Implementing MI and TIC in Integrated Care

NationalHealthCarefortheHomelessConference

BehavioralHealthIntegrationPre-ConferenceInstituteWashington,DCMay22,2019

KenKraybillCenterforSocialInnovationkkraybill@center4si.comwww.center4si.com

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WhatisMotivationalInterviewing?Thedesiretohelppeopleimprovetheirhealthandwell-beingisanoblecalling.However,alltoooftenoureffortstohelparespenttryingtogetpeopletochange,ratherthanusingaguidingapproachtotapintopatient’sownmotivationforchange.Considerwhetheryou’veeverheardyourcolleagues(oryourself)uttersomethinglikethis:

• Igivepeoplemybestadvice,buttheyjustwon’tlisten.• Sheresistsallofmyeffortstoconvincehertogetscreened.• Shejustneedstokeephermedicalappointments.• He’sintotaldenialabouthisheartcondition.• Somefolksjustdon’twanttobehelped.

Manyofushaveampleexperienceintryingtopersuade,educate,entice,cajole,bribe,guilt-trip,oruseothermeanstogetpeopletochange.Itisanaturalhumaninstincttofix,ormakeright,whatweperceiveasmisguidedorharmful.However,sucheffortstopersuadesomeonetochangearetypicallycounterproductive,especiallyifthepersonisnotconvincedthatmakingachangeisdesiredorneeded.Itturnsoutthatpeopledon’tlikebeingpressuredtodosomethingbecausesomeoneelsethinkstheyshoulddoit,evenifit’sintheirbestinterest.Thedesireforself-determinationrunsdeepinthehumanspirit.Motivationalinterviewing(MI)isamethodoftalkingwithpeopleaboutchange.Itis“acollaborativeconversationstyleforstrengtheningaperson’sownmotivationandcommitmenttochange”(Miller&Rollnick,2013).Theindividualdeterminesthefocusorchangegoalwhilethepractitionerservesasaguide.MIassumesthatpeoplealreadypossesswhattheyneedtobemotivatedtochange.Theyarenotemptyvesselsinneedofbeingfilledbyanexternalsource.They’realreadyfilledwithdesires,lifeexperience,values,hopes,knowledge,skills,wisdom,andmore.MIhelpsshinealightonandexploretherichresourcespeoplealreadypossess,inordertohelpthemmakedecisionsaboutnextstepsontheirlife’sjourney.Accordingtopositivepsychology,thisprocessbuildspositiveemotions,whichinturnopenspeopleuptotheirinternalandexternalresourcesthattheycanusetoimprovetheirlives.Whereandwhendiditdevelop?TheconceptofMotivationalInterviewing(MI)grewoutoftheexperienceofprovidingtreatmentforproblemdrinkersandwasfirstdescribedbypsychologist,WilliamR.Miller,inanarticlepublishedin1983.Historicallytheaddictionstreatmentfield,especiallyintheUnitedStates,hasbeencharacterizedbyahighlyconfrontational,shame-basedapproachbelievedtobreakdownpeople’sdenialsotheywillcometotheirsensesabouttheirneedtochange.Thisapproachhasproventobemostlyineffective.Ingeneral,humanbeingstendtoresistotherpeople’sattemptstogetthemtochange,evenwhenthoseeffortsarewellintended.

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WiththepublicationofWilliamR.MillerandStephenRollnick’sseminalbook,MotivationalInterviewing,in1991,practitionerswereintroducedtoanalternativewaytoengageina“helpingconversation”withpeoplemisusingsubstances.Theauthorsdescribedawayofinteractingbasedonaparticularconversationstyleanduseofspecificcommunicationskillsandstrategies.Asecondedition,MotivationalInterviewing:PreparingPeopleforChange,waspublishedin2002.ItfurtherrefinedtheMIapproach,providedanemergingresearchbaseforMI,anddetaileditsspreadtootherareasbeyondsubstanceusedisordersincludinghealth,behavioralhealth,corrections,andschools.Athirdedition,MotivationalInterviewing:HelpingPeopleChange,2013,expandedontheMIapproachandincludedsomenewconceptsincludingthefourprocessesofMIconversations(engaging,focusing,evoking,andplanning)anddistinguishingbetweensustaintalkanddiscord.Today,MIhascircledtheglobe,andsupportandrespectforthepracticeisgrowing.Howdoesitwork?PracticingMIrequiresahealthysenseofhumility.Itbringsusface-to-facewiththerecognitionthatwedon’thavethepowertochangeothers.Intruth,wecanonlychangeourselves.However,weareabletohaveaninfluenceonothersandtheirmotivationtochange.AsMadelineHuntersays:“Theysayyoucanleadahorsetowater,butyoucan’tmakehimdrink.ButIsay,youcansalttheoats.”ThegoalofMIistohelppeoplebecome“thirsty”forchangebycreatingconditionsunderwhichafruitfulconversationaboutchangecanoccur.WhiletheMIapproachisgenerallylow-key,ithasthepotentialtostirupuncomfortablethoughtsandfeelingsforpeopleduetoitsevocativenaturethatinvitesthemtolookatdifficultrealitiesintheirlives.Theaimistohelppeoplelookhonestlyattheirbehaviorswithoutbecomingoverlydefensive.Aspractitioners,weseektocreateasafe,trustingpartnershipwithindividualssothattheyseeusasalliesintheprocessoflookingatdiscrepanciesbetweenwhotheyareandwhotheywanttobe,andbetweentheiractionsandtheirvalues.Ifweconfront,peoplewilltendtodefendthemselves.MIdifferssignificantlyfromadvice-givingorconfrontationalstylesofcounselinginthisway.TheMIstyleisnotflashyor“intheclient’sface.”Thefocusisondrawingouttheperson’sownknowledge,experience,andinnerwisdominagenuine,empathicmanner.Thosewhoareusedtoconfrontingandgivingadvicemayfeelthey’renot“doinganything”whenpracticingMI.Asonepractitioner—moreaccustomedtoaconfrontationalstyleofcounseling—observed,“IfeellikeMItiesmyhandsbehindmyback.”Forsomehelpers,thisapproachcanfeeldangerous,likewe’regivingpermissionforpeopletomaintainriskypositions.But,asMillerandRollnick(2013)pointout,theseaggressivestrategies,typicallydrivenbyadesiretohelp,moreoftenpushthepersonawayfromengagementandretentioninservices,aswellasmisstheirgoalofenhancingmotivationtochangeandimprove.

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TheevidenceforMIAwealthofstudiesindicatethatMIhasastatisticallysignificantpositiveeffectonbehaviorchange,withsomestudiesshowingthatthosechangesaredurableovertime.MIremainseffectivewhenusedasastand-aloneintervention,infusedwithinotherapproachestotreatment,aswellasaprecursortoothertreatment(Lundhaletal.,2013).Anumberofstudieshaverevealedthatpatientsdefinedas“leastreadytochange”experiencethelargestMIeffect(Heckmanetal.,2010).Ofcourse,MIworksonlyaswellasthepractitionerusingitandthequalityofthealliancethatdevelopsbetweenpractitionerandperson.PoorMIpromotespoorresults.StructuralandenvironmentalfactorscanalsoaffectthesuccessofMI,likeanybestpractice.Forexample,housinginstabilitycanhindereffortstoaddresssubstanceuse.Forothers,ahistoryoftraumamaycreateobstaclestoaccessingmentalhealthtreatment.MIseespeople’sstrugglesinthecontextoftheirlivesandworkswiththemtofocusandprioritize.DevelopingcompetenceOngoingpracticewithaccuratefeedbackandcoachingisneededtodevelopMIskills.ResearchshowsthatMIcompetencerequiresexpertfeedbackbasedonobservedpracticeandcoachingtosupportshiftsfromcurrentpracticetoMIproficiency.ManyindividualsandorganizationshaveinstitutedLearningCirclesasawayofincreasingtheirMIknowledgeandskills.Inaddition,manyexcellenttrainingandcoachingopportunitiesexist.ForinformationaboutMIresourcesincludingthelatestMIrelatedresearch,visittheMotivationalInterviewingNetworkofTrainerswebsiteat:https://motivationalinterviewing.org/motivational-interviewing-resources

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IfYouHaveFive,Fifteen,orFiftyMinutes:MIBasicsAdaptedfromMiller&Rollnick,2013

Whatisit?

“Acollaborativeconversationstyleforstrengtheningaperson’sownmotivationandcommitmenttochange”...“awayofhelpingpeopletalkthemselvesintochanging"

Thespirit(mindsetandheart-set)ofmotivationalconversations

Partnership–collaboratingwiththeclient’sownexpertise

Acceptance–communicatingabsoluteworth,accurateempathy,affirmation,and autonomysupport

Compassion–promotingtheclient’swelfare,givingprioritytotheclient’sneeds

Evocation–elicitingtheclient’sownperspectivesandmotivation

Fourprocessesthatguidemotivationalconversations

Engaging–establishingtherelationalfoundation

Focusing–clarifyingaparticulargoalordirectionforchangeEvoking–elicitingtheperson’sownmotivationforaparticularchangePlanning–developingaspecificchangeplanthatthepersoniswillingtoimplement

Fourconversationalskills(OARS)

Openquestions–offersclientbroadlatitudeandchoiceinhowtorespondAffirmation–statementvaluingapositiveclientattributeorbehaviorsReflections–statementsintendedtomirrormeaning(explicitorimplicit)ofprecedingclientspeechSummaries–reflectionsthatdrawtogethercontentfromtwoormorepriorclientstatements

Samplequestionstoexploreambivalenceandelicit/strengthenmotivationTellmemoreaboutthisissue/concern/dilemma(that’sbeenidentified)?What’sokayabouthowthingsare?What’snot?Ifyoudecidenottochangeanything,whatwouldbeatstake?Ifyouweretomakeachange,whatwouldbethebenefitsof(oryourreasonsfor)doingso?Themostimportantbenefitorreason?

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Ifyouweretodecidetochange,howwouldyougoaboutittobesuccessful?Whatdoyouthinkwouldworkforyou?Lookingatyourlifecurrently,howimportantorurgentisitforyoutomakethischange?Forexample,onascaleof0-10(0=notatallimportant;10=totallyimportant),wherewouldyouplaceyourself?Whatmakesitalreadya___andnota___(severalnumberslower)?Whatwouldittaketomovefroma___toa___(nexthighestnumber)?Howconfidentareyouthatyoucouldbesuccessfulinchanging?(scalingquestionsworkswellheretoo)HowcanIorothersbehelpfultoyouinsupportingthischange?Whatdoyouthinkyoumightdoasaverynextsteptomovetowardsthischange?

Exchanginginformation

Afewconsiderations• It'sallright,andsometimesimperative,toexpressyourconcerns• Therearemanypathwaystochange• Focusonhelpingthepersonevaluateoptions• Offerinformationandadvice,don'timposeit

Method:Elicit-Provide-ElicitElicit

• Askwhatpersonalreadyknows• Askwhatpersonwouldliketoknow• Askpermissiontoprovideinformation/advice

Provide

• Prioritizewhatpersonmostwantstoknow• Beclear;useeverydaylanguage• Offersmallamountsofinformationwithtimetoreflect• Acknowledgefreedomtodisagreeorignore

Elicit

• Askforperson’sresponse,interpretation,understanding

AdaptedfromMotivationalInterviewing,3rdeditionbyMiller&Rollnick,2013

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MISelf-Appraisal

Astheinterviewer,I…

0-not5-extremelyatallwell

1.Providedasafe,welcomingpresencewithmywordsandactions.Example:

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2.Engagedwithandshowedgenuineinterestintheperson,e.g.,whatsheorheenjoys,needs,values.Example:

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3.Foundoutandclarifiedwhatthepersonwantedtofocusoncurrently.Example:

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4.Helpedexplorebothsidesoftheperson’sdilemma,e.g.,what’sworkingandwhat’snot;upsidesanddownsides.Example:

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5.Avoidedtryingto“fix”theproblemorgetthepersontochangebyadvising,confronting,warning,orteaching.Example:

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6.Elicitedwhatmightbesomepossiblereasonstochangeifthepersonweretodecidetochange.Example:

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7.Learnedaboutpossiblewaysthatheorshemightgoaboutmakingthischange.Example:

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8.Askedhowimportantitisatthistimeforthepersontomakethischange.Example:

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9.Askedhowconfidentsheorhefeelstobeabletomakethischange.Example:

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10.Inquiredaboutwhatsteps,ifany,thepersonmighttakenext.Example:

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11.Askedpermissionbeforeprovidinginformationorsuggestions.Example:

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12.UsedthecoreskillsofMI(openquestions,affirmations,reflectivelistening,summaries)throughouttheconversation.

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13.ConsistentlydemonstratedthespiritofMI:>Partnership

>Acceptance

>Compassion

>Evocation

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DevelopedbyKenKraybillbasedonMiller,W.R.&Rollnick,S.,MotivationalInterviewing:HelpingPeopleChange,2013

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ImplementingMotivationalInterviewinginYourOrganizationOrganizationalstrategies

DesignateanMISkillsDevelopmentpersonorteamtopromoteongoingtrainingandskillspracticeopportunitieswithintheagencyDevelopanorganizationalphilosophyofcarestatementthatalignswithMIspiritandpracticeIncludeMIexperienceasajobrequirementorpreferencewhenadvertisingfor,screening,andhiringnewstaff,especiallydirect-serviceandsupervisorypositionsInjobinterviews,askapplicantstoprovideMI-adherentresponsestosamplestatements(e.g.HelpfulResponsesQuestionnaire),demonstratetheirMIskillsina“mockinterview”inthemoment,orsubmitasampletapeoftheirpracticetobereviewedlater

EnsurethatclinicalsupervisorsaretrainedinMIandareMI-consistentintheirsupervisorymethodsInsupervisorysessionsmakeitanexpectationforsupervisorstopayattentiontostaffprogressinMIskill-buildingIncludeMIskill-buildingasaprofessionaldevelopmentgoalforallpractitionersintheirjobperformanceplansReviseprogramintakeformsandprogressnotestoreflectandpromoteanMI-consistentapproachParticipateinMI-relatedclinicalresearchstudies(orpossiblyseekoutopportunitiestoconductresearch)CreateMI-relatedvisualreminders(posters,signs,buttons,importanceandconfidencerulers)DevelopanonlineMIdiscussionforumwithinyouragencyProvideopportunitiesforselectstafftobetrainedinusingtheMICA(MotivationalInterviewingCompetencyAssessment)orMITI(MotivationalInterviewingTreatmentIntegrity)tooltocodeMIconversationsforfeedbackandcoachingEncourageselectedstafftobecometrainedasMItrainersthroughtheMotivationalInterviewingNetworkofTrainers(MINT)andparticipateintheMINTcommunityofpractice

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StrategiestoBuildSkills

EstablishMIlearningcircles(akacommunitiesofpractice,coachingcircles)thatmeetregularlytosustainlearningandstrengthenskills

• Groupsof4-8• IdentifyskillfulfacilitatorsandequipthemwithMIpracticeactivities/resources• FocusonpracticingspecificMIskillsandincorporatingthemintopractice

conversationswithaccuratefeedbackandcoachingOfferregularlyscheduledintroductoryandadvancedMItrainingopportunities(ensuringthatparticipantsareassignedtooralreadyapartofanongoinglearningcircle)ContractasneededwithexternalMIcoaches,trainers,andconsultantstopromoteongoinglearningEncourageself-initiatedlearningbyprovidingresourcessuchasMIbooks,eBooks,articles,trainingtapes,skill-buildingexercises,andotherlearningtoolsCodeaudiotapedsegmentsofMIconversationsusingtheMICA(MotivationalInterviewingCompetencyAssessment)orMITI(MotivationalInterviewingTreatmentIntegrity)tooltoprovidefeedbackandcoachingInitiateyourowninspiredideas…

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SelectedResources

Arkowitz,H,Westra,H.A.,&MillerWR,RollnickS.(Eds.).(2015).MotivationalInterviewinginTheTreatmentofPsychologicalProblems(2ndedition).NewYork,NY:GuilfordPress.Hohman,M.(2011).MotivationalInterviewinginSocialWorkPractice.NewYork,NY:GuilfordPress.Miller,W.R.,&Rollnick,S.(2013).MotivationalInterviewing:HelpingPeopleChange(3rdEd.).NewYork,NY:GuilfordPress.Miller,W.R.,&Rose,G.(2009).TowardaTheoryofMotivationalInterviewing.AmericanPsychologist,64(6),527-537.Naar-King,S.,&Suarez,M.(2011).MotivationalInterviewingwithAdolescentsandYoungAdults.NewYork,NY:GuilfordPress.Rollnick,S.,Miller,W.R.,&Butler,C.(2008).MotivationalInterviewinginHealthCare.NewYork,NY:GuilfordPress.Rosengren,D.B.(2017).BuildingMotivationalInterviewingSkills:APractitionerWorkbook(2ndEd.).NewYork,NY:GuilfordPress.WagnerCC,IngersollKS.(2012).MotivationalInterviewinginGroups.NewYork,NY:GuilfordPress.Website:www.motivationalinterviewing.orgZuckoff,AllanwithGorscak,B.(2015).FindingyourWaytoChange.NewYork,NY:GuilfordPress.

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Trauma-InformedCareBasicsHowcanyouprovideoptimalcareforpeoplewhohaveexperiencedtrauma?Inthisarticle,wesharebestpracticesfortrauma-informedcare.Theseincludeunderstandingtraumaanditseffects,creatingsafephysicalandemotionalspace,supportingcontrolandchoice,andintegratingtrauma-informedcareacrossservicesystems.Somepeopleexperienceveryfewtraumaticeventsintheirlives.Othersexperiencechronictraumaticstressthatcanpotentiallyhaveamajorimpactonhowpeopleunderstandthemselves,theworld,andothers.Peoplewhohaveexperiencedmultipletraumasdonotrelatetotheworldinthesamewayasthosewhohavenot.Theyrequireservicesandresponsesthatareuniquelysensitivetotheirneeds.Whatmakesanexperiencetraumatic?

• Theexperienceinvolvesathreattoone’sphysicaloremotionalwell-being.• Itisoverwhelming.• Itresultsinintensefeelingsoffearandlackofcontrol.• Itleavespeoplefeelinghelpless.• Itchangesthewayapersonunderstandsthemselves,theworldandothers.

Trauma-awarenessWeknowpeoplecananddorecoverfromtrauma,andwewanttoprovideservicesandenvironmentsthatsupporthealing.Tobea“trauma-informed”provideristorootyourcareinanunderstandingoftheimpactoftraumaandthespecificneedsoftraumasurvivors.Wewanttoavoidcausingadditionalharmtothoseweserve.Whatdoesthismeaninpracticalterms?Howisthisdifferentthanbusinessasusual?Herearesomeconcretepracticesoftrauma-informedcare.UnderstandingtraumaanditsimpactUnderstandingtraumaticstressanditsimpactisessential.Traumasurvivors,particularlythosewhohaveexperiencedearlychildhoodtrauma/developmentaltrauma,oftendevelopasetofsurvivalskillsthathelpthemtomanagepasttrauma.Thesesurvivalstrategies(likesubstancemisuse,withdrawal,aggression,self-harm,etc.)makesensegivenwhatpeoplehaveexperienced.Buttheycanbeconfusingandfrustratingtoothersandoftengetinthewayofcurrentgoals.Withoutanunderstandingoftrauma,providersmayviewthosetheyserveinnegativeways.Providersmightdescribebehaviorsas“manipulative,”“oppositional,”or“unmotivated.”Yetthesebehaviorsmaybebetterunderstoodasstrategiestomanageoverwhelmingfeelingsandsituations.Trauma-informedtrainingcanhelpprovidersunderstandtheseresponsesandoffertrauma-sensitivecare.PromotingphysicalandemotionalsafetyTraumaticexperiencesoftenleavepeoplefeelingunsafeanddistrustfulofothers.Creatingasenseofphysicalandemotionalsafetyisanessentialfirststeptobuildingeffectivehelpingrelationships.Safephysicalenvironmentsmayinclude:

• Well-litspaces• Securitysystems;anabilityforindividualstolockdoorsandwindows

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• Visiblepostingrightsandotherimportantinformation• Culturallyfamiliarsignsanddecorations• Child-friendlyspacesthatincludeobjectsforself-soothing

Practicesthathelptocreateasafeemotionalenvironmentinclude:

• Providingconsistent,respectfulresponsestoindividualsacrosstheagency• Askingpeoplewhatdoesanddoesnotworkforthem• Beingclearabouthowpersonalinformationisused• Permittingpeopletoengageintheirownculturalandspiritualrituals• Providegroupactivitiesthatpromoteagencyandcommunity(e.g.movement,

exercise,yoga,music,dancing,writing,visualarts)

SupportingcontrolandchoiceSituationsthatleavepeoplefeelinghelpless,fearful,oroutofcontrolremindthemoftheirpasttraumaticexperiencesandleavethemfeelingre-traumatized.Waystohelpindividualsregainasenseofcontrolovertheirdailylivesinclude:

• Teachemotionalself-regulationskillssuchasalteringbreathingandheartrate• Keepindividualswellinformedaboutallaspectsoftheircare• Provideopportunitiesforinputintodecisionsabouthowaprogramisrun• Givepeoplecontrolovertheirownspacesandphysicalbelongings• Collaborateinsettingservicegoals• Assistinwaysthatarerespectfulofandspecifictoculturalbackgrounds• Maintainanoverallawarenessofandrespectforbasichumanrightsandfreedoms

IntegratingcareacrossservicesystemsBecomingtrauma-informedmeansadoptingaholisticviewofcareandrecognizingtheconnectionsbetweenhousing,employment,mentalandphysicalhealth,substanceabuse,andtraumahistories.Providingtrauma-informedcaremeansworkingwithcommunitypartnersinhousing,education,childwelfare,earlyintervention,andmentalhealth.Partnershipsenhancecommunicationamongprovidersandhelpminimizeclients’experiencesofconflictinggoalsandrequirements,duplicatedefforts,andoroffeelingoverwhelmedbysystemsofcare.Ithelpsbuildrelationshipsandresourcestoprovidethebestqualityofcarepossible.Becomingtrauma-informedmeansatransformationinthewaythatprovidersmeettheneedsofthosetheyserve.Theideasaboveareonlyabeginning.Changehappensasorganizationsandproviderstaketheseideas,aswellastheirown,andusethemtoevaluateandadapttheirapproachestocare.AdaptedfromTrauma-InformedCare101,HomelessnessResourceCenterforSocialInnovationhttp://homeless.samhsa.gov/Resource/View.aspx?id=46857&g=ComResPosts&t=423

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ComplexPostTraumaticStressDisorder(C-PTSD)

ComplexPostTraumaticStressDisorder(C-PTSD)isaconditionthatresultsfromchronicorlong-termexposuretoemotionaltraumaoverwhichapersonhaslittleornocontrolandfromwhichthereislittleornohopeofescape,suchasincasesof:

• Childhood/domesticemotional,physicalorsexualabuse• Repeatedviolationsofpersonalboundaries• Long-termobjectification• Exposuretogaslighting/mentalabuseandfalseaccusations• Long-termexposuretoinconsistent,push-pull,splittingoralternatingragingand

hooveringbehaviors• Long-termtakingcareofmentallyillorchronicallysickfamilymembers• Entrapment,kidnapping• Slaveryorenforcedlabor• Longtermimprisonmentandtorture• Longtermexposuretocrisisconditions

Whenpeoplehavebeentrappedinasituationoverwhichtheyhadlittleornocontrolatthebeginning,middleorend,theycancarryanintensesenseofdreadevenafterthatsituationisremoved.Thisisbecausetheyknowhowbadthingscanpossiblybe.Andtheyknowthatitcouldpossiblyhappenagain.Andtheyknowthatifiteverdoeshappenagain,itmightbeworsethanbefore.

ThedegreeofC-PTSDtraumacannotbedefinedpurelyintermsofthetraumathatapersonhasexperienced.Itisimportanttounderstandthateachpersonisdifferentandhasadifferenttoleranceleveltotrauma.Therefore,whatonepersonmaybeabletoshakeoff,anotherpersonmaynot.Therefore,moreorlessexposuretotraumadoesnotnecessarilymaketheC-PTSDanymoreorlesssevere.

C-PTSDsufferersmay"stuff"orsuppresstheiremotionalreactiontotraumaticeventswithoutresolutioneitherbecausetheybelieveeacheventbyitselfdoesn'tseemlikesuchabigdealorbecausetheyseenosatisfactoryresolutionopportunityavailabletothem.Thissuppressionof"emotionalbaggage"cancontinueforalongtimeeitheruntila"laststraw"eventoccurs,orasaferemotionalenvironmentemerges,andthedamnbeginstobreak.

The"Complex"inComplexPostTraumaticDisorderdescribeshowonelayerafteranotheroftraumacaninteractwithoneanother.Sometimes,itismistakenlyassumedthatthemostrecenttraumaticeventinaperson'slifeistheonethatbroughtthemtotheirknees.However,justaddressingthatsinglemost-recenteventmaypossiblybeaninvalidatingexperiencefortheC-PTSDsufferer.Therefore,itisimportanttorecognizethatthosewhosufferfromC-PTSDmaybeexperiencingfeelingsfromalltheirtraumaticexposure,evenastheytrytoaddressthemostrecenttraumaticevent.

ThisiswhatdifferentiatesC-PTSDfromtheclassicPTSDdiagnosis-whichtypicallydescribesanemotionalresponsetoasingleortoadiscretenumberoftraumaticevents.Adaptedfromhttp://outofthefog.website/toolbox-1/2015/11/17/complex-post-traumatic-stress-disorder-c-ptsd

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SelectedRecovery-OrientedPrinciplesandGuidelines

• Engageincontinuallearningabouttypes,causes,prevalence,andimpactoftraumaandstrengtheningoftrauma-informedknowledgeandskills

• Developarecovery-oriented“mindsetandheart-set”focusingonpartnership,

acceptance,compassion,andevocationinallareasofprovidingcareandservices

• Makeeveryefforttoensurephysicalandemotionalsafetyforguestsandstaff

• Integratebio-psycho-social-spiritualcareapproaches

• Createspacesandopportunitiesforself-regulation,quieting,expressingemotions

• Provideopportunitiesforgueststoengageinawarenessandmindfulnesspractices–e.g.,stretching,yoga,meditation

• Provideopportunitiesforrobustphysicalexerciseandplay

• Promotehealingthroughcreatinghealthyconnectionsandasenseofcommunity

withstaffandothers

• Recognizethatrecoverycananddoeshappen

• Focusonstrengths,resilience,andrecovery.Recognize“negative”behaviorsasadaptive

• Minimizepossibilitiesoftriggeringbehaviorsandre-traumatization

• Maximizepersonalchoiceandself-determinationinallcommunicationsandactions

• Practiceculturalhumilityandresponsivenessbyseekingtounderstandeachperson

inthecontextoftheirlifeexperiencesandculturalbackground

• Solicitinputandinvolvepeopleseekingservicesindesigningandevaluatingservices

• Addresssecondarytraumatizationforstaffandpromoteself-care

Compiledfrommultiplesources

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ImplementingTrauma-InformedCareinYourOrganizationOrganizationalstrategies

DesignateaTrauma-InformedCare(TIC)ImplementationTeamtoassessneeds,makespecificrecommendations,andguideimplementationeffortstobecomemoretrauma-informedinallaspectsoftheorganizationUseaTICOrganizationalSelf-Assessmenttooltodeterminetheorganization’sinitiallevelofunderstandingandadoptionoftrauma-informedpracticestocreateabaselinefromwhichtomeasureprogressovertime(usingthesametoolrepeatedlyatregularintervals)Developanorganizationalphilosophyofcarestatementthatalignswithtrauma-informedprinciplesandpracticesIncludeTICknowledgeandexperienceasajobrequirementorpreferencewhenadvertisingfor,screening,andhiringnewstaff,especiallydirect-serviceandsupervisorypositionsInjobinterviews,askapplicantsabouttheirunderstandingoftrauma-informedcareandtoprovidespecificexamplesofworkinginatrauma-informedmanner

Ensurethatclinicalsupervisorsaretrainedinandprovidingtrauma-informedsupervision,payingparticularattentiontotheimpactoftheworkonstaffwell-beingInsupervisorysessionsmakeitanexpectationforsupervisorstoassessandhelpstaffstrengthentheirtrauma-informedknowledgeandskillsIncludeTICknowledgeandskillsasaprofessionaldevelopmentgoalforstaffintheirperformancereviewplansReviseprogramintakeformsandprogressnotestoreflectandpromoteatrauma-informedapproachParticipateinTIC-relatedclinicalresearchstudies(orpossiblyseekoutopportunitiestoconductresearch)CreateTIC-relatedvisualreminders(posters,signs,quotes,prompts)topostintheagencyDevelopanonlineTICdiscussionforumwithintheagencyEncourageselectedstafftobecometrainedasTICtrainers

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StrategiestoBuildSkills

EstablishTIClearningcircles(akacommunitiesofpractice,coachingcircles)thatmeetregularlytobuildknowledgeandskills

• Groupsof4-8• IdentifyskillfulfacilitatorsandequipthemwithTICpracticeactivitiesand

resources• Focusonpracticingtrauma-informedconversationswithcoachingandfeedback

(notjusttalkingaboutthem)OfferregularlyscheduledintroductoryandadvancedTICtrainingopportunities(ensuringthatparticipantsareassignedtooralreadyapartofanongoinglearningcircle)ContractasneededwithexternalTICcoaches,trainers,andconsultantstopromoteongoinglearningEncourageself-initiatedlearningbyprovidingTICresources–books,eBooks,articles,trainingtapes,skill-buildingexercises,andotherlearningtoolsInitiateyourowninspiredideas…

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SelectedResources:Trauma-InformedCareACESConnectionResourcesCenterhttps://www.acesconnection.com/g/resource-center/blog/resource-list-topic-trauma-informed-practiceBassuk,E.L.,Olivet,JO,Winn,LP,&Nichols,K.(2014).SafetyinSupport:AnInteractiveeBookonTrauma-InformedCare.Availablefromtheibookslibrary.CenterforSocialInnovation.(2015).MeasuringTrauma-InformedCareinHumanServiceOrganizations:HowtoUsetheTICOMETER.Availablebycontactinginfo@thinkt3.com.

Herman,J.(1992).Traumaandrecovery.NewYork:BasicBooks.

Hopper,E.K.,Bassuk,E.L.,&Olivet,J.(2010).Shelterfromthestorm:Trauma-informedcareinhomelessnessservicessettings.TheOpenHealthServicesandPolicyJournal,3,80-100.

NationalChildTraumaticStressNetworkwww.nctsn.orgNationalCouncilforBehavioralHealth.Trauma-InformedBehavioralHealthCareTrauma-InformedCareOrganizationalSelf-Assessmenthttp://www.thenationalcouncil.org/areas-of-expertise/trauma-informed-behavioral-healthcareSubstanceAbuseandMentalHealthServicesAdministration.Trauma-InformedCareinBehavioralHealthServices.TreatmentImprovementProtocol(TIP)Series57.HHSPublicationNo.(SMA)13-4801.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration,2014.

SAMHSANationalCenterforTrauma-InformedCareandAlternativestoSeclusionandRestrainthttp://www.samhsa.gov/nctict3(think.teach.transform.)Resourcefortrauma-informedcaretrainingandimplementationsupportswww.thinkt3.comTheTraumaCenteratJusticeResourceInstitutehttp://www.traumacenter.orgThroughaDarkerLens:TheTraumaofRacisminCommunitiesofColorhttps://www.pathwaysrtc.pdx.edu/pdf/fpS1507.pdfvanderKolk,Bessel.(2014).TheBodyKeepstheScore:Brain,Mind,andBodyintheHealingofTrauma.NewYork:Viking