>>> HELLO, EVERYONE, AND WELCOME TO THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH'S WEBINAR USING TRAUMA-INFORMED MOTIVATIONAL INTERVIEWING TO SUPPORT TOBACCO CESSATION. THANK YOU FOR YOUR PATIENCE AS WE GOT STARTED, AND THANKS SO MUCH FOR JOINING US TODAY. MY NAME IS DANA LANG. I'M A PROJECT MANAGER AT THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH. I'LL BE SERVING AS YOUR MODERATOR FOR TODAY'S WEBINAR. I'D ALSO LIKE TO INTRODUCE YOU TO MY COLLEAGUES AND PRESENTERS ON TODAY'S WEBINAR, PAM PIETRUSZEWSKI, ELIZABETH GUROFF, AND TASLIM VAN HATTUM. YOU CAN FIND OUR PRESENTERS' FULL BIOS FOR DOWNLOAD IN OUR PANE WHERE YOU'LL FIND A FULL PDF HANDOUT OF TODAY'S SLIDES FOR DOWNLOAD. BEFORE WE BEGIN, I'D JUST LIKE TO COVER A FEW HOUSEKEEPING NOTES. THIS IS BEING RECORDED AND ALL PARTICIPANTS WILL BE KEPT IN LISTEN-ONLY MODE. YOU CAN FIND THE CALL-IN NUMBER FOR THE WEBINAR ON THE RIGHT-HAND SIDE OF YOUR SCREEN. YOU CAN SUBMIT QUESTIONS THROUGHOUT THE WEBINAR BY TYPING YOUR QUESTION INTO THE CHAT BOX TO THE RIGHT OF YOUR SCREEN AND SENDING IT TO THE ORGANIZER. WE'LL GET TO AS MANY QUESTIONS AS WE CAN WITH THE TIME ALLOWED TODAY. PLEASE FEEL FREE TO ALSO DOWNLOAD THE SLIDES IN THE HANDOUT PANE, ONCE AGAIN. LINK TO CLOSED CAPTIONING IS AVAILABLE IN THE CHAT BOX FOR THOSE OF YOU WHO WOULD LIKE CLOSED CAPTIONS. AND WITH THAT, I'D FIRST LIKE TO PROVIDE A BRIEF OVERVIEW OF THE HOST OF THE PRESENTATION, NBHN. NBHN IS ONE OF EIGHT CDC NATIONAL NETWORKS TO ELIMINATE CANCER AND TOBACCO DISPARITIES IN PRIORITY POPULATIONS. THROUGH NBHN, WE PROVIDE WEBINARS LIKE TODAY'S, COMMUNITIES OF PRACTICE, AND MANY OTHER VALUABLE RESOURCES AND INFORMATION, ALL FOCUSED ON ADDRESSING TOBACCO AND CANCER DISPARITIES IN INDIVIDUALS WITH MENTAL ILLNESS AND ADDICTIONS. FEEL FREE TO VISIT US AT BHTHECHANGE.ORG TO JOIN THE NETWORK FOR FREE AND GAIN FREE, DIRECT ACCESS TO HELPFUL RESOURCES AND INFORMATION. SO, HERE'S A QUICK OVERVIEW OF THE TOPICS THAT WE PLAN TO COVER IN THE HOUR THAT WE HAVE THIS AFTERNOON. WE'RE GOING TO SHARE A BRIEF OVERVIEW OF MOTIVATIONAL INTERVIEWING, OTHERWISE REFERRED TO AS MI, AND HOW IT IS EMPLOYED WITHIN TOBACCO CESSATION. WE WILL THEN WEAVE IN A CONVERSATION ABOUT HOW TRAUMA-INFORMED APPROACHES ARE IMPORTANT TO CONSIDER WHEN UTILIZING THIS MI APPROACH. FINALLY, FOR THE FINAL PORTION OF THE WEBINAR, WE WILL LOOK AT CASE EXAMPLES AND DRAW CONNECTIONS FROM TRAUMA-INFORMED MOTIVATIONAL INTERVIEWING TO STRENGTHEN OUR INTERVENTIONS AND APPROACHES TO TOBACCO CESSATION. SO, WITH THAT, I WILL NOW HAND IT OVER TO TASLIM, WHO WILL PROVIDE A BRIEF INTRODUCTION TO TODAY'S PRESENTATION ON THE NEXT SLIDE. >> WONDERFUL. THANK YOU SO MUCH, DANA, AND THANK YOU, EVERYONE, FOR JOINING US TODAY. WELCOME ON BEHALF OF THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH FOR TOBACCO AND CANCER CONTROL AND THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH. I'M EXCITED TODAY AND ABOUT TODAY'S WEBINAR AND HOW IT WILL BUILD UPON OUR LAST WEBINAR AND REALLY TALK THROUGH WAYS TO SUPPORT YOU IN OPERATIONALIZING TRAUMA INFORMED INTERVENTION. MANY OF YOU JOINED US IN THE FIRST WEBINAR IN JUNE AROUND CONNECTING THE DOTS: ADDICTION, TRAUMA AND TOBACCO USE. AND TODAY'S WEBINAR SERVES AS A PART TWO OF A SERIES OF LINKAGES BETWEEN TRAUMA AND TOBACCO. AND MOST IMPORTANTLY, HOW TO IMPLEMENT INTERVENTIONS THAT CAN SPEAK TO POTENTIALLY SOME ROOT CAUSE ISSUES. SO, AS A BRIEF REMINDER ON THE SLIDE HERE TODAY, THERE ARE SOME FACTS THAT WE CURRENTLY KNOW ABOUT THE LINKAGES BETWEEN TRAUMA AND TOBACCO, AND SOME WHICH WE TOUCHED ON IN THE PREVIOUS WEBINAR BUT FEEL ARE REALLY IMPORTANT TO RESTATE SO WE CAN FULLY UNDERSTAND THE IMPORTANCE AND TIMELINESS OF THE ISSUE. THESE STATISTICS AND MORE UNDERSCORE THE NEED FOR NOT JUST EARLY INTERVENTION, SUCH AS MOTIVATIONAL INTERVIEWING AND TRAUMA-INFORMED CARE WITH INDIVIDUALS WHO SMOKE, BUT ALSO OPERATIONALIZING THESE INTERVENTIONS AND INTEGRATING THEM AS MUCH AS POSSIBLE SO THAT WE CAPTURE A CRITICAL AND LARGE POPULATION. THOSE WHO HAVE EXPERIENCED TRAUMA AT SOME POINT IN THEIR LIVES. SO AGAIN, I ENCOURAGE YOU TO LISTEN TO PART ONE OF THIS WEBINAR SERIES TO UNDERSTAND MORE IN DEPTH THE LINKAGES BETWEEN TRAUMA AND TOBACCO, AND I REALLY LOOK FORWARD TO TODAY'S PRESENTATION AND OUR PRESENTERS REALLY ENGAGING US IN WAYS TO OPERATIONALIZE FURTHER ENHANCEMENTS AROUND THESE INTERVENTIONS. SO, WITHOUT FURTHER DELAY, I'LL TURN IT OVER TO OUR EXPERTS. PAM? >> HI, THANK YOU! THIS IS PAM PIETRUSZEWSKI. AND I'M GOING TO START US, ACTUALLY, WITH THE NEXT SLIDE THAT IS APTLY TITLED -- ARE YOU READY, GET SET, LET'S GO! WE OFTEN APPROACH PEOPLE MAKING HEALTH CHANGES WITHIN OUR OWN MIND-SET, AND IT'S A REMINDER THAT WE'VE GOT TO MEET PEOPLE WHERE THEY'RE AT BEFORE WE CAN PUSH THEM TO CHANGE. NOW, WHAT WE OFTEN DO IS UNDERESTIMATE SOMEONE'S READINESS OR WILLINGNESS. AND TRULY, THE DATA'S QUITE SIMILAR IF A PERSON HAS A MENTAL HEALTH CONDITION OR NOT. MOST PEOPLE DO WANT TO QUIT USING TOBACCO. NOW, WHERE AND WHEN THEY WANT TO QUIT OR MAKE CHANGES MIGHT VARY. SO AS YOU SEE HERE IN THIS STUDY, YOU KNOW, WITHIN THE NEXT MONTH, MAYBE IT'S ONLY 20%, 25% OF PEOPLE. IN A LONGER PERIOD, OH, MAYBE OVER THE NEXT SIX MONTHS, THAT NUMBER DOES JUMP UP. SO, TRULY, READINESS IS NOT NECESSARILY RELATED TO A DIAGNOSIS, SO WE NEED TO NOT JUST ASSUME OR GIVE UP ON PEOPLE BECAUSE WE THINK, OH, YOU KNOW, THAT'S THE LEAST OF THEIR ISSUES. OR GOSH, WHO AM I TO TELL THEM THEY NEED TO ALSO, YOU KNOW, GET HEALTHY IN THIS AREA? PEOPLE TEND TO WANT TO QUIT, AND WE HAVE TO RECOGNIZE WHERE AND HOW THEIR READINESS FITS THAT. SO, ON THE NEXT SLIDE IS ACTUALLY A DEPICTION OF THE STAGES OF CHANGE, WE CALL READINESS STAGES. AND I REALLY LIKE THIS VERSION BECAUSE IT REMINDS US THAT READINESS TO MAKE A CHANGE IS NOT LINEAR. YOU KNOW, ANYBODY LISTENING TO THIS WEBINAR THAT HAS MADE SOME KIND OF HEALTH CHANGE PROBABLY HAD, YOU KNOW, WHAT WE MIGHT CALL SETBACKS OR HAD REALLY GOOD DAYS WHERE THEY WERE ON A ROLL WITH MOVING TOWARD THAT CHANGE. AND SO, IF WE REALIZE THAT THE PERSON WE'RE WORKING WITH MAY NOT BE NECESSARILY IN AN ACTION STAGE, THEY MAY BE MORE REALISTICALLY IN A CONTEMPLATING STAGE, WE'VE GOT TO MEET THEM THERE, BUT NOT LEAVE THEM THERE. SO, MOTIVATIONAL INTERVIEWING, ON THE NEXT SLIDE, IS HELPING US GET PEOPLE MORE READY AND IDENTIFY WHERE THEY ARE WITH THAT. SO, MI IS A COLLABORATIVE CONVERSATION. IT'S NOT ABOUT MAKING SOMEONE CHANGE. IT'S NOT ABOUT CREATING MOTIVATION IN THE OTHER PERSON. IT'S ABOUT IDENTIFYING WHERE THAT PERSON'S OWN MOTIVATION AND READINESS AND ABILITY AND COMMITMENT TO CHANGE LIES. SO, LET'S MOVE TO THE NEXT SLIDE. YOU MAY BE FAMILIAR WITH THE FIVE As FOR TOBACCO CESSATION. IT'S BEEN AROUND FOR QUITE A WHILE. AND I WANTED TO ACKNOWLEDGE IT IN THE CONTEXT OF MI, WHERE IN MI, WE TALK ABOUT CORE PROCESSES. SO, THEY'RE PRETTY COMPATIBLE. THAT'S ALWAYS OBVIOUSLY SOME DIFFERENCES. WHAT I'LL TALK ABOUT TODAY IS WHAT WE'RE SEEKING TO DO IS ENGAGE WITH THIS PERSON, WHICH PROBABLY SITS A LOT WITH ASKING, RIGHT? KIND OF IDENTIFYING WHERE THEY'RE AT WITH THIS, THEIR WILLINGNESS, THEIR READINESS, THEIR INTEREST, THEIR UNDERSTANDING IN THE HEALTH BENEFITS OF QUITTING OR CUTTING BACK. THEN WE'RE GOING TO DO SOME FOCUSING, WHICH MIGHT INCLUDE ADVISING AND ASSESSING FROM THE FIVE As, RIGHT? SO, STARTING TO ZERO IN ON WHAT WOULD BE GOOD ABOUT CUTTING BACK FOR THEM, WHAT WORRIES THEM, WHAT ARE THE BARRIERS, AND THEN EVOKING THEIR IDEAS AND SUPPORTING THEM IN THINGS THEY FEEL ARE TANGIBLE IN MAKING CHANGES, AND THEN DOING SOME PLANNING. AND WE OFTEN JUMP TO THE PLANNING BECAUSE WE WANT TO BE HELPFUL AND WE WANT TO GET PEOPLE TREATMENT PLANS, WE WANT TO TELL THEM WAYS IN WHICH THEY COULD QUIT, BUT THE PLANNING PIECE, WHICH PROBABLY IS LIKE THE ASSIST OR ARRANGE IN THE FIVE As, REALLY HAS TO COME AFTER WE PROPERLY ENGAGE, FOCUS AND EVOKE THE OTHER PERSON'S OWN WILLINGNESS AND REASONS FOR CHANGE. SO, THE NEXT SLIDE IS IT'S REALLY IMPORTANT THAT NO MATTER WHAT WORDS YOU USE OR ANY OF THE SKILLS I'LL DESCRIBE WHEN IT COMES TO USING MOTIVATIONAL INTERVIEWING, IT HAS TO COME FROM A CONTEXT OF WHAT IS CALLED THE SPIRIT, MEANING WE HAVE TO MEET THE CLIENT IN A FRAMEWORK OF PARTNERSHIP. WE'VE GOT TO BE WILLING TO SAY, YOU KNOW, YOU ARE THE EXPERT IN YOUR OWN LIFE. I HAVE A LOT OF INFORMATION, I'M CONSIDERED AN EXPERT IN TOBACCO CESSATION. MAYBE I'M AN EXPERT IN CERTAIN MENTAL HEALTH DIAGNOSES. BUT I CAN'T POSSIBLY SAY THAT I'M AN EXPERT IN THAT OTHER PERSON. SO WE VALUE THEIR PARTNERSHIP AND THEIR RELATIONSHIP IN FIGURING OUT TOGETHER HOW TO BEST HELP THEM BE HEALTHY. WE'RE ALSO GOING TO DO A LOT OF EVOKING. THAT WAS ALSO IN THE FOUR STEPS OF MI. WE'RE GOING TO BE GATHERING INFORMATION. WE'RE GOING TO STAY CURIOUS AND COMPASSIONATE IN TRYING TO UNDERSTAND FROM THE OTHER PERSON'S VIEWPOINT WHAT THIS COULD LOOK LIKE, AND REALLY HONORING THEIR OWN AUTONOMY, THEIR ABILITY TO MAKE DECISIONS AND CHOICES AND TO TRY THINGS THAT MAY OR MAY NOT BE WHAT WE THINK WOULD BE BEST. AND IN DOING SO, YOU KNOW, WITH ALL OF THE RESEARCH ON MOTIVATION SHOWS IS THAT IT'S THESE PUNDITS OF THE SPIRIT THAT HELP PEOPLE FEEL EMPOWERED AND FEEL LIKE THEY CAN AND WANT TO MAKE FURTHER CHANGES. SO, THE NEXT SLIDE JUST SHOWS THAT IN A LITTLE BIT OF A DIFFERENT WAY, THAT AS YOU WORK WITH PEOPLE, IS YOUR VIEWPOINT THAT YOU'RE COMING INTO THAT RELATIONSHIP KNOWING OR BELIEVING THAT THERE IS A DEFICIT IN THAT OTHER PERSON AND THEY JUST SIMPLY LACKED INFORMATION ON WAYS TO QUIT SMOKING? IS IT THAT SOMETIMES WITH ALL THE BEST INTENTIONS, WE WANT TO FIX IT OR RESOLVE IT OR MAKE CHANGES FOR THAT OTHER PERSON? IF WE COME AT IT IN THAT MIND-SET, WE TEND TO DO A LOT MORE TELLING AND CORRECTING THAN WE DO LISTENING. SO, ON THAT SIDE OF THIS, IT'S A REMINDER TO KEEP IN OUR OWN MIND-SET AS MUCH AS WE KNOW THAT PEOPLE ARE SEEKING OUR HELP AND WANT SUPPORT, AND MAYBE DON'T HAVE ALL OF THE INFORMATION THEY NEED, WE SHOULD REALLY BE MINDFUL OF LISTENING AND ASKING MUCH MORE THAN FIXING AND TELLING. SO, I THINK A LOT ABOUT COMPASSIONATE CURIOSITY, RIGHT? SEEKING TO UNDERSTAND. TELL ME MORE WHAT IT'S BEEN LIKE FOR YOU. HOW HAVE YOU THOUGHT ABOUT APPROACHING IT? HOW DOES THIS IMPACT THE WAY IN WHICH WAY YOU'VE BEEN MANAGING YOUR DIAGNOSIS, QUESTIONS AND COMMENTS THAT DESIGNATE TO THE OTHER PERSON, I'M NOT HERE TO FIX YOU, I'M NOT HERE TO TELL YOU WHAT TO DO. I'M HERE TO SUPPORT AND BE A PARTNER WITH YOU IN ASKING AND IN BEING A GOOD LISTENER. THE NEXT SLIDE I'M GOING TO TURN TO SEE HOW THIS PLAYS A ROLE IN THINKING ABOUT BEING TRAUMA-INFORMED. >> I THINK WE'RE HAVING A LITTLE PROBLEM HEARING YOUR AUDIO. THANK YOU, EVERYONE, FOR YOUR PATIENCE. >> WHAT I COULD DO -- I KNOW WE WERE TRYING TO GET LIZA'S AUDIO READY TO GO. I THINK ONCE YOU'RE ON, INTERRUPT ME AND I'LL LET YOU CONTINUE WITH THE TRAUMA-RELATED SIDE. THE PARADIGM SHIFT IN THINKING ABOUT WORKING WITH FOLKS THAT MAY HAVE HAD TRAUMA IN THEIR LIFE IS TO THINK ABOUT THE WAY IN WHICH WE WORD OUR QUESTIONS IN THE FIRST PLACE, RIGHT? SO, WE OFTEN FIND WE MAY SAY THINGS LIKE, WELL, WHAT HAPPENED, RIGHT? WHICH IS INFORMATION-GATHERING BUT ISN'T NECESSARILY CONNECTING WITH A PERSON IN A WAY THAT IS ALSO CONSISTENT WITH THE MI SPIRIT. SO, QUESTIONS, WHAT'S WRONG WITH YOU, WHAT'S HAPPENED TO YOU, WOULD BE MUCH MORE EFFECTIVE IF WE ASKED THINGS LIKE, YOU KNOW, WHAT IS STRONG, RATHER THAN WHAT IS WRONG, OR WHAT HAPPENED TO YOU IS BETTER THAN WHAT HAPPENED WITH YOU? SO WE WANT TO DEFINE THIS IN A WAY THAT ISN'T SHAMING OR WITHOUT COMING DOWN ON THE OTHER PERSON LIKE THEY ARE TO BLAME -- >> REALLY QUICKLY -- CAN YOU HEAR ME? >> HEY, GREAT. YOU'RE ON. >> HEY. SORRY ABOUT THAT. >> NO PROBLEM. >> YEAH, SO, WHAT I WAS SAYING -- SORRY ABOUT BEING DISCONNECTED EARLIER. IT WAS EXACTLY, PAM, WHAT YOU WERE JUST TALKING ABOUT, IS AS YOU'RE TALKING ABOUT THAT LENS, THE WAY THAT WE'RE VIEWING THE WORLD, AS TASLIM KIND OF TALKED ABOUT IN YOUR LAST WEBINAR ON TRAUMA. IF WE RECOGNIZE THAT EVERYONE PRIOR TO EVEN ENTERING OUR DOOR HAS BEEN THROUGH SO MUCH, RIGHT, AND THAT WE START, REGARDLESS OF OUR INTERVENTION, REGARDLESS OF OUR CONVERSATION, WITH THIS FRAMEWORK OF WHAT'S HAPPENED TO YOU AND WHAT'S STRONG ABOUT YOU, WHAT'S GOTTEN YOU HERE TODAY? THOSE ARE GOING TO BE THE SPRINGBOARDS TO HELPING PEOPLE THEN TAP INTO THOSE MOTIVATIONAL INTERVIEWING SKILLS KIND OF GOING FORWARD. SO, WHEN WE -- ON OUR NEXT SLIDE, WE REALLY TALK ABOUT HERE, THE PURPOSE OF HUMAN LIFE IS TO SERVE AND TO SHOW COMPASSION AND THE WILL TO HELP OTHERS. SO, WHEN WE'RE LOOKING AT THE WORLD THROUGH THAT TRAUMA-INFORMED LENS, WE WANT TO REALLY BRING THAT COMPASSION SIDE TO EVERYTHING THAT WE'RE DOING. AND YOU KNOW, AS WE SEE NEXT, IT'S ALSO ABOUT THAT UNIVERSAL EXPECTATION. WE WANT TO START FROM THE EXPECTATION THAT EVERYONE, REGARDLESS OF WHAT THEY'VE REPORTED TO US, REGARDLESS OF WHAT WE KNOW ABOUT SOMEBODY ON AN INDIVIDUAL LEVEL, THAT ANY HUMAN THAT WE'RE COMING INTO CONTACT WITH, WE EXPECT HAS ALREADY BEEN TRAUMATIZED IN SOME WAY. AND SO, PRIOR TO INTERACTING, WE MOVE BACK TO THAT PERSPECTIVE OF WHAT'S HAPPENED TO YOU AND PUT IN A FRAMEWORK OF TRAUMA-INFORMED CARE. THE OTHER PIECE ABOUT THAT IS CULTURAL HUMILITY AND REALLY THE IMPORTANCE OF, AS PAM WAS TALKING ABOUT EARLIER -- AND THIS IS WHY, YOU KNOW, MOTIVATIONAL INTERVIEWING IS REALLY A TRAUMA-INFORMED INTERVENTION -- IS WE START FROM THE PERSPECTIVE OF HELP ME UNDERSTAND YOU AND HELP ME UNDERSTAND YOUR WORLD, YOUR EXPERIENCE, NOT WHAT I THINK IT SHOULD BE OR WHAT MY EXPERIENCE HAS BEEN. SO, WHEN WE COMBINE THAT UNIVERSAL EXPECTATION WITH A LEVEL OF CULTURAL HUMILITY, THEN EVERYTHING THAT WE DO GOING FORWARD WILL HELP IMPACT SOMEONE IN A REALLY POSITIVE WAY. AND REALLY, THE REASON WHY WE ALL STARTED DOING THIS WORK TO BEGIN WITH WAS TO BE HERE TO HELP. AND SO, WE STRUGGLE TO BELIEVE, WHEN WE UNDERSTAND THE IMPACT OF TRAUMA AND THE CONNECTION BETWEEN TRAUMA AND TOBACCO USE, THAT TAKING THESE TWO FRAMEWORKS AND REALLY THEN PUTTING IN THAT MOTIVATIONAL SPIRIT PROCESS REALLY WILL GET US TO A GREAT PLACE ON THE OTHER SIDE. AND SO, I WANT TO TURN IT BACK TO PAM TO JUST TALK ABOUT SOME OF THOSE SPECIFIC SKILLS. >> GREAT, THANKS. SO, IN MOTIVATIONAL INTERVIEWING, WHAT WE CONSIDER THE STRATEGIES OR THE SKILLS ARE CALLED THE ORs. SO IT'S OPEN-ENDED QUESTIONS, WHICH YOU SAW IN THE TRAUMA SLIDES, YOU KNOW, WHAT IS STRONG ABOUT YOU? WHAT HAPPENED TO YOU. THEY'RE OPEN-ENDED QUESTIONS THAT ARE SEEKING TO GET MORE THAN A YES, NO OR BRIEF ANSWER. IT'S SEEKING TO UNDERSTAND THE OTHER PERSON'S PERSPECTIVE. AND THEN AFFIRMATIONS AND REFLECTIONS. AND I'LL BREAK THESE DOWN JUST A LITTLE BIT WITH THE PRECEDING SLIDE. SO, SOME EXAMPLES OF OPEN-ENDED INQUIRY. GO TO THE NEXT SLIDE, PLEASE. SO, INSTEAD OF ASKING A QUESTION LIKE, CAN YOU CUT BACK ON YOUR SMOKING? WE'RE NOT REALLY GETTING THAT MUCH USEFUL INFORMATION OUT OF A CAN YOU, CAN'T YOU TYPE OF QUESTION. WE'RE GOING TO GET, YEAH, YEAH, OR I DON'T KNOW. IT'S REALLY HARD. YEAH, MAYBE. A QUESTION LIKE, WHAT DO YOU LIKE AND DISLIKE ABOUT SMOKING HELPS US BETTER UNDERSTAND THEIR PERSPECTIVE. AND I KNOW IT CAN SOUND REALLY WEIRD TO ASK SOMEBODY WHAT THEY LIKE ABOUT OR WHAT DO THEY ENJOY ABOUT A BEHAVIOR OR SOMETHING WE'RE TRYING TO ACTUALLY REDUCE, BUT IT'S ALREADY PRESENT WITHIN THEM, SO LET'S FIRST UNDERSTAND THAT, RIGHT? SO, WHAT DO YOU LIKE ABOUT IT? WE'RE GOING TO FIND OUT, YOU KNOW, IT HELPS ME RELAX OR, YOU KNOW, I GREW UP AROUND CIGAR SMOKING, AND SO YOU KNOW, EVEN WHEN I HAVE A CIGARETTE, IT REMINDS ME OF MY GRANDPA, OR YOU KNOW, I THINK IT HELPS WITH MY ANXIETY. WHATEVER THEY SAY, IT'S IMPORTANT TO VALIDATE HEARING THEM. THEN OBVIOUSLY, WE DO WANT TO ASK THE FLIP SIDE, WHICH IS WHAT DO YOU DISLIKE ABOUT IT, BECAUSE THEN WE START TO UNDERSTAND THEIR POTENTIAL REASONS FOR MAKING A CHANGE. THE SECOND ONE -- DO YOU KNOW ABOUT OUR TOBACCO GROUP? YOU KNOW, IT'S GREAT TO KNOW IF THEY KNOW OR DON'T KNOW ABOUT IT, BUT MORE IMPORTANTLY, TO ASK A QUESTION LIKE WHAT DO YOU KNOW ABOUT OUR GROUP? BECAUSE IF THEY KNOW ABOUT IT IS ONE THING, BUT IF WHAT THEY TELL YOU THEY KNOW ABOUT IT IS, WELL, I HEARD IT'S ON TUESDAYS AND I DON'T HAVE TRANSPORTATION TO GET THERE. NOW WE HAVE SOME INSIGHT INTO ONE OF THE BARRIERS FOR THEM TO ATTEND. OR THEY MAY SAY, WELL, I DON'T KNOW MUCH ABOUT IT, BUT YOU KNOW, I REALLY DON'T KNOW IF I WANT TO BE AROUND OTHER PEOPLE WHEN I HAVE TO TALK ABOUT THIS. AGAIN, MORE USEFUL INSIGHT. THE THIRD QUESTION HERE -- WHY HAVEN'T YOU BEEN ABLE TO QUIT? IS NOT A BAD QUESTION, PER SE. WE JUST HAVE TO BE CAUTIOUS ABOUT HOW A "WHY" QUESTION MAY COME ACROSS. IT CAN CAUSE SOME DEFENSIVENESS WITH PEOPLE IF IT FEELS VERY HEAVY-HANDED. IF WE ARE SEEKING TO UNDERSTAND, YOU KNOW, IT'S NOT A BAD QUESTION. BUT THE ALTERNATIVE THERE -- HOW HAVE YOU APPROACHED QUITTING IN THE PAST -- MAY BE MORE USEFUL, BECAUSE THEN WE CAN HEAR FROM THEM WAYS IN WHICH THEY'VE TRIED, WHAT DIDN'T WORK, WHAT THEY ARE INTERESTED IN TRYING. AND IT'S, AGAIN, GATHERING MORE INSIGHT AND REALLY, REALLY HELPING FACILITATE THE OTHER PERSON'S OWN THINKING ABOUT THEIR OWN MOTIVATIONS. THE NEXT SLIDE IS REALLY WHAT WE'RE TRYING TO GET AT WITH THIS IS THE REALIZATION THAT AMBIVALENCE TO CHANGE IS REALLY NORMAL. IT'S REALLY NORMAL, RIGHT? SO, THERE'S CHANGE TALKS, WHICH IS THINGS LIKE, WELL, I WANT TO QUIT, OR I'VE THOUGHT ABOUT MAKING A CHANGE. EVEN THE WORD MAYBE IS NOT REAL STRONG CHANGE TALK, BUT IT'S LEANING IN THE DIRECTION OF CHANGE. AND WE HAVE TO HONOR THAT THERE MAY BE A FLIP SIDE OF THAT AMBIVALENCE, WHICH IS CALLED SUSTAINED TALK, WHICH IS, I WON'T BE ABLE TO DO IT, IT'S TOO HARD, I CAN'T. WE TEND TO HEAR THAT SIDE OF THE ARGUMENT MUCH MORE. IT'S JUST HUMAN NATURE TO WANT TO, AGAIN, FIX AND RECOGNIZE THOSE THINGS AND TRY AND GET THAT PERSON TO CHANGE. BUT REALLY HONORING BOTH SIDES HELPS LOOSEN THE DEFENSIVENESS AND ACKNOWLEDGE THAT CHANGE ISN'T EASY AND THERE ARE OFTEN REASONS PEOPLE WANT TO MAKE CHANGES AND THERE ARE PLENTY OF REASONS WHY IT'S A SCARY PROPOSITION. SO, THE NEXT SLIDE IS ANOTHER PRACTICAL TOOL. IF YOU KNOW ANYTHING ABOUT MI, YOU'VE PROBABLY SEEN THIS ONE. IT'S CALLED A READINESS RULER. AND YOU CAN MIX THE QUESTIONS UP BY MAYBE ASKING NOT JUST HOW READY ARE YOU, BUT YOU MIGHT ASK HOW IMPORTANT IS IT FOR YOU TO QUIT USING TOBACCO, OR HOW CONFIDENT ARE YOU THAT YOU CAN MAKE SOME CHANGES. AND AGAIN, IF YOU THINK OF MI AS THE OPPORTUNITY TO FACILITATE THE OTHER PERSON'S THINKING, THIS ISN'T JUST ABOUT GIVING THEM A PLAN AND SAYING, "I HOPE YOU CAN DO IT," OR "I THINK THIS WOULD BE GOOD FOR YOU." IT'S ASKING THEM, HOW IMPORTANT IS IT? MAYBE IT'S REALLY IMPORTANT TO THEM, BUT THEY DON'T FEEL VERY CONFIDENT OR MAYBE THEY FEEL LIKE YEAH, THEY CAN QUIT ANY TIME, BUT IT'S NOT IMPORTANT TO THEM. REALLY, MAKING CHANGES TAKES CONFIDENCE AND IMPORTANCE, AND SO, THESE ARE WAYS TO KIND OF ASSESS FOR THAT. AND MOST IMPORTANTLY, WHATEVER NUMBER THEY SAY THEY ARE -- I'M A REAL BIG STICKLER ON THIS -- IT DOESN'T MATTER IN THE SENSE THAT THERE'S NO DEFINED SUCCESS IF THEY SAY THEY'RE AN EIGHT, NINE, OR TEN, RIGHT? WHATEVER NUMBER THEY GIVE YOU, LET'S HONOR THAT. THAT GOES BACK TO THE WHAT'S STRONG VERSUS WHAT'S WRONG. IF I SAY I'M A FOUR, AND I SAY, YOU KNOW, THAT'S TOUGH. WE'VE GOT TO GET IT UP TO AN EIGHT. YOU'VE NOW HELPED ME IDENTIFY WHAT IS WRONG, AND THAT DOESN'T FEEL GOOD, RIGHT? IF YOU SAY IT'S A FOUR, WOW, THAT'S GREAT. WHY IS IT A FOUR AND NOT A ONE OR A TWO, I AM ACTUALLY NOW FEELING STRONGER ABOUT THAT, BECAUSE I'M GOING TO WANT TO DEFEND THAT FOUR. I'M GOING TO SAY, WELL, IT'S AT LEAST A FOUR BECAUSE, YOU KNOW, YOU'VE BEEN TELLING ME ABOUT THIS FOR A LONG TIME AND, YOU KNOW, WHEN I DID QUIT, I WAS FEELING A LITTLE BETTER. THEY NOW HAVE THEIR OWN REASONS. SO, USING THAT NUMBER IN A WHAT'S STRONG MANNER INSTEAD OF WHAT'S WRONG IS ANOTHER WAY OF ALIGNING IT WITH TRAUMA AND CORE PRINCIPLES. THE NEXT SLIDE IS TALKING A LITTLE MORE ABOUT WHAT AFFIRMATIONS AND REFLECTIONS ARE. THEY'RE JUST STATEMENTS THAT IDENTIFY A PERSON'S CHARACTER OR, AGAIN, STRENGTHS. THEY REINFORCE THAT WE'RE PAYING ATTENTION, THAT WE'RE REALLY LISTENING TO THEIR WORDS AND WHAT THEY ARE SAYING. AND SOME EXAMPLES ON THE NEXT SLIDE -- THIS MIGHT BE WHAT A PERSON SAYS. I'VE BEEN COMING HERE FOR SIX MONTHS, EVER SINCE I GOT OUT OF THE HOSPITAL. AND I'VE BEEN WORKING REALLY HARD TO TAKE MY MEDS AND SHOW UP FOR THERAPY. I DON'T NEED YOU TAKING AWAY THE ONE THING THAT HELPS ME, MY CIGARETTES. SO, WE WANT TO BE CAUTIOUS NOT TO JUMP ALL OVER THIS AND SAY, YEAH, BUT WE TALKED ABOUT THIS, AND YOU WERE GOING TO CUT BACK, OR, YEAH, I KNOW, BUT. WE WANT TO ACTUALLY HEAR THEM OUT AND REFLECT WHAT WE'RE HEARING. SO, IT MIGHT BE A REFLECTION OF, SEEMS AS THOUGH THE CIGARETTES HELP WITH THE SYMPTOMS. WHETHER WE AGREE OR NOT DOESN'T MATTER RIGHT NOW. THAT'S HOW THEY'RE FEELING. AND TO HEAR THAT HELPS US BETTER UNDERSTAND WHERE THEY'RE COMING FROM. WE COULD REFLECT, YOU KNOW, YOU DON'T WANT TO BE IN THE HOSPITAL AGAIN. WELL, THIS PERSON DIDN'T SAY THOSE EXACT WORDS, BUT THAT'S CALLED AN AMPLIFIED REFLECTION, WHERE WE ARE ACTUALLY ADDING A LITTLE BIT MORE TO OUR UNDERSTANDING. AND IF WE'VE GOT IT WRONG, THEY CAN CORRECT US. IT'S PROBABLY SAFE TO SAY THEY DON'T WANT TO BE IN THE HOSPITAL AGAIN. ANOTHER REFLECTION HERE IS, YOU'VE BEEN COMMITTED TO YOUR TREATMENT PLAN. SO, AGAIN, I DON'T EXACTLY KNOW THAT, BUT I CAN KIND OF INFER FROM WHAT I'M READING BECAUSE THEY'VE SAID, I'VE WORKED REALLY HARD TO TAKE MY MEDS AND SHOW UP FOR THERAPY, SO I WANT TO HONOR THE WHAT'S STRONG PART OF THAT. AND NOW I'M BUILDING AN ALIGNMENT AND I'M BUILDING THEIR STRENGTH OF HAVING SOME AMOUNT OF COMMITMENT ABOUT WANTING SYMPTOM RELIEF AND ABOUT WANTING TO AVOID THE HOSPITAL, WHICH HELPS US, HOPEFULLY, MOVE FORWARD WITH OTHER CHANGES. LET ME TURN TO THE NEXT SLIDE SO WE CAN BUILD ON THIS AGAIN IN A TRAUMA-INFORMED WAY. >> THANKS, PAM. SO, YES, IF YOU WERE THINKING -- IF YOU WERE GIVING THAT EXAMPLE, REALLY, WHAT I WAS THINKING ABOUT AS WE PUT IN THIS TRAUMA-INFORMED OVERVIEW AND REALLY LENS AND CULTURE, SOME OF THOSE THINGS WE WANT TO KEEP IN MIND, BECAUSE IT'S NOT JUST ABOUT CIGARETTES, BUT AS INDICATED IN THE PREVIOUS EXAMPLE, THE PERSON'S JUST GOTTEN OUT OF THE HOSPITAL, SO HE'S BEEN STRUGGLING WITH SOME THINGS. SO, WHAT DO WE NEED TO RECOGNIZE OR KEEP IN MIND? THE FIRST THING IS THAT SURVIVAL MODE AND HOW ALL OF OUR INFORMATION THAT WE'RE RECEIVING OF ANY KIND REALLY COMES THROUGH THE LOWER PART OF OUR BRAIN, RIGHT, AND GOES THROUGH THAT FILTER OF FIGHT, FLIGHT OR FREEZE, BEFORE WE CAN GET TO A LOGICAL CONVERSATION ABOUT IT. SO, IF SOMEONE HAS A SIGNIFICANT TRAUMA BACKGROUND, OR LIKE IN THIS LAST EXAMPLE, THEY MIGHT NOT HAVE HAD A BACKGROUND, BUT THEY ARE ABSOLUTELY COMING OUT OF A VERY HIGHLY EMOTIONAL STATE, IF THEY WERE JUST IN THE HOSPITAL, YOU KNOW, AND SOMETHING HAS TRIGGERED, THERE ARE THINGS THAT ARE ELEVATED AND GOING ON FOR THEM BEYOND JUST KIND OF NORMAL OPERATING, SO WHERE ARE THEY IN THAT FIGHT, FLIGHT, OR FREEZE RESPONSE? AND WHEN WE START TO TALK TO THEM ABOUT THE CIGARETTES, AND SAY YOU START TO SEE A RESPONSE OF, HEY, I'VE BEEN WORKING REALLY HARD HERE, DON'T GO AFTER MY CIGARETTES RIGHT NOW, THAT THEY MIGHT BE IN THAT MORE PRIMAL SURVIVAL MODE. AND SO, RECOGNIZING THAT AND SUPPORTING THEM HELP TO REGULATE THAT RESPONSE IS GOING TO BE REALLY IMPORTANT. THE OTHER THING WE WANT TO CONSIDER AND REALLY LOOK AT, AND THE NEXT SLIDE REALLY TALKS ABOUT THE ACEs STUDY, UNDERSTANDING THE IMPACT OF THE CHILDHOOD ADVERSITIES AND CHILDHOOD EXPERIENCES ON HOW WE'RE FUNCTIONING TODAY, AND NOT THAT IT DICTATES OUR RESPONSE BUT ABSOLUTELY AS PROVIDERS CAN HELP US BETTER UNDERSTAND WHY SOMEONE MIGHT GO INTO THAT FIGHT, FLIGHT, OR FREEZE SPACE BASED OFF OF THESE TRIGGERS. IN THE NEXT SLIDE, IT GIVES YOU JUST KIND OF THAT OVERVIEW OF THE ACEs STUDY. IT WAS 17,000 ADULTS IN THE '90s AND THE REPORT OF ALL OF THOSE DIFFERENT ADVERSE CHILDHOOD EXPERIENCES REALLY BEING LINKED TO THESE LONG-TERM HEALTH OUTCOMES, AND WE DEFINITELY KNOW THAT ONE OF THOSE LINKS IS TO AN INCREASED TOBACCO USE. THE OTHER THING ABOUT ACEs IS -- ON THE NEXT SLIDE IS THIS TRIANGLE THAT YOU REALLY WANT TO UNDERSTAND THE IMPACT OF HOW THINGS START TO BUILD UPON EACH OTHER. SO WHEN WE START THAT FOUNDATION OF REALLY THAT HISTORICAL, GENERATIONAL TRAUMA, OVERLAID BY ADVERSE CHILDHOOD EXPERIENCES AND DISRUPTIVE DEVELOPMENT, AND THEN WE LOOK AT THE NEGATIVE IMPACTS THAT THAT HAS, UNFORTUNATELY, ON REALLY IMPAIRING OUR SOCIAL, EMOTIONAL, AND COGNITIVE ABILITIES AT TIMES, MOVING INTO THOSE UNHEALTHY OR HIGH-RISK BEHAVIORS -- AND THAT'S WHERE WE CAN SEE THAT TOBACCO USE COMING IN. AND SO, UNDERSTANDING KIND OF ALL THAT'S BELOW IT FOR THAT PERSON IN TERMS OF THEIR EXPERIENCES. AND SO, WHEN WE'RE SITTING IN THE ROOM WITH SOMEONE, STARTING TO OVERLAY, YOU KNOW, ALL OF THESE DIFFERENT AREAS SO THAT WE CAN HAVE A REALLY BROAD UNDERSTANDING OF A PERSON IN FRONT OF US IN THE ROOM. THE NEXT SLIDE, AS YOU CAN SEE, AT THE TOP OF OUR LIST REALLY HERE IS THAT ALCOHOL, TOBACCO, AND OTHER DRUG ADDICTIONS. IN ADDITION TO -- AS YOU CAN SEE, THEY'RE IN ALPHABETICAL ORDER, BUT THE ADDITION OF ALL OF THESE OTHER THINGS, THAT WHEN SOMEONE HAS THAT HIGHER LEVEL OF -- THE HIGHER NUMBER ON ACEs, ARE MORE MULTIPLE, NEGATIVE, ADVERSE EXPERIENCES WITHOUT BEING ABLE TO BALANCE THAT WITH RESILIENCIES AND PROTECTIVE FACTORS, WE COULD ABSOLUTELY START TO SEE THESE LINKS IN LONG-TERM BEHAVIORAL HEALTH OUTCOMES. THE OTHER THING WE WANT TO KEEP IN MIND IS THIS PROCESS OF TRAUMA AND THIS PROCESS OF HOW WHEN SOMETHING OCCURS, HOW WE MANAGE IT ON THAT, REALLY, AUTOMATIC FIGHT, FLIGHT OR FREEZE LEVEL, RIGHT? SO, FIRST THING THAT HAPPENS WHEN WE HIT A TRIGGERING EVENT AND UNDERSTANDING THAT THAT TRIGGERING EVENT CAN BE DIFFERENT FOR DIFFERENT PEOPLE, IS THAT WE EXPERIENCE SOMETHING AND OUR BODY AUTOMATICALLY GOES INTO THE SYMPATHETIC FIGHT, FLIGHT, OR FREEZE SPACE. AND IN A HEALTHY DISCHARGE OF THAT REACTION, WE CALM DOWN, WE'RE ABLE TO REFOCUS, WE DON'T FEEL THAT OUR LIVES ARE IN IMMEDIATE LIFE-OR-DEATH THREAT, AND WE MOVE INTO OUR SYMPATHETIC NERVOUS SYSTEM, BACK TO THAT REST AND DIGEST STATE. BUT ON THE NEXT SLIDE, YOU CAN REALLY SEE WHERE SOMEONE HAS BEEN THROUGH EXTENSIVE ADVERSE EXPERIENCES, YOU KNOW -- FOR THE LAST EXAMPLE PAM WAS TALKING ABOUT, SOMEONE HAD JUST COME OUT OF THE HOSPITAL. IF THEY'VE HAD MULTIPLE HOSPITALIZATIONS, THE PERSON REFERS TO BEING IN TREATMENT FOR AN EXTENDED PERIOD OF TIME AND REALLY BEING ABLE TO RELY ON THIS, ON THE SMOKING, TO HELP MITIGATE THEIR OTHER RESPONSES, YOU MIGHT REALLY BE SITTING WITH SOMEONE WHO HAS THIS REALLY OVERREACTIVE NERVOUS SYSTEM. SO, INSTEAD OF FOLLOWING THAT RED LINE OF A HEALTHY DISCHARGE OF TRAUMA OR THE TRIGGER, YOU SEE THAT PERSON STUCK IN ON. SO, WHAT THEY MIGHT BE REPORTING TO YOU IS THAT THE SMOKING, DON'T TAKE THIS AWAY FROM ME RIGHT NOW, I CAN'T HANDLE ONE MORE THING -- THEY MIGHT BE REPORTING THAT NERVOUS SYSTEM FOR THEM REALLY STUCK IN ON. AND SO, THEN, WHEN WE START TO STEP IN TO JUST REMOVE THE TOBACCO, YOU KNOW, AND NOT USING OUR MOTIVATIONAL INTERVIEWING SKILLS LIKE PAM WAS TALKING ABOUT, START TO DIG DEEPER AND REALLY UNDERSTAND WHY IT'S IMPORTANT TO THEM. WE START, YOU KNOW, IF WE JUST STEP IN WHERE YOU JUST HAVE TO STOP SMOKING, WE WOULD SEE THAT TRIGGERING MORE OF A VERY REACTIVE, MAYBE AGGRESSIVE, OR DEFIANT KIND OF POSITION, BECAUSE WE'RE NOT HEARING WHERE THEY ARE AND HOW THEY'RE DOING THE BEST THEY CAN TO COPE WITH WHAT THEY HAVE IN THE MOMENT, AND THIS IS A TOOL FOR THEM THAT IN THE MOMENT IS A POSITIVE ONE. WE HAVE TO REMEMBER ON THE NEXT SLIDE THAT WHEN WE'RE IN THAT STRESS PLACE, WE'RE NOT REALLY ABLE TO RESPOND, LEARN, OR PROCESS. AND SO, WHAT I REALLY LIKE ABOUT THE MOTIVATIONAL INTERVIEWING TECHNIQUES, AS PAM'S REALLY HELPING WALK US THROUGH THEM, IS FROM A TRAUMA-INFORMED PERSPECTIVE, IT ADDRESSES THIS PIECE SO THAT WE DON'T GET STUCK IN A NONPRODUCTIVE CONVERSATION AND A POWER STRUGGLE, BUT WE REALLY CAN TAKE THAT CULTURALLY HUMBLE PLACE AND THAT STEP BACK OF HELP WE UNDERSTAND WHY THIS IS IMPORTANT TO YOU AND WHERE WE CAN HELP AND BE SUPPORTIVE IN YOUR IDENTIFIED CHANGE PROCESS. IN THE NEXT STEP OF FIVE, MOVE FROM THAT INDIVIDUAL TO REALLY UNDERSTANDING KIND OF THE BIGGER TRAUMA-INFORMED LENS. SO, THIS IS A NICE SLIDE THAT I LIKE BECAUSE IT GIVES US REALLY A REMINDER OF ALL OF THOSE DIFFERENT PLACES THAT TRAUMA CAN IMPACT US ON A PHYSICAL LEVEL. AND SO, WHEN WE'RE STARTING TO LOOK AT THAT CONNECTION WITH TOBACCO, YOU KNOW, WHERE IS THE INTERPLAY HERE OF IMPACTING A PERSON IN THE SAME WAY. THE NEXT SLIDE REFERS TO KIND OF THAT TRAUMA-INFORMED LENS IN INTERVENTION. ALL OF OUR INFORMATION IS GOING THROUGH THAT PRIMARY PART OF OUR BRAIN, SO IF SOMEONE IS STUCK IN ON, IF SOMEONE IS STUCK AT THAT REACTIVITY PLACE, THE FIRST THING WE NEED TO DO IS UNDERSTAND THAT MIND-BODY CONNECTION AND HELP THEM REGULATE TO A PLACE WHERE THEY CAN HAVE A DIFFERENT LEVELS CONVERSATION. AND SO, THIS IS JUST A SLIDE TO GIVE US SOME REMINDERS OF SOME OF THE THINGS WE CAN CREATE, EITHER IN OUR ENVIRONMENT OR IN OUR SESSION TO HELP PEOPLE REGULATE EMOTIONALLY AND NOT KIND OF GET STUCK IN THAT AUTOMATIC STRESS RESPONSE AS THEIR ONLY RESPONSE. THE NEXT SLIDE TALKS TO US HERE REALLY ABOUT REMEMBERING FROM A TRAUMA-INFORMED PERSPECTIVE THAT 50% OF OUR INTERVENTION AND OUR REACTION AND OUR WORK IS AROUND THE WAY THAT WE'RE INTERACTING WITH OUR CLIENTS. THE OTHER 50% IS MAKING SURE THAT AS CAREGIVERS, WE'RE BEING TRAUMA-RESPONSIVE. WE CAN'T DO THAT UNLESS WE'RE TAKING CARE OF OURSELVES AS WELL. TO BE TRIGGERED AND TO BE STUCK IN ON AND TO HAVE YOUR SYMPATHETIC NERVOUS SYSTEM THAT FIGHT, FLIGHT, OR FREEZE, GET TRIGGERED IS A HUGE RESPONSE. AND THE WORK THAT WE'RE DOING IN TERMS OF BEING AND HOLDING SPACE FOR PEOPLE WHO ARE REALLY IN AN EMOTIONALLY DIFFICULT PLACE TO REALLY START TO WEAR ON US AS CAREGIVERS AS WELL, EVEN IF WE DON'T HAVE A PREDISPOSITION OR A TRAUMA HISTORY IN OURSELVES, WHERE WORK ITSELF CAN BE EXHAUSTING AND CAN BE TRIGGERING, AND WE NEED TO LOOK AT COMPASSION FATIGUE AND SECONDARY TRAUMA. YOU KNOW, THERE'S A STATEMENT HERE FROM DR. FRANKEL OF WHAT IS TO GIVE LIGHT MUST ENDURE BURNING -- WE GIVE OF OURSELVES EVERY DAY. AND SO, TO STAY IN THAT MOTIVATIONAL INTERVIEWING PLACE, IN THE SPIRIT OF MOTIVATIONAL INTERVIEWING AND TO BE ABLE TO BE GENUINE AND PRESENT, WE HAVE TO MAKE SURE THAT WE'RE TAKING CARE OF OURSELVES AS WELL. AND HOW DO WE DO THAT? SO, WHAT I REALLY LIKE ABOUT THIS SLIDE IS GOING TO ALL OF -- REMINDING US OF ALL OF THOSE DIFFERENT COMPONENTS OF RESILIENCIES. AND THIS IS OUR WAY OUT. THIS IS HOW WE MOVE FROM THAT TRIGGERING PLACE OR THAT FIGHT, FLIGHT, OR FREEZE SPACE, AND WHAT CAN KIND OF HELP US TRANSITION OVER. AND SO, THE MORE RESILIENCIES AND PROTECTIVE FACTORS THAT WE HAVE AND THE MORE THAT WE UNDERSTAND THESE DIFFERENT AREAS FOR OUR CLIENTS, THESE ARE THE STRENGTHS THAT PAM WAS TALKING ABOUT THAT WE CAN START TO PULL ON IN ORDER TO BE ABLE TO HELP OUR CLIENTS TAKE WHATEVER ISSUE THEY'RE BRINGING TO US, IN THIS CASE, THAT SLIPPING SENSATION, TO THE NEXT LEVEL. AND THEN MY LAST SLIDE HERE REALLY JUST REMINDS US OF THAT CULTURE PIECE. SO, FROM A TRAUMA-INFORMED PERSPECTIVE, WHAT CULTURE ARE WE IDENTIFYING, WHAT ARE WE PUTTING INTO PLACE, AND HOW ARE WE RECOGNIZING THE CULTURE OUR CLIENTS ARE BRINGING US TO FROM A CULTURALLY HUMBLE PERSPECTIVE AND OVERLAYING THOSE TWO VIEWS AND THOSE TWO WORLDS TO REALLY START TO MAKE A PRODUCTIVE ENVIRONMENT FOR OURSELVES AND FOR OUR CLIENTS. SO, WHAT I'D LIKE TO DO IS SWITCH BACK TO PAM. AND PAM, IF YOU CAN WALK US THROUGH KIND OF THESE SKILLS AND THEN WHAT WE'D LIKE TO DO IS WE HAVE TWO EXAMPLES THAT WE WANTED TO KIND OF WALK THROUGH WITH EVERYBODY AND GET YOUR FEEDBACK ON HOW YOU WOULD TAKE THIS TRAUMA-INFORMED LENS AND OVERLAY IT WITH THE MOTIVATIONAL INTERVIEWING SKILLS TO RESPOND TO THE EXAMPLES THAT WE HAVE. PAM? >> GREAT, THANKS. SO, THIS SLIDE IS BRINGING BACK THOSE PARTICULAR SKILLS USED IN MOTIVATIONAL INTERVIEWING AND I'M OVERLAYING IT NOW WITH SOME THINGS TO CONSIDER WHEN WE'RE WORKING WITH SOMEONE WITH A DUEL DIAGNOSIS. SO, SOME STRATEGIES TO THINK ABOUT. WHEN IT COMES TO ASKING GOOD QUESTIONS, WE DON'T WANT THOSE QUESTIONS TO BE TOO COMPOUNDED OR TOO COMPLICATED. YOU KNOW, THE QUESTION WITHIN A QUESTION WITHIN A QUESTION. WE WANT TO ASK SOMETHING SIMPLE, LIKE, WHAT IS MOST IMPORTANT TO YOU? WHICH MIGHT FEEL LIKE A QUESTION THAT IS WAY OFF BASE, BUT IT OFTEN IS A WAY OF BRINGING US BACK TO WHAT IS THE REALITY FOR THIS PERSON, WHAT IS IT THAT THEY VALUE MOST. SPECIFICALLY TO TOBACCO, THERE COULD BE A GOOD OPEN-ENDED QUESTION AROUND, IF YOU DECIDED TO QUIT -- AND NOTICE ACTUALLY HONORING THEIR AUTONOMY -- IF YOU DECIDED TO QUIT, HOW WOULD YOU DO IT? AGAIN, VERY SIMPLE, JUST ASKING THEM TO OUTLINE WHAT THEY COULD DO IF THEY WERE TO DO IT. WE'RE JUST LOOKING TO OPEN UP THE POSSIBILITIES WITHIN THAT OTHER PERSON. SOME THINGS TO THINK ABOUT WHEN IT COMES TO PROVIDING AFFIRMATIONS. THESE CAN BE REALLY IMPORTANT AND USEFUL BECAUSE SOMEONE MAY BE EXPERIENCING A LOT OF STIGMA, A LOT OF SELF-DEFEATING FEELING OF, YOU KNOW, BEING DEFINED BY THEIR MENTAL HEALTH DIAGNOSIS OR BEING TOLD THAT THEY ARE NOT WORTH ANYTHING OR WHATEVER OTHER MESSAGES THEY MAYBE HAVE HAD IN THEIR LIVES, SO TO REALLY BE ABLE TO GIVE AN HONEST AFFIRMATION CAN GO A LONG WAY. SO, THE EXAMPLE HERE -- YOU'RE NOT SOMEONE WHO GIVES UP EASILY. IF I HAD NOTICED THAT IN THE OTHER PERSON, I'VE NOTICED IT IN WAYS OF PERSISTENCE, RESILIENCE. MAYBE SOME PEOPLE WILL INTERPRET IT AS THE PERSON'S A VERY DEMANDING PERSON. BUT IF WE CAN TURN THAT IN A WAY THAT DEMONSTRATES THAT AS A POSITIVE, THEY ARE GOING TO WANT TO PROBABLY MEET THAT. SO SAY, YOU'RE NOT SOMEONE WHO GIVES UP EASILY. THEY MAY RESPOND TO THAT AND SAY, YEAH, BECAUSE YOU KNOW, THIS IS IMPORTANT TO ME, OR I DON'T REALLY UNDERSTAND WHY, OR WHATEVER IT IS, WE'RE TRYING TO HELP ADD TO THAT RESILIENCE. AND THEN REFLECTION, WHICH AFFIRMATIONS ARE REFLECTIONS, BUT IN OTHER WAYS WITH REFLECTIONS. YOU KNOW, IT'S NOT THAT WE HAVE TO GIVE SOME KIND OF LONG, COMPLICATED ANALYSIS, BUT WE WANT SIMPLE ACKNOWLEDGEMENT OF THINGS WE'RE HEARING OR THINGS WE'RE NOTICING. SOME OF YOU MAY WORK WITH PEOPLE THAT ARE REALLY QUIET, THAT AREN'T GOING TO SAY A WHOLE LOT. WE CAN ALSO REFLECT WHAT WE SEE, WHICH COULD BE SOMETHING LIKE, YOU'RE NOT SURE YOU WANT TO BE HERE TODAY. MAYBE I'M JUST THINKING I'M PICKING THAT UP FROM THEIR BODY LANGUAGE, BUT I'M GIVING THEM A WAY TO HOPEFULLY SPEAK MORE TO THAT AND HONORING THAT'S WHAT I'M NOTICING, AND GIVE PEOPLE SOME PAUSE TIME. IT'S OKAY TO NOT JUST RATTLE OFF, YOU KNOW, FIVE DIFFERENT REFLECTIONS OR QUESTIONS, BUT TO PAUSE, GIVE THEM SOME PROCESSING TIME. SO, THE EXAMPLE HERE IS, QUITTING SMOKING IS NOT SOMETHING YOU WANT TO DO RIGHT NOW, AND YET, YOU'VE THOUGHT ABOUT WHETHER IT'S ACTUALLY MAKING THINGS WORSE. THAT REFLECTION IS A SIGN OF HONORING AMBIVALENCE. SO IT'S CALLED A DOUBLE-SIDED REFLECTION, WHERE WE'RE ACKNOWLEDGING THAT THERE'S TWO SIDES TO THIS, RIGHT? THEY DON'T WANT TO QUIT. THAT'S WHAT THEY'VE TOLD US. THAT'S WHAT WE'VE KNOWN IN WORKING WITH THEM. NAME IT. LET'S PUT THAT OUT THERE AND SAY, I HEAR YOU. YOU DON'T KNOW IF YOU WANT TO DO THIS RIGHT NOW. IF WE CAN ALSO BALANCE IT WITH THE OTHER SIDE OF THAT, ASSUMING THEY ARE ALSO HAVING SOME DOUBTS ABOUT CONTINUING TO DO IT OR THEY'VE SAID IN THE PAST THAT THEY WISH THEY COULD QUIT, LET'S NAME THAT, TOO, WHICH IS, YOU KNOW, AND YET, YOU'RE THINKING ABOUT IT, OR KIND OF THINKING THIS MIGHT BE MAKING THINGS WORSE. WE'RE TRYING, AGAIN, TO GIVE THEM A REFLECTION OF WHAT WE'RE HEARING OR NOTICING IN A WAY THAT ALLOWS THEM TO RESPOND TO THAT, TO NOT FEEL CORNERED INTO MAKING ANY PARTICULAR DECISION TO PLEASE US, BECAUSE THIS ISN'T ABOUT US, IT'S ABOUT THEM, AND GETTING BEHIND THEIR OWN MOTIVATION FOR CHANGE, OKAY? SO, WHAT WE WANT TO DO IS WE'VE GOT OPEN-ENDED QUESTIONS, AFFIRMATIONS AND REFLECTIONS. WE WANT TO PUT OUT THIS EXAMPLE. AND LET ME READ IT FIRST. SO, THE PERSON YOU'RE WORKING WITH SAYS, I'M TAKING THE MEDS, BUT I DON'T LIKE THEM. THEY MAKE ME GROGGY AND NUMB AND I THINK SMOKING PERKS ME UP. IT HELPS ME GET THROUGH THE DAY. I KNOW YOU WANT ME TO QUIT, AND I DON'T WANT LUNG CANCER, BUT IT'S PROBABLY TOO LATE ANYWAY. SO, WHAT WE WANT TO DO IS I'M GOING TO GIVE SOME POTENTIAL MI RESPONSES, QUESTIONS. LIZA'S GOING TO SPEAK A LITTLE BIT TO HOW WE MIGHT MAINTAIN THAT TRAUMA-INFORMED LENS. AND WHILE WE'RE DOING THAT, WE WANT TO HEAR FROM YOU. IF YOU WANT TO TYPE IN THE CHAT BOX, HOW WOULD YOU APPROACH THIS? WHAT ARE SOME MI-CONSISTENT THINGS YOU MIGHT SAY, BECAUSE THERE'S NO ONE WAY TO COME AT THIS, RIGHT? KNOW ALL ABOUT THIS PERSON AND WE ALL HAVE DIFFERENT STYLES, AND THAT'S ANOTHER NICE THING ABOUT MI, THERE'S A LOT OF WAYS YOU CAN APPROACH IT. BUT KEEPING IN MIND WHAT WE'VE BEEN TALKING ABOUT SO FAR. ONE OF THE THINGS I WOULD DO WITH THIS IS I WOULD HONOR WHATEVER STRENGTHS OR HOPEFULNESS I'M GAUGING FROM THIS PERSON, WHICH IS THEY DON'T WANT LUNG CANCER. OR I MAY NOT START WITH THAT, BECAUSE IF I DON'T KNOW THEM WELL, I HAVE TO SPEND SOME TIME ENGAGING WITH THEM. THAT'S THE FIRST STEP OF MI. SO, I MIGHT START WITH ACKNOWLEDGING, I'M NOT SURE IF YOU LIKE THE WAY THOSE MEDS ARE MAKING ME FEEL. AND YOU'RE REALLY THINKING ABOUT, IF YOU WERE TO QUIT, IT WOULD REALLY RELIEVE SOME WORRIES ABOUT GETTING LUNG CANCER, OKAY? SO, THAT'S ONE WAY WE COULD APPROACH IT IS HONORING THE CONCERN AND NOT IGNORING THE FACT THAT THEY DID GIVE US SOME CHANGE TALK, WHICH IS, I DON'T WANT LUNG CANCER. SO, WE CAN'T JUMP ON EITHER ONE OF THOSE TOO MUCH BECAUSE THEN WE'VE NOW SUDDENLY BEEN DIRECTING THEM DOWN THE READINESS PATH WE DON'T KNOW IF THEY'RE READY FOR. SO, THAT'S ONE REACTION I HAVE. LIZA, WHAT DO YOU SEE WHEN YOU LOOK AT THIS? THEN WE'LL TAKE SOME PARTICIPANT COMMENTS. >> YEAH, THANKS, PAM. YOU KNOW, THE THING THAT -- THE TWO THINGS THAT STAND OUT TO ME ARE THE SECOND LINE, WHERE THEY SAY THEY DON'T LIKE THE MEDS BECAUSE THEY MAKE THEM GROGGY AND NUMB, THEY FIND A POSITIVE PEACE WITH THE SMOKING. AND THEN THEY SAY, "I KNOW YOU WANT ME TO QUIT." SO, FROM A TRAUMA-INFORMED PERSPECTIVE, I WOULD GO TO A CLIENT'S VOICE AND CHOICE AND REALLY LOOKING AT, YOU KNOW, THEY'RE TAKING SOMETHING THAT DOESN'T FEEL GOOD TO THEM, BUT THEY'RE STILL TAKING IT, YOU KNOW, BUT THEY ALSO ARE SAYING AND PROJECTING THAT IT'S MY GOAL FOR THEM TO QUIT AS OPPOSED TO SOMETHING THEY WANT TO DO. AND SO, THAT WOULD SPEAK TO ME ABOUT THE POTENTIAL THAT THEY'VE HAD OTHER SITUATIONS WHERE THEY FEEL LIKE THEY DON'T HAVE A CHOICE IN WHAT'S HAPPENING TO THEIR BODY, THAT THEY DON'T HAVE A CHOICE IN HOW THEY CAN MANAGE THINGS, AND THAT IT'S MORE IMPOSED UPON THEM. SO, I WOULD LOOK TOWARDS THOSE TWO AREAS AND MAKING SURE, LIKE PAM WAS TALKING ABOUT, FROM AN MI PERSPECTIVE AND WITH THOSE SKILLS, THAT WE'RE TAPPING INTO, BUT WHAT DO YOU WANT AND REALLY GIVING THE PERSON, OUR CLIENT, THE POWER OF THEIR OWN VOICE IN MAKING THEIR OWN DECISIONS. >> DANA, WHAT ARE WE SEEING IN THE CHAT BOX? >> YEAH, WE'VE GOTTEN A FEW RESPONSES. I CAN READ THEM OFF QUICKLY. SOME FOLKS HAVE SAID RESPONSES SUCH AS YOU CAN IMPROVE QUALITY OF YOUR LIFE -- YOU CAN IMPROVE THE QUALITY OF THE LIFE YOU HAVE LEFT, YOU ARE TAKING YOUR MEDICATION, IT SHOWS YOU'RE DEDICATED TO YOUR HEALTH. YEAH, YOUR HEALTH IS VALUED. IT SOUNDS LIKE YOU WANT SOMETHING TO HELP WITH THE FEELINGS OF BEING GROGGY AND NUMB. I HEARD YOU SAY THE MEDS ARE MAKING YOU FEEL THIS WAY. I WOULD START AND GIVE A POSITIVE RESPONSE IF THEY STARTED THE MEDS, WORK ON RELATIONSHIP-BUILDING, UNDERSTANDING THEM, SAY SOMETHING LIKE, YOUR MEDICATION HAS NEGATIVE EFFECTS, AND AT THE SAME TIME, YOU ARE WILLING TO LISTEN TO THE BENEFITS BECAUSE YOU CARE ABOUT YOUR HEALTH. I'M SEEING AN OVERALL THEME OF THE VALUING YOUR OWN HEALTH AND YOUR OWN WELL-BEING. >> THIS IS GREAT. THIS IS PAM. I HEARD LOTS OF AFFIRMATIONS IN THOSE EXAMPLES, RIGHT? IT SHOWS YOU'RE REALLY DEDICATED. YOU HAVEN'T TAKEN THOSE MEDS, EVEN THOUGH YOU DON'T LIKE THE WAY THEY MAKE YOU FEEL. YOU COULD BUILD OFF OF THAT POTENTIALLY, RIGHT? TELL ME A BIT MORE ABOUT, YOU KNOW, THE WAY IN WHICH YOU'RE FEELING AND HOW IT SEEMS LIKE SMOKING IS ACTUALLY HELPING WITH THAT. BECAUSE THAT'S A PIECE WE'VE GOT TO UNDERSTAND, RIGHT? WE CAN SIT THERE AND TELL THEM, YOU SHOULDN'T BE DOING THIS, SMOKING ACTUALLY ISN'T GOOD, BUT THEIR REALITY IS, IT'S COUNTERACTING THE NUMBNESS THAT I DON'T WANT TO FEEL. AND SO, TO BARREL PAST THAT AND NOT HONOR THAT EXPERIENCE IS FLYING IN THE FACE OF ALL OF IT, SO I'M HEARING A LOT OF THAT, RIGHT? SHOWS YOU'RE DEDICATED. "I HEARD YOU SAY" IS A REALLY NICE REFLECTION. IT'S NOT, "I INTERPRETED THIS AS," OR, "WELL, BUT WHAT I THINK IS" -- THAT'S NOT PARTNERSHIP. PARTNERSHIP IS, SOUNDS LIKE YOU WANT THIS, OR I'M HEARING YOU SAY THAT. AND ANOTHER IMPORTANT THING OF THINKING ABOUT THIS IS, THIS CASE EXAMPLE ALSO VERY MUCH DEPENDS ON ARE WE MEETING THIS PERSON FOR THE FIRST TIME? HAVE WE BEEN WORKING WITH THEM FOR A WHILE? THE ENGAGEMENT AND RELATION-BUILDING IS IMPORTANT. NOW, IT DOESN'T MEAN WE ALL HAVE THE LUXURY OF MEETING WITH PEOPLE FOR MULTIPLE TIMES, BUT IF THEY'RE ON DEFENSE AND THEY'RE NOT SURE WHAT TO MAKE OF US, WE DO HAVE TO BE THOUGHTFUL ABOUT HOW WE STAND WITH THIS PERSON METAPHORICALLY, AND AT THE SAME TIME, WE WANT TO OFFER SOME GUIDANCE WITH THEIR OWN MOTIVATION TOWARD A CHANGE. SO, THOSE ARE ALL REALLY NICE EXAMPLES IN MY MIND OF STARTING TO JUST MEET THEM WHERE THEY'RE AT, BUILD THAT ENGAGEMENT AND FOCUSING, WHICH IS STEP TWO, AROUND WHAT THE ISSUE IS. LIZA, ANY OTHER THOUGHTS ON THAT ONE OR SHOULD WE GO TO THE SECOND? >> LET'S GO TO THE SECOND ONE. >> I'LL READ THIS ONE. THIS PERSON SAYS, "I'VE TRIED TREATMENT AND IT DOESN'T HELP. WHEREVER I SEE A PSYCHIATRIST, I END UP IN A MENTAL HOSPITAL. I HAVEN'T SEEN A DOCTOR IN A LONG TIME. I KNOW MY HEALTH IS BAD, SO I DON'T NEED A LECTURE ABOUT CIGARETTES RIGHT NOW." OKAY, SO, I SAID THAT ONE WITH A LOT OF EXCLAMATION POINTS JUST TO AMP UP THE POTENTIAL AROUSAL CONTINUUM, IF YOU WILL. SO, WITH THIS ONE, WE'VE GOT SOME POTENTIALLY REAL STRONG BELIEFS, RIGHT? NOTHING IS HELPING. YOU KNOW, IF I EVEN BOTHER TO GET HELP, THIS IS WHAT COMES FROM IT. I DON'T NEED A LECTURE. THIS PERSON'S IN A PLACE WHERE WE DON'T NECESSARILY NEED TO JUST GIVE THEM A LIST OF WAYS TO QUIT SMOKING. THAT'S NOT WHERE THEY'RE READINESS IS, RIGHT? THEY'RE PROBABLY IN A PRECONTEMPLATION STATE. MAYBE THERE'S A LITTLE BIT OF CONTEMPLATION WE CAN DRAW OUT, BUT OUR JOB IS NOT TO JUST GET THEM TO TAKE ACTION. I'M GETTING A LITTLE BIT OF FEEDBACK THERE. SO, LIZA, DO YOU WANT TO COMMENT ON TRAUMA-INFORMED LENS? >> YEAH. SO, WHAT THIS FRAMES UP FOR ME IS SAFETY AND TRUST AND TRANSPARENCY. WE CAN'T GET TO ANY CONVERSATION REALLY ABOUT THE CIGARETTES, BECAUSE THAT IS SO FURTHER AWAY. AND PAM, AS YOU SAID, RIGHT, WHERE ARE THEY IN THAT RESPONSE PLACE? IT SOUNDS VERY -- THE RESPONSE SEEMS TO BE VERY MUCH IN A FIGHT, FLIGHT, OR FREEZE SPACE. THEY SET THE STAGE FOR, I'VE COME TO TREATMENT BEFORE, I HAVE NOT FELT HEARD, I HAVEN'T FELT RESPECTED, THAT'S WHY I DON'T COME BACK. I KNOW THAT MY HEALTH HAS SUFFERED, BUT YOU'RE KIND OF -- WE HAVE AN OPPORTUNITY HERE. WE'RE LUCKY THAT THEY'RE HERE IN THIS MOMENT. AND SO, I THINK WHEN WE STEP IN WITH THIS INFORMATION IN ANY DIRECTION OTHER THAN RELATIONSHIP-BUILDING, YOU KNOW, HELPING SOMEONE REGULATE OF THANK YOU FOR COMING IN, AND I'M NOT SEEING ANYTHING, IF YOU'RE NOT OBVIOUSLY BEING GENUINE AND HONEST, IT WOULD STRIKE ME TO SEND YOU TO A MENTAL HOSPITAL RIGHT NOW. IT JUST SOUNDS LIKE THEY'RE IN THAT FIGHT, FLIGHT, OR FREEZE, AND THEY'RE WAITING FOR US TO RESPOND IN A WAY THAT THEY'VE UNFORTUNATELY KNOWN BEFORE THAT TRIGGERS THEM. SO, MOST LIKELY WHAT WE'VE SEEN IS SOMEONE HAS STEPPED IN WITH AN EXPECTATION WITH AN ABSOLUTE, WITH A POWER STRUGGLE, AND THIS PERSON REACTED BECAUSE OF HOW WE AS PROVIDERS WERE INTERVENING WITH THEM AND ENDED UP IN THE HOSPITAL, AS OPPOSED TO US SAYING, WOW, YOU KNOW, YOU'VE BEEN THROUGH A LOT, HELP ME UNDERSTAND WHAT GOT YOU HERE, WHAT HAPPENED TO BRING YOU IN TO ME TODAY, AND WHAT IS THE OPPORTUNITY WE HAVE TO ENGAGE IN A DIFFERENT WAY THAT REALLY HONORS SAFETY AND TRUST AND TRANSPARENCY AND JUST SITTING THERE BEFORE WE GET TO ANY TREATMENT GOALS, BECAUSE THIS CLIENT DOESN'T APPEAR TO HAVE HAD A SAFE OR TRUSTING RELATIONSHIP YET WITH ANY MENTAL HEALTH PROVIDER. >> WHAT KINDS OF RESPONSES HAVE WE GOTTEN FROM THE CHAT BOX? AND THEN LET'S MOVE TO SOME QUESTIONS AND COMMENTS. >> YEAH, ABSOLUTELY. SO, SOME EXAMPLES THAT HAVE BEEN GIVEN. YOU'RE TIRED OF MEDICAL TREATMENT THAT DOESN'T HELP YOU GET TO WHERE YOU WANT TO BE IN LIFE. YOU FEEL FRUSTRATED BY THE KIND OF HELP YOU'VE BEEN GETTING AND YOU WANT SOMETHING DIFFERENT. WHAT DO YOU NEED FROM ME TO HELP PUT YOU IN THE RIGHT DIRECTION? YOU'RE PERSISTENT AND YOU KNOW YOURSELF. WHAT CAN I DO TO HELP YOU? I WOULD LIKE TO HEAR MORE ABOUT YOUR EXPERIENCES AND HOW I CAN HELP YOU NOW WITH WHAT YOU WOULD LIKE TO TALK ABOUT AND WORK ON. THOSE ARE A FEW EXAMPLES THAT WE'RE GETTING. WE'RE GETTING PLENTY HERE. >> LET ME JUST COMMENT THAT THOSE ARE AWESOME, AND WHAT I REALLY LIKE ABOUT THEM IS THEY'RE STILL FORWARD-MOVING, RIGHT? WE HAVE TO BE CAREFUL WHERE WE DON'T WANT TO GET STUCK ALSO IN THE, THIS IS HARD, I CAN'T, I SHOULDN'T, BUT WE ALSO HAVE TO GO THERE TO SOME DEGREE, AND THEN THE STATEMENTS THAT WERE GIVEN WERE THINGS LIKE WHERE YOU WANT TO GO NEXT OR WHAT WOULD HELP YOU NOW, HONORING THAT THIS PERSON IS ALSO THINKING ABOUT WHAT THEY WANT AND COULD AND SHOULD DO MOVING FORWARD. >> ABSOLUTELY. OKAY, SO, I THINK WE -- >> ONLY HAVE A FEW MORE MINUTES. >> YEAH, WE ONLY HAVE A COUPLE MINUTES, FOLKS. IF WE GO A MINUTE OR TWO OVER, JUST SO EVERYBODY KNOWS, FOR THOSE WHO HAVE TO LEAVE, WE'LL BE RECORDING -- WE ARE RECORDING THIS ENTIRE WEBINAR, SO THAT WILL BE AVAILABLE FOR YOU TO VIEW ANYTHING THAT YOU MIGHT MISS AT THE END HERE. BUT WE'LL QUICKLY GO INTO A FEW QUESTIONS, ORDER OF WHEN I RECEIVED THEM. IS QUITTING ASSOCIATED WITH LOSS MAYBE OF SOCIAL RELATIONSHIPS, INTERACTION THAT CAN OCCUR DURING A SMOKE BREAK? >> YEAH, YOU KNOW, I THINK CHANGE OF ANY KIND HAS SOME LOSS TO IT, RIGHT? SO, WHAT IS IT WHEN IT COMES TO TOBACCO USE FOR THIS PERSON THAT WOULD BE A LOSS, YOU KNOW? IF YOU ALL TELL ME I'VE GOT TO EAT HEALTHIER, I'M THINKING ABOUT THE THINGS I CAN'T EAT ANYMORE OR I'M GOING TO BE TOLD NOT TO EAT ANYMORE. SO, ABSOLUTELY THERE'S A LOSS INVOLVED HERE. WE'VE GOT TO HONOR THAT AND FIGURE OUT WHAT THAT MEANS FOR THAT PERSON. >> WE GOT ANOTHER QUESTION ABOUT THE DISCHARGE OF TRAUMA GRAPH AND SOMEONE WAS ASKING FOR CLARIFICATION, IF THE TRAUMATIC -- IS THE RED LINE ON THE DISCHARGE OF TRAUMA A HEALTHY DISCHARGE? >> YES. YEAH, THE RED LINE FOCUSES ON THAT HEALTHY DISCHARGE OF PRIOR TO, BUT THE BLACK LINE IN THAT SLIDE WHERE THE PERSON WHO STAYED STUCK ON AND ISN'T ABLE TO DISCHARGE, WE SEE THAT MORE ERRATIC OR OVERACTIVE NERVOUS SYSTEM PLAYING OUT. >> ANOTHER QUESTION WE GOT HERE -- WHAT IS A GOOD INDICATOR FOR KNOWING WHEN YOU SHOULD BACK OFF ON TRYING TO MOVE THE CONVERSATION FORWARD? A GREAT QUESTION. >> A GREAT QUESTION. THIS IS PAM. I WOULD SAY WE REALLY WANT TO BE MINDFUL OF WHAT IS IT LOOKING LIKE? AND WE USED TO CALL IT RESISTANCE. BUT IT'S REALLY LOOKING FOR DISCREPANCIES IN HOW WE SEEM TO BE VIEWING THE ISSUE, OR THERE MAY BE THAT, YOU KNOW, THE PERSON'S BODY LANGUAGE IS CHANGING, THEY'RE USING MUCH MORE SUSTAINED TALK BECAUSE THEY NEED THE NEED TO DEFEND AND BEING REALLY MINDFUL OF THAT, AND THAT IS WHEN WE BACK OFF. AND WE MAY SAY VERY TRANSPARENTLY, YOU KNOW, I THINK I MAY HAVE BEEN PUSHING A LITTLE TOO HARD, TELL ME MORE OF WHAT YOU THINK. >> GREAT! THANK YOU SO MUCH. SO, IF THERE ARE ANY ADDITIONAL QUESTIONS, THIS IS OUR CONTACT INFORMATION FOR OUR WONDERFUL PRESENTERS TODAY. THANK YOU SO MUCH, PAM AND LIZA. THAT'S ALL THE TIME WE HAVE TODAY FOR QUESTIONS. WE'RE SO APPRECIATIVE OF YOUR WILLINGNESS TO SHARE YOUR EXPERTISE WITH US AND FOR ALL OF YOU FOR JOINING TODAY. AS A QUICK REMINDER, IF YOU LOOK UNDER THE HANDOUT PANE OF YOUR WEBINAR PLATFORM, YOU SHOULD SEE AN AREA WHERE YOU CAN DOWNLOAD THE SLIDES FROM TODAY. WE'LL ADDITIONALLY BE POSTING THEM ON OUR WEBSITE, WHICH I WILL PULL UP HERE ONE MORE TIME, BHTHECHANGE.ORG. WE'LL HAVE THE SLIDE HANDOUTS AND THE RECORDING AVAILABLE WITHIN A WEEK OR LESS. FINALLY, WHEN YOU EXIT THE WEBINAR, A BRIEF SURVEY WILL POP UP. WE WOULD REALLY APPRECIATE YOU TAKING A FEW MINUTES TO FILL IT OUT. IT WILL GIVE US AN OPPORTUNITY TO LEARN HOW YOUR EXPERIENCE WAS TODAY AND HOW WE CAN FURTHER IMPROVE OUR CONTENT. FINALLY, ONE QUICK PLUG. OUR CONFERENCE, THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH NETCON '20 REGISTRATION IS NOW OPEN. IT'S TAKING PLACE IN AUSTIN, TEXAS. EARLY BIRD RATES ARE AVAILABLE. WE'RE ALSO ACCEPTING CALL FOR PAPERS UNTIL OCTOBER 4th. YOU CAN VISIT WWW.THENATIONALCOUNCIL.ORG, CLICKING THE EVENTS TAB AND THEN NETCON20. ONCE AGAIN, THANKS SO MUCH TO OUR PRESENTERS AND THANK YOU TO EVERYONE. HAVE A GREAT REST OF YOUR DAY.