mi and tic · summary: trauma impacts •world view •adaptive behavior •brain development...

12/19/17

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Wisconsin Public Psychiatry Network Teleconference (WPPNT)

• This teleconference is brought to you by the Wisconsin Department of Health Services (DHS) Bureau of Prevention Treatment and Recovery and the University of Wisconsin- Madison, Department of Psychiatry.

• The DHS makes no representations or warranty as to the accuracy, reliability, timeliness, quality, suitability, completeness, or results of the materials in this presentation.

• Use of information contained in this presentation may requireexpress authority from a third party.

• 2018 Shawn Smith, Reproduced with permission.

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TIC + MI “Often it isn’t the initiating trauma that creates seemingly insurmountable pain, but the lack of support after.”

-S. Kelley Harrell

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A Story from Jasper.

Almainstitute.org [email protected]

A Definition of Trauma • We refer to trauma from a psychological perspective

to describe experiences that are emotionally painful and distressing and that overwhelm an individual’s capacity to cope. Although there has been some debate about how to define a traumatic event, most definitions agree that when internal and external resources are inadequate to cope with external threat, the experience is one of trauma. The powerlessness that a person experiences is a primary trait of traumatization.

• (Van der Kolk, 2005)

[email protected] almainstitute.org

What do we already know about MI?

What do we already know about Trauma?

How do they align?

mailto:[email protected]


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Trauma Impact #1: World View

Beliefs, attitudes, values and cognitions which a child develops in response to their environment

• Based upon the child’s experience • Is absolutely reflective of the child’s reality

©Alma Institute 2017 almainstitute.org [email protected]

What does the child learn?

• About the world? • About adults &

authority? • About their purpose

/ job in the world?

• About love & relationships?


What does the child learn?

• About the world? • About adults &

authority? • About their purpose

/ job in the world?

• About love & relationships?





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•

•

Trauma Impact #2: Adaptive Behaviors

The set of behaviors a child develops to survive the adversity in their

home/environment


I Must Survive.


Trauma Nurturing

• The world is a frightening and dangerous place

• The world is a loving and safe place

• I can not trust anyone • I am vulnerable and

unprotected

• I can trust the adults in my world

• I must take care of myself • No-one really cares about me • I must survive

• I am protected and supported • I am capable • I am important • There is much to learn &

experience





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What does a child do to Survive?

Drugs Alcohol • Trust no-one

• Show no emotion

• Control others

• Manipulate others

• Disregard authority

• Get others before they get you

• Take what you need • Immediate gratification

• Might = right ©Alma Institute 2017 almainstitute.org [email protected]

Impacts of Traumatic Stress

Cognitive • Difficulty concentrating

& focusing attention

Affective • False / exaggerated

perceptions of reality

• Cognitive & problem solving challenges • Excessive reactivity to

triggers

• High levels of restlessness and agitation

• Unable to regulate emotions

• High levels of anxiety ©Alma Institute 2017 almainstitute.org [email protected]

Trauma Impact #3: Brain Development


Seigel




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Trauma Impact #4: Triggers

Unresolved pain to which we are particularly sensitive.


Trauma & Neuroscience


Behavioral

Fight

Flight Freeze ©Alma Institute 2017 almainstitute.org [email protected]




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Gender.


Summary: Trauma Impacts

•World View

•Adaptive Behavior

•Brain Development

•Triggers van der Kolk, Bessel, The Body Keeps the Score, Mind and Body in the Healing of Trauma. Penguin Publishing, New York, NY, 2014.


What are “Triggers”

• Disrespected • Rejected • Vulnerable • Weak • Ashamed • Inadequate • Ignored • Judged

• Insecure • Dependent • Used • Unworthy • Stupid • Neglected • Excluded • Misunderstood





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Real men control their woman. Real men don’t cry.

Real men feel no pain.

Real men win at all cost.

Real men show no weakness.

B E A M A N

Real men are tall.

Real men hold their liquor.

The Mask You Live In.


Be pretty. Be sexy & alluring.

Be skinny.

Be sweet. Be nice. Be quiet.

Be a mother.

B E A L A D Y

Have good hair. Be submissive.

Miss Representation


Community Violence


Real

men

hav

e lo

ts o

f sex

.

Real men drive fast cars.

Real men never back dow

n from a fight.

Don’t act too sm

art. Let men be the boss.

Be dainty

Sit with legs crossed.

Real men don’t w

ear pink.

Real men have lots of m

oney. B

e available to your man.

Real

men

are

toug

h.

Real

men

hav

e no

fear

.

Be

tidy,

nea

t & c

lean

.

Be

beau

tiful

.

Sm

ell g

ood.

C

ook

& ba

ke

Don

’t ge

t dirt

y Re

al m

en li

ke “c

erta

in”

spor

ts.

Real

men

don

’t fo

llow

the

rule

s.

Take

car

e of

oth

ers.




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Mass

“Separate Middle but equal” passage

incarceration segregation

FORCED Illiteracy

Abducted

Klu klux klan

Unable to protect

Red-lining Jim crow brutalized

enslaved War fodder

tuskegee

murdered Lynched discrimination

Dis- enfranchised

bondage Forced “breeding”

Stolen children

©Alma Institute 2017 almainstitute.org [email protected] Dr. Joy DeGruy

Historical Trauma


Violence in the Community

Guns & violence

Gangs

Trafficking

Racism

Bullying





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Spirit of MI

Evocation

Partnership

Acceptance

Compassion [email protected] almainstitute.org

MI Conversation Structure: Four Processes

Engage Focus Evoke Plan


What is trauma?





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Dis-covering


Subtext I can’t fix it for you,

but I can help you figure it out.

Guide with the OARS

Open Questions

Affirmations

Reflections

Summaries




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What are the alignments?

MI Spirit (Values) • Partnership

TIC Values • Safety

• Acceptance • Trustworthiness

• Compassion • Choice

• Evocation • Collaboration

• Empowerment

3 Layers of Holding Space

Expression of

Empathy + Guiding

Expression of Empathy

Empathetic Listening

Intention: Hold Space



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MI Techniques + Spirit


Sharing Information in Partnership (Technical Term: Elicit Provide Elicit (EPE))

• Discover: What the person already knowsJ!

• Ask: permission to add in your two cents, “All right if I make a suggestion …?” (your version)

• Te ll: information in a neutral manner and manageable chunks.

• Ask: the person’s response to, understanding of the information. “What do you think?” “How does that fit for you?” (your version)


How do we express these in our Behavior?

MI Spirit • Partnership

• Acceptance

• Absolute Worth • Autonomy • Accurate Empathy • Affirmation

• Compassion

• Evocation

TIC Values • Safety

• Trustworthiness

• Choice

• Collaboration

• Empowerment

Partnership • Agenda Mapping

• DATA (EPE)

• Reflection Acceptance • Avoid Discord Traps

• Surf Sustain Talk • Cultivate Change Talk

Evocation • ID the Mismatch • Hopes, Values, Goals



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Holding Space

People who have experienced Trauma: • Have been made unsafe, emotionally as well as

physically • Establish a sense of Safety

• Have learned from past experience that they can least afford to trust the people who should be trustworthy • Create Trust

• Have learned to expect the worst • Enhance systems of support

• Use Anger / Rage as default emotion • Practice emotional & behavioral regulation ourselves

The only way out of trauma is HEALING.


Any pain that is not transformed is transferred.




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Trauma can be healed. How does MI do these?

• Provide psycho-education on the effects of trauma • Share Information in Partnership (DATA)

• Teach / experience emotional & behavioral regulation • Heal from our own trauma. Know our triggers. Maintain Empathy + Compassion. Practice Mindfulness.

• Build self capacities & enhance executive functioning • Evoke reasons for change and plans. Build Plans in Partnership.

• Re-establish relational attachment • Model Empathy + Compassion so that those we serve can experience it. Provide a safe harbor.

• Re-frame and integrate traumatic experiences • Use OARS/MI to help those we serve to safely explore how they can heal and thrive.

• Meaning-making: sense of purpose and future goals • Evoke evoke evoke.

• Appreciate post-traumatic growth • Affirm affirm affirm


Trauma can be healed. How does MI do these?

• Establish a sense of safety • Open Questions: Allow the person to share their story from their perspective • Affirmations to recognize strengths and efforts to support resilience • Reflections to express empathy and share back to persons stated reasons for change • Engage to develop rapport/alliance • Focus: Identify the focus of an encounter in partnership with the person – Agenda

Map • Evoke to empower • Create consistency across providers (front desk, case manager, therapist, probation

officer, etc. Use the MITI to assess and coach. • Enhance systems of support

• Focus as a Target Behavior • Help people surface the reasons they would want to change

• Evoke to Empower


Holding Space

People who have experienced Trauma: • Are easily triggered

• Teach emotional & behavioral regulation • May be challenged in learning new ideas / skills

• Build self-capacity & opportunity for problem solving and critical thinking

• Have adapted their behavior to survive • Provide education on the effects of trauma • Re-frame & re-integrate traumatic experiences • Meaning-making: find a sense of purpose &

future goals (post-traumatic growth)



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Wellness for Providers

Burnout

Vicarious Traumatization

Compassion Fatigue

buck

Wellness

Served Person Trauma Staff Trauma

How Alma Views TIC: Healing Trauma …

Trauma Awareness

Wellness for Service Providers, Administrators,

Support Staff, and all.

Wellness for Served Persons

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What is WRONG with you?

Traditional Medical Model


Healing Focused Care

Cultural Reverence

Trauma Informed

Care Motivational Interviewing

Reflective Supervision

Triggered?

• Your client does not believe what you tell him and asks to speak to someone “in-charge” who can “verify” the information.

• After an interview and assessment, you tell a client that she’s not a good fit

for service you offer. Your supervisor talks to her for a few minutes, and then tells you that you’re wrong and says the client should be admitted.

• You walk into the room and overhear a client talking disparagingly about

you to another client.

• Your kids are in a school play during your work hours and you’re unable to go because you can’t find anyone to cover your work while you’re gone.

• Your client has his phone out and continues to use it while you’re having a

conversation with him.


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.

My job is to Understand your

experiences.


What HAPPENED to you? Trauma Informed


My job is to FIX you.





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We are ALL on our own

HEALING JOURNEY.


HEALING FOCUSED CARE My job is to

hold space for you to heal.


HEALING FOCUSED CARE What is RIGHT with you?





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MI + Cultural Reverence January 18, 2018

Hope you’ll join us!

Truth Purpose

Soul



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Resources

• AlmaInstitute.org

• Amazon Wish List

• [email protected]

• Dr. Joy DeGruy

• Bessel Van der Kolk

• MI 3rd Edition

• 2nd annual WIMI Conference: April 24, 2018


mi and tic · summary: trauma impacts •world view •adaptive behavior •brain development...

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