C4 Innovations

Motivational Interviewing 18: David Avruch

An episode of “Changing the Conversation” podcast

David Avruch discusses macro Motivational Interviewing and the importance of addressing structural and systemic oppressions that people experience with host Ali Hall.

November 28, 2022


Ali Hall, Host (00:05): Hello and welcome to Changing the Conversation. I’m your host today, Ali Hall. Our topic is macro motivational interviewing or macro MI, and my guest today is David Avruch, a licensed clinical social worker calling in from Baltimore, Maryland. He’s recently the co-author of Macro MI: Using Motivational Interviewing to Address Socially-Engineered Trauma. Thanks David for joining us today.

David Avruch, Guest (00:33): Thanks Ali for having me. It’s a pleasure to be here and thanks to C4 for inviting me. I really appreciate the opportunity.

Ali (00:39): Oh, it’s a great delight to be talking with you today. I heard you talk recently at the International MI Network of Trainers or MINT International Conference, and really your contributions are the most exciting thing that’s happened in MI in a really long time. And I’m just so delighted that you agreed to join today to talk.

David (01:02): Thank you, Ali. I really appreciate the compliment and I want to make sure that the credit also goes to my co-author, Wendy Shaia, whose ideas were totally foundational for the work that we were able to produce in this paper. Wendy wasn’t able to be here or join us at the conference in Chicago, but she’s with us in spirit and her ideas are electrifying, so I want to make sure she gets credit as well.

Ali (01:26): Absolutely. And thank you to Wendy, for sure. You had mentioned a pedagogical crisis in human services. Please say more about that.

David (01:37): I think that the trauma is warranted in my language there because when we say there’s a pedagogical crisis in human services, what I mean is that young people are entering the helping professions, nursing, medicine, teaching, social work, psychology, and they are expecting to be taught tools to engage clients around the social determinants of health, which at this point we have a great deal of data about. We know that racism, economic inequality, sexism, really impact outcomes across the lifespan. That’s been well documented and the data is rich and goes back decades. And young people are coming into the fields really expecting to be taught how to change these systems of oppression.

(02:36): That’s the expectation that I encounter when I teach young people at Morgan State University where I’m an adjunct instructor in the social work department, and I think there’s a crisis because we don’t know what to tell them. We don’t know how to do systems change from within the institutions where we provide instruction in the healing arts. There’s a disconnect because young people are coming in and they know that racism shortens people’s lifespans and they know that racism is not just an interpersonal experience. It’s not just one person calling another person the bad names. They know that racism means that, depending on your skin color, you’re going to have fewer opportunities for safe, affordable housing. You’ll have fewer opportunities for work that pays a dignified wage.

(03:31): You’re less likely to live in places with dignified public transportation options. That racism means systems that predate us, that are bigger than us, that have very real consequences on the lived experiences of individuals. And so systems change is absolutely the most urgent problem to solve of the present day, and especially within health professions it’s been documented how racism impacts the physical bodies of individuals. This is no longer anecdotal. It’s settled science. The data is in, but we don’t know how to translate that information into actual interventions, into tools that we can use to change those systems that are causing harm.

(04:32): And that’s why it’s a crisis because we’re still focused on evidence-based best practices, which are valid and important, but they don’t address the elephant in the room which is that inequality kills. And as long as we’re not addressing that problem, the systems of oppression will continue to create harm in marginalized communities, and we’re not focusing on what’s most important. And that’s a huge problem across multiple clinical disciplines.

Ali (05:07): Yeah, and then we’re placing the blame and the responsibility for change on the individual and urging individuals to just eat better, lower your A1C, take your asthma medication, move to a better neighborhood, whatever the individually-based solution is. And I’m imagining that the helpers that you’re training have to walk away feeling disenchanted at best, but certainly feeling burnout and a sense of hopelessness as, “How do I grapple with this when the facts are in quite clearly.” You’ve also mentioned this idea of knowing too much about structural violence. What’s that about?

David (05:51): Sure. So structural violence is a term that comes to us from sociology and anthropology, and this term describes the ways in which the State creates harm for individuals. We can use that language to describe how policing operates in Baltimore City where I reside. We can use structural violence as a way to talk about food deserts, the lack of access to healthy foods. It’s a term that is expansive enough to capture the really diverse forms of harm that trickled down based on policy decisions that are made at the top of the decision-making ladder in society. So when I say that we know too much about structural violence, Knowing Too Much is the name of a book about the Israeli occupation of Palestine by a Jewish author, Norman Finkelstein, who is the child of Holocaust survivors.

(07:02): He chooses that title because he says that it’s not possible to unknow things that have been documented. When you act as though documented truths are not true, you’re causing harm and you’re creating cognitive dissonance in yourself. You’re harming yourself. And so when it comes to the data on structural violence on how racism shortens lifespans, on how sexual violence, 90% of sex crimes, 95%, are perpetrated by cisgender men, right? This creates the situation that we refer to as rape culture. Again, the data is in. We know everything that we need to know.

(07:52): Further data collection is helpful but not necessary because we’re not making policy decisions based on the data that we already have. It’s urgent that we move away from just focusing on convincing people that there is a problem. That’s already happened. We’ve accomplished that. We need to move toward policy change and the building of social movements to support policy change, to reduce and end structural violence, and then move to make amends for the harms that have been perpetrated by state actors and non-state actors that are supported by the social culture.

Ali (08:34): Right. And it sounds impossible to be neutral, so those who would pretend to be are perpetuating the problem as well. And you and your co-author, Dr. Shaia, describe the SHARP model, an acronym, S-H-A-R-P. What’s that SHARP model all about?

David (08:55): Yeah. Dr. Shaia developed the SHARP model as a tool for clinicians who seek to bring the language of systems change into the clinical encounter. Dr. Shaia is a social worker, I’m a social worker, and so we write in the discipline of social work, which I enjoy doing because social work is sort of the lowest rung of the scientific ladder. But I think that it has a lot to say. It’s the confluence of psychology and sociology, right? And that’s what the SHARP model is. So what it stands for, the acronym, so SHARP, the S is structural oppression, H, historical context, A, analysis of role, R, reciprocity and mutuality, P is power. And so I’ll just briefly go through what each of those refers to.

(09:54): Structural oppression refers to what’s the context within which this person is operating that you’re talking to and doing social work or psychology with? Do they live in a food desert? Do they live in a place where they don’t have access to affordable childcare? What are the systems that are in place in their environment that are preventing them from achieving their goals? And the reason that we need to name those systems relentlessly is because we know that when we don’t name those systems, people will blame themselves for their own problems. And so structural context and structural oppression is about naming the systems.

(10:34): Historical context is about looking at what are the intergenerational events that have occurred that are impacting this individual today? So for me, my family is Ashkenazi Jewish and there was a lot of trauma that occurred in history and in the current day for Jewish people, including in my family. I’m a person who has major depressive disorder. It’s been a part of my life for many years, treated it in various ways, and to talk about depression for me, but to not talk about intergenerational trauma related to anti-Semitism, to not talk about my experiences of exclusion related to being a queer person, you’re really limiting yourself in how you approach a clinical treatment.

(11:30): And so the historical context about what it means to be a gay person in America, what it means to be a Jewish person in the world, these are essential lenses that we bring into play. When I was starting out in social work, I was working in the Pacific Northwest and I was working on Native American reservations. And what I was taught in grad school is that you can’t work with indigenous people as a social worker without acknowledging that you’re operating in the context of genocide. You can’t build relationships that are authentic if you’re not acknowledging this reality that impacts people every single day. And the genocides are still occurring in different ways. So that’s the historical context.

(12:20): Analysis of role refers to, what is the provider’s role? Are we the maintainer or the disruptor of the status quo? And that question is about, am I engaging this client in a discussion of structural oppression, or are we just going to do some mindfulness meditation and fill out some forms and call it a day? And again, that’s not a bad thing to do. Those are helpful interventions, right? That’s basic social work and important to do. But a classic feminist argument is, when you don’t analyze power, the people with power benefit. And so analysis of role reflects the contributions of feminism to psychology.

(13:08): And it says, “Are you maintaining the status quo vis-a-vis this client and the systems that are holding them down? Or are you disrupting that by naming?” Like actually the situation that you find yourself in is connected to structural violence, to forms of harm that are being perpetrated against you and against your ancestors. And are you also disrupting the status quo in terms of the provider-client relationship? Because historically, providers and clients, I mean, the power differential is massive entering into that relationship. And that’s just part of being a therapist or a social worker or a nurse or a doctor. You wear a tie and you have a degree on your wall, and clients who are of marginalized identities or oppression don’t have those things necessarily, right? And so it reinforces that they’re in a lower position than you.

(14:05): And so the analysis of role element of SHARP really challenges the provider to ask, “What are you doing to disrupt that differential of power? Are you being a nice person giving an evidence-based practice to a less fortunate individual? Or are you willing to actually look at that person in front of you as somebody with unique skills and gifts, both tapped and untapped that they can contribute to society and to their community?” And that bleeds into R, reciprocity and mutuality, which is about really not holding yourself above the person that you’re sitting in front of, but being curious, “What can I give you, and what can you give to your community? What can you give to social movements that are seeking to create affordable housing as a human right?” for example.

(15:00): In Baltimore we have an enormous affordability crisis. There are more unhoused people than abandoned buildings in Baltimore City, and we have a lot of abandoned buildings. That’s structural violence, right? Power, the P in SHARP, is about the responsibility of the provider to know who in the community is fighting back against structural violence, and are you offering your clients opportunities to become connected to social movements? I think about this in a very social work way, which is just referrals. You make referrals. And so if I offer somebody a referral to a food pantry because they’re experiencing housing insecurity, that’s my job, is I give them options and I let them choose.

(15:48): I trust them to choose the choice that’s right for them, and if I can give them a referral to a food pantry, I can also offer them a referral to a food justice nonprofit that maybe
they’re doing urban farming or maybe they’re doing lobbying at the state level to create vouchers for performance markets. And that’s something that has happened in Maryland and it’s still happening. And so using referrals is a really important and basic way to disrupt the classic dynamic of service provider, service recipient. So that’s what the SHARP model is all about.

Ali (16:23): Yeah, it’s really powerful and puts into amazing focus a different way of being with people, as, well, at least for myself as a trainer and consultant in MI for quite a few years now. And we do a pretty good job of helping people address change on an individual level and collaborative conversations, strengthening a person’s own motivations, helping them form commitments, helping them identify importance and confidence and readiness inside to live life as they would like. And all of that is wonderful.

(16:55): And yet there’s always been something a little bit missing, right? And this idea of how incredibly helpful and dynamic MI is and can be with a relentless focus on the individual and responsibility on the individual. And we have some good evidence for MI, but at least when we think about addressing socially engineered trauma as you’re describing it, and for all of the important reasons that you described already, why might MI be suitable here?

David (17:27): Motivational interviewing is the premier form of helping, right? The evidence base is amazing, documented effectiveness across all kinds of populations for all kinds of problems and situations. And it’s the reason that Dr. Shaia and I chose MI as a locus to develop the ideas of the SHARP model in a more practical way is because MI has really found its home in the trenches of healthcare delivery and social service delivery. The most down and out, the most oppressed, the most marginalized folks are interacting with human service providers who are practicing motivational interviewing.

(18:21): There is an abolitionist organizer and writer named Mariame Kaba who is really an influential feminist thinker, and she posits that only the empowerment and engagement of the most marginalized members of society, that that’s the only way to achieve radical social transformation. That there’s no other way to actually end structural violence than to engage the most marginalized, the most oppressed individuals. You can’t just be about recruiting non-profit directors. You have to actually be working with the people who are unhoused, who have substance use disorders because they are excluded from society. And MI is the tool that is most often used to serve those individuals in a way that is caring and respectful and ethical. MI, motivational interviewing is often the first form of therapy that younger providers are taught in school, is the other thing.

(19:36): And so again, when we come back to the idea of pedagogy, it’s the young people in the field who are going to develop the new ways of bringing structural confidence and a structural focus into individual therapy and healthcare delivery. And so motivational interviewing is the bridge. It’s the space where that radical transformation can unfold because it’s in a room and it’s a person being really kind and really present to another person who’s having a real problem, who’s in trouble, in a way that’s really effective and direct. The paper that we wrote seeks to go to that moment and infuse it with an analysis of structural violence, of systemic oppression, and to create opportunity to not just do that individual work that MI is well regarded for, but to expand the lens of what is possible in that encounter.

Ali (20:44): Yeah, it’s really interesting. I think there’s been an evolution in MI from the heartset and mindset that’s classically known to us with partnership and acceptance and compassion. And you can either say evocation or empowerment, but this real true treasure hunt, heartset and mindset that we bring to each and every encounter. But the evolution that I’ve been thinking of really is from taking the lower place, challenging ideas about social dominance, and also an increased interest in social justice across the world of MI.

(21:21): So it almost feels like this was the exact right time and you and Dr. Shaia were right there at that exact time, and to be able to share these wonderful ideas with us and these absolutely exhilarating and transformational ideas with us to really get to the piece that has… To some extent we’ve been blinded to by the relenting focus on the individual, but you’d also mentioned something about environmental enrichment as a treatment for substance use. What’s that all about?

David (21:54): Yeah, I’m glad that you asked. But before I share about that, I want to just respond to the piece about individualism. And so another style of therapy that I practice and that I’m training in is internal family systems therapy, IFS. In IFS we talk about burdens that individuals carry, and there’s different kinds of burdens. One form of burden is what we call a cultural burden, and Dick Schwartz, the progenitor of IFS, has named individualism as an American cultural burden that we carry along with materialism, racism, and patriarchy. These are the four cultural burdens indigenous to our society that Dr. Schwartz named. And I think that he’s right about individualism. I think that individualism is a model that’s run its course to some extent, and I think that it’s a shame that we’re still arguing about whether trickle-down economics is a thing or not.

(22:54): It’s laughable and that’s also structural violence, frankly, but here we are. I think that balancing individualist and collectivist forms of health and wellness is where we’re headed. And it’s not the future that we’re headed into, it’s the past, because in indigenous societies, African societies, this idea of reciprocity, the idea that wellness is reciprocal, that you can’t be okay if the people around you aren’t okay, that’s a really ancient idea. And so I appreciate your compliments when you say that Dr. Shaia and I’s paper is this and that. We’re really just gathering information that has been lying around and we’re just packaging it and saying, “Can we focus on this now? It’s time.”

(23:46): But to your prompt about environmental enrichment for substance use disorders, I live in Baltimore, Maryland, which is understood to be the substance use disorder capital of North America, along with maybe Vancouver, British Columbia. Rates of opioid use disorders are really high in this city and nobody can really figure out why. Nobody can really figure out what to do about it. We’re still living in the biomedical construction of addiction. It’s a disease, and here’s a medicine to take to treat that disease, and we know that that’s not true. Again, the data is in and environmental enrichment is a really interesting way to treat substance use disorders. And so in Vancouver in the ’70s, a series of experiments were done on rats that had become addicted to opioids in the form of morphine-laced water. This is known as the Rat Park experiments.

(24:43): And what that psychologist, Bruce Alexander, described in his studies was that when you take rats that live in sterile cages and really deprived environments, and you get them chemically dependent on opioids, and then you introduce those rats into what he called Rat Park, which was a kind of a multi-level rat playground where there were non-addicted rats and toys and things to climb and play and eat and all that, that really the rats stopped using opioids. He gave them access to the opioid-laced water in that new space, and they weaned themselves off of it naturally. And so other data has also documented the effectiveness of environmental enrichment on mice that were addicted to cocaine. Unfortunately the data set is really limited because this is not a form of research that’s prioritized. It’s driven by the pharma companies, right?

(25:44): There’s no profit model to be had in an environmental enrichment focus on treating substance use disorders. But when I go around my city, when I go around Baltimore and I see block after block of abandoned homes with trees growing out of them, neighborhoods that don’t have trees in them other than the invasive species, trees that are growing out of the abandoned homes, no access to playgrounds, places where violence, where despair and hopelessness are rampant, these are the conditions where substance use disorders take root. And when we approach individuals who come from those neighborhoods and they come to our clinics and they have substance use disorders and we say to them, “You have a disease. Here’s some Suboxone. Best of luck. See you tomorrow.”

(26:41): And we pay no attention to the violence that they are exposed to, to the pain and the shame and the fear of what it’s like to be in a neighborhood where the police are there to keep you there and make sure you don’t leave that neighborhood. And the police are there to humiliate you and strip you naked in front of your neighbors if they suspect you of doing something that they don’t like. Where the sanitation workers don’t pick up the garbage. Living in Baltimore, we talk about there’s two Baltimores. I live in one Baltimore and 10 minutes away is the other Baltimore, and rates of substance use disorders track with that, right?

(27:33): We need to move beyond it, and environmental enrichment is the next step. What that means is massive social spending and investment in divested neighborhoods, reallocation of resources, reparations for genocide and harm that was caused by slavery. That’s what we mean when we say environmental enrichment. Literal enrichment. Like riches that were taken and put over here need to be brought back. And that is a way to talk about how to treat substance use disorders that needs to be brought much closer to the mainstream than it currently is.

Ali (28:13): Well, David, you’re absolutely right. The data is in, and you’ve given us the language to move ahead. And I know that your students must be very grateful to be learning alongside of you and have a chance to try these ideas out in real time. I hope that our audience will, as well, continue to read and study and develop themselves in this language and in this way of being and this way of thinking. Thank you so much, David Avruch for joining us today, and thank you for all that you do, making the world a better place.

David (28:45): Thank you, Ali, and thanks to C4 for having me. It’s been such a pleasure and an honor. I really appreciate it.

Ali (28:50): And to our listeners, please join us next time on Changing the Conversation.

Erika Simon, Producer (28:54): Visit C4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.


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