1. Elizabeth Santa Ana, Ph.D.; Brian Lozano, Ph.D. Ralph H. Johnson VA Medical Center Homeless Outreach Meeting Columbia, SC July 23rd, 2014 Adapting Motivational Interviewing for Homeless Outreach Services for Homeless Outreach Services

2. 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?

3. What is MI? What have you already learned or heard about Motivational Interviewing?

4. 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

5. Motivational Interviewing Is an Evidence-Based Practice associated with improved health outcomes. Is an Evidence-Based Practice associated with improved health outcomes. Can be used in brief encounters. 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. 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.

6. You approach an individual living on the street and inform him about homeless services. You approach an individual living on the street and inform him about homeless services. The person thanks you and doesn’t seem interested. The person thanks you and doesn’t seem interested. You tell the person that you really think he can benefit from the services. 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.). 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: One Scenario

7. The nature of the problem (continued)… You again recommend the person use the homeless services. You again recommend the person use the homeless services. You provide logical reasons why he should do so. 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. 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? Does the person argue or does he agree? The person say he’s fine… The person say he’s fine… …and still no change is made

8. What’s going on? Why isn’t this person jumping on the offer to get off the street? 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. 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! “Ambivalence is a state of having simultaneous, conflicting feelings toward something” – Thanks Wikipedia!feelings Or, feeling the same way about two different conflicting things Or, feeling the same way about two different conflicting things

9. 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.

10. 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. 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? 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. 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”) It is human nature to assert our autonomy if/when we feel our freedom is being threatened (“Psychological Reactance”)

11. 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. Motivation is not a trait:

12. 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. 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… In this context we use the following skills… Open-ended questions Open-ended questions Affirmations (reflecting a patient’s sense of his/her own accomplishment) Affirmations (reflecting a patient’s sense of his/her own accomplishment) Reflections (MOST IMPORTANT SKILL!) Reflections (MOST IMPORTANT SKILL!) Summaries Summaries

13. 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?....” 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.” 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…” 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. Summarizing: Brings all the above together in a summarizing statement highlighting client change talk.

14. Goal of MI Providers often hope that Motivational Interviewing will motivate individuals to immediately engage in desired behaviors. 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… But MI Involves engaging in a conversation in the spirit of Partnership, Acceptance, Collaboration, and Evocation, using OARS… ….To elicit and strengthen Change Talk… ….To elicit and strengthen Change Talk… The theory of MI: Increased Client Change Talk -> eventual change The theory of MI: Increased Client Change Talk -> eventual change Can happen quickly…. or over time as a process (may take several MI conversations) Can happen quickly…. or over time as a process (may take several MI conversations)

15. What is Client Change Talk? Client language that moves toward change 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. Specific to a particular target behavior or set of target behaviors. Usually initiated by the client, but also elicited by the mental health professional. Usually initiated by the client, but also elicited by the mental health professional. Expresses patient’s desires, ability, reasons, & need to change. Expresses patient’s desires, ability, reasons, & need to change. States willingness & intention to change. States willingness & intention to change.

16. 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

17. 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) Assertive Community Treatment (ACT) Motivational Interviewing (MI) Motivational Interviewing (MI)  McGraw and colleagues report on the experiences of the CICH projects in their use of ACT and MI.

18. 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.

19. Why use MI with the Homeless Population? 1. Practice that is most compatible with the Housing First philosophy 2. Client-centered 3. Imparts respect for client choice and self-direction 4. Enhances a culture of trust and hope 5. Fosters positive client change and recovery 6. More likely to enhance intrinsic-motivation for change Using MI has been shown to (McGovern et al., 2010): 1. Increase rate at which clients begin treatment 2. Enhance length of time clients remain in treatment 3. Motivate adherence to treatment recommendations 4. Reduce substance use 5. Motivate adherence for taking prescribed medications

20. 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.

21. 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” 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)

22. In terms of using MI What Challenges Do You Have Engaging People In Homeless Services?

23. “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 Make an open-ended question Repeat something a person just said using slightly different wording Repeat something a person just said using slightly different wording Emphasize someone’s strengths Emphasize someone’s strengths Repeat something a person just said that involves change Repeat something a person just said that involves change (The use of at least one of these skills is better than none)

24. “I’m not sure where and when can I use MI” 1. During outreach contacts: In the street (noisy, crowded, chaotic) In the street (noisy, crowded, chaotic) Soup kitchen (noisy, crowded, chaotic) Soup kitchen (noisy, crowded, chaotic) 2. As the client enters the front door (front desk staff) 3. Initial interviews to determine interest and eligibility 4. Once client is in services: On-going week-to-week discussions about employment, daily activities, self-care, etc. 5. Medical and behavioral needs 6. Treatment planning Essentially: During any interactions with clients!

25. TIME “MI takes time to do”: It takes time to learn, but can be done in brief fashion when mastered. 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. Sometimes just a minute or two (combined) of reflective listening can diffuse tension and make people more receptive. Can save time for the future. 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) “If all you have is a few minutes, you can’t afford not to do MI.” (Bill Miller, personal communication)

26. “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?”

27. “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.

28. 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?”

29. Needs for Future MI Training Training interest How should the training be delivered? Length and amount of time for training?