[Natalie Lonstein]

• What are your general reactions to Stephanie’s personal narrative?
o I really liked Stephanie’s personal narrative. It is a great example of the work promoted throughout this training, and instead of coming at treatment from a deficit, psychopathology based lens, she advocates for strengths-based and recovery-oriented approaches to care. She strongly shows that individuals with mental illness are not meant to ‘pushed away’ (ie forced on medical leave, experts making decisions for., etc.) but that they are intelligent, insightful, and unparalleled tools for supporting others in reaching their versions of success.

• What are your thoughts on the difference between the medical model, pathology-based approach and a person-driven, recovery-oriented approach to helping as embodied by a peer recovery support approach that Stephanie describes in her story?
o For me, what comes to mind first is how positive, optimistic, and hopeful I feel when considered this work from the lens of person-driven, recovery-oriented approach to care. The medical model approach to care is so focused on symptoms – duration, frequency, intensity, etc. –and how “bad” something is, and then how to fix quickly, versus long-term, sustainable solutions. This has me thinking about the world of managed care, specifically in how in our services we submit requests through Kepro for ongoing care or referrals for therapy supports. Though we may practice from a recovery-oriented lens, lifting up youth and families’ strengths, assets, etc. we need to request units for services by discussing how a youth is “on their worst day”.

• What are some strategies you have or would use to link consumers to peer recovery support services in your community and develop collaborative relationships with peer specialists?
o Within out programs we have Family Support Specialists, who are parents with lived experience raising a child with mental health diagnoses and have navigated mental health symptoms on their behalf. What we find in our services if that when we have parents that are extremely overwhelmed with their children’s needs, have limited social supports of their own, or identify feelings of loneliness (among other reasons), we really try to encourage a referral to our Family Support Specialist. The role of the Family Support Specialist is so different than a Care Coordinator. They get to dig deep with parents, to then slow down and breakdown their goals – FSSs come alongside families and work at their pace, and work to intentionally share their story when it something resonates with them, and they believe it would positively impact the parents. We work to seek out any other peer supports that we can and try to access the Youth Peer Support Statewide Network.

• Take a moment to reflect on the course material over the past four weeks and the new insights you have gained about wellness and recovery promotion. How do you envision bringing these new insights into your work with consumers?
o I feel really positively about how much this coursework has confirmed the approaches to care that we use in our services. In using a Wraparound approach as the foundation to our work, we are really leaning into the recovery-oriented model care; we hone in on strengths, assets, hopes, and dreams, that we hear from our clients, and support them in harnessing the things they have to address their needs and move toward their goals. The mindset of wellness and recovery promotion holds such optimism at the forefront that it is a great reminder of why I came into this field. It has reinvigorated me to keep thinking deeply about my approach to this work with youth, families, and other staff.

[Natalie Lonstein]

1) What are your general reactions to this exercise of identifying wellness goals and taking action to achieve them?

I really liked this exercise. It shed some light on my priorities and what is currently getting in the way of reaching my goals. It got me thinking deeply about potential barriers, and the importance of working through these realities because if they are not explored and planned for, they will prevent me from reaching my goals. I especially enjoyed thinking about the concrete action steps that could help me in reaching these goals. It has me considering that if I commit to taking these steps, which are attainable, I would actually be on track (or closer) to meeting my goals. I also really appreciate that the first few domains don’t typically fall into the categories we automatically think of when we consider wellness, but are still really vital pieces.

2) What did you discover about how your strengths, supporters, and or community resources might help you overcome barriers to taking an action step or reaching your goal?

This exercise helped me to consider what resources (strengths, supports, etc) I already have that can be harnessed to meet the goals I have outlined. With the living situation goal, the action steps I have outlined are easily attainable with commitment and conversation with my husband. When I consider some of my strengths to be vulnerability and help-seeking, both of these come into play in recognizing and being open to discussion about barriers, and then being willing to ask for help in working through the action steps to meet my goals. There is a lot of problem-solving work here, and matching strengths to needs.

3) What are some strategies you would employ to help consumers develop and implement their own wellness/recovery plans?

Keeping in mind that a strong focus on barriers, or things not going well, can bring down a hopeful discussion around goals and plans, I think that exploration of barriers is really important. Goals can’t be attained if there are large barriers in the way. I think very clear, open, and honest discussion around barriers that arise for consumers, and then planning for these barriers is necessary to successful recovery and wellness planning. I think that it also empowers consumers and increases confidence in meeting their wellness goals. In other words, if we have discussed all the potential barriers or issues that could arise, and have plans A-G for how to overcome them, we have a really well thought out plan for meeting these goals! I think prioritization is important because a long list is very overwhelming. I also think continued and regular exploration and reflected back to the consumer of their strengths, and how to connect this to the resources and supports that already exist for them, is an exercise in sustainability for the long run.

[Natalie Lonstein]

1. What are your general reactions to this exercise of identifying strengths and reflecting on how a strength can help you achieve a recovery or wellness goal?

I found this exercise more validating around the support that I have received from the family and from my husband. It made me realize how thankful I am for my relationship and how important it has been for me to lean into this support over the last several years. I think sometimes we are fearful of or resistant to asking for help and instead would rather try to do things on our own; what I realized through this exercise was that I actually would not be where I am today without my husband’s support. Knowing how supportive he has been in the past is evidence for his continued support of me in the future – meaning more help in reaching my wellness goals.

2. What did you discover about your own strengths that might have been previously hidden from view?

I think this helped me to discover that my vulnerability, openness, and help-seeking qualities, are strengths that I have that were hidden from view. I have generally seen myself as a vulnerable person, and willing to be open and honest about my experiences, but I think the authentic nature in which I approached conversations with my husband in the beginning of our relationship are a testament to these strengths. Though I can be stubborn and independent, I also realized that I am generally help-seeking, and not afraid to ask for the support that I believe I need.

3. How would you or have you used a strengths assessment to help consumers identify their strengths and uncover their hopes and dreams?

I found this section of the course very interesting and to really resonate with me and the work that I do with youth. In my programs, we approach our work utilizing a Wraparound perspective, which is a model of care focused on keeping complex and at risk youth in their home communities. Some key components of the model of Wraparound include performing a Strengths, Needs, and Cultural Discovery Assessment, very similar to what was identified here. Instead of an intake assessment inquiring about a client’s past and history, a Strengths, Needs, and Cultural Discovery is an informal conversation with a family to gather information about their family culture, interests, leisure activities, and thoughts about the future etc., in order to highlight key strengths we hear from their stories, and match these to the needs we hear in the narrative. We want to explore what resources they currently have and how these can be harnessed to support them moving forward. Another major piece of Wraparound is having the family identify their Vision, or what we will support them in working towards; we ask them “Life will be better when……” which helps us get them to explore their hopes and dreams.

[Natalie Lonstein]

1. What are your general reactions to the mindful writing? What were some of the personal resources, skills, and abilities you relied on to help you through a difficult experience in your life?

I actually really enjoyed this mindful writing. I typically I don’t enjoy writing and have never been a person who can start and stick with a journal. My professional life is pretty stressful at the moment and so this is what naturally came to the forefront for me to write about. I enjoyed being able to reflect on some challenges of the past and now being on the other side, have been experiencing some feelings of validation and strength, knowing that I stuck through something that was very challenging and difficult. I allowed myself to write my thoughts, unabridged, and take me down some different paths. I felt like this mindful writing is definitely a different experience than trying to articulate these thoughts out loud. Some of the resources, skills, and abilities I relied on were patience, persistence, and staying open-minded and willing to learn. I think there is an element of ‘surrender’ as well, or maybe more trust in the process, that things will turn out ok. I want to say that knowledge and information also helped, but truly it was time and experience, and being vulnerable and optimistic around these factors to let this unfold.

2. What are some of the ways the questions and or the mindful writing helped you uncover your narrative of resilience?

I think the framing of the question, specifically, “a time you got through”, poses a different ask then just, experienced a difficult time. The question encourages one to think about their journey through some difficult and how they came to be on the other side of something you may have felt was not possible in the beginning. These questions are also really strengths-based, and ask us to think about the factors and qualities we possess, and really name how they serve us. I also don’t normally think of myself as a patient person – in my personal life I am, maybe because I save all my patience for my work. But having patience to navigate a difficult situation is really challenging when the easy road may be to do the opposite, avoid, etc. I do value the importance of patience and was surprised that doing this writing pulled out my belief that having patience is important to me and served me through this tough time.

3. How might you apply the Narrative questions and or mindful writing in your work with others to help them uncover a neglected story of resilience in their lives?

I think these strengths-based questions are ones I can infuse in my work, not only with clients but with staff navigating difficult situations or circumstances with their clients/families, peers, or personal lives if relevant. These questions take the perspective of assuming people have experienced difficulties, and they are here! They made it through! So how can we reflect on and harness what saw them through in the past, and reemploy those resources, skills, etc. now.

[Natalie Lonstein]

My name is Natalie Lonstein. I am an LCPC and have worked in an outpatient setting in the past. I am currently the Director of Youth Services at The Opportunity Alliance overseeing the Children’s Behavioral Health Home, High-Fidelity Wraparound, and Homeless Youth Services programs. I interested in learning more about ROSC and how I can support this more in our work with youth and families.

[Natalie Lonstein]

Question 1:

I thought this provider did a pretty good job using MI skills to support his client. I feel like exploring the good things about smoking in the initial video increased her buy in and she felt validated. By asking about the good things she experiences, it also named for the client that she gets something positive out of the experience instead of focusing heavily on things she needs to change. I believe that he used some good reflections, summarized things well, and naturally used the importance and confidence rulers. I would have tried to ask permission when explaining what different medications could be used when planning for quitting.

Question 2:

I thought the provider did a good job of exploring his client’s ambivalence in this video. As noted above, I think by leaning into both sides of her ambivalence and exploring both the good things and not so good things about smoking, it increased her buy in and validated her. Instead of feeling pressure to report out on why she “knows smoking is bad”, she was able to be genuine, open, and honest, about the multiple factors influencing her to keep smoking, or the good things about it. These were placed on a level playing field of both being impactful for her. After this exploration, the provider first asks about the importance of quitting smoking, then asks her confidence in doing so. The client gave a high score for the importance of quitting, but a low one on her confidence – the provider asked about why he did not rate herself even lower, which gave space to encourage more change talk from the client.

Question 3:

I think there was a pretty good balance between Asking, Listening, and Informing in these videos. In the first video, the provider focuses more on asking open-ended questions to gather information from the client, explore her current feelings about smoking, and inquiries about the two sides of her ambivalence. He listens to her responses, validates her, and summarizes what she shares by repeating back to her what he has heard. In the spirit of MI, he supports the client in her ambivalence, and gently explores the importance and change rulers with her. In the third video is when the provider does more informing, which landed well with the client. If the provider did more informing in the first video, I’m not sure the client would have had as positive as a reaction. By focusing on asking and listening as they developed a working relationship, the client built confidence in herself, and was actually excited to share change and quitting plans with her provider. Her confidence increased the more success she had.

Question 4:

I have enjoyed working through this course of the last several weeks. I have greatly appreciated the concrete information and skill building work, and how we can integrate these skills into our practice. In the work that we do in the community with children/youth and families – I can see MI skills being helpful in a majority of situations. Not only are there conversations that can be had with some of our youth/teens about their decision-making, use of substances, and other risky behaviors, MI skills and approaches can be used when working with parents on behalf of their children. In addition to continued practice using OARS, incorporating the importance and change rules into my work could be especially helpful not only for clients, but with staff. Something I continually try to remind myself and staff of, is that we are responsible for the process and intervention, not the outcome.

[Natalie Lonstein]

Question 1:

I had a bit of a hard time staying focused on these videos. I thought there were more closed-ended questions and times where the clinician provides feedback or information when permission was not yet asked. There was feeling that the clinician was acting as the expert and that he was guiding the client to do what he believed was needed. Some open-ended questions/statements were used in attempts to evoke commitment to a plan were “What are you going to do?” and “When are you going to do that?”, which did get the consumer to think in concrete terms about committing to a plan and taking steps in the plan. However, I’m not confident in and did not get a feeling that the consumer was really committed to the plan and would follow through when leaving.

Question 2:

If I were the counselor in this role, I would have used more open-ended questions, double sided and amplified reflections, and rolled with the resistance. I think more validation around the hard parts of making steps toward change would have increased rapport, and led to more in depth discussion around the two sides of ambivalence. I also was put off at times when the counselor provided education and information without asking permission – I would make sure this is done. I also think that even though there felt like some guidance toward a plan, there was some discussion around plans to attend AA, etc. I think I would also have used the change ruler scale to assess the consumer’s commitment to the plan (though I think more exploration could have been done to nail down and even more concrete plan).

Question 3:

I see MI strategies for change planning coming up a lot in the work that we do with children/youth and families. Often, there are discussions around families or clients being “stuck”, or staff noting concerns about the ambivalence of clients (namely, having ideas or goals or thoughts around service options and resources, but that clients do not move forward with them). I think that leaning into validating the two sides of ambivalence is a way to build rapport with families, and also accept them. I think intentional work can be done around identifying the change talk we hear from our clients and families, returning to it, and exploring it more deeply. It also takes the frustration out of the equation for staff as they are not responsible for the outcome. Youth are particularly responsive when given space, freedom, and control – which comes naturally within the spirit of MI.

[Natalie Lonstein]

Question 1:

I thought this video was a really good example – I think the interviewer did a great job of staying the spirit of MI and leaning into Jim’s sustain talk to develop a positive, trusting relationship; to hopefully get Jim’s buy in. The interviewer “rolled with resistance”. You can hear lots of justifications and minimizations in Jim’s narrative, and the interviewer made a point of reflecting this back to Jim. I felt like there was really a dance between the sustain talk and change talk Jim used, highlighting how we all as humans have these two sides of how we feel about making changes or making choices.

Question 2:

Rounders Sustain Talk:
1.) And I don’t know what the hell she means I need help….And I don’t know where she’s getting all this from.
2.) The only reason I’m coming here is so I can maybe save my driver’s license so I won’t lose my job and so I won’t lose my house. It’s not because I want to do any of this crap you know.

Rounders Change Talk:
1.) If I don’t stop drinking I’m probably going to be right back in this mess again. – REASON
2.) Cause, if I get out of this, if I can save my house and my job I’d better do something that’s gonna keep me from doing this again, don’t you think? – REASON

Question 3:

1.) Reflective response (double-sided reflection): So you kind of feel two ways about it. On the one hand, you know, you think you’d like to have a change and you’d like to quit drinking and on the other hand you think you kind of dread it.

The interviewer is highlighting the two sides of Rounder’s feelings about not drinking. Though the sustain talk is coming second in this statement, her using a double-sided reflection names two experiences Rounder is having at the same time. He questions if it is typical to have mixed feelings, so this double-sided reflection serves to normalize this experience for him. This hopefully creates even more buy in.

2.) Strategic response (reframing & autonomy): “What would that be like for you? If you didn’t drink and you were around them?”

The interviewer is asking Rounder to just imagine a gathering with his friends where he doesn’t drink; from this perspective, can he consider what this experience could be like. I think there is a deeper meaning here as well, that in terms of feeling like he has to drink with his friends for various reasons, this question also encourages Rounder to consider what it would be like for him by getting his personal choice to drink in the situation. Rounders response to this shows that this is really difficult for him to even imagine this type of situation at all; drinking with his friends is so engrained for him, it is a part of his being. Though Rounder continues to have some sustain talk, he begins to verbalize a little change talk by naming that this could be something he has to think about more.

Question 4:

Rounder’s statements of change talk and sustain talk interweave. Earlier on, Rounder says:
1.) I think I could. I’ve tried a couple of times and I wasn’t very… I think one time I quit for a week or two just to show people I could stop drinking.

Then at the end he says:
2.) As long as I’m putting all this money into it I’d like to come out with something.

In addition to the change talk in Q2: “If I don’t stop drinking I’m probably going to be right back in this mess again,” and “Cause, if I get out of this, if I can save my house and my job I’d better do something that’s gonna keep me from doing this again, don’t you think?” I think my next step might be to try to gather together these statements and summarize what change talk I have heard throughout the interview. I think I would also do some exploration of past successes and what made them successful, particularly how did he did not drink for those two weeks.

[Natalie Lonstein]

Question 1:

I was really struck by the aggressive nature of the non-MI video, the telling to someone of what they “should do” about their life, and felt a real “power over” dynamic. Sal became defensive, annoyed, and frustrated. In the Spirit of MI video, there was a collaborative tone and what felt like a true understanding on the part of the counselor around how difficult of a decision there was to make, where the non-MI video portrayed Sal’s circumstances as if the answer were easy, no big deal to give away a family pet. In the MI video, Sal was open, interested in the conversation, appeared help seeking and invested, calm, and had a willingness to be more honest and forthcoming. You can see that the style of the MI video moves Sal closer to action because a culture of safety and trust is established by validating his ambivalence, and again, the tough decisions he has in front of him. In the MI video it felt as though Sal was eager for support and help in shedding light on a path for him of what he should do, though this was not named for him. He was interested in processing his opposing feelings to see what the ‘right’ decision could be for him.

Question 2:

Behavior: Working Out More

Ambivalence:
1.) “I want to spend time with my son after work since we only get a hour in the mornings together and a couple hours together after work before his bedtime.”
1.) “I have no time to work out in the mornings because I would have to wake up earlier, and therefore go to bed earlier and would have less tv/reading/on the couch time.”
2.) “I haven’t noticed a change in my weight or overall appearance.”

Other side of Ambivalence:
1.) “I know physical activity is important for my overall health”.
2.) “I enjoy many forms of exercise, have fun exercising, and feel it is an important part of my self-care.”
3.) “I like how I feel and look when I am exercising regularly.”

Double sided:
1.) “You know that exercise is important for your health. And yet finding time to exercise right now is particularly hard because spending time with your son is the priority.”
2.) “You enjoy relaxing and having time to yourself to read and watch tv shows, and yet you also have fun working out in many different ways.”
3.) “On one hand, you haven’t noticed much of a change in your body since you haven’t been working out as much as you used to. On the other hand, you have noticed that you like how you feel better when you are regularly working out.”

I really liked this exercise – I try to do this type of exercise with myself a lot around decisions that I have difficulty making or moving forward with (social relationships, eating habits, etc.) The reflective listening responses really feel validating around how hard it can be to make decisions you aren’t sure about when things ‘aren’t broken’ (for me at least). It feels supportive to have someone sit with you in that gray space for as long as you need.

Question 3:

Client:
1.) I want to get my driver’s license.
2.) I want to get a job.
3.) I want to move out and get my own apartment.

My target behaviors:
1.) Make a plan with client to register for driver’s ed, get their permit, complete driving hours, and go for the test.
2.) Look for openings, apply for positions, and go to interviews.
2.) Get a job/keep working, start saving, and create a budget.

My target behaviors or responses to these client’s goal statements appear like quick, concrete, easy solutions. Like the provider is saying “Ok great! I know all the answers for you, just do these 80000 things.” It downplays how hard some of these things could be to accomplish for the individual; a lot more exploration around any values or beliefs underlying or driving the wants could be helpful to get a sense of the whole person. Its important to stay curious – use of open ended questions! My ‘righting reflex’ comes from a place of wanting to help and provide resources and information, without knowing the full story. Using the Agenda Setting strategy, I could write down overall topics identified like ‘work/employment’, ‘living situation’, ‘transportation’, etc. and see if there were additional life domains the client felt would be important to add to their priority list. We could use index cards to write the different areas, then shift them around in the order the client identifies by using a rating scale or comparison of one topic to the other. Using reflective listening around any ambivalence to the way goals are prioritized would be important and validating their perspective of where each topic is placed in their list. Summaries would be important as well to make sure I am understanding what they are expressing.

[Natalie Lonstein]

Hello! My name is Natalie Lonstein, I am a LCPC in the State of Maine and am the Director of Youth Services at The Opportunity Alliance. I hope to strengthen and build on my MI skills to further support the clients we work with and staff in my programs.

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