Adapting Motivational Interviewing for Homeless Outreach Services. Elizabeth Santa Ana, Ph.D.; Brian Lozano, Ph.D. Ralph H. Johnson VA Medical Center Homeless Outreach Meeting Columbia, SC July 23rd, 2014. Outline. 1. What is Motivational Interviewing (MI)?
Adapting Motivational Interviewing
for Homeless Outreach Services
Elizabeth Santa Ana, Ph.D.; Brian Lozano, Ph.D.
Ralph H. Johnson VA Medical Center
Homeless Outreach Meeting
July 23rd, 2014
What is MI?
What have you already learned or heard about Motivational Interviewing?
…a conversation about behavior change
…uses reflective (person-centered) listening (among other skills)
…emphasizes the person’s own reasons for change
…collaborative & imparts acceptance and compassion
It is a strategic conversational method to help a person move toward a particular change goal:
…that uses specific counseling skills to elicit, strengthen and reinforce client change talk
…and provides a way to respond to discord (non-change talk) in a non-confrontational way
Is an Evidence-Based Practice associated with improved health outcomes.
Can be used in brief encounters.
NOTE: Not a panacea…appropriate for people who are ambivalent, but may not be useful for people completely ready to change or people determined to make no changes.
The Nature of the Problem: One Scenario
You again recommend the person use the homeless services.
You provide logical reasons why he should do so.
Perhaps you remind the person of the health consequences if he doesn’t get off the street.
Does the person argue or does he agree?
The person say he’s fine…
…and still no change is made
Why isn’t this person jumping on the offer to get off the street?
The person may want to get off the street, but may be conflicted.
“Ambivalence is a state of having simultaneous, conflicting feelings toward something” – Thanks Wikipedia!
Or, feeling the same way about two different conflicting things
We can’t assume that because we have a service we know is helpful that people are going to understand it, be motivated to use it initially, or decide immediately how the service will fit into their lives.
Motivation is not a trait:
We share the responsibility for enhancing our client’s motivation for change.Clients are not responsible for being sufficiently motivated for change at the outset.Motivation is malleable and is formed in the context of relationships.
Open-ended questions: Can’t be answered with a simple YES or NO. Examples: “What brings you here today? Tell about…Tell me more about that… How might I be of help to you?....”
Affirmations: NOT praise, but a reflection of the patient’s sense of accomplishment. Ex.: “You’re managed to stay sober since living on the street.”
Reflections: Paraphrasing, mirroring what patient says, labeling emotions. Ex.: “You are worried about your health if you continue to live on the street …You seem worried about your diabetes…”
Summarizing: Brings all the above together in a summarizing statement highlighting client change talk.
Providers often hope that Motivational Interviewing will motivate individuals to immediately engage in desired behaviors.
But MI Involves engaging in a conversation in the spirit of Partnership, Acceptance, Collaboration, and Evocation, using OARS…
….To elicit and strengthen Change Talk…
The theory of MI: Increased Client Change Talk -> eventual change
Can happen quickly…. or over time as a process (may take several MI conversations)
Support for MI in the Homeless Population
Adopting best practices Project:
Lessons learned in the Collaborative Initiative to Help End Chronic Homelessness (CICH)
(McGraw et al., 2010)
Collaboration of 5 Agencies:
-Substance Abuse and Mental Health Services Administration (SAMHSA)
-Housing and Urban Development
-Department of Veterans Affairs
-Health Services and Resources Administration
-U.S. Interagency Council on Homelessness
Collaborative Initiative to Help End Chronic Homelessness (CICH)
Primary Goal of CICH: Provide supportive services using clinical practices shown to be effective or “based on sound evidence” in the engagement and retention of clients in housing services.
Survey on the application of two models:
Perceived Benefits of MI: CICH Findings
Survey of team members reported positive changes such that their clients:
Staff associated changes with providing unconditional acceptance:
Why use MI with the Homeless Population?
Using MI has been shown to(McGovern et al., 2010):
1. During the information gathering process, MI may be ‘woven in’ (think of a container of glass beads….the water poured in is MI).
2. Engage the client first (get to know his values, what is important to him).
3. Use a couple of open-ended questions, followed by a few reflections.
4. It’s okay to use MI for just a few minutes.
5. It may take a few conversations for any change to occur.
6. Decide to ‘plant a seed’ (may not have an outcome right away). MI has been shown to work over time.
7. Ask: “How willing are you to talk about this?”
Ask: “Tell me what it is like for you to live here”
OR—”What are some of the challenges that you face?” (get an understanding of the person’s circumstances)
“Unless I am Formally Trained in MI, I Can’t Use It”
(The use of at least one of these skills is better than none)
“I’m not sure where and when can I use MI”
Essentially: During any interactions with clients!
“MI takes time to do”:
A. Elicit-Provide-Elicit (E-P-E)
E: “Would it be okay with you if I talked with you a little bit about our housing services?”
Key: “What if anything, do you know about them already?”
P: “Yes…that’s true….and we also provide…..”
E: “How might any of these services, if any of them, fit into your life?”
“What is life like for you on the street?” (reflect—Note: this may involve reflecting personal values)
“What challenges, if any, do you experience living here?” (reflect)
Summarize, pointing out any ‘change talk’ placed on the back end of the summary.
End with permission to talk again.
So Mr. Stephenson, let me summarize what I heard you say today. You’ve been living on the street for about 3 years now. You’ve really managed to take care of yourself quite well on the street. For the most part, you know where to find food and you are pretty good at seeking shelter when the weather is bad. You have made some good friends and it would be hard to leave them, and you are really used to this neighborhood. On the other hand, you are really worried about your diabetes and you are thinking that if you had an permanent home to stay, you would take better care of your diabetes and this is important to you. You are also worried about getting attacked on the street again. You recovered from getting badly beaten up last year and you are worried that the longer you stay on the street, that this could happen again. You mentioned you are not quite ready to make a firm decision now, but I appreciate the chance to talk to you about housing services. What did I miss?
End with:“Would it be alright with you if we talked again in the future about housing services? When/where do you think we might do that?”
How should the training be delivered?
Length and amount of time for training?