Transcript A Motivational Strategy for use with Substance

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)?
2. In what ways is MI useful for engaging
homeless individuals in services?
3. How can MI be used flexibly?
4. How can MI be adapted to the setting where
you are meeting a homeless individual?
5. What concerns do you have using MI with
homeless individuals?
What is MI?
What have you already learned or
heard about Motivational
Interviewing?
Motivational Interviewing is:
…a conversation about behavior change
…explores ambivalence
…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
Motivational Interviewing



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 approach an individual living on the
street and inform him about homeless
services.
The person thanks you and doesn’t seem
interested.
You tell the person that you really think he
can benefit from the services.
The person gives you a reason why he can’t
participate in the services (his dog, his friends, etc.).
What do you do?
The nature of the problem (continued)…
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

What’s going on?




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.
How NOT to address
ambivalence




Our first instinct is often to provide information to
“make it right,” to persuade or convince the
person to do something using logic.
Why may it be ineffective?
Hypothesis: If someone is AMBIVALENT and we
argue for one side of an issue, their reflex will be
to defend the OPPOSITE side of the issue.
It is human nature to assert our autonomy if/when
we feel our freedom is being threatened
(“Psychological Reactance”)
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.
Review of MI: Spirit and Basic Skills


While we talk to patients, we want to emphasize their
AUTONOMY, talk in a COLLOBORATIVE (partnership)
manner and EVOKE their values and abilities.
In this context we use the following skills…
 Open-ended questions
 Affirmations (reflecting a patient’s sense of his/her
own accomplishment)
 Reflections (MOST IMPORTANT SKILL!)
 Summaries
OARS: Basic MI Skills…




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.
Goal of MI





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)
What is Client Change Talk?





Client language that moves toward change
 Opposite from “Sustain Talk” – these are the reasons
that clients give to defend their behavior.
Specific to a particular target behavior or set of target
behaviors.
Usually initiated by the client, but also elicited by the
mental health professional.
Expresses patient’s desires, ability, reasons, & need to
change.
States willingness & intention to change.
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

11 programs, nation-wide, chosen to apply models of best
practices to support clients in housing
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:
•
Assertive Community Treatment (ACT)
•
Motivational Interviewing (MI)

McGraw and colleagues report on the experiences of the CICH projects
in their use of ACT and MI.
Perceived Benefits of MI: CICH Findings
Survey of team members reported positive changes such that
their clients:



took dramatic steps to engage in treatment and reduce
substance use.
became more open to discuss persistent medical problems
with staff.
seemed to develop trust, leading them to talk about their
concerns and hopes.
Staff associated changes with providing unconditional acceptance:
 Conveying “the belief in him” and his ability to change.
 “Sticking with him” through good days and bad days.
Why use MI with the Homeless Population?
1.
2.
3.
4.
5.
6.
Practice that is most compatible with the Housing First philosophy
Client-centered
Imparts respect for client choice and self-direction
Enhances a culture of trust and hope
Fosters positive client change and recovery
More likely to enhance intrinsic-motivation for change
Using MI has been shown to (McGovern et al., 2010):
1.
2.
3.
4.
5.
Increase rate at which clients begin treatment
Enhance length of time clients remain in treatment
Motivate adherence to treatment recommendations
Reduce substance use
Motivate adherence for taking prescribed medications
Using MI Flexibly: Some Suggestions
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.
Using MI Flexibly: Some Suggestions
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)
In terms of using MI
What Challenges Do You
Have Engaging People In
Homeless Services?
“Unless I am Formally Trained in MI, I Can’t Use It”





Almost all of us have the ability to:
Make an open-ended question
Repeat something a person just said
using slightly different wording
Emphasize someone’s strengths
Repeat something a person just said that
involves change
(The use of at least one of these skills is better than none)
“I’m not sure where and when can I use MI”
1.
During outreach contacts:
•
•
2.
3.
4.
5.
6.
In the street (noisy, crowded, chaotic)
Soup kitchen (noisy, crowded, chaotic)
As the client enters the front door (front desk staff)
Initial interviews to determine interest and
eligibility
Once client is in services: On-going week-to-week
discussions about employment, daily activities,
self-care, etc.
Medical and behavioral needs
Treatment planning
Essentially: During any interactions with clients!
TIME
“MI takes time to do”:




It takes time to learn, but can be done in brief
fashion when mastered.
Sometimes just a minute or two (combined) of
reflective listening can diffuse tension and make
people more receptive.
Can save time for the future.
“If all you have is a few minutes, you can’t
afford not to do MI.” (Bill Miller, personal communication)
“I’m not sure how to begin a conversation using MI”
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 if the person refuses services after EPE?”
“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.
Example of a summary
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?”
Needs for Future MI Training
Training interest
How should the training be delivered?
Length and amount of time for training?