SocioEcological Theory of Addiction

SocioEcological Theory of Addiction


To the presentation on models and
theories of addiction, the socio-ecological theory. Over the next
hour we’re going to define the socio-ecological model, apply this model
to addiction, explore different variables that create this mode,l and discuss how
this framework can be used in the prevention and the treatment of co
occurring disorders. The socio-ecological model was designed
to try to explain human behavior is the interaction between individual and five
different environmental systems the key here is the interaction between it’s not
just a one-way the environment doesn’t just act on the person the person also
acts on the environment and changes what they may be encountering the five
environmental systems are the microsystem meso system XO system macro
system and chrono system which we will talk about in the next few slides so
let’s take a look at the model I’ve put the visual representation right here the
individual is at the core of the model his or her sex age health just general
characteristics of the person are this foundational center dot the individual
exists within a microsystem the microsystem are those people and systems
that the person encounters on a daily basis but those systems and those people
may not encounter larger systems so we’re talking about basically the people
that the person encounters ref roughly every day so we want to look at family
peers school church or religious institution or recreational activities
and health services so in this person’s micro system if you want to think about
it in terms of like a map you have the individual which is your house and the
micro system which might be your city or your town we’re not talking the county
yet we’re just talking this small little area that has the greatest amount of
influence on what may be going on with the individual and likewise the
individual has a lot of impact on this micro system so let’s think about this
for a minute and we’re going to really look at it piece by piece as we go
through if the individual is lative Lee healthy let’s say we start
with someone who is relatively healthy relatively functional and they’re
immersed in a micro system that is dysfunctional there’s a lot of violence
and crime at school the teachers are burnt out don’t really want to be there
there aren’t very many recreational activities and opportunities outside the
family in this particular town the family is replete with people who are
struggling with addictions or mental health issues or both and the peers
there’s not a whole lot to do since there aren’t a lot of recreational
activities except for maybe hang out and use this sort of describes a couple of
the counties that I used to work in so you take a person who normally wouldn’t
they don’t have a whole lot of personal predisposition toward addiction or
mental health issues but if you put them in a situation where they’re exposed to
a lot of risk factors on a daily or almost daily basis you can see how those
things might impact the individual now the individual can make a choice about
who they hang out with if there are choices to be had or they can extract
themselves from that micro system which when we go into recovery we talk about
changing people places and things we’re talking about adjusting that micro
system to create one that is supportive of recovery and wellness behaviors the
meso system is the interconnection between micro systems so how does the
family interconnect with the school if it all how does the family interact with
peers if at all how does the family interact with health and wellness
services so is there um family engagement in the youths or into the
individuals life is there some interweaving or are these micro systems
sort of operating in isolation they’re impacting one another but they’re not
positively involved the relationship between the child’s peers and the family
can have big impact and I say child because when
we talk about the socio-ecological model oftentimes we’re looking at the
development of an individual over time but this can be true of anyone think
about when you went to college and your entire microsystem from for the most
part really changed almost overnight you went from having curfew and living under
mom and dad’s roof all the structure of high school all that sort of stuff the
friends that you always knew too you know for me I went to school five hours
away from where where I lived so everything changed I was kind of like a
fish out of water or a butterfly spreading its wings depending on how you
want to look at it so how did I impact my environment well when I went to
college I chose my peers I chose my recreational activities and those things
reciprocally interacted upon me you know you choose healthy behaviors then that’s
probably going to be reinforced in your life you choose unhealthy behaviors
that’s probably going to be reinforced school you know obviously I went from
high school to college and that was a big change trying to adapt to the
different rules the different structure of school looking at how school
interacted with my peers who was skipping class it was going to class
those variables played a big part in it so you can see how you change your micro
system you can really change the course of someone’s development now does that
mean we have to take someone who is struggling with addictions or mental
health issues and completely transplant them no it might make it easier for them
but it is not likely to actually be something that is doable so we have to
look at helping the micro system or helping them alter their micro system
instead of letting the microsystem bring them back to where they were before
treatment see what I’m seeing what I’m saying here
you know that you can’t change your family you you are born into that family
so the person can either choose to go back to the same dysfunctional family
patterns that were there or they can choose to react a different way which
will probably impact how the family reacts with them so these are our first
two systems and remember there’s five so this is a complicated complicated theory
it does do a better job than just about any of the other things that we looked
at at trying to account for the multiple reciprocal variables that are involved
in the development of depression anxiety addiction the XO system involves links
between a social setting in which the individual does not have an active role
and the individuals immediate context so the XO system is like the spout your
spouse’s work or social services mass media local politics you may not have an
active role in it on a day-to-day basis or even you know once a week basis but
it does have an impact on you your neighbors if you live in a neighborhood
that has a homeowner’s association this is one of those XO systems you may not
have an active role in that on a regular basis but it does impact how you keep
your yard how you paint your house how you do all kinds of things the XO system
is important because it sets a tone in a community it sets ground rules and when
we start talking next week about risk and protective factors we’re really
going to hone in on the fact that neighborhood disorganization and lack of
a sense of connection to the neighborhood into the community are huge
risk factors because people turn a blind eye and they don’t develop social
supports within the community so we’ll move on to macro system which are the
attitudes and ideologies of the culture describes the culture in general that
the person exists in American culture for example we can look at it on a
slightly smaller scale such as socioeconomic status but it we’re
looking at how is this person surviving within the larger culture not just their
community not just their County not just their state but on a bigger level as a
human being how are they interacting and interfacing and the chrono system now
this one’s kind of interesting because you’ve got to think we’re thinking
tangible sort of systems right now as they get bigger and bigger and bigger
the chrono system involves all the events and transitions over the life
course as well as so has historical things for example my life was going
along and I decided to go to college so that was an event and a transition in my
life I got married that was an event and transition in my life I had a child well
that was a big big event and big transition um my child
yeah you know I hadn’t had children so I was under the foolish but that I would
work on my dissertation while he would sleep he didn’t sleep ever the poor
little guy had gastric reflux so you know it wasn’t his fault but for the
first three months that he was home he would sleep for 15 minutes at a time
which means I would sleep for 15 minutes at a time so a lot changed as a result
of my micro system changing I had to become more flexible I had to change the
way I did things a little bit as a result of this new little person in my
life deaths moves job changes empty nest syndrome all of these major changes that
sort of shake up the way you do things need to be considered in the chrono
system the other things that we need to consider our diagnosis if you get a
diagnosis of heart disease or kidney disease or something that may impact the
way you interact with the environment and other people it’s going to be
important to consider that now the CDC uses a four-level socio-ecological model
to better address addiction this model considers the interplay between the
individual the relationships the community and societal factors so this
is sort of a very very simplified version of what we were talking about in
bronfenbrenner model the model suggests that in order to prevent addiction
mental health issues it’s necessary to act across multiple levels of the model
at the same time so let’s think about this practically does that make sense do
we need to act can’t can we expect recovery if we just provide treatment to
the individual and effect nothing else in the end
merriment chances are no I haven’t seen people experience a lot of success when what we need to look at is what things
in their environment can we help them work on I mean a lot of our clients come
to treatment and they are in treatment by themselves if you will it’s not a
family treatment it is Jim Bob coming to try to start feeling better but Jim Bob
probably is coming out of some sort of dysfunctional micro system we don’t know
what’s going on but we know that since he has been behaving and acting with
certain behaviors that is probably created or influenced the micro system
so we need to look at what is it that we can help JimBob change in his micro
system that can help him embrace recovery and wellness behaviors we want
to look at the family peers health behaviors those are kind of the three
big ones this approach is more likely to sustain prevention efforts over time
than any single intervention so instead of just saying alright JimBob I want you
to figure out I want you to learn how to change your thinking and use the ABCs of
our EBT and everything will be wonderful well Jim Bob can do that but it is not
going to be a panacea and over time its ineffectiveness will start wearing down
his desire to use it his motivation to use it and he’ll probably fall back into
old behaviors what we need to remember and this comes from systems theory is
that a system wants to maintain homeostasis it wants to maintain balance
and if it formed balance around dysfunction then when you take
somebody who has changed and plot them back into a balanced dysfunctional
system it’s going to become unbalanced so either the person has to change and
revert to dysfunctionality or the system has to change and revert or and move on
to recovery so individual factors we want to look at biological and personal
history factors that increase the likelihood of addiction or mental health
disorders we’re going to look at risk and protective factors we’re going to
look at family history of addiction we’re going to look at the family
environment and remember when we talked about theory of addiction we’re going to
learn we’re going to look at what social learning influences from that micro
system may have increased the likelihood that this person may choose addictive
behaviors and or may experience mental health issues now people don’t choose
mental health issues they may learn dysfunctional thinking patterns that
contribute to depression and anxiety they may be exposed to a micro climate
micro system that is very very stressful and promotes depression and anxiety
instead of health and wellness but people don’t wake up in the morning and
go you know I think I’d really like to be depressed today now people don’t say
they really want to be an addict today but they may wake up and say you know
I’d really like to get high today so there’s a little bit of a difference
here not a whole lot but it is important to recognize that there’s a lot in that
micro system that can be adjusted and just like em if you’ve ever you know I’m
one of those people I can’t stand have strings and if I have a string that is
hanging off the shirt I will pull it now when you pull a string unfortunately i
found out over and over again that it generally doesn’t just snap it unstart
stu unravel the whole shirt or the whole sweater or the whole
line we can use that analogy in a positive way and think to ourselves well
if we help JimBob create one positive environment if we pull one positive
string in that micro system guess what it’s probably it is going to have a
reciprocal effect on the environment it’s going to have a positive one if he
stops being stressed out and negative and using all these cognitive
distortions people are going to observe that people are going to notice that and
it may lower the stress in that system I’m not saying people are going to
observe it and go I want to be just like Bob I’m going to do the ABCs I’d like to
think that but it’s not going to happen any change you make in a system is
probably going to have similar reciprocal effects throughout the system
so little small changes will produce little small changes for the better or
for the worse we don’t need to build try to build rome in a day let’s just start
with trying to get the site level before we even start pouring the foundation we
want to look at pre-existing mental health issues you know maybe JimBob has
been struggling with depression or anxiety since he was knee-high to a
grasshopper if that’s true there are probably because of those reactive
neurological pathways he probably has developed some inaccurate thought
patterns or cognitive distortions or whatever you want to call them because
when you’re little especially when your knee high to a grasshopper kids think in
all or nothing terms they’re not able to think in shades of grey until they
develop further along so if things stressed him out then he may have
internalized these things and figured that those things always and forever
would stress him out we can help him start changing his black and white
thinking that’s no not changing how he thinks about you
know and things all day long about everything we’re just encouraging him to
notice his black and white thinking and change it to something that’s less
dichotomous encourage him to look for exceptions anyhow i digressed individual
factors so these pre-existing mental health issues may set him up to be more
likely to develop worse mental health issues other mental health issues or
addiction issues does it mean he will know by no means but it does pose a risk
factor chronic pain is another individual factor whether it’s
fibromyalgia we’re dealing with or you know maybe JimBob played football in
high school and blew out his ACL and now he has knee problems or back problems we
all know somebody who has a football injury and they’re 45 years old still
talking about it I have to believe that still causes them chronic pain or they
wouldn’t talk about it so the impact of chronic pain is one that we really need
to not dismiss what is painful for one person may not be a big deal for another
but if it’s painful for somebody then it’s going to affect their attitude it’s
going to affect their stress tolerance it’s going to affect their mood it’s
going to affect possibly their sleep which will also affect their attitude
mood concentration you see how this is you know reciprocal changes so we need
to address the chronic pain we need to look at it and say okay this may be a
risk factor for you you know having some other issues people who have chronic
pain also tend to be more likely to develop depression why well if you’re in
pain all the time there’s that sense of hopelessness and helplessness you wake
up and you’re like everything hurts those of us who are blessed with not
being in chronic pain all the time we’ve had injuries we’ve had things that have
happened and you wake up in the morning and i’m
getting over a shoulder injury right now and i wake up in the morning i’m like oh
it still hurts today and it frustrates me because i can’t do the things i want
to do i can’t do the things i feel i should do and we know should a nasty
word that wears on a person after a while if their chronic pain is enduring
so hopelessness helplessness pre-existing mental health issues
chronic pain which may also impact sleep as well as mood and low self-esteem if
the person didn’t develop a healthy self-esteem when they were growing up
they are at a greater risk it is a risk factor for the development of addiction
and mental health disorders so you can see house there are a few things that we
can key in on during our assessment is this all of the individual factors so by
no means but it’s a start biological and personal history factors increase the
likelihood of addiction or mental health disorders some other factors that we
want to look at our age education income substance use or history of abuse so
what do I mean what is overwhelming exhausting depressing terrifying to a
five-year-old is going to be different than what is overwhelming terrifying
exhausting to a 25 year old because developmentally we’ve had more
experiences we’ve developed more coping skills we can handle things differently
and cognitively we’re just more advanced if you will education sometimes knowing
is half the battle so once people develop the ability to do research as a
double-edged sword now with the internet but someone with a higher educational
level typically rationalizes looks for answers does research instead of just
going oh my gosh I don’t know what to do if the person has so
since use currently or a history we want to look at that because that will impact
how they’re dealing with life on life’s terms and do they have a history of
abuse there have been studies that have shown that a history of abuse and
neglect while the person grew up may cause brain changes changes in the
development of the child and adolescent brain we need to consider all these
factors and you know there’s a whole set of classes that I do want on PTSD that
we can look at and talk about some of those things but it definitely
influences how people look at their environment now think about this if a
child grew up in a household that where there was a lot of domestic violence and
they were in another situation you know maybe five years later they’re in
another situation and across the room they see somebody that looks kind of
angry talking with large movements what is their interpretation probably going
to be I grew up in a household where we were loud all the time and we use big
gestures if you’ve watched any of my videos you know I gesture constantly I’m
not angry that’s just how I talk but the way I interpret that situation that
person standing over there I figure they’re probably recounting something to
the person they’re talking to a person who grew up in an environment that had a
lot of violence may start to feel anxious and want to extract themselves
from the situation fearing that that person that is speaking with big
gestures is angry so you can see how prior experiences affect our
interpretation of it what we see they fact our interpretation of our
environment where one person may see it is perfectly safe another person may
feel threatened prevention strategies designed to promote attitudes beliefs
and behaviors that ultimately provide the person with healthy coping skills
and awareness of positive health behaviors and the ability to effectively
communicate we need to help them change the way they think we need to
help them change the way they take care of themselves because we know there’s a
connection between the mind and body and we need to help people effectively
communicate their needs wants and desires to those around them creating a
micro system that is more supportive of what they need specific approaches may
include education and life skills training the relationship the second
level that we need to look at examines close relationships that may increase
the risk of experimenting with high-risk behaviors peers family neighbors a
person’s closest social circle their peers partners and family members
influence their behavior and contribute to their range of experiences so if you
grew up in a household my household was rather protective and as such I’m 40
some years old I still don’t know how to ride a bike cuz my mom didn’t want me
out riding a bike I never had one never learned how that influenced who I
interacted with I mean I couldn’t go out and ride bikes with with the people in
the neighborhood because I didn’t have one so we want to look at what is the
social circle what are the Pierce partners and family members modeling
what are they outright teaching and what are they trying to achieve in their life risk factors include a lack of family
involvement if Jimmy can come home from school and nobody even notices exactly
when he comes home he goes up to his room shuts the door comes down long
enough to grab a plate goes back up to his room goes to sleep gets up the next
morning leaves for school before anybody notices that’s a much different
environment than a family where Jimmy comes home you know even maybe mom and
dad are at work but he calls mom and dad or sends him an email or a text and says
hey I’m home they say how was your day he
says fine then he goes up to his room plays video games comes down eats dinner
with the family now you know and that looks different for everybody but I’m
kind of giving you two extremes it’s dinner with the family does his chores
does his homework at the dinner table or at the computer in the living room and
then may go to bed very different levels of family involvement very different
levels of family influence the first version Jimmy is basically avoiding his
family and not going to be influenced very much at all by what they’re doing
when I hear that I’m wondering what he’s trying to avoid what’s the benefit of
not hanging out with the family makes me look at what’s going on with the family
that is so off-putting a lot of times when we have youth and adolescents in
treatment we can’t go oh well it’s not you it’s your family that is a
dysfunctional bunch so we have to figure out how to help the patient deal with it
but understanding what this lack of family involvement looks like and why it
is there and the Wyatt is there is so important if it is more harmful for
Jimmy to be involved with the family then we don’t want to have as one of our
treatment recommendations you’ll spend you’ll eat dinner with the family every
night and spend two hours with them that might make him want to you know pull his
own hair out other risk factors in the relationships or parents or siblings
with mental health problems or addictions not only because that says
there may be a genetic predisposition but it also because it says that there’s
an environment where someone is struggling for one reason or another
that puts stress on the rest of the family that can be exhausting to the
rest of the family that person with mental health problems or addiction may
also be modeling unhealthy behaviors so when we think about social learning we
think about what this neutral child is exposed
to what are they learning what are they experiencing and what is the impact for
that child of these other people in their family and peer pressure well that
goes without saying so I’m not going to be labor the peer pressure issue we know
that that’s a big issue so what do we do about it strategies for prevention may
include parenting or family-focused prevention programs we try to run some
of those when i ran facility in florida and we had some limited success but a
lot of times parents couldn’t or wouldn’t a lot of times couldn’t commit
to save 16-week programs so how can we take these programs and make them so
they’re accessible if you’re going to provide them they have to be accessible
and they have to be tolerable if it’s one of you know think back to when you
were in in grade school and I think you know a lot of us still remember those
videos that were actually still on the on the movie reel that were from like
1940 and you would just sit there and listen to the narrator and go oh my gosh
this is laughable okay those are not going to work we need to make something
that is engaging that’s practical that’s meaningful to the parent we don’t want
to talk about a bunch of meta concepts yeah like we’re doing now because it
doesn’t matter to them they want to know what’s the problem what’s the solution
how can i implement it and it needs to be presented like I said in a way that
is accessible to them you know if they’re working an hourly job they can’t
just take off to come you know participate in a program because they’re
going to lose money and a lot of times they need that money to do things like
buy food mentoring and peer programs those are wonderful if you can get them
going because it encourages youth to hang around with pro-social youth and
this also includes like after school activities and
Church programs community recreation programs drama clubs the idea here is we
want the relationships to help improve the person’s self-esteem foster
problem-solving skills and promote healthy relationships teach them how to
communicate teach them how to interpret verbal and nonverbal communication teach
them to identify what it is about themself that’s really awesome then we
move on to the community we want to I down identify characteristics of
settings in which social relationship sarkar which are associated with
developing addictive or behaviors or mental health problems such as schools
workplaces in neighborhoods so let’s start with schools if drugs are
available that’s a problem if there is a lot of violence peer pressure bullying
lack of ability of teachers to monitor what’s going on all of those things set
schools to be a problematic place now you can’t have schools it is possible to
have schools where teachers teach and they’re able to supervise and deal with
things that is on the school the township and you know the parents that
are involved to figure out how to make that work because we do expect a lot out
of our teachers now workplaces if parents are going to work
places that are burnout work environment stressful work places they don’t know if
they’ll have a job tomorrow they’re getting paid minimum wage you know
there’s a lot of things that make work stressful or dysfunctional anything that
is going to create a situation where a person can feel helpless hopeless
stressed out or need to escape we need to address those things we need them to
feel hopeful empowered not as stressed out you know able to handle the things
they can change and let go of the things they can’t and we want them to generally
feel happy you know I may not want to go to school I may not want to go to work
but generally it’s not something that I’m like oh my gosh don’t make me do
this again most days you want people to enjoy or at least not dislike going to
where they work or go to school and then the neighborhood if there is low
community involvement if people are moving in and out all the time that’s a
risk factor when people are in the same community for a while in the same
neighborhood you get to know the cars you get to know the people so there are
less risk factors for interlopers coming in there are less risk factors for things to get out of control in the
community where bad elements have integrated where people are committing
crimes and car burglaries and all that kind of stuff people watch each other’s
back when there’s Community Connection neighborhoods that aren’t safe
neighborhoods where there’s a lot of drug activity those are things that are
going to be problematic prevention strategies at the community are
typically designed to impact the social and physical environment by reducing
isolation get people to come out of their apartments come out of their
houses meet their neighbors and say hey you know I know that you I noticed that
you work night sir you work days or so you can watch out
for one another improving economic and housing opportunities if people are not
struggling to survive and they’ve got a roof over their head think Maslow’s
hierarchy get those basic biological needs met and people are going to do a
whole lot better than if they are hungry homeless sick and exhausted improve the
climate processes and policies within the community school and workplace
settings this is the meta concepts again we want people to feel comfortable in
their community we want people to be proud of their community and we want
people to be feel supported by their community school and workplace so we
don’t want an environment where people are just waiting for the other shoe to
drop or they’re expecting to get thrown under the bus every time they turn
around we want to encourage a climate where law enforcement works with the
community it’s a partnership not an adversarial relationship and societally
the broad societal factors that help create a climate in which addiction is
encouraged or inhibited so we’re talking about mass media we’re talking about the
Internet well mass media uh other societal factors include policies that
encourage recovery and health um like health policies do people have health
insurance do people have access to get what they need in terms of health care
preventive preventive health care and can they get enough nutritious food
economic policies that encourage recovery and health you know even things
like canned food stamps be used to buy cigarettes you know that’s one of those
things that we need to look at educational polity policies we want
people to feel like successes at school and at work
want them to feel like they have opportunities you know that whole we
want them to have hope and empowerment that’s what the educational system is
designed to do help them figure out who they are what they want and feel like
they have you know the world by the tail and social policies that encourage
recovery in health many communities well I guess this is true of the southern
communities I haven’t lived up north very much have a lot of policy um
policies and activities a lot of parks a lot of 5k runs half marathons
health-related behaviors open farmers markets things within the community that
encourage people to eat healthfully exercise get out no one another and just
generally care about one another prevention strategies at the societal
level are typically aimed to reducing the availability of addictive substances
you know if we get rid of the addictive substances that would be great because
then we can stop this whole dopamine overload thing reality is we may be able
to get rid of some of the illicit substances but that doesn’t take away
the behavioral addictions and that doesn’t take away alcohol and some other
things so this is only a partial solution increase availability of
treatment so people who are currently starting to struggle can get into
treatment before it becomes a big huge issue the other thing we want to do is
really look at putting prevention strategies in place early on in the
school systems in pediatric clinics helping parents learn how to teach their
children how to cope with life on life’s terms because we don’t think about it
when my son was little poor thing I talk about him all the time and these things
um he was at micro preemie so he was in therapy he had a physical therapists and
occupational therapist for several months after he came home
and you know was passed that gastric reflux thing but um the occupational
therapist would come to our house and would work within three days a week and
some of the things that I just assumed he knew how to do he didn’t know how to
do now and you’ve got to remember I’ve already taken developmental psychology
I’m working on my doctorate and I don’t realize that he doesn’t understand he
can stick his hand into a clear glass bowl to retrieve a necklace we are not
given an instruction manual for building self-esteem for or for helping people
develop positive coping skills and unfortunately these are things that are
not taught very well and you know my little soapbox I think if we did a
better job of teaching those things early on we could set people up for
success and able to deal with some other issues as they come up we can also help
people learn more effective coping skills but a lot of grown-ups don’t have
effective coping skills so how can they teach them if they don’t have them and
we want to alter media portrayal and societal attitudes toward addictive
behaviors right now it’s just one another one of those things on the
internet or on the news or on the this sort of that about who’s going to
treatment it’s almost a fad whereas we’re not really focusing on the
devastation that clinical depression generalized anxiety PTSD and addiction
can cause and those are only a few I mean there’s a whole DSM full of
diagnoses that create quote clinically significant distress we need to start
taking these things seriously so the bio psycho bio socio-ecological
model they threw in the bio to take to take into account the individual factors
that the person is born with identifies how the individual impacts and is
impacted by not only his own characteristics but also those of family
Pierce community and culture prevention can take the form of preventing the
problem preventing worsening of the problem or preventing associated fallout
from the problem so we can prevent the addiction all together or if somebody
starts to develop an addiction we can keep them from getting worse you know we
don’t want the addiction to get worse and we don’t want them to develop
multiple addictions and we want to prevent associated fallout we don’t want
them to also on top of the addictive behaviors develop some significant
mental health issues financial difficulties homelessness yadda yadda
yadda so there are multiple levels of prevention we’re not going to
necessarily be able to get in there before the problem starts all together
so we need to get in wherever we can and work backwards from there any change in
the system will have an effect on all other parts of the system if it’s a good
change it will likely have good changes if it’s a bad change its going to likely
have bad changes so we need to pay attention to what’s going on and it can
be a small small thing we don’t need to make these huge sweeping readjustments
addressing addictive behaviors requires a multi-pronged approach looking at the
individual family community and society if you have watched and participated in
this program for CEUs log into the classroom at all ceus calm and you can
take the quiz if you’ve watched and participated and one city use but have
not yet registered you can purchase access to the quiz and certificate at
all ceus com / live interactive dash webinars this
presentation was recorded as part of a live interactive webinar if you’re
watching it on replay please remember you can always contact dr snipes on her
personal chat page pure chat emmy /q TV x you

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