September 24, 2009IVAT 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

AgeDisability

Mothering

Context/ Isolation

Partnership /Friendship

Public policySystemic 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 healthExpecting 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 leavePractitioners, 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 leavingLack of resourcesLack of motivationCultural issuesValues systemsOthers?

From S. Wahab, Minute (2004) Vol. 11, No.1

Leaving or Not Leaving

Inconsistent with client-centered workImposes “one size” valuePlaces “leaving” as the target behavior

may not be desired outcomeResistance can be createdAssumes worker/practitioner knows bestLeaves 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 toolboxWe 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-Centered Trauma-Informed

Collaborative Partnership / Equality Collaborative

Respect autonomy Autonomy Maximize choice

Evocative Self-determination client input

Understand / Listen Respect Recognize the impact of trauma and violence

Empower Empower Empower

Resist the righting reflex Emphasis on safety and avoiding re-victimization

MI as tool in the trauma-informed treatment toolboxMI 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 EmpathyDevelop DiscrepancyRoll with ResistanceSupport 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 ExerciseLet’s see if this works…

One speaker and one listener (NOT your boss)SPEAKER:

Topic-- Something about yourself you really…Want to changeNeed to changeShould or ought to changeHave been thinking about changingBut you haven’t done yet (ambivalence)

Persuasion ExerciseLet’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…

AngryOppositionalDiscountingDefensiveJustifyingNot understood/heardProcrastinateDisengagedHelpless

A Taste Of MIOne speaker and one listener (NOT your boss)SPEAKER:

Topic-- Something about yourself you really…Want to changeNeed to changeShould or ought to changeHave been thinking about changingBut you haven’t done yet (ambivalence)

A Taste Of MILISTENER: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…CollaborationAmbivalence is

normalEvocationAutonomy

TECHNIQUES…Open-ended

questionsAffirmReflectSummarize

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.”

COLLABORATINGLimit 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), 11-22

Safety Planning

Substance Use

Health Issues

Parenting

Trauma-Informed Treatment = respectful

treatmentAll skills can be used with all

clients, not just those who have a history of trauma

Can’t assume we understand traumatic eventsUse MI approach to interact with

respect to benefit all clients (Elliot, et al, 2005)