps. Great. Let me get you to my, I mean, our cabin. Lila, do you mind manning the fort? We can finish our conversation when I return. I don't mind. I release a breath. Please go before I ask him to sign the guest book. See you. I guess Teddy says, eyes blank. The guy is obviously not happy to be there. Drama indeed. Yeah, see you. The two make their way to the back, leaving me in the office with the sound of Bing Crosby piping through the speakers. Teddy's arrival weighing heavily on my mind. I just gave up my hours to my boss's cute nephew. What the heck am I supposed to do with that? So as you can see, it already begins with Lila and Teddy. And that's in the first chapter when Lila and Teddy meet. And it's, it's not great. So there's something going on with him, obviously. So what makes this book so special for me in writing it, I had mentioned before, is that I was able to put the main characters as Filipino-American, which is really tremendous. And then I was able to bring in some of my own holiday and some of my own Christmas traditions. And I wanted to go ahead and just do a quick mention that the book cover was illustrated by Jacqueline Lai. And Jacqueline Lai is Asian-Canadian, which is so super special. And the audiobook is narrated by Laila Leana Bertrand. And she's also Filipino-American. So all of this representation in this entire book has been so tremendous and special. I wanted to talk about my inspiration, what's up there on the screen. It says my own Christmas traditions. I don't want to give it all away because it was such a special thing to put on the page, but there's some things that I put in there, which is something that's out of my own childhood tradition. And that is going to mass and then going and having Buena Noche afterwards and having something to eat during Christmas Eve. And there's a little bit of karaoke in there, which is something that I also grew up with. And then I also introduced what's called leftover Christmas, which is something that we do now with my own family, which is when we get together with folks, not last Christmas, but usually we get together with folks who bring their leftovers and repurpose their leftovers. There's some also Filipino, general Filipino traditions that I placed in the book, which was so special, which the titles that we give one another. So Ate for Big Sister and Tito and Tita and Lola and Lola and all of these foods and just titles for elders that I think should come naturally in a book. So you'll notice that in this book that they are not italicized because it's just part of the language of the book. A second inspiration are the epic iconic movies that I loved growing up such as Dirty Dancing, The Holiday, The Notebook. And what comes from these epic movies are just the feeling of the setting. With Dirty Dancing you have that whole, you have that entire resort that you just get immersed in in the movie The Holiday. It's just fully Christmas, it's a rom-com and you just get so excited being in that world that it really contributed to my formation of creating the town of Holly. Finally, books were an inspiration. Lila is a book blogger and books mean something to her and books are a way for her to explore herself and her emotions and also pushes her thought process. And that's what books meant to me as a library grower growing up and continues to affect me today. So I wanted to make sure that that was definitely in this book. And finally, the idea of you can change your mind. This statement has been so important to me in both my young life and in my adult life. And it's something that I tell my children, it's something I tell other authors, it's something I tell other writers. And in this book, and I hope that I'm able to convey that, that no matter where you are in your life, that you can change your mind. Now, I always am asked what the process is to write. And every book is so different. Some books, I come up with the characters first. Sometimes there is a scene or there is a moment that I experienced in my real life where I witnessed something with somebody that kind of sparks the inspiration and the process. But with this, Holly really came first, Holly the city. Holly, New York is a fictional town. And it is an upstate New York, and it is in the Finger Lakes region. If you guys know where that is, it is super duper cold with a lot of snow. And we actually lived, actually lived with my family in upstate New York and Watertown. But that's more north, that's more east than Holly, than where Holly would be. And I really saw Holly as its own inclusive town. And I really saw its streets. So my focus, I remember when I was thinking up this book was drawing this town and trying to figure out like how far things were and where the town square was. That was so much fun to do. And it really built from there, like how much, how big is this tree in the town square? And how many decorations are there? And how big is the sign that says Holly, New York population, 13,000 or whatnot. So what I wanted to do was create a Christmas town. And Holly, though it is not holidayed out all year long, it is for most of the year. And what happens with that is inherently there's going to be characters in there that support this little town. So what comes after Holly is finding out that all of these characters that are in this little city have such, have like a ton of spirit. So it's sort of like school spirit, but like exponential because they want to make sure that this town survives because it's all about Christmas. It's all about the holidays. The second thing I worked on was Lila and the bookworm in. Lila came to me almost immediately after. I knew that she was a lover of books. And I knew that she was a hard worker and that she was focused. And it only made sense for her to work at the bookworm in, which is really the, it was the scene or it was the in that was in the fictional movie called Holly by a lake. And that's why everybody's coming to Holly is because they want to be in this in and they want to take pictures at this in and they want to get to know this in. It only makes sense that Lila would have worked in like the play best place ever in Holly, New York. So then I started to look up what ends would look like. And she has a little she has a library within this in. And then I looked up all of these pictures of different libraries and and how we would look in a library. So it's like a gift shop and a library and and an in on the back. So I really had such a good time drawing this out of my drawings, not that great, but drawing this out and really knowing where she was moving around in this in. So it was quite exciting. And of course, she's Filipino American to me, that was just so important and exciting. And I wanted to surround her with people that I see every day. So it is a diverse cast for this book. And it's it's diverse in both. It's racially diverse. And it's and it's what I would see in my world. So it's nice to be able to write a small town with diverse characters. And then I moved on and I said, you know what, Lila needs to be challenged. So you'll notice that folks around Lila are just as strong in their personalities. And that is because when you have somebody like Lila, who is like super duper Taipei, the folks that will change her are almost the opposite or equally as strong in their personalities. Teddy is a strong personality too. Um, but for other reasons. But to Lila, Teddy is just stubborn, right? But actually, Teddy is strong in his own way. And he pushes her to think outside of the box, while she pushes him to think within the box. So they're really such a good pair. And I wanted them to get along but to challenge each other, as well as to teach one another. Because, you know, you hope that's the people that your friends with can do that. They can be your friends and they can support you. But at the same time, challenge you to be a better person. And what more when your crush is that way too? Finally, they're not finally, but Tinsel and tropes. Tinsel and tropes is Lila's book blog. You know, I really do think that most people have their way of expression. Some folks have their art. Some people dance. Some people sing. Some people write. And some people speak their expression. And Lila writes, she reads books and she reviews books. But what happens in Tinsel and tropes, her book blog, is that she actually teases out what she's feeling inside in accordance to what she read in her book. So it's really interesting.  And she keeps this book blog a secret for a little while. But we find that we'll find that as we read the blog segments, that she is changing too. So that's why that's why I created Tinsel and tropes. And finally, the 10 things to do in Holly. So this is a bucket list. I don't know, I'm sure that you guys have seen some lists, like 10 things to do in San Francisco, where, you know, you have like all of these tourist traps that you do. And you hope you hit the big ones and take tons of pictures. And I really wanted Lila to go on a physical journey with her and her friends and her crush. And they undertake the 10 things to do in Holly. So now this process, I just have to say that it all didn't come at the same time. It kind of, it came slowly and it came through revisions, through rewrites, and it came also with the help of my editor who said, you know what, this really sounds great. And what I did at the next, the next time I revise was that I rewrote certain parts. Now, people usually ask me how I became an author. And I really wanted to share this because, again, that whole statement of I can always change my mind really rings true. So I mentioned that I love the San Francisco Public Library. And that is because everything for me started with library and books, started with that first green library card that I received when I was in elementary school. And then I would check out 13 books at a time, and I would scour through these bookshelves. And I read through pretty much all through the all through the children's section and then moved on to the adult books. So back then, when I was much younger, the children's shelves were like all smushed together. Nowadays, of course, you have like the teen section, and then you have the chapter books, and then you have the, the picture books, and everything in between. But back then, it was like just one big glob in the front of the library. So I went to the Tarraval branch, Tarraval Street branch, which is the Parkside branch of the San Francisco Public Library. And I used to go there after school, after getting off the muni. And I used to spend time there in the summer as well. And I did all the library programs, the summer reading programs. And that's where it all began for me. But I did, I was not always an author. So I was guided by my parents, as many of you are, and I was guided towards to become a nurse. And I joined the army after that. And it was fantastic. I loved being a nurse for a very long time. And I loved being in the army. But there came a time when I decided to make a decision, right? But we will not go there yet. So I was not always an author. However, I continued to read. Okay, so I went to the University of San Francisco, I got my nursing degree. I went into the army. And I got out of the army after four years. And I was still a military spouse. I'm still a military spouse, we move around a lot. But I still went to the libraries wherever I go and get my library cards there and continue to read. And I also joined book clubs, which is amazing, because then I'm able to talk about books. And I grow as a reader because of it. And what happened is in between, I started to scribble. I started to journal once more. I used to write in my diary when I was much younger. And I kind of lost that, you know, in school. And then I just started writing once more. I started writing in journals. And then blogging started blogging back in 2001. blogging began. And that's when I began my practice of writing. And I was blogging two to three times a week. So if you think about that, that's about 500 words, 250 to 500 words each time. And I would write it, and then read it, and then rewrite it. And I would do that two or three times before I posted it. And I blogged for about 10 years. So lots of my family memories are there. Lots of my ideas on books and my conclusions about books. And then I was also knitting and doing all these other things. And I was talking about all of my crafts. But no matter what, I just kept writing. I kept the practice of writing. And then at some point, I decided, you know what, it's time to switch things up. So about 10 or 11 years ago, I decided it's time for me to write a book. I think, I think I can do it. And sure enough, I wrote my first book. It wasn't the best book. So I wrote another book. And then I continued to write more books. So writing a book takes a long time. So sometimes I would work on two projects at one time. But I try to finish my stories, which is the most important thing, is to be able to finish your stories. And about five years ago or six years ago, actually, no, like eight years ago or something, I decided, you know what, I really want to get published. I really want to book out in the world. And I researched on how to do that. There are two paths or there are many ways to get a book out into the world. But generally, there are two paths. There's a traditional path, and that is that you get an agent, a literary agent, and then they pitch your book to a publisher, a big publisher. And there is the other path that's called independent publishing, where you publish yourself. Because I wanted to write teen novels, I wanted to go the traditional route. However, it didn't work out that way. So here comes another switch, right? So here I am, I'm thinking that everything is good to go. I have my books. But I realized that it's not going to be that easy. I wanted to write for young adults, but I could not get an agent for young adults. And I then had to make another decision. And I said, you know what, let me try to write for grown-ups, for the adult audience. And it's with that that I got my agent. And my first contracts were for adult novels. And so actually, the holiday switch is my eighth novel. So it took a little bit of time. So it is worth the wait, though, right? And it is worth the learning. And it's worth the trouble of figuring things out and finding new things and figuring things out that you love to write other things. So be open to that switch. So I like to give some writing tips. Read, read, read. So there is no substitution for reading. I would say read everything, different genres, enjoy the ways that people write. In fact, I still read for fun. I still read for fun about 20 to 30 minutes a day.  I also am still in book clubs because I still want to talk about books with other people. And the great thing about libraries, let me tell you, and this is what I loved about going to the library, is that if a book doesn't work for me, it's totally okay. You can bring that book back and you can pick up another book. It's like never ending source of fun when you're in a library. You should see me today or when we were going to public libraries. I would walk in and it's like being a kid in the candy store. I just pick as many books as I can and then I just sort through them and keep them until the very last minute and then turn them back in. But, you know, you'll notice that as you continue to read a lot that there are going to be books that are going to jump out at you. And those are the books that I think that you should examine. And by examining what I mean by that is that you can take a look at the things that really strike you. You can see that if a dialogue like makes you laugh, you can actually take that dialogue between those characters and say, what here makes me laugh? Did he say something funny or was he doing something? Did the author write him doing an action that made me laugh or what made me cry? Look at the things that really strike you about a book and that's what you should examine. And perhaps that's something that you can keep in mind for the book that you're going to write. Now, if you own the book, because I own a lot of books, not everybody can own as many books, but if you own a book that you can mark up, I don't know if the librarians are going to like this, but when I own my own books, I mark up my books because I like to highlight it. If I fall in love with something, I highlight it. And I come back to it because if it inspires me, then it's really doing its job, right? The author is really doing their job. So the next thing I want to encourage you to do is to journal and to write. Now, everybody writes in a different way. Some folks can write snippets. Some folks write linearly, which means they go from the beginning of the story to the end of the story. Some folks just do poetry. You can brainstorm and just put words on the page, but there's really no substitution to journaling and to writing. And you can write whatever you want. This is the most exciting thing about writing is that you can literally make things up. Like, I mean, if you just think about that, sometimes when I'm writing my books and I'm having a hard time or it's a hard writing day, I tell myself this, like, Tiff, you can make it up. So go ahead and be free with your notebook. Just make stuff up and write what you want to write and just open your heart to be able to put things down on paper. Now, I listed that if you can take writing classes, you can probably have it in your schools or you can take a summer program or you can take an online course. But I want to tell you all that I was not formally educated in English or did not have a degree in creative writing or in journalism or any of that. And still I was able to become an author. So I think what's important here is that you read and then you write. And then when you get to a point where you can share your work, that you can take feedback. But if you can also take a writing class that's available for you, go ahead and take it. It's a great way to learn tips. It's a great way to kind of open your mind and heart to a new way of accomplishing a certain thing, like how do I write funny books and perhaps you can learn learn some tips here and there to and I still take writing classes myself. Honestly, I go to conferences or online conferences with other authors and they break down their work. They take a look at it, we examine their work and we figure out, okay, what makes this scene funny? So everybody can improve. And finally, I wanted to mention and this is the most important thing is that to keep your dreams. I am a person that did not have her work published until she's 41 years old. So I had an entire career and and I have no regrets.  You can be who you want to be. So if you want to be a nurse or a doctor and then right on the side, you can do that. If you wanted to be a lawyer, an attorney, if you wanted to be, you know, a dentist or a teacher and then right on the side, you can. If you want to be a writer only, you can also. But keep your dreams in front because, you know, there's going to be things that you'll need to do, like get a job and do all of these adulting things that we all have to deal with. But if you keep your writing dreams for a front, then you will accomplish it. And so the final thing is that just remember sometimes a little switch can lead to some fun and something good. So hopefully Lila and Teddy will be able to show that too when you read them on the page. That is it. Any questions? Thank you so much, Tiff. I have to agree with Erica, who wrote in the chat, just love these tips. I mean, just one after the other, I was like, yes. Yes. Yes. So please publish those so that we can have easy access to them.  And we're, we really, you know, we welcome everyone to be able to come to this program. But we're hoping that we have young viewers who are, you know, teen readers themselves. And I just really appreciate your adulting tips, because sometimes I, you know, in mentoring, young people do, you know, sort of think that it is just all linear. And if you just kind of set your mind in one way, that that's just how it's all going to happen.  So it's just, I really thank you so much for just laying out, you know, your process so openly with us. Oh, thank you. I'm so glad to be here. And it's just, it's, it's exciting because there are also so many options. I did not get into it, but the independent publishing side of the house really provides the opportunity for anyone to be to be read. So there's really no barrier. If you have the support, you know what I mean, if you have the support and the encouragement and most importantly, a book. So, and that's why it's so important that if anything, reading and writing is really the two key things because everything else is all going to just fall on your lap after that happens. A nominal thank you so much for just that positivity and confidence and for plugging the library so much along your journey too. We really do appreciate folks for you not to mark in your books, but I was like, I know, I'm like, you can put my daughter, I have an 11-year-old daughter and she asked me today, she's like, mom, can I, she didn't know I was going to talk about this, but she said, mom, with my books, can I mark them? And I said, oh my gosh, of course you can. If they're your books, you may mark them. Well, we have a wonderful audience that's giving us a lot of love in the chat and I do want to make sure that we get their questions answered. So if you have questions, just go ahead and throw it in the Q&A box. I have a question from one of our audience members, Monica, who's saying, how do you stay focused on your characters when writing more than one thing at a time? Yeah, and more than one book at a time? Does she mean that? I think that's what she means, yes. Okay, yeah, you know, I just try to get into the space and that is something that is hard. Shonda Rhimes wrote this book, it's called The Year of Yes, and she talks about getting into the door, her imagination, and then once the door is open, then she's good to go. But getting to the door is like, oh my gosh, how do I get there? And that's how I find my process is. I just need to be able to get to the door and once it's open, then I am just full on writing my book. So what I do try to do is I listen to, I have a different playlist for different books. And what I do is I segment my day so that in the morning I will be working on a specific book and then I will break and then do another book in the afternoon. I try not to mix it up too much. And when I say break, it's like a full, like I'll walk the dog and have lunch and then maybe, maybe work out so that it's a full kind of dump of what I did before. And then I'm in a new project. That's great. I love the association of the switch being audibly with music. I think that's awesome. Mary asks a really good question and one that I also I'm going to say was a question that came up for me. Are you planning on writing any more holiday stories? Specifically, are you planning to flesh out some of the books in the tinsel and tropes blog, which I just found was so intriguing. Yeah, I've had so many people ask that. And I was like, wow, this is great. I mean, it's definitely an idea. You know, it's all of my contracts thus far. So the holiday switch is my eighth novel. My ninth and 10th novel novels are coming out next year in 2022. And they're both adult titles. And then I have another adult title in 2023. So I don't know when that next teen novel is going to come. I'd like to be able to sneak in an adult Christmas novel. At some point, you know, I have all of these big dreams. But wow, you know, it's so interesting that whole blog, those books and the blogs, it's it is an idea, isn't it?  I had fun writing those and I had fun pretending that there was really a movie associated with the bookworm in and pretend, you know, pulling things from different iconic movies like the canoe, which is the canoe from what is that? The notebook. You know, they were in the canoe. So I was like, oh, this is a canoe from whatever. You know, so it's like all these little kind of itzy bitzy things. Yeah, absolutely. I just think the setting that you created, I mean, immediately I was like, I want to go to Holly New York. Is that real?  And so I thought it was so interesting to have this story be set, you know, in more of like a quaint, like you described Christmas town. And I'm just curious kind of how that came about for you in terms of really deciding that this was going to be, you know, not only the setting, you said that was how you started, but that this was going to be really centered on Filipino characters. How did that piece come into play? Yeah, I just knew that my goal is to have as many Filipino American characters in my books. And then I didn't want, and when I've, I've lived in upstate New York and I've been in that area, and there's not very many Filipino Americans up there. And so I really wanted to create a space where it is like California, but it's up with all the snow. Yeah, yeah. So, but I fell in love with upstate New York, quite honestly, when we lived there, we only lived there for 23 months. So we had two winters there. And I fell in love with that place. It was very cold. And there was a lot of snow, but there's just a magic to it being up there with all the trees. And the snow is really pretty when you're inside. Yeah, some chocolate and some books. Exactly. So it created like the perfect backdrop of Christmas and the white Christmas of having all the snow. Yeah. Yeah, I think this is just a perfect time that we're having this program, you know, as we start kind of thinking about the holidays coming up. So it's making me feel very cozy. Yay. Before we finish, I definitely want to get a question in from Angela, who asks about, you know, getting through difficult plot problems and how do you stay writing even when you're feeling discouraged? Yeah, you know, I think that there is a thing to this to determine is this a plot issue or a motivation issue, right? When it's a motivation issue, that is like a totally different answer. So if it's a motivation issue, potentially, then what do you need to do to kind of get your motivation up? Perhaps you need to get up and walk, or you need to listen to a lot of music, or you need to fill that well. Maybe that well is depleted. Maybe you need to watch movies or read books. But when it's a plot issue, and I really can't get it, that's when critique partners and my critique group has really helped. So I have a close set of friends. There's five of us. And we have been together since before any of us were published. So it's been a long time. And we go to one another for plot issues. Sometimes they don't even really need to know the entire plot. They just need to know like the basics. And they'll brainstorm with you. They can brainstorm with you and then come up with many different ideas. And potentially the answer is not there, but it will kind of strike a chord.  I love that. Yeah, it's hard. This is the imagination. There's so many places to unlock. And sometimes it takes a lot to walk a door. Absolutely. And I love just, you know, you reminding us that this is done in community. And I hear a lot of people talk about how writing is a solitary process. But I also, my favorite thing to read in a book often is the acknowledgements because you see all the people that helped create this. And I always tell folks, or well, folks have told me and so I repeat it is that you can't compare your book, your work in progress to a finished book. Because your work in progress is what you're working on currently. And a finished book has been read and reread probably 13 to 20 times. And it's been through editors. And so critical that you have a wonderful editor. So I have just been so lucky in all the I'm with three publishers. So I'm with Simon and Schuster and Random House and with Amazon Publishing. And I have had the most amazing editors that really see the heart of the book. And they're able to tease out that answer. So just know that you're not doing this all alone. Like yes, you can come up with a first draft and yes, you can revise. But at some point, then it's time for feedback. Yeah. Thanks for that reminder, Tiff. As we wrap up, I do want to thank our audience for being here and just invite you. Are there any words of farewell that you'd like to say to the to the audience here today?  This is a full circle for me. So I as soon as the opportunity was available, I'm like, please raise my hand, take me please. So I'm absolutely happy Philippine American History Month. I mean, this is just October is always so wonderful. And I just want to wish everybody a great month and and a very safe holiday season. Thank you. Thank you so much Tiff for saying yes. And for the homecoming of San Francisco and we're seeing some USF love on the YouTube chat as well. So thank you to our audience for being here. Oh, Don. Yes. And if you love today's program, folks, please check out our calendar of events. We still have some wonderful opportunities to celebrate Philippine American History Month, for example, right behind me are poster. It's it's a little bit in the shadow. But this was custom designed and created by local artist Lydia Ortiz, who also works at Chronicle Books. She's got one foot in publishing as well as an artist in her own right. So she's going to do a program as well coming up. So check out the chat for the dates and details about that. And, you know, just like to say, take care of yourselves, folks, and be well. Stay safe. We hope to see you. Our libraries are open. We'd love to see you here in person and also at our virtual library at a program like this soon. So thank you so much, everyone. Have a wonderful evening.


The atmosphere, when seen edge-on, is a very thin layer around the Earth. And we are now putting into that thin layer of atmosphere 110 million tons of global warming pollution, principally CO2, every 24 hours.


This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on mental disorders caused by addiction. Now a lot of the stuff we've been talking about over the past few sessions are correlated and we can see where like depression and anxiety may be triggered by. But what we're talking about today is stuff that there is a direct causative link between alcohol use in this case and, well, opiates to a certain extent too, and the development of these disorders. They actually cause them. So we're going to define alcohol related brain damage. That's where we're going to start like autism spectrum disorders and fetal alcohol spectrum disorders. ARBD is a spectrum and you can have certain characteristics. You can have certain issues. It can be mild, moderate or severe. But we're going to talk about what in general to look for today. We're going to explain how awareness of ARBD is vital for mental health as well as addiction counselors. Learn about the symptoms of ARBDs including alcoholic dementia and vascular dementia. And learn about fetal alcohol spectrum disorders. Now there is so much information out there on fetal alcohol spectrum disorders. And I've already done some presentations which are on our YouTube channel at youtube.com slash all CEU's education. If you want to go there and review those, we also have some CEU classes on it. And I will be doing more FASD classes in the future. I say that because we're not going to cover 1% of the information that's out there. So hopefully you'll get some useful tools for identifying if you might be working with a client with a FASD. And what you can do in order to improve the effectiveness of your treatment with that person. So alcohol related brain damage, ARBDs. Damage directly caused to the person by exposure to alcohol or other drugs. Now alcohol related dementia and in here we're also talking about Wernicke-Korsakov syndrome is one of them. Vascular dementia is another one and it's caused by the brain not getting enough oxygen, not getting enough blood supply and fetal alcohol spectrum disorders. So those are the three that we're really going to cover today. According to the CDC, and this is important, most excessive drinkers do not meet the criteria for dependence, meaning that they may present in mental health clinics for treatment of mood disorders. So, you know, think about some of the shows that you may watch on TV. Arrow is one I'm thinking of where his mother constantly had a martini or something in her hand. It didn't matter if it was 10 in the morning or 10 at night. She may not have met the criteria for alcohol dependence. She may not have been, you know, to the point where she would experience the physiological withdrawal symptoms and the tolerance, but she drank a lot. And we'll talk about what a lot is in a minute. About 17% of the adult population reported binge drinking and 6% reported heavy drinking, which is more than the recommended amount. So when we're talking about substance use disorders, you've got, you know, almost one in five people that reports binge drinking. So that's rapidly increasing the level of that toxin in your system that talks into your brain.  ARBDs are caused by regularly drinking too much alcohol over several years. And what does regularly mean? We don't really know. But we do know that you don't have to be alcohol dependent in order to cause ARBDs. We do know that drinking too much such as binge drinking on the weekends can cause ARBDs. So think again, college, I don't know what your college was like. Mine was not a dry campus. So there was a lot of drinking that took place. And, you know, the people that were drinking typically binge drank on the weekends and not so much during the week. ARBDs cover several different conditions, which are similar to, but not actually dementia. And when we talk about dementia as the diagnosis, what we're talking about is certain brain changes that occur, such as in Alzheimer's. With ARBDs and alcoholic dementia, the symptoms are similar, but there are some vital differences. Namely, people with alcoholic related dementia, especially if it's caught early, may make a full or partial recovery. People with Alzheimer's, they don't turn that corner. And people with ARBDs, if they stop drinking and develop a healthy lifestyle, will likely not experience a worsening of their condition. So this is really optimistic for people if they notice that, you know, they're starting to have some cognition issues, starting to get harder to focus. And, you know, what we're talking about often we see in patients that are in their 40s and 50s.  You know, when I was in my 20s, I called it mommy brain. Because, you know, with two little kids and not sleeping, I couldn't remember my own name some days. But a lot of people may present in treatment with depressive type symptoms and have difficulty with concentration, have difficulty with remembering things and not attribute it necessarily to alcohol yet. But then you find out that they're drinking kind of heavily or binge drinking regularly. And this might start to become something that we look at because if they stop, they can improve their cognition. They can reverse some of these problems. And that is the hope that I want them to, you know, grab on to not, oh my gosh, what did I do to myself? But, oh my gosh, it can get better. ARBD is greatly undiagnosed. And the NIAAA is the National Institute for Alcoholism and something else. But there's a lot of A's in there. Anyway, what the study finds is that postmortem findings, and this is just think about this for a second, indicate that ARBDs affect about one out of every 200 of the general adult population. That means go into Walmart or go over to, you know, when you're in church, look around, especially if you go to a church that has two or 300 people in there. And I remember when I was in college, you know, we would have certain seminars that there were 700 people. So of those people, you know, if there were 700, well, let's do 800, so I don't have to do math too hard. That means four people in there may at some point, you know, drink enough that they're going to develop an alcohol-related brain disorder. That's, you know, interesting. That's kind of scary. Among those with alcoholism, those who actually meet the criteria for tolerance and dependence and withdrawal, this figure rises to as high as one in three. So if you work with people who are diagnosed as having alcoholism, it's important to recognize that as many as one in three of them may have enough going on or may have consumed enough alcohol that they have caused actual brain changes that will probably get better with time and not drinking. So we want to help people look at this, but we also want to educate them if they keep drinking their memory, their ability to think clearly, all that stuff is going to get worse. People with an ARBD tend to be in their 40s or 50s. So they've been doing this binge drinking or excessive drinking probably for a while. But like I said, a lot of times when we diagnose it, if you will, or when we identify it, it's people who are coming into treatment, maybe with some depression or anxiety, but also complaining that they're foggy-headed and they're confused all the time and they forget things a whole lot more easily and they attribute it to stress. Well, what do you do when you're stressed? I have a few drinks. Okay, so let's take a look at that. Alcohol-related brain damage is thought to cause more than 10% of dementia symptoms in people under 65. So interesting to kind of take a look at that. Now, for your quiz, I'm not going to test you on specific percentages. That's kind of irrelevant. I just want you to get an idea of the scope of what we're talking about and how often clients who are walking into your office who don't meet any criteria for alcohol dependence may actually have an alcohol-related brain disorder or alcohol-related brain damage. Drinking more than the recommended limit for alcohol increases a person's risk of developing common types of dementia, such as Alzheimer's and vascular dementia. So, drinking does increase your risk of developing actual dementia, but alcoholic dementia or Wernicke-Korsakov syndrome are not true dementia. Recommended limits, I keep saying heavy drinking. Well, what is heavy drinking? Recommended limits are now a maximum of 14 drinks each week with a maximum of two each day.  I'm talking about normal amounts.  Those sorts of things is what we're talking about is one drink. So a maximum of two per day is moderate drinking. Go higher than that. You've crossed over into that heavy area. One of the things that's important to recognize about that is alcohol becomes much more toxic in women's bodies much more quickly, partly because we have more fat composition and just the makeup of our bodies and everything else. We know that alcohol affects us more strongly, more quickly. So, well, well, you may have a man and a woman and both have a blood alcohol of 0.25 and they're both standing amazingly. The woman with 0.25 is going to experience more symptoms and probably be a whole lot drunker and sicker. So it's important to recognize also that that also means that the toxicity to our brain tissue is a lot stronger and happens at kind of a lower level. Repeated binge drinking, heavy drinking in one session is particularly harmful.   I mean, there's more to the biochemistry than that, but you get my point. There's an increased risk of dementia, the higher the level of alcohol consumption. But remember, you don't need to be an alcoholic or to get drunk often to be at an increased risk of developing vascular dementia, alcohol-related brain damage. Those are things that could happen, you know, just with heavy drinking or regular binge drinking. Regular drinking, even a little above recommended levels increases your risk and they didn't define what a little above means. But, you know, we'll just stick with the 14 drinks each week with a maximum of two per day. Alcohol-related brain damage causes a range of conditions, including alcohol, dementia, or alcohol-related dementia depending on where you are, the same thing. And we're Nikki Korsakov syndrome, sometimes just called Korsakov syndrome. ARBD, as you know, an umbrella, is defined as long-term decline in memory or thinking caused by excessive alcohol use and lack of vitamin B1. Alcohol affects the way your body processes vitamin B1 and excessive use also damages the internal lining and stuff so your body can't absorb nutrients as well, which causes B1 to go down. Regular heavy, more than 14 drinks a week, drinking over time can cause damage to nerve cells because of the alcohol. Chemical changes in the brain, so your neurochemicals get all wonky. Shrinkage of brain tissue, so you're kind of shrinking those things down.  Not the same way, but just helps you remember it. Intestinal damage leads to poor nutrient absorption. Poor handling of thiamine. Damaged blood vessels. So your blood vessels get stiffer and can get thicker, which causes problems, can cause high blood pressure. And damaged blood vessels, reduced circulation, high blood pressure combined with that increases your risk of heart attacks and strokes. Why do we care? Well, because when heart attacks and strokes happen, then blood and or oxygen gets cut off to the brain because blood brings oxygen to the brain. And if you don't have enough blood going to the brain, then you're clearly not going to have enough oxygen. So it's important to make sure that the cardiovascular system keeps going. Symptoms of alcohol related dementia largely reflect the areas in the person's brain that are damaged. Well, that makes sense. What we're looking at are any of these poor planning and organizational skills, problems with decision making, judgment and risk assessment. When we get down to fetal alcohol syndrome, a lot of this is going to sound really familiar. Why is that? Because the fetus was exposed to toxic levels of alcohol in utero. But I digress. Problems with impulsivity, making rash financial decisions, for example, and difficulty controlling emotions. So they may have some irritability outbursts. So we can use emotion regulation, vulnerability prevention, distress tolerance, skills. And in certain circumstances relapse prevention techniques to help people control their emotions because they just may be really hair trigger for lack of a better phrase when they are at the state of ARBD that they're at. If it improves, a lot of other stuff will probably improve. But, you know, sometimes we interact with somebody when they are at this point. I remember distinctly one client I worked with who had Korsakov syndrome and bless his heart. He was having difficulty with organization. He would, you know, have problems getting dressed in the morning.  A lot of times, you know, especially getting ready for group and stuff in the morning when he was having to do a lot of things independently. So we can look at when do these outbursts occur? How can we help them manage this during their recovery period? And that's what I always emphasize is it's probably going to get better. But during your recovery period, what do we need to do to help you get through the day? They may have problems with attention and slower reasoning. So go slow. Some people with ARBDs, many actually, will not do well in group, psychoeducational groups because it just goes too fast for them. They may need smaller chunks of information. So if you're working in a treatment center and you've got 12 patients in a group and one of them has an ARBD, being aware that that person is probably only getting about 20% of what you're talking about. So they're going to need handouts to look at maybe some more individual sessions, etc. They may have lack of sensitivity to the feelings of other people, inability to kind of read what's going on. It sounds a lot like a FASD once we get down there. Behavior which is socially inappropriate. Unlike Wernicke-Korsakov syndrome, however, not everyone with alcoholic dementia has a loss of day-to-day memory. So they may remember things from day-to-day but have these big gaps in what's going on. In order to diagnose this, the person must have stopped drinking alcohol for several weeks to enable the symptoms of alcohol intoxication to withdrawal. Alcohol intoxication and withdrawal to resolve. Then they need a full physical from a doctor which will include a detailed history from the person and ideally someone who knows them well. Why? Because of those gaps in memory. We need to know what's going on and we don't want our best guess. We would like to know exactly how much is the person drinking, how long have they been drinking, what else has gone on, have they had head injuries, how their symptoms started and they're affecting their life. The test of the person's mental abilities, their memory and their thinking. Now that's something we can do without a significant other but sometimes it's helpful if we're asking where were you born. We don't necessarily know that. So if we have the significant other, we've got a fund of information that we can draw from to test prior memory. And tests for depression because confusion, difficulty with decision making, many of these symptoms are also common in depression. So if they're experiencing a major depressive episode, you know, we want to differentially diagnose. A brain scan obviously ordered by the physician might be required to rule out other possible causes of symptoms such as an actual stroke, brain bleed or a tumor. And this can kind of freak people out but generally I reassured them that, you know, a lot of the time it's from the alcohol. So, you know, let's just go in and rule out these other things so we can get the best course of treatment. The brain scan may show changes such as shrinking at the cerebellum at the back of the brain, which supports diagnosis of ARBD rather than true dementia. So if they get the brain scan and they see the shrinking in the cerebellum, you know, remember alcohol causes shrinking in the brain tissue, then we can kind of make a positive diagnosis at that point or the doctor can, which in a way gives people hope because we can say this is not Alzheimer's. This is alcohol related brain damage, but the chances are it will improve at least some with good treatment, which makes people feel a little bit better. And ARBD should be diagnosed if the person has impaired memory thinking or reasoning, which is bad enough to affect daily life and a recent history of several years of alcohol misuse.  And I'll give you a little anecdote here. My grandfather, when, oh golly, he was probably in his mid 60s when his Parkinson's disease started setting in.  The doctor, you know, that was leading up to saying the doctor put him on a benzodiazepine. And evidently this doctor was not familiar with working with the geriatric population because there are certain benzodiazepines, the majority of them actually do not clear an elder's system the same way they clear a younger person system. So grandpa was taking the recommended dose for somebody of his size, but not of his age, which built up in his liver. And he developed severe toxicity and had to be in the hospital for a little over a week, I believe, to get the benzos out of his system, but his symptoms were very similar to what's going on here. I mean, he had respiratory depression, depression, depression, confusion, basically no memory at all.  So being aware if you're working with someone that side effects of Medicaid medication can also cause these opiates, even taken as prescribed in some people. I know if I take opiates at the level that the doctor prescribes, I can't think straight. I can, I have blurry vision. I have no short term memory at all.  So it's important to recognize that sometimes even taken at the prescribed level. Some people have a sensitivity to these medications and they'll react more strongly to them, which can produce these sorts of symptoms, which takes us back to looking at how long of these symptoms been going on. Was there a triggering factor that we can identify other than alcohol. So Corsikov syndrome is a form of alcohol related brain damage caused by a lack of thiamine. It's much less common than other forms of ARBD, such as alcoholic dementia, which we've talked about and does improve in most people over time, maybe not completely, but a lot of the skills and stuff generally come back. It's diagnosed in about one in eight people with alcoholism. Remember ARBD is it was one in three. Corsikov's is only one in eight. Woohoo. But this is a really important thing for us as mental health clinicians to be aware of. And you'll understand why in a minute. It develops as part of a condition called Wernicke-Corsikov's that consists of two separate but related stages, Wernicke's encephalopathy, followed by Corsikov syndrome. It's important to remember though, not everyone has a clear case of Wernicke's encephalopathy before Corsikov syndrome develops. So just because they don't have some of the symptoms we're fixing to talk about doesn't necessarily mean they're not going to develop Corsikov syndrome, which is a medical emergency. There are no specific lab tests or brain scan procedures to confirm this diagnosis. Wernicke's encephalopathy usually develops suddenly, often after abrupt and untreated withdrawal from alcohol. And that's why it's important for us as mental health clinicians to be aware. If we have a client who has been drinking and maybe they got divorced and they hadn't drunk, you know, really hadn't had a problem with alcohol. They got divorced or separated or something and they've been drinking pretty hard for about two months. Well, we might have a problem. If they started, they decided, you know what, I'm not going to drink anymore. I'm going to get my life back on track and pick myself up and move on. That's awesome. But if they abruptly stop that alcohol and they are not under medical supervision because a doctor would be able to, you know, figure out the thiamine issue. They can start developing Wernicke-Corsikov syndrome. Symptoms of Wernicke's encephalopathy, and this is, you know, phase one if you want to think of it. Disorientation, confusion or mild memory loss, malnutrition. They may be eating well but not gaining weight. Involuntary, jerky eye movements or paralysis of the muscles that move the eyes. And this is one of those telling factors. Not everybody has it, but if you notice they've got some jerky eye movements going on. That is a huge clue that we got a problem. Poor balance, unsteadiness, staggering, stumbling and lack of coordination. They may not be drunk. They may not be intoxicated at all. It may be because they're not intoxicated that they're experiencing this right now. So if we notice something's going on like that, we need to pay attention. The last one, poor balance or unsteadiness, staggering, stumbling and lack of coordination is also a symptom of serotonin syndrome, which is another medical emergency. So if somebody starts acting physiologically not like they normally do, we need to pay attention to sweet. If we're in a case encephalopathy is suspected, immediate medical treatment is essential to prevent permanent brain damage. So unlike ARBD, which often gets better, there's lack of thiamine. It can be a problem and cause permanent brain damage. If the encephalopathy is left untreated or isn't treated soon enough, Corsikov syndrome gradually develops. And you remember I told you the client I worked with had Corsikov syndrome. He had been drinking hard for many, many years. He was in his mid 60s when he came to our treatment center. So it had been a long progression where he had tried to stop for a while. He'd gone to 12 step meetings.  So he would detox himself at home and start going to 12 step programs and stay clean for a little while and then relapse. But because he was doing it that way without any medical monitoring, unfortunately it also contributed to the thiamine deficiency. Damage occurs in several regions of the brain. Symptoms include severe loss of short term memory and day to day memory. He would put on his socks and then forget he put on his socks and start going around looking to try to find socks in the morning.  So paying attention to some of these things which can seem, you know, peculiar that we want to look out for. Problems learning new information including new routines and life skill. Somebody in treatment who has Corsikov syndrome and most likely you're probably only going to see people with Corsikov syndrome. If you're in a dual diagnosis facility, if they come to you in a mental health facility, you're probably going to see that there's more going on there than you can handle once a week for an hour. But, you know, hypothetically if you're seeing them any new routines or life skills that you're teaching them from distress tolerance to mindfulness to, you know, avoiding triggers to getting good sleep. They're going to have problems learning that so we're going to have to go back to basics writing it down, breaking it into small chunks. Their ability to remember recent events is going to be damaged. They may have gaps in their long term memory. They may not be able to remember what they did last Christmas and it can be very frustrating, especially if, you know, maybe last Christmas was the last time that they saw their children and they can't remember that. It can be devastating to them. Memory problems may be severe while other thinking and social skills are relatively unaffected. For example, individuals can carry on a coherent conversation and he could, I mean, he could spin a yarn, but moments later be unable to recall that the conversation even took place or to whom they spoke. So, you know, occasionally I'll have these, I think we all do, we have these periods where we can't remember if we said it in our head or we said it out loud. I was talking to my husband about something today and I said it and I'm like, did I already tell you that? And he's like, no, I was like, okay, said it in my own head, but that's normal. What we're talking about here is totally not even remembering a conversation you just had not 15 minutes ago, which is not uncommon. So you can see in treatment centers, especially in residential treatment centers where this can cause problems. If you're telling somebody to do something and they are spot on, they're like, okay, I got it. I'm going to go do it. And they walk away and don't do it. Not because they're being resistant, but because they completely forgot that you even had the conversation. It doesn't transfer from that immediate short term memory into anything else. Those with Korsakov syndrome, and this is another problem in treatment as well as in the legal system and relationships. Those with Korsakov syndrome may confabulate or make up information they can't remember, but they're not lying. They may actually believe their invented explanations. So if you're talking to somebody and you tell them, I need you to go arrange the chairs for the meeting in the cafeteria. And the person says, okay, I'm on it. And they walk away and they forget the conversation and they don't do it. Then when you confront them later about, we had this conversation. You said you were going to go arrange the chairs in the cafeteria for the meeting and you didn't do it. What happened? They may come up with some, there was a fire drill and we had to go outside. Well, maybe they went outside to have a smoke or something. So parts of it, they may remember and they try to weave it together to figure out, okay, what was it that I was doing? How did I get distracted? So they're not lying. They actually believe their explanations. And that's a hard one for a lot of us to wrap our heads around the difference between confabulation and intentional misleading. There's a good chance of stabilization or improvement if the person is given high doses of thiamine and remains free from alcohol and adopts a healthy diet with vitamin supplements. So, you know, there's, you may have some minor improvement. Chances of them going from not being able to live independently to living independently, they're pretty small, not unheard of, but pretty small. But there are likely going to be improvements as the fog clears, so to speak. Brain scans show that with abstinence, abstinence, some of the damage caused by excessive drinking can be reversed. The brain is really cool. It wants to maintain the person. It wants to survive so it can rewire itself.  The brain can actually do workarounds and people can regain some skills that they didn't, that they had lost because of the injury or accident. So the brain is really cool. And I encourage people, if they're dealing with this or even family members who are trying to support their loved ones through it, I encourage them to look with curiosity at how is the brain helping this person recover now. What really cool things did it do today? I think about when you've got young children at home, and especially really young ones where every day they do something new. And it's just like, oh, wow, that's so cool that you figured out that you can put your hand into a glass jar. That's awesome. Well, look on it with the same curiosity. What is the brain doing? And that makes it more of a activity than rehabilitation, which can be kind of daunting sometimes. So vascular dementia is a little bit different. Vascular dementia can be caused by a variety of things, not just alcohol or opiates, but it's caused when blood supply to the brain is interrupted. So auto-asphyxiation, we're not going to talk about that right now. But if it interrupts the blood supply to the brain, crush those arteries on either side can cause a stroke, can cause vascular dementia. You also see this potential during the second stage of alcohol withdrawal, which is usually 24 to 72 hours post-drink. It's when the blood pressure starts to go up, the anxiety really goes up, body temperature goes up, heart rate becomes unusual. You can have fluttering, you can have tachycardia, you can have alternating bouts of tachycardia, which is too fast, and bradycardia, which is too slow. You know, the heart starts doing flippy flops during the second stage. It's trying to figure out what the heck's going on and confusion. If you're not getting enough blood and oxygen to the brain, you're going to get confused. It's just the way it happens. So this is the period where people are a lot more likely to actually have a stroke, which can cause vascular dementia. If somebody has a vein collapse from IV drug use, they can also cause reduction in circulation and impairment of blood to the brain. You can impair blood to one portion of the brain, for example, which can cause a stroke or can just cause lack of blood to that area, which can cause vascular dementia. And stimulants use can cause high blood pressure and result in somebody having a stroke. So when I talk about stimulants, I'm not just talking about illegal drugs, cocaine, methamphetamine. I'm talking about spice, which can make people's heart rate go up to, you know, 200, and that's not exaggerating. It can make their blood pressure go way up. I'm talking about pre-workout supplements that some people take that are loaded with lots of caffeine and other things to increase blood pressure and heart rate. So there are a lot of over-the-counter herbs and medications and supplements that people can take that are stimulatory, which can increase blood pressure and increase the risk of stroke dramatically. And Guarana, which was legal back when I was in college. It was in a lot of pre-workout supplements is now not able to be sold in pre-workout supplements or in, you know, mixes, but it is still legally being sold in the United States. And a lot of athletes, not professional athletes, but like bodybuilders and stuff, do take it. So be aware, if you've got a bodybuilder who is, you know, working out, you want to talk about what kind of subs that person uses. And that's something they love talking about. So it's not hard to get into that conversation and make sure to educate them about high blood pressure. Bratocardia, too slow of a heart rate, can be caused by severe hypothyroid. Usually this is caused by some sort of an injury. You don't just go from being fine to having severe hypothyroid, but something to look at. Opiate overdose, if somebody takes too much, it slows your respiration, slows your heart rate. It can slow it down to literally nothing, which cuts off that blood supply to the brain. Heavy alcohol use produces arrhythmias and hypertension, which can disrupt the brain access to alcohol. But it can also, the arrhythmias going too fast and then too slow for a while and then too fast again, really monkeys with the works. And alcohol poisoning. You drink too much of it. Alcohol is a depressant. What do you think happens? Which is why people blackout, why people pass out, among other things. I mean, they are poisoned at that point, but alcohol is a system depressant.  The most common cognitive symptoms are problems with planning, organizing, making decision or solving problems. Difficulty following a series of steps, like cooking a meal. What do I do first? A slower speed of thought, problems concentrating, including short periods of sudden confusion. A person in the early stages may also have difficulties with memory, language and visual spatial skills, such as perceiving objects in three dimensions. Vascular dementia can be caused when somebody has a stroke for a variety of other reasons too. So it's good for us to be aware of what the signs of this are because, you know, how many people do we know who especially once they got older had a mini stroke or multiple mini strokes. Many times when people start having strokes, it starts causing some degree of vascular dementia. We want to alter or tailor their treatment plan using some of this information by making sure that we help them with planning and organizing. That can be a treatment plan issue. Anything that we ask them to do that is complex or a series of steps, write it down so they can see it and they can follow it one at a time. Take things slower. They may not be able to get what's presented in a group setting. They may have to be in individual counseling or have an additional individual sessions. Problems concentrating and short periods of confusion, encouraging them to be willing to say when, if they're starting to get confused so they don't get frustrated. If they're having difficulty concentrating, then they start getting confused and they start getting frustrated and they get angry, then they're flooded with adrenaline and you're going to get nothing after that. So we want to help them become mindful so they can say, whoa, I need to back up for a second. With language, giving them time to speak because their speech may become less fluent, not jumping in, not finishing their sentences, but being patient and letting them try to get the words out. Many patients who use substances even recreationally may experience strokes or mini strokes well under the influence and not even realize they had one. So again, thinking about our bodybuilders, thinking about people who use recreationally on the weekends at raves, at frat parties, at, you know, for whatever reason. It's important to understand that when you're under the influence of any sort of minor mood altering drug, you're probably not going to be aware if you have a mini stroke because it's going to seem a lot like intoxication in most cases. High blood pressure plus alcohol or stimulant use greatly increases your chances of a stroke. If you've already got high blood pressure and then you start ingesting things that increase your blood pressure, it's a no brainer. Clinicians must be aware of the symptoms of dementia, be able to differentiate it from intoxication, which can be challenging. Encourage clients to seek immediate medical assistance if we notice anything that looks like a stroke or serotonin syndrome or alcohol related dementia, or wernicke's encephalopathy, and be additionally attentive if a patient reports self detoxing from alcohol. And by additionally attentive, I mean telling them they need to go see their doctor and have that monitored. We can't force them to, but helping educate them about how dangerous it is that they may experience a B1 deficiency. So FASDs are caused by fetal exposure to alcohol. So you think you have this thing full size of a peanut in your body, and there it's exposed to the blood in your body, and you drink and you've got a blood alcohol of 0.08. Well, that's the legal limit. So what's the big deal? Well, what you drank is the blood alcohol content for somebody your size to have a 0.08. For somebody that's the size of a peanut, that child is trashed. And I don't say that to make light of it, but I say that to help you kind of put things into perspective. The amount of alcohol that the fetus is exposed to is pretty significant, combined with the fact that their brain is still developing causes problems. So remembering that fetal alcohol spectrum disorders are a spectrum, and there are a lot of different features. Not every person with an FASD has the facial features, and even those that do often outgrow the facial features. So when you're seeing them as adults in counseling, they may never have been diagnosed with an FASD, but they may have some of the symptoms we're talking about. And it should give you pause to think, hmm, what's motivating these behaviors? Are these intentional behaviors? What else might be going on here? So facial features that they may have had as a child, I guess we're going to get to that on the next slide. People with FASD have many neurobehavioral problems which interrelate to produce profound problems with accurately processing information and relating to the world around them. What does that mean? This is the best visual I can give you. So they may be 18 years old chronologically. Okay, so theoretically they're graduating from high school, they're old enough to enroll in the military, not old enough to drink yet. Physical maturity, 18 years old. Developmental level, 9. Oh, daily living skills, 11. I wouldn't leave my 11 year old to live independently. So now we start to see we're having problems. So we've got this person who is, you know, 18 years old and you think they should be taking on adult responsibilities with a developmental level of 9. Daily living skills of 11, but expressive language of 23. Oh, we start to complicate the picture. Because people with an FASD may have, be very, very verbal and very able to carry on a conversation with adults and a lot of times there's no cognitive impairment. So they are very expressive and able to talk to people and interrelate well. So it's surprising when you start seeing problems in developmental functioning and daily living skills. They're receptive language. So what they're able to interpret from other people is that of a seven year old. So they can talk the talk of a 23 year old, but they're only interpreting that of a seven. So it creates a big conflict. And there's a lot of inappropriate interpretation of nonverbals, not understanding nonverbal behaviors. And not getting things like idioms and things like that. Artistic ability or other strengths can be at a 29 for this particular client that they used as a, as a prototype. Reading level was at 16 for decoding. So he could read the words, but actually understanding what it meant, he was at the level of a six. So he could read the words, but didn't get anything out of it. Money and time concepts, level of an eight year old. That's second grade. So just to kind of put that into perspective. So people with, with an FASD don't all fit in this category. This is one particular person that's pretty prototypical, if you will. But understanding that their developmental functioning late living skills, receptive language, reading comprehension and concepts of money and time are usually all at the elementary level. Whereas their expressive language and artistic ability, maybe much more developed than even their chronological age. So they present a very confusing picture when you start assessing them in, in counseling. Diagnostic features, three distinct features. The philtrum, the ridge between the nose and the upper lip that there's usually a little groove right there. It's not there on people with an FASD sometimes very thin upper lip and a distance from their nose to the top of their upper lip is usually wider than for most people. And a short distance between the inner and outer corners of the eyes, giving the eyes a wide spaced appearance. So you can go online and look at facial features of an FASD to see what it looks like in children. But remember that as people grow, they generally grow out of those facial features. So that is not something you even want to really rely on at all for an adult diagnosis. And even for a child diagnosis, there's a significant percentage of children with an FASD, especially on the lower end of the spectrum that don't have the facial features. We don't want to miss them because we're only looking at people with the facial features. The children may have a height or weight or both at or below the 10th percentile. You know, this can be due to the mother smoking while she was pregnant using crack while she was pregnant. It can be due to a variety of other physiological issues between the mother or baby. So we don't want to just assume that it's FASD, but it's a factor to consider smaller than normal head size for the person's overall height and weight. So their height and weight might be 50th percentile, where their head size is the 10th percentile. So proportionally, it's a little bit wonky. But they can have height, weight and head size all below the 10th percentile. So you've got a little itty-bitty person. Significant changes in the structure of the brain as seen on brain scans such as MRI or CT scans. So we can see some changes if we put children through the or people through the MRI or CT scans.  The neurological system was flooded with alcohol when it was trying to develop. So it short circuited in some places. Cognitive deficits, including specific learning disabilities, executive functioning deficits, including activities of daily living. Attention problems or hyperactivity, poor social skills and difficulty interpreting nonverbal behavior. And you're looking at these and you're going, well, that sounds like six other diagnoses. And my answer is yes, it does. So we need to look at the person in the situation and figure out what they're presenting, what symptoms they're presenting with, how it's impacting their life and how we can help them improve that. Recognizing that, you know, if we start talking to them about mom's drug use or alcohol use when she was pregnant, they may not know that mom drank when she was pregnant. We do know that fetal alcohol spectrum disorders are often intergenerational because of the problems with impulse control and a variety of other things. People with FASDs are more likely to start drinking, you know, especially if they're undiagnosed, be susceptible to peer pressure, more susceptible to peer pressure, start drinking and have a FASD child themselves. Issues for clients, problems with cause and effect relationships and impulse control. So they don't really understand if I do this, you know, if I yell at Sam, then he might yell back at me. So maybe I ought not yell at Sam. Problems with the ability to conceptualize, internalize and structure time. So getting them to work, getting them ready in the morning, getting them to be somewhere on time is a difficult chore because they're not able to grasp the passage of time. You know, sometimes they feel like it could be three days, sometimes it could be three months. They also don't understand the concept of time in terms of if you tell them they're going into residential treatment, for example, for a month. That means nothing to them. Three days, three years, they don't know how long a month is. It's not meaningful. They have problems with the ability to generalize information, difficulty understanding concepts and abstract thoughts. So we're talking about concrete operational thought, which, you know, you go back to that list that I showed you and that would be right about right as far as age in Piaget's development. They don't progress to formal operational thought where they can think abstractly and generalize very well. Another key feature that can separate an FASD from some other things is problems with with perseverative behavior. Perseveration is commonly described and thought of as some form of repetitive behavior, not necessarily stemming like you see in autism, but like tapping toes, drumming fingers, knocking, pacing. These are things that this particular type of diagnosis has people with this diagnosis have problems with. We can also manifest as a particularly rigid rigid way of looking at things, a refusal to let go of an idea, a rigid tenacity which can border on fanaticism and or certain way of feeling or interpreting a feeling and refusing to consider any alternate explanation. Now, you know, I can think of some very some people who don't have an FASD that have some of these characteristics that they are bulldogs when they get an idea in their head. So we don't want to just say perseverative behavior means the person has an FASD, but we do want to recognize that these types of behaviors can set an FASD apart from something else, like some of the dementias that we talked about before. And for some people with an FASD, there may be some elements of obsessive compulsive disorder in it, but generally not. That's not something that's really talked about a lot in the FASD literature. Problems in all areas of processing information, particularly auditory. So think about how our sessions go. We talked to people. They're not going to pick it up that well. So we need to make sure to write things down. Ideally have them write things down and then go over it with them. Problems with short term memory, difficulty anticipating consequences, good expression, but poor comprehension, like we talked about earlier, and good at reading, but poor writing skills. So they're really good at reading and have difficulty with auditory processing and difficulty with comprehension. So if we have them, if we write down lists and make sure that they understand what's on the list and they can explain to us what it means, and they have that to look at. That's the best case scenario for a client with an FASD. They will likely not benefit from standard treatments that require conformance, motivation and follow through on multiple tasks. So have them write out their own weekly goals at the end of the session, say, okay, we talked about a lot today. And, you know, they may remember what what you talked about. They don't have deficits in immediate short term memory. So we can, at that point, start brainstorming what are your goals for this week and hand them a piece of paper and help them, you know, if they need help writing because writing is difficult. You could write it for them, but you need to have them go over it at the end, you know, hand up to them after you've written it and say, Now I want you to read this to me and tell me what each thing means and what you're going to do. So make sure that they can explain to you what they're going to do. Cannot accurately anticipate consequences and repeatedly make the same mistake. They may seem to shoot themselves in the foot. So repeatedly getting DUIs. A lot of times if they've got criminal charges is the same low level misdemeanor criminal charge. They don't escalate the felonies or anything. They just keep doing the same darn thing and you're like, Dude, did you not learn that you can't do that. So identifying those the same thing can be in treatment if they know show and they give you a reason for no showing and you talk about why, why that's not okay what to do to prevent that and then they know show again. They may not be able to anticipate and manage their time well enough to get there may be unable to demonstrate remorse and get incorrectly labeled as anti social they have difficulty interpreting what's going on with other people and have difficulty expressing that remorse. So expression can be on the high level but when it comes to remorse that's one of the areas that seems a little gray because a lot of times they don't understand they did anything wrong. They have a right to specialize treatment and accommodations and remember they may not be using alcohol or drugs at all may never have used. So we don't want to lump them in as saying that they've got some sort of substance use disorder. They see themselves each time as making a single mistake, unable to conceptualize the past. So they don't see a pattern. They can't see patterns. It's like, Oh, I made a mistake won't do that again. They do it again. Oh, I made a mistake won't do that again. They're easily manipulated and often take the fall for people who don't have these problems. They may have gaps in their personal history account including important facts like where they went to high school. They tend to be quite impulsive and comedic. A lot of this is developed in order to fit in and gain acceptance when they're younger. May not follow through with appointments due to inability, not lack of interest or motivation. Last few strategies. When you're working with a client with an FASD uses few words as possible and keep them basic. Don't use, you know, lots of fancy Scrabble words. Always be clear and state what you want to happen. The desired behavior be very, you know, straightforward. Don't argue, debate or negotiate. You know, if you start negotiating, I will, if you will, they can't anticipate consequences. So negotiating often doesn't, it falls on deaf ears. Being direct is good, but don't become too authoritarian or the person with an FASD may likely shut down. Please don't expect them to be reasonable or act their age. A lot of times they're unable to and unable to interpret appropriate adult nonverbal behavior to act their age. If you get stuck in a no loop, and they're just, you know, no, I'm not going to do that. No, I'm not going to do that. You short questions you think the person will answer yes, just to get them stuck out of out of being stuck in the no loop. I'm not talking about trying to trick them like rabbit season duck season. I'm talking about just getting them to get out of that negativity for a second. And let's talk about some yes things. And then we'll go back and ask the questions again and see if they still say no. Try to be non-judgmental and remember to start with a clean slate each day, because they do. Don't get frustrated that you just dealt with the same type of issue yesterday. Think about the movie Groundhog Day. You know, for many people with an FASD each day, it's like starting all over again and the stuff that they already did, they haven't been able to learn from and may not even remember some of it. Mental health clinicians are likely to see clients who present with depression and or anxiety who are misusing or excessively using substances but not dependent upon them. Alcohol related brain damage can be caused by the use of a substance increasing blood pressure, causing a stroke, slowing the heart or collapsing veins. Withdrawal from the substance, namely alcohol, can also cause or trigger a cascade of effects that causes alcohol related brain damage. Heavy use is defined as more than 14 drinks per week with more than two per day. Many clients with alcohol related brain damage are not alcoholics. Remember that FASD is brain damage caused by fetal exposure to alcohol and those with an FASD experience deficits in interpersonal and executive functioning, which make it difficult or almost impossible to comply with traditional treatment. Special approaches are available and required for persons with FASD to provide ethical and effective treatment. Thank you for sticking with me on that. Are there any other questions? I will put that is our YouTube channel if you haven't already been to it and we do have some article videos on there on addressing FASD, specifically hour long videos on FASD. So if you have clients that may be struggling with that issue, you can access that information without having to get CEUs or whatever. Alright everybody, have a fabulous day and I will see you tomorrow. Since 2006.