Friday, November 2, 2018

Even Folks in Our Field Get the Blues: When Implementation of Best Practices Goes Wrong, Part 2

By David S. Prescott, LICSW

This is part 2 of a 2 part blog, part 1 can be found here – Kieran

This post picks up where the last one left off. The context is that a participant in a training recently described frustration with implementing Motivational Interviewing in their practice.  This echoed a concern I’d seen expressed in social media. As the discussion progressed, another participant expressed similar experiences. Although small in number, their concerns were important: There can be side effects when adjusting to the use of positive, collaborative, strengths-based approaches such as Motivational Interviewing (MI) and the Good Lives Model (GLM). How can this be? What can we do?

Beyond the considerations mentioned earlier (context, status of working alliance, etc.), a factor that has often gone under-appreciated until recently is the effect of early trauma and other adverse experiences. From the outset, clearly trauma and adversity can be difficult concepts to work with. What is traumatic to one person may not be traumatic to the next, while many people (including professionals in our field) appear to develop extreme strength and resilience in the aftermath of abuse.

Further, what can appear as traumatic to the person who experiences it may not be in the eyes of others. This becomes especially difficult to understand when the experience(s) took place at an early age, when the client had not yet developed the necessary language skills to describe his or her experiences. As one person once stated it, “From the outside looking in, it’s hard to understand, and from the inside looking out it’s hard to describe.”

Finally, in some cases, the uncertainties involved in sexual development can combine with mental health conditions to create unusual situations. For example, one ATSA pre-conference workshop several years ago focused on a person on the Autism spectrum who had somehow been deeply affected by watching cartoons while masturbating, with the end result being a very rare form of sexual disorder in early adulthood. Although a statistical outlier, a deep understanding of how the events in his life had affected his development was critical to understanding him and providing treatment.

Any of these scenarios can combine to make clients appear challenging, unmotivated, or written off with such language as, “He just doesn’t get it.” Consider the following statement from a person in a community-based residential program. He has a history of trauma who was found not quite competent to stand trial. When asked to describe a seemingly innocuous event from the preceding week, he says: “I can’t… Ummm…. It doesn’t matter… Look, never mind.” Imagine that this has actually been similar to past responses to questions about his current status; discussing his past behaviors has been virtually impossible, and when it occurs ends in his experiencing shame and hopelessness.

In this client’s case it can be easy to assume that he is unwilling to participate meaningfully in treatment despite his statements that he wants to do what he needs to complete the program and return to the community. It’s easy to think that his statement translates directly into “I don’t want to talk with you, and I am not going to let you know that. Instead, I’m going to feign being upset.” While this translation may be partially true, it likely isn’t the entire story in this case. This pattern of responding might also translate as, “The only reason I’ve survived my life up to this point is because I am constantly evaluating my environment for evidence of threats. Now you are asking me to look inside my own experience, and I’ve never developed meaningful skills for that. Also, my words have been used against me much of my life, and I don’t understand how you can expect me to trust you so quickly. On top of that, I’ve never developed the kind of language skills to express to you how hard it is for me to view the world as anything but a dangerous place. You want me to talk. I can’t do that safely right now. The only option I can see is to shut down. If you keep pushing, I may need to become violent.

Ultimately, the move to trauma-informed care is not about helping people feel as though they are passive victims of a cruel world. It’s about understanding how events shape people at the individual level, one client at a time, and designing interventions that they can respond to, in adherence to the responsivity principle of effective corrections. 

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