September 24, 2009 IVAT Conference, San Diego, CA presented by Kaite Slack, MSW & Dee-Dee Stout, MA, CADC-II A Perfect Fit: MI in Trauma- Informed Work with Women

What are Trauma Informed Services? All types and levels of service are influenced by staff understanding of the impact of interpersonal violence and victimization on an individual ’ s life and development. (Elliot, et al, 2005)

Substance Use Mental Health Violence/ Trauma Poverty Sexual Orientation Racial Discrimination Access to health care Experience of Loss Punishment/ Incarceration Age Disability Mothering Context/ Isolation Partnership /Friendship Public policy Systemic discrimination Resilience Making the Connections HIV/AIDS

The Connections As many as 2/3 of women with substance use problems have a concurrent mental health problem (e.g., PTSD, anxiety, depression) (Zilberman, et al., 2003) Many women with substance use problems have experienced physical and sexual abuse either as children or adults (Ouimette, et al., 2000; Martin et al., 1998)

Poor/homeless women are more likely to have historical and/or current experiences of violence (between 84-92%) (Bassuk, et al., 1996) Mothers of children w/FADS report serious histories of violence, high levels MH problems, controlling partners who don’t want them to quit drinking (Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K., 2000) Violence during pregnancy is cause of more deaths in PG than any single medical complication (Liebschutz et al., 2003) The Connections

Recreating Dynamics of Power & Control Interactions with providers can reproduce dynamics of power already experienced in a woman’s relationship Ignoring issues of safety or discussing safety inaccurately Minimizing illnesses (mental and physical) Giving inappropriate diagnoses/labels that pathologize Ignoring context of abuse, poverty, racism on health Expecting compliance Being less than caring and supportive Shame/judgement critical to continued use of substances

Trauma-Informed Services… Sees the whole person, understanding the context of all behaviors/coping strategies Provides respectful & accurate empathetic listening to best enter the world of the client Focus is on the client – not the symptoms, behavior or problems - & reduction of symptoms not treating an illness

10 Principles of Trauma-Informed Services 1.Recognize the impact of violence and victimization on development and coping strategies 2.Identify recovery from trauma as a primary goal 3.Employ an empowerment model 4.Strive to maximize a woman’s choices and control over her recovery 5.Are based in a relational collaboration Elliot et al. (2005). Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women Journal of Community Psychology, 33(4), 461–477.

10 Principles of Trauma-Informed Services 6.Create an atmosphere that is respectful of survivors’ need for safety, respect, and acceptance 7.Emphasize women’s strengths, highlighting adaptations over symptoms and resilience over pathology 8.The goal is to minimize the possibilities of retraumatization 9.Strive to be culturally competent and to understand each woman in the context of her life experiences and cultural background 10.Solicit client input and involve clients in designing and evaluating services

Trauma-Informed Approach Competence model; focus on strengths Sees traumas in context of client’s life Appreciates that recovery is personal & must be defined by client not staff Staff is a guide not fixer; client is Change Agent Treatment is driven by clients’ needs

The Dynamics of Abuse Going back or staying with an abusive partner are part of the change process Our task as practitioners is to focus on behaviors our clients can control and those that they choose to address. This approach is distinct from traditional abuse survivor treatment in which the clinician assumes “ privileging leaving ” From S. Wahab, Minute (2004) Vol. 11, No.1

Privileging Leaving The focus of treatment is to empower women to leave Practitioners, agencies, systems promote & often expect that women will leave abusive situations We unintentionally re-create power differential of abusive relationships From S. Wahab, Minute (2004) Vol. 11, No.1

Privileged Leaving Reasons for not leaving Lack of resources Lack of motivation Cultural issues Values systems Others? From S. Wahab, Minute (2004) Vol. 11, No.1

Leaving or Not Leaving Inconsistent with client-centered work Imposes “ one size ” value Places “ leaving ” as the target behavior may not be desired outcome Resistance can be created Assumes worker/practitioner knows best Leaves clients in “ one-down ” (deficit) position – not the expert of their life From S. Wahab, Minute (2004) Vol. 11, No.1

Leaving or Not leaving: Binary thinking No exploration or engagement in multi-cultural practices of their circumstance No acknowledgement of successful strategies & tactics of clients From S. Wahab, Minute (2004) Vol. 11, No.1

How can we provide successful treatment for trauma/abuse survivors? How can we provide choice and at the same time guide clients toward choosing an appropriate behavior to target for change?

Motivational Interviewing Creates a favorable climate for change Addresses ambivalence and resistance Uses stage specific skills and strategies to move people forward

MI as tool in the trauma- informed treatment toolbox We may want our clients to work on their trauma issues, and/or live a violence-free life, but we cannot impose these changes. When practitioners impose their values, will and/or agenda, the chance of alienating the client increases, and resistance appears. It also keeps us from learning from our clients. From S. Wahab, Minute (2004) Vol. 11, No.1

Integrated Framework: Guiding Principles Motivational Interviewing Women-CenteredTrauma-Informed CollaborativePartnership / EqualityCollaborative Respect autonomyAutonomyMaximize choice EvocativeSelf-determinationclient input Understand / ListenRespect Recognize the impact of trauma and violence Empower Resist the righting reflexEmphasis on safety and avoiding re- victimization

MI as tool in the trauma- informed treatment toolbox MI helps us to support clients in evaluating their safety, choices and resources. MI allows us to be advocates with survivors instead of advocates for survivors. It keeps us from making assumptions about what the client needs, and allows us to help them build motivation and skills to make the best choices for themselves. From S. Wahab, Minute (2004) Vol. 11, No.1

Principles of Motivational Interviewing Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy

MI Principles in Trauma- Informed Services Build Empathy and Rapport Emphasis is on whole person – how you lead your life. Talk about what they want to address “ How can I more fully understand this person? ” Focus not just on functioning Agency message becomes “ your behavior makes sense given your circumstances. ” clients begin to see their behaviors as coping and brave, not pathological or unhealthy; no character defects here MI avoids confrontation to “ break down ” denial. Such interventions can trigger memories of trauma/abuse. Priority is on choice and autonomy

Persuasion Exercise Let’s see if this works… One speaker and one listener (NOT your boss) SPEAKER: Topic-- Something about yourself you really… Want to change Need to change Should or ought to change Have been thinking about changing But you haven’t done yet (ambivalence)

Persuasion Exercise Let’s see if this works… LISTENER: 1. Explain why the person should make the change. 2. Give at least 3 specific benefits that would result from making the change. 3. Emphasize how important it is to change. 4. Persuade the person to do it! If you meet resistance, repeat the above. (This is NOT Motivational Interviewing) 5. SWITCH

Common Reactions To Not Feeling Listened To… Angry Oppositional Discounting Defensive Justifying Not understood/heard Procrastinate Disengaged Helpless

A Taste Of MI One speaker and one listener (NOT your boss) SPEAKER: Topic-- Something about yourself you really… Want to change Need to change Should or ought to change Have been thinking about changing But you haven’t done yet (ambivalence)

A Taste Of MI LISTENER: 1. Listen carefully with the goal of understanding the dilemma. 2. Give no advice. Ask these four open questions and listen with interest: 1. Why would you want to make this change? 2. How might you go about it in order to succeed? 3. What are the three best reasons to do it? 4. Summarize what you heard. 5. Ask, “What will you do next?” 6. SWITCH

Common Reactions to Being Listened To… Understood Want to talk more Liking the worker Open Accepted Respected Engaged Able to change safe Empowered Hopeful Comfortable Interested Want to come back cooperative

Motivational Interviewing SPIRIT… Collaboration Ambivalence is normal Evocation Autonomy TECHNIQUES… Open-ended questions Affirm Reflect Summarize

Ambivalence MI offers a way to understand – normalize - ambivalence in change Need to shift from “Why isn’t she motivated?” to “For what is she motivated?” (Miller & Rollnick, 2002)

Traps to Avoid Question-answer trap: The Interrogation Expert trap: You are an expert but not on her life. Early focus: Too much information too early Labeling: Labeling client as “ survivor ” before client is willing/able to recognize self as surviving abuse or trauma Blaming: Occasionally we accidentally “ blame the victim. ”

COLLABORATING Limit focus to areas she CAN control ie: Wahab, S. (2006). Motivational Interviewing: A client centered and directive counseling style for work with victims of domestic violence. Arete, 29(2), Safety Planning Substance Use Health Issues Parenting

Trauma-Informed Treatment = respectful treatment All skills can be used with all clients, not just those who have a history of trauma Can ’ t assume we understand traumatic events Use MI approach to interact with respect to benefit all clients (Elliot, et al, 2005)