BestPracticesinHomelessServices

TarrantCountyHomelessCoalition

ForthWorth,TXJune14,2017

KenKraybill,MSWCenterforSocialInnovation/t3

www.thinkt3.com

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BestPracticesinHomelessServicesJune14,2017

TrainingObjectives:Participantswillbeableto:

• Identifythefourelementsofthemindsetandheart-setofbestpractices• Givetwoexamplesofrespondinginatrauma-informedmanner• DescribethethreephasesofCriticalTimeIntervention• DescribethefourprocessesofMotivationalInterviewing• Namethreebenefitsofintegratingpeersupportprovidersinhomelessservices• Explainwhatittakestosuccessfullyimplementabestpractice

9:00 WelcomeandOpening

RiverofResilienceactivity–values,strengths,andsupports9:30 OverviewofBestPracticesinHomelessServices

WhattheyareandwhytheymatterThemindsetandheart-setofbestpractices

10:00 FromHousingReadytoHousingFirst HousingFirstprinciples,practices,andoutcomes Tenancysupportinpermanentsupportivehousing10:30 BREAK10:45 CaseManagementApproachesinHomelessServices Historyandmodelsofcasemanagement CriticalTimeIntervention–atime-limitedapproach11:30 Trauma-InformedCare Theimpactoftrauma

Respondingfromatrauma-informedperspective12:15 LUNCH1:00 EnhancingMotivationtoChange Spirit,skillsandprocessesofMotivationalInterviewing AguidedMIconversation2:15 BREAK

2:30 IntegratingPeerSupportProviders Involvingandintegratingpeersinservicedelivery Principlesandpracticesofrecovery-orientedcare3:15 CaringforSelfwhileCaringforOthers Whyself-carematters Sourcesofresilienceandrenewal3:40 ImplementingBestPractices Whytrainingisnotenough Stepsforsuccessfulimplementationofbestpractices4:00 ADJOURN

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TheMindsetandHeart-setofBestPractices

“Bestpracticesaredonefororwithpeople,notonortothem.”WilliamR.Millerparaphrased

WilliamR.MillerandStephenRollnickinMotivationalInterviewing:HelpingPeopleChange(3rdedition)describefourelementsofthemindsetandheart-setofMotivationalInterviewing:partnership,acceptance,compassion,andevocation.Aconvincingcasecanbemadethatthesesameelementsreflectthecorevaluesofallbestpracticesinhomelessservices–ofwhatittrulymeanstocare.Itiswellknownthatthemannerorspiritinwhichweprovidecarehasasignificantimpactonpeople’sreceptivitytoacceptingthehelpbeingoffered.Thismindsetandheart-setmustbegenuineandsincere;itcannotbefabricated.Itisexpressedthroughourbodylanguage,non-verbalfacialexpressions,toneofvoice,attitudes,intentions,andhowweuselanguagetoexpressourselves.Thismindsetandheart-setistheessenceofwhatpeopleexperienceinourpresence.Theelementsofthemindsetandheart-setofbestpracticesarebrieflydescribedbelow:PARTNERSHIPFormingacollaborativeworkingrelationshipwithsomeone;lettinggooftheneedtobetheexpert;showinggenuinerespectfortheotherperson’slifeexperience,hopes,andstrengths;assumingthatbothofyouhaveimportantexpertiseandideas;“dancingratherthanwrestling”ACCEPTANCEMeetingsomeone“wherethey’reat”withoutjudgment;believingintheperson’sinherentworthandpotential;conveyingempathy–seekingtounderstandwherethey’recomingfrom;shiningalightonthegoodthingsyouseeintheminsteadoffocusingonwhat’swrongwiththemCOMPASSIONComingalongsidepeopleintheirsuffering(e.g.,homelessness,trauma,mentalillness,addiction,grief,stigmatization,racialinjustice,denialofrights);offeringthegiftofasafe,listeningpresence;beinginsolidaritywith;actingforandwithpeopleEVOCATIONInvitingor“callingforth”frompeoplewhattheyalreadypossess–theirhopes,values,desiresandaspirations;learningwhatpeoplearepassionateabout,whattheyalreadyknowandcando,whattheywanttolearn,what’simportanttothem,howthey’dliketheirlivestobedifferent,whatchangesthey’rewillingtoconsidermaking,andmore.

AdaptedfromMotivationalInterviewing,3rdeditionbyMiller&Rollnick,2013

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HousingFirstHousingFirsthasbeenrecognizedasapromisingpracticebynationalresearchersandpolicymakers.Asaresult,communitiesinmanypartsoftheworldarepilotingprojectsthatemployHousingFirstprinciples.TheNationalAlliancetoEndHomelessness(NAEH)definestheHousingFirstapproachforaddressingthechronichomelessnessofdisabledandvulnerablepeopleas“aclient-drivenstrategythatprovidesimmediateaccesstoanapartmentwithoutrequiringinitialparticipationinpsychiatrictreatmentortreatmentforsobriety.”

HousingFirstisbasedontwocoreconvictions:1.Housingisabasichumanright,notarewardforclinicalsuccess,and2.Oncethechaosofhomelessnessiseliminatedfromaperson’slife,clinicalandsocialstabilizationoccurfasterandaremoreenduring.HousingFirstprinciples:1.Movepeopleintohousingdirectlyfromstreetsandshelterswithoutpreconditionsoftreatmentacceptanceorcompliance.2.Theproviderisobligatedtobringrobustsupportservicestothehousing.Theseservicesarepredicatedonassertiveengagement,notcoercion.3.Continuedtenancyisnotdependentonparticipationinservices.4.Unitstargetedtomostdisabledandvulnerablehomelessmembersofthecommunity.5.Embracesharmreductionapproachtoaddictionsratherthanmandatingabstinence.Atthesametime,theprovidermustbepreparedtosupportresidentcommitmentstorecovery.6.Residentsmusthaveleasesandtenantprotectionsunderthelaw.7.Canbeimplementedaseitheraproject-basedorscatteredsitemodel.

AdaptedfromDowntownEmergencyServiceCenter,Seattle,WAwebsitewww.desc.org

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CriticalTimeInterventionBasicsCriticalTimeIntervention(CTI)isaspecialized,time-limitedcasemanagementinterventionforthecriticaltransitionperiodfrominstitutionaltocommunitycareforpeopleexperiencinghomelessnessandmentalillness.CTIwasoriginallydesignedtohelppeopletransitionfromlivingininstitutions(e.g.hospitals,jails,prisons)tocommunityliving,butnowhasbroadenedtoincludeothertypesoftransitions(e.g.,fromstreettohousing,orfromonelevelofhousingtoanother).CTIisdesignedtobridgethegapbetweenhomelessspecificservicesandcommunityservices.CTIpreventsrecurrenthomelessness,residentialinstabilityandfragmentedcarebyconnectingthepersontoinformalnetworks(e.g.,family,shopkeeperatthecornerbodega,friends)andtoformalcaregivers(e.g.,casemanager,psychiatrist).Thegoalistohelpthevariouscaregiversandothersupportpeopleinthecommunityconnectwitheachothertoformanetworkofcare.PrinciplesofCTI

• Atwo-waystreet,withtheclientadjustingtocommunityservicesandcommunityresourcesadaptingtoindividualneedsforsupport

• Strivestohavetheclientliveintheleastrestrictiveenvironmentpossible,butwiththemaximumamountofsupport

• Assessesclientsalongacontinuumofneeds• Complements rather than duplicates existing service systems

KeyCharacteristicsofCTI

• Timelimited(approximately9months)• Threephaseswithdecreasingintensityofservicesovertime• Focusononlyafewareasoftreatmentatatime• Community-basedmodel–outreach,assessment,monitoringandtreatment–not

office-based• Smallcaseloads• Harmreductionapproachtobehavioralchange• CTIteamsupervisionbyaCTI-trainedMSWorPsychiatrist• Earlyengagementwithclient• Earlylinkingtocommunity• Nodrop-outs:CTIinterventionrarelyshorterthan9months

PhasesofCTICTIisanine-monthinterventionthatbeginsondayofdischargefromaninstitutionorothersetting.CTIendsapproximatelyninemonthslater.PRE-CTIPriortoclient’sactualtransition,anassessmentismadeofcommunitylinksandclientstrengths.

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PHASE1:TRANSITIONTOCOMMUNITYThisphasebeginsonthedayofdischarge/transition.Itismarkedbyintensivesupportandassessmentofresourcesforthetransferofcaretocommunityproviders.Duringthisphase:

• CTIworkeristhereondayofdischargetohelpindividualgetsettledandbeginmakingcommunitylinkages.

• PeopleinthecommunityappreciateknowingtheCTIworkerwillhelpthemwithsomeoftheresponsibilitiesinhelpingtheclienttransition.

• Mediationandnegotiationarecriticalskillsforthisphase.• CTIworkermakesageneralplanwiththeclientonwhatareasoftreatmentwillbe

thefocusduringPhase1(ThisprocessbeginsinPre-CTIphase.)• CTIteammembersidentifykeyproviderswhowillhelpwithservices.• Workerbringstogethercommunitymembers.• Mostofthisphaseisspentonoutreach.• CTIworkerdoesinvivoassessmentofclient’sneedsandskills.

PHASE2:TRYOUTPhase2focusesontryingoutandadjustingsupportsystemsthatwereinitiatedinPhase1.Thegoalistostrengthenconnectionsbetweentheclientandsupportsinthecommunity.PHASE3:TRANSITIONOFCAREInPhase3,thefocusisontransferringcarefromtheCTIteamtocommunityresourcesforlong-termsupport.TheCTIteamstepsbacktoobserve,anticipatependingproblems,andtoensurethecommunitysupportsarefunctioningwell.Inaddition:

• Phase3focusesonthefinaltransferofcareandincludesafinaltransferofcareplan.• TwoweeksbeforetheendofCTI,theworkerandclienthaveawrapupmeetingtoget

client’sfeedbackanddeterminewhohe/shemightcallincaseofneed.• Clientbeginstopicturethefutureandseehowfarhe/shehascome.

THROUGHOUTTHEPHASESOFCTI:

• Servicesdecreaseandresponsibilityispassedontoothers.Thisismadeclearallalongtheway.

• ClientandcommunitygetinthehabitofoperatingwithoutCTIworker.

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Trauma-InformedCareBasicsHowcanprovidershelpcareforpeoplewhohaveexperiencedtrauma?Inthisarticle,wesharebestpracticesfortrauma-informedcare.Theseincludeunderstandingtraumaanditseffects,creatingsafephysicalandemotionalspace,supportingconsumerchoiceandcontrol,andintegratingtrauma-informedcareacrossservicesystems.Somepeopleexperienceveryfewtraumaticeventsintheirlives.Forothers,experiencesoftraumaticstressarechronic.Researchandexperiencetellusthatforpeopleexperiencinghomelessness,ratesoftraumaareextraordinarilyhigh.Manywhoenterthehomelessservicesystemhaveexperiencedviolence,loss,anddisruptionstoimportantrelationshipsfromanearlyage.Additionally,peoplewholackhousingexperiencethelossofplace,safety,stability,andcommunity.Theselossesarealsotraumatic.Theyhaveamajorimpactonhowpeopleunderstandthemselves,theworld,andothers.Peoplewhohaveexperiencedmultipletraumasdonotrelatetotheworldinthesamewayasthosewhohavenot.Theyrequireservicesandresponsesthatareuniquelysensitivetotheirneeds.Whatmakesanexperiencetraumatic?

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

BecomingTrauma-InformedWeknowpeoplecananddorecoverfromtrauma,andwewanttoprovideservicesandenvironmentsthatsupporthealing.Tobea“trauma-informed”provideristorootyourcareinanunderstandingoftheimpactoftraumaandthespecificneedsoftraumasurvivors.Wewanttoavoidcausingadditionalharmtothoseweserve.Whatdoesthismeaninpracticalterms?Howisthisdifferentthanbusinessasusual?Herearesomeconcretepracticesoftrauma-informedcare.UnderstandingTraumaanditsImpactEducatingprovidersontraumaticstressanditsimpactisessential.Traumasurvivors,particularlythosewhohaveexperiencedmultipletraumas,havedevelopedasetofsurvivalskillsthathelpedthemtomanagepasttrauma.Thesesurvivalstrategies(likesubstanceabuse,withdrawal,aggression,self-harm,etc.)makesensegivenwhatpeoplehaveexperienced.Buttheycanbeconfusingandfrustratingtoothersandoftengetinthewayofcurrentgoals.Withoutanunderstandingoftrauma,providersmayviewthosetheyserveinnegativeways.Providersmightdescribebehaviorsas“manipulative,”“oppositional,”or“unmotivated.”Yetthesebehaviorsmaybebetterunderstoodasstrategiestomanageoverwhelmingfeelingsandsituations.Trauma-informedtrainingcanhelpprovidersunderstandtheseresponsesandoffertrauma-sensitivecare.

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PromotingPhysicalandEmotionalSafetyTraumaticexperiencesoftenleavepeoplefeelingunsafeanddistrustfulofothers.Creatingasenseofphysicalandemotionalsafetyisanessentialfirststeptobuildingeffectivehelpingrelationships.Safephysicalenvironmentsmayinclude:

• Well-litspaces• Securitysystems;anabilityforindividualstolockdoorsandwindows• 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.Waystohelpconsumersregainasenseofcontrolovertheirdailylivesinclude:

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

IntegratingCareAcrossServiceSystemsBecomingtrauma-informedmeansadoptingaholisticviewofcareandrecognizingtheconnectionsbetweenhousing,employment,mentalandphysicalhealth,substanceabuse,andtraumahistories.Providingtrauma-informedcaremeansworkingwithcommunitypartnersinhousing,education,childwelfare,earlyintervention,andmentalhealth.Partnershipsenhancecommunicationamongproviders,andhelpminimizeconsumers’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.ThereforemoreorlessexposuretotraumadoesnotnecessarilymaketheC-PTSDanymoreorlesssevere.C-PTSDsufferersmay"stuff"orsuppresstheiremotionalreactiontotraumaticeventswithoutresolutioneitherbecausetheybelieveeacheventbyitselfdoesn'tseemlikesuchabigdealorbecausetheyseenosatisfactoryresolutionopportunityavailabletothem.Thissuppressionof"emotionalbaggage"cancontinueforalongtimeeitheruntila"laststraw"eventoccurs,orasaferemotionalenvironmentemergesandthedamnbeginstobreak.The"Complex"inComplexPostTraumaticDisorderdescribeshowonelayerafteranotheroftraumacaninteractwithoneanother.Sometimes,itismistakenlyassumedthatthemostrecenttraumaticeventinaperson'slifeistheonethatbroughtthemtotheirknees.However,justaddressingthatsinglemost-recenteventmaypossiblybeaninvalidatingexperiencefortheC-PTSDsufferer.Therefore,itisimportanttorecognizethatthosewhosufferfromC-PTSDmaybeexperiencingfeelingsfromalltheirtraumaticexposure,evenastheytrytoaddressthemostrecenttraumaticevent.ThisiswhatdifferentiatesC-PTSDfromtheclassicPTSDdiagnosis-whichtypicallydescribesanemotionalresponsetoasingleortoadiscretenumberoftraumaticevents.

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DifferencebetweenC-PTSD&PTSDAlthoughsimilar,ComplexPostTraumaticStressDisorder(C-PTSD)differsslightlyfromthemorecommonlyunderstood&diagnosedconditionPostTraumaticStressDisorder(PTSD)incausesandsymptoms.C-PTSDresultsmorefromchronicrepetitivestressfromwhichthereislittlechanceofescape.PTSDcanresultfromsingleevents,orshort-termexposuretoextremestressortrauma.ThereforeasoldierreturningfromintensebattlemaybelikelytoshowPTSDsymptoms,butakidnappedprisonerofwarwhowasheldforseveralyearsmayshowadditionalsymptomsofC-PTSD.Similarly,achildwhowitnessesafriend'sdeathinanaccidentmayexhibitsomesymptomsofPTSDbutachildwhogrowsupinanabusivehomemayexhibittheadditionalC-PTSDcharacteristicsshownbelow:C-PTSDWhatitFeelsLikePeoplewhosufferfromC-PTSDmayfeelun-centeredandshaky,asiftheyarelikelytohaveanembarrassingemotionalbreakdownorburstintotearsatanymoment.Theymayfeelunlovedorthatnothingtheycanaccomplishisevergoingtobe"goodenough"forothers.PeoplelivingwithC-PTSDmayfeelcompelledtogetawayfromothersandbebythemselves,sothatnoonewillwitnesswhatmaycomenext.Theymayfeelafraidtoformclosefriendshipstopreventpossiblelossshouldanothercatastrophestrike.PeopleexperiencingC-PTSDmayfeelthateverythingisjustabouttogo"outthewindow"andthattheywillnotbeabletohandleeventhesimplesttask.Theymaybetoodistractedbywhatisgoingonathometofocusonbeingsuccessfulatschoolorintheworkplace.Adaptedfromhttp://outofthefog.website/toolbox-1/2015/11/17/complex-post-traumatic-stress-disorder-c-ptsd

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ABriefHistoryofMotivationalInterviewingMotivationalInterviewing(MI)isawayoftalkingwithpeopleaboutchangerelatedtothingsweoftenhavemixedfeelingsabout–exercise,diet,alcoholandotherdruguse,relationshipissues,riskysexualbehaviors,schoolandjobrelatedconcerns,spiritualpractices,certainattitudes,andotherissueswefaceinourlives.TheMIapproachgrewoutWilliamR.Miller’sworkwithproblemdrinkers.Inthepast,itwasbelievedthatpeoplewhodranktoomuchwereunabletoseehowtheirusewasharmingthemselvesandothers.Theyweresaidtobeindenial.Counselorsandotherswhowantedtohelpwouldtrytobreakthroughthisdenialbyusing“in-your-face”tacticssuchasconfrontationandshametotrytoconvincepeopleoftheirneedtochange.Asyoucanimagine,thisapproachdidn’tworkverywell.Noneofuslikeitwhenotherpeoplethinktheyknowwhat’sbestforusortrytogetustochange.Wewanttodecideforourselveshowtoliveourlives.In1991,WilliamR.MillerandStephenRollnickwroteabooktitledMotivationalInterviewing:PreparingPeopletoChangeAddictiveBehavior.Itexplainedhowtotalkwithpeopleabouttheiralcoholanddruguseinwaysthatrespectedtheirabilitytodecideforthemselveswhethertheywantedtochange.Inthebook,theauthorsdescribedthespirit(coreattitudesandbeliefs)ofthisapproachandthespecificskillsandstrategiesofMI.Asecondedition,MotivationalInterviewing:PreparingPeopleforChange,waspublishedin2002.ItfurtherexplainedhowMIworks,theresearchbehindit,andhowtogetbetteratusingMI.ItalsodescribedthespreadofMItootherareasbeyondsubstanceusedisordersincludinghealthcare,mentalhealth,corrections,andschoolsettings.Athirdedition,MotivationalInterviewing:HelpingPeopleChange,2013,expandedontheMIapproachandincludedsomenewideassuchasthefourprocessesofMIconversations:engaging,focusing,evoking,andplanning.MIisdefinedas“acollaborativeconversationstyleforstrengtheningaperson’sownmotivationandcommitmenttochange.”MIcanalsobedescribedas“awayofhelpingpeopletalkthemselvesintochanging.”Thisapproachembodies“amind-setandaheart-set”thatincludespartnership,acceptance,compassion,andevocation.MotivationalInterviewingisaguidingstylethatinvitespeopletoexaminetheirownvaluesandbehaviorsandcomeupwiththeirownreasonstochange.Itdoesn’ttrytoconvincepeopleorarguewiththem.Instead,itdrawsoutpeople’sownhopes,experience,andwisdomaboutthemselvesincludingwhetherornottochange.AsWilliamR.Millersays,“Youalreadyhavewhatyouneed,andtogetherlet’sfindit.”Peoplewhoareusedtoconfrontingandgivingadvicewilloftenfeellikethey’renot“doinganything.”But,asMillerandRollnickpointout,theproofisintheoutcome.Moreaggressivestrategiesoftenpushpeopleaway.MI,ontheotherhand,increasestheoddsthatpeoplewillgivechangeachance

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MotivationalInterviewing:AGuidedConversationHereisageneraloutlineofhowamodelMIconversationmightflow.Inthiscase,drinkingisthefocus.Ofcourse,reallifeconversationsrarelyplayoutinsuchastraightforwardmanner.NotethatthespiritandcoreskillsofMIareappliedthroughoutthefourprocessesofMI.Asageneralguideline,itisusefultofollowabasicrhythmofaskinganopenquestionfollowedbyoneormorereflections,beforeaskinganotherquestion.ENGAGINGProvideawarmwelcome;offerabeverage;exchangesmalltalk;makesurethepersonfeelssafe;showthatyoucare;gettoknowthepersonasaperson;behopeful

§ “Hi.It’sreallygoodtoseeyou.Wouldyoulikesomejuiceortea?”“Howhavethingsbeengoinglately?”(Respondwithreflectivestatements)

FOCUSINGAgreeonwhattotalkabout

§ “What’sonyourmind?”“Youmentionedseveralthings.Whereshallwestart?”“Woulditbeallrightifwetookacloserlookatyouanddrinking?”(Reflect)

EVOKINGExploreambivalence

§ “Whatdoesdrinkingdoforyou?Whatconcerns,ifany,doyouhaveaboutit?”(Reflect)

Elicitchangetalk§ DESIRE(want,wish,like)

“Howwouldyoulikethingstobedifferentthantheyarenow?”(Reflect)

§ REASONS(specificreasonsforchange) “Ifyouweretocutbackorstopdrinking,whataresomereasonsyoumightdothat?” (Reflect)

§ ABILITY(can,could,able)

“Howmightyougoaboutitinordertosucceed?”(Reflect)

§ NEED(havetoorimportantto-withoutstatingspecificreason)“Howimportantisittoyoutomakethischange?”(use0-10scalingquestion)(Reflect)

§ TESTINGTHEWATER(readinessandconfidence)

“Howreadyareyoutomakethischange?”“Howconfidentareyoutomakethischange?”(oruse0-10scalingquestion)(Reflect)

PLANNING

§ COMMITMENT(will,planto,intendto,goingto,willing,ready,etc.)

“Whatdoyouthinkyouwilldonext?”“Whatisyourplan?”“HowcanIhelpyouwiththat?”(Reflect)

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MISelf-Appraisal

Infacilitatingaconversationtohelpstrengthentheperson’sownmotivationandcommitmenttochange,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.Elicitedwhatmightbesomepossiblereasonstochange,ifthepersonweretodecidetochange.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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PeerSupportProvidersPeersupportprovidersarepeoplewithapersonalexperienceofrecoveryfrommentalhealth,substanceuse,ortraumaconditionswhoreceivespecializedtrainingandsupervisiontoguideandsupportotherswhoareexperiencingsimilarmentalhealth,substanceuseortraumaissuestowardincreasedwellness.Thetermpeersupporterisanumbrellaformanydifferentpeersupporttitlesandroles,suchaspeeradvocate,peercounselor,peercoach,peermentor,peereducator,peersupportgroupleader,peerwellnesscoach,recoverycoach,recoverysupportspecialist,andmanymore.Ingeneral,apeersupporterisanindividualwhohasmadeapersonalcommitmenttohisorherownrecovery,hasmaintainedthatrecoveryoveraperiodoftime,hastakenspecialtrainingtoworkwithothers,andiswillingtosharewhatheorshehaslearnedaboutrecoveryinaninspirationalway.Inmanystates,thereisanofficialcertificationprocess(trainingandtest)tobecomeaqualified“peerspecialist.”Notallstatescertifypeersupportproviders,butmostorganizationsrequirepeersupportproviders(whoareemployed)tocompletetrainingthatisspecifictotheexpectedresponsibilitiesofthejob(orvolunteerwork).Often,apeersupporterhasextraincentivetostaywellbecauseheorsheisarolemodelforothers.Thosewhoprovideauthenticpeersupportbelieveinrecoveryandworktopromotethevaluesthat:

• Recoveryisachoice.• Recoveryisuniquetotheindividual.• Recoveryisajourney,notadestination.• Self-directedrecoveryispossibleforeveryone,withorwithoutprofessionalhelp

Apeersupportprovideriscaringandcompassionateforwhatapersonisexperiencing.Ifthepeersupportproviderhasbeenthroughsimilarchallenges,heorshemayofferideasorwisdomgainedthroughhisorherpersonalexperiencestoinspirehope,supportpersonalresponsibility,promoteunderstanding,offereducation,andpromoteself-advocacyandself-determination.Strengthsthatpeerprovidersaddtotheworkplaceinclude:

• Personalexperiencewithwholehealthrecoverythatincludesaddressingwellnessofbothmindandbody

• Insightintotheexperienceofinternalizedstigmaandhowtocombatit• Compassionandcommitmenttohelpingothers,rootedinasenseofgratitude• Cantakeawaythe“youdonotknowwhatit’slike”excuse• Experienceofmovingfromhopelessnesstohope• Inauniquepositiontodeveloparelationshipoftrust,whichisespeciallyhelpfulin

workingwithpeopleintraumarecovery• Adevelopedskillinmonitoringtheirillnessandself-managingtheirlives

holisticallyFromInternationalAssociationofPeerSupportershttps://inaops.org/definition-peer-specialist/andSAMHSA-HRSACenterforIntegratedHealthSolutionshttp://www.integration.samhsa.gov/workforce/team-members/peer-providers#General

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Recovery-OrientedPracticesWhatisrecovery?Recoveryisaprocessofgrowthandchangethroughwhichpeopleimprovetheirhealthandwellness,liveaself-directedlife,andstrivetoreachtheirfullpotential.Peopleinrecoverysaythattheprocessofrecoveryisaboutfindingnewmeaning,purpose,andpossibilityinlife.Formanypeople,recoverymeans:

• Nolongerdefiningoneselfbytheexperienceofmentalillness• Beingafullparticipantinthecommunitywithvaluedrolessuchasworker,parent,

student,neighbor,friend,artist,tenant,lover,andcitizen• Runningone’sownlifeandmakingone’sowndecisions• Havingarichnetworkofpersonalandsocialsupportsoutsideofthementalhealth

system• Celebratingnewfoundstrengthandskillsgainedfromlivingwith,andrecovering

from,mentalillness• Havinghopeandoptimismforthefuture

AModel:Person-CenteredRecoveryPlanningForindividualsreceivingbehavioralhealthservices,aperson-centeredapproachmeansthattheyhavechoicesintheservicesandsupportstheyuse.Italsomeansthattheyareactivepartnersinselectingtheirrecoverysupportteamandininvitingfamilymembersandothernaturalsupports(suchasemployers,tutors,neighbors)tobeinvolved.Further,itmeansrealizingthat,orbeinghelpedtorealizethat,theyhavethepowertochangetheirlivesandcanpartnerwiththeirrecoveryteamindoingso.Forproviders,Person-CenteredRecoveryPlanning(PCRP)meanspartneringwithpeoplereceivingservicestohelpthemachievegoalsthatarepersonallymeaningfultothem,evenwhensuchgoalsextendbeyondthoseareastraditionallyaddressedbyclinicalcare.Suchgoalsmayincludereturningtowork,finishingschool,makingfriends,havingagirlfriendorboyfriend,learninganewskill,ordevelopingahobby.PCRPisinformedbymanysources,particularlytheexperiencesofpeople(providersandpeopleinrecovery)whohavestruggledwiththelimitationsoftraditionalmodelsofcareandhavecalledforradicalchangestowardmoreperson-centeredplanningapproaches.LimitationsoftraditionalmodelsofserviceplanningSomeofthelimitationsofthesetraditionalmodelsidentifiedinresearchandclinicalexperienceincludethefollowing:

§ Powerisallocatedlargely(oronly)totheserviceprovidertodeveloptreatmentgoals

§ Peoplereceivingservicesarenotcommonlyencouragedtotakeanactiveorself-directedrolewhichfostersbothshort-termdisengagementandlong-termdespairanddependency

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§ Serviceagenciesfocusonsystemicallydefinedoutcomes(e.g.,hospitalizationrates)andareheldlessaccountableforotheroutcomesthatholdrealvalueforthosetheyserve(e.g.,employment,relationships,communityactivities)

§ Successismostoftendeterminedbysystemstandardsandisgaugedonnarrowlydefinedgoalssuchastreatmentcomplianceorsymptomreduction

§ Servicesaretypicallyfragmentedanddisconnectedfromotherimportantpartsofaperson’slife.

HowisaPerson-CenteredCarePlandevelopedandevaluated?Thecreationofaperson-centeredplancanbeorganizedintoseverallogicalstepsthatfollowinorderandinclude,incollaborationwiththepersonreceivingservices:

• Conductingastrength-basedassessment• Formulatinganintegratedunderstandingoftheindividual• Prioritizingareastobeaddressed• Settingrecoverygoalsandavisionforthefuture• Identifyingbarrierstoaddressaswellasstrengthstodrawon• Creatingshort-termobjectivesthathelptoovercomebarriers• Describinginterventionsoractivitiesreflectingarangeofevidence-basedand

emergingpractices• Determiningactionstepsbythepersonserved,aswellasanyinvolvednatural

supporters,inanefforttoactivatetherecoverynetwork• Evaluatingprogressandoutcomes(includesevaluatingdischarge/transition

criteria)ExcerptedfromtheRecoveryRoadmap(inprogress)basedontheworkofJanisTondora,Psy.D.&RebeccaMiller,Ph.D.,YaleProgramforRecoveryandCommunityHealth

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FindingResiliencyandRenewalinOurWork“Intheeventthatoxygenmasksmaybeneeded,placethemaskoveryourownfacebeforeassistingothers.”Providingcaretopeopleexperiencingtrauma,displacement,andvariousformsofoppressioninvolvesworkingunderdemandingcircumstances,bearingwitnesstotremendoushumansuffering,andwrestlingwithamultitudeofagonizingandthornyissuesonadailybasis.Atthesametime,wehavetheprivilegeofbecomingpartnersinextraordinaryrelationships,marvelingattheresiliencyofthehumanspirit,andlayingclaimtosmallbutsignificantvictories.Suchisthenatureofthisworkthatitcandrainandinspireusallatonce.Despitetherewardsinherentinthework,itinevitablyexactsapersonaltoll.Bylisteningtoothers’storiesandprovidingasenseofdeepcaring,wewalkadifficultpath.Yetwedosowillingly,knowingthatfirstwemust“enterinto”another’ssufferingbeforewecanofferhopeandhealing.AsHenriNouwennotes,itisinterestingthatthewordcarefindsitsrootsintheGothic“kara”whichmeans,“lament,mourning,toexpresssorrow.”Caringcanbecomeburdensomecausingustoexperiencesignsandsymptomsofwhattheliteraturevariouslycallscompassionfatigue,secondarytraumaticstress,orvicarioustraumatization.Theimpactiscompoundedbythefrustrationsoftryingtoprovidehelpinthefaceofmultiplebarrierstocareincludinginadequateresourcesandstructuralsupportsforpeople.Tofeelweigheddownbythesecircumstancesisnotunusualorpathological.Itis,infact,aquitenormalresponse.Inpart,the“treatmentofchoice”fordiminishingthenegativeeffectsofthisstressistoseekresiliencyandrenewalthroughthepracticeofhealthyself-care.Self-careismosteffectivewhenapproachedwithforethought,notasafterthought.Inthesamemannerthatweprovidecareforothers,wemustcareforourselvesbyfirstacknowledgingandassessingtherealitiesofourcondition,creatingarealisticplanofcare,andactinguponit.Thoughmanyproviderspracticeself-careincreativeandeffectiveways,weallsometimesloseoursenseofbalance,andfailtoprovidethenecessarycareforourselveswiththesameresolutenessthatweoffercaretoothers.Tobetterunderstandwhatself-careis,herearethreethingsitisnot:1)Self-careisnotan“emergencyresponseplan”tobeactivatedwhenstressbecomesoverwhelming.Instead,healthyself-careisanintentionalwayoflivingbywhichourvalues,attitudes,andactionsareintegratedintoourday-to-dayroutines.Theneedfor“emergencycare”shouldbeanexceptiontousualpractice.2)Self-careisnotaboutactingselfishly.Instead,healthyself-careisaboutbeingaworthystewardoftheself–body,mindandspirit–withwhichwe’vebeenentrusted.Itisfoolhardytothinkwecanbeprovidersofcaretootherswithoutbeingtherecipientsofpropernurtureandsustenanceourselves.

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3)Self-careisnotaboutdoingmore,oraddingmoretaskstoanalreadyoverflowing“todo”list.Instead,healthyself-careisasmuchabout“lettinggo”asitisabouttakingaction.Ithastodowithtakingtimetobeahumanbeingaswellasahumandoing.Itisaboutlettinggooffrenziedschedules,meaninglessactivities,unhealthybehaviors,anddetrimentalattitudessuchasworry,guilt,beingjudgmentalorunforgiving.ThefollowingA,B,C’sofself-carecanprovideausefulguideinreflectinguponthestatusofyourownpracticesandattitudes.AWARENESS–Self-carebeginsinstillness.Byquietingourbusylivesandenteringintoaspaceofsolitude,wecandevelopanawarenessofourowntrueneeds,andthenactaccordingly.Thisisthecontemplativewayofthedesert,ratherthantheconstantactivityofthecity.ThomasMertonsuggeststhatthebusynessofourlivescanbeaformof“violence”thatrobsusofinnerwisdom.Toooftenweactfirstwithouttrueunderstandingandthenwonderwhywefeelmoreburdened,andnotrelieved.ParkerPalmerinLetYourLifeSpeaksuggestsreflectingonthefollowingquestion:“IsthelifeIamlivingthesameasthelifethatwantstoliveinme?”BALANCE–Self-careisabalancingact.Itincludesbalancingactionandmindfulness.Balanceguidesdecisionsaboutembracingorrelinquishingcertainactivities,behaviors,orattitudes.Italsoinformsthedegreetowhichwegiveattentiontothephysical,emotional,psychological,spiritual,andsocialaspectsofourbeingor,inotherwords,howmuchtimewespendworking,playing,andresting.Ioncehearditsuggestedthatahelpfulprescriptionforbalanceddailylivingincludeseighthoursofwork,eighthoursofplay,andeighthoursofrest!CONNECTION–Healthyself-carecannottakeplacesolelywithinoneself.Itinvolvesbeingconnectedinmeaningfulwayswithothersandtosomethinglarger.Wearedecidedlyinterdependentandsocialbeings.Wegrowandthrivethroughourconnectionsthatoccurinfriendships,family,socialgroups,nature,recreationalactivities,spiritualpractices,therapy,andmyriadotherways.Oftentimes,ourmostrenewingconnectionscanbefoundrightinourmidstintheworkplace,withco-workersandwiththeindividualstowhomweprovidecare.Thereisnoformulaofcourseforself-care.Eachofour“self-careplans”willbeuniqueandchangeovertime.Wemustlistenwelltoourownbodies,heartsandminds,aswellastothecounseloftrustedfriends,asweseekresiliencyandrenewalinourlivesandwork.Fastenyourseatbeltsandenjoytheride!

KenKraybill

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Self-AssessmentTool:Self-CareHowoftendoyoudothefollowing?(Rate,usingthescalebelow):

5=Frequently4=Sometimes3=Rarely2=Never1=Itneverevenoccurredtome

PhysicalSelfCare

! Eatregularly(e.g.breakfast&lunch)! Eathealthfully! Exercise,orgotothegym! Liftweights! Practicemartialarts! Getregularmedicalcareforprevention! Getmedicalcarewhenneeded! Taketimeoffwhenyou'resick! Getmassagesorotherbodywork! Dophysicalactivitythatisfunforyou! Taketimetobesexual! Getenoughsleep! Wearclothesyoulike! Takevacations! Takedaytrips,ormini-vacations! Getawayfromstressfultechnologysuchaspagers,faxes,telephones,e-mail! Other:

PsychologicalSelfCare

! Maketimeforself-reflection! Gotoseeapsychotherapistorcounselorforyourself! Writeinajournal! Readliteratureunrelatedtowork! Dosomethingatwhichyouareabeginner! Takeasteptodecreasestressinyourlife! Noticeyourinnerexperience-yourdreams,thoughts,imagery,feelings! Letothersknowdifferentaspectsofyou! Engageyourintelligenceinanewarea-gotoanartmuseum,performance,

sportsevent,exhibit,orotherculturalevent! Practicereceivingfromothers! Becurious! Saynotoextraresponsibilitiessometimes! Spendtimeoutdoors! Other:

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EmotionalSelfCare

! Spendtimewithotherswhosecompanyyouenjoy! Stayincontactwithimportantpeopleinyourlife! Treatyourselfkindly(supportiveinnerdialogueorself-talk)! Feelproudofyourself! Rereadfavoritebooks,reviewfavoritemovies! Seekoutcomfortingactivities,objects,people,relationships,places! Allowyourselftocry! Findthingsthatmakeyoulaugh! Expressyouroutrageinaconstructiveway! Playwithchildren! Other:

SpiritualSelfCare

! Maketimeforprayer,meditation,reflection! Spendtimeinnature! Participateinaspiritualgathering,communityorgroup! Beopentoinspiration! Cherishyouroptimismandhope! Beawareofnontangible(nonmaterial)aspectsoflife! Beopentomystery,tonotknowing! Identifywhatismeaningfultoyouandnoticeitsplaceinyourlife! Sing! Expressgratitude! Celebratemilestoneswithritualsthataremeaningfultoyou! Rememberandmemorializelovedoneswhohavedied! Nurtureothers! Contributetoorparticipateincausesyoubelievein! Readinspirationalliterature! Listentoinspiringmusic! Other:

Workplace/ProfessionalSelfCare

! Taketimetoeatlunch! Taketimetochatwithco-workers! Maketimetocompletetasks! Identityprojectsortasksthatareexciting,growth-promoting,and

rewarding! Setlimitswithclientsandcolleagues! Balanceyourcaseloadsonoonedayis"toomuch!"! Arrangeyourworkspacesoitiscomfortableandcomforting! Getregularsupervisionorconsultation! Negotiateforyourneeds! Haveapeersupportgroup! Other:

AdaptedfromSaakvitne,Pearlman,andTraumaticStressInstituteStaff,TransformingthePain:AWorkbookonVicariousTraumatization,1996.

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Thiswork…

exhilaratingandexhausting

drivesmeupawall

andopensdoorsIneverimagined

laysbareawiderangeofemotionsyetleavesmefeelingnumbbeyondbelief

providestremendoussatisfaction

andleavesmefeelingprofoundlyhelpless

evokesgenuineempathyandprovokesafearsomeintolerancewithinme

putsmeintouchwithdeepsuffering

andpointsmetowardgreaterwholeness

bringsmefacetofacewithmanypovertiesandenrichesmeencounterbyencounter

renewsmyhope

andleavesmegraspingforfaith

enablesmetoenvisionafuturebutwithnoabilitytocontrolit

breaksmeapartemotionallyandbreaksmeopenspiritually

leavesmewoundedandhealsme

KenKraybill