Presented by James Winarski, MSW Department of Mental Health Law and Policy

1. Motivational Interviewing Applied to Homeless Service DeliveryProject for Assistance in Transition from Homelessness (PATH)Virginia State ConferenceAugust 24, 2016 Presented by James Winarski, MSW Department of Mental Health Law and Policy Louis De La Parte Florida Mental Health Institute University of South Florida/Tampa

2. Goal Apply the spirit and methods of Motivational Interviewing to help in establishing a personal connection that provides the spark for the journey back to a vital and dignified life.

3. Objectives • Discuss principles underlying the MI approach & relationship to homeless services • Describe Stages of Change Model • Learn and practice basic MI practices/interactions • Be ready to try strategies tomorrow in your practice

4. Erroneous Assumptions About Homelessness • Moral Failing • People choose to be homeless • People with MH/SA problems need to hit bottom fist. • MH/SA problems must be resolved before the person is housed. • Housing should be a reward for treatment compliance.

5. Keys to Effective Support Services Flexible, Voluntary, and Recovery-Focused Services • Client freedom to choose the services they need. • Focus on services and supports that will help the person be successful and satisfied in housing rather than on symptom reduction. • Important to engage without using coercive methods, and to know the person’s needs, abilities, goals and preferences. (SAMHSA, 2010)

6. Motivational Interviewing… • An effective tool for engaging persons who are homeless, without coercion, …and helping them chart their own course for change.

7. Motivational Interviewing Definition: “A person-centered, goal-oriented approach for facilitating change through exploring and resolving ambivalence." Miller, W.R. (2006) Motivational factors in Addictive Behaviors. In W.R. Miller & K.M. Carroll (Eds.), Rethinking substance abuse: what the science shows and what we should do about it (pp 134-150). New York: Guilford Press.

8. Spirit of Motivational Interviewing • It is NOT primarily a collections of techniques or interventions • A way of being with clients • A way to interact with clients • A style of counseling that helps resolve ambivalence that prevents clients from realizing personal goals • directed by a guiding philosophy

9. The Goal of Motivational Interviewing The goal of MI is to facilitate: • Fully informed, • Deeply thought out, • Internally motivated choices, • Not to change behavior….., though we may indeed see changes in behavior. Resnicow, et al., 2002

10. Who Does the Motivating? • We don’t motivate clients. We find the motivation that lies within them and help them recognize it. We reject the “righting reflex” (Rollnick et al., 2008). • We help people talk themselves into changing.

11. When to Use Motivational Interviewing? • Issues of motivation (“being stuck”) can come up at any moment in an interaction. • Even a brief interchange can powerfully effect a client (Rosengren, 2008)

12. When to Use Motivational Interviewing in Homeless Services Delivery? • Our key cue to use Motivational Interviewing is whenever a client expresses ambivalence about taking an action: • Examples: • Client expresses objection to the plan • Client sounds uncertain • Client expresses mixed feelings • Client expresses lack of confidence. • Client expresses lack of time, energy, or resources. • Helper feels annoyed, frustrated, or angry

13. The Key To This work “Reflective listening is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn’t. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen” (Miller and Rollnick, 1991)

14. Person Focus • MI supports the person in articulating • How personally important this change (e.g., treatment) is, as opposed to how important we think it is • What stands in the way of making this change (time, money, cultural factors, etc.) • Changes that might work in their life • How best to increase the chances of success

15. Assumption About Change • Motivation is a state, NOT a trait. • Resistance is not a force we must overcome. • “Working with ambivalence is working with the heart of the problem.” (Miller and Rollnick, 1991) • Focus on person as an ally rather than an adversary. • Recovery and change/growth are intrinsic to the human experience.

16. The Risk of Hope • Recognize that people who have suffered many losses relinquish hope as a means of survival. • “ Hope is a dangerous thing. Hope can drive a man insane.” (Ellis Boyd "Red" Redding in the Shawshank Redemption)

17. Three Factors that Influence Readiness to Change

18. Perception of Need (Felt Need) Person’s experience of discrepancy between the pain of present and potential for future improvement. • Recognize histories of neglect and abuse. • Pain tolerance. • Need safety and stability to explore discrepancies.

19. Belief that Change is Possible and Can Be Positive Positive outcome is perceived as achievable within a reasonable period of time. • Change = Negative Experience • Outcomes may seem distant. • Strategies should target development of supportive relationship and short term goals.

20. Sense of Self Efficacy Belief by the person that he/she can take an action to make a change. • Locus of control. • Taking action can create change. • Power in the hands of others? • Tension between compliance and initiative. • Need experience of being effectual. • Need opportunities for success (risk?). • Adapt pace and intensity of interventions.

21. Motivational Interviewing Process:Stages of Change Provides the Frame for Conversations: Conversations About Change: Conversations Include: Open-ended questions Affirmations Reflections Summaries Desire Ability Reason Need Commitment Activation Taking steps

22. The Stages of Change

23. Stages of Change • Precontemplation • Contemplation • Preparation/Decision • Action • Maintenance • Relapse

24. A Stage Model of the Process of ChangeProchaska and DiClemente (1982) PERMANENT EXIT ENTER HERE Maintenance Relapse Action Precontemplation Preparation - Decision Contemplation TEMPORARY EXIT

25. The Stages of Change • Precontemplation • No perceived need to change. • Uninformed or under informed about consequences. • Demoralized by previous attempts? • Underestimate benefits and overestimate costs. • Contemplation • Initial awareness of a problem. • Feelings of ambivalence about change (Consider change versus status quo). • Can be immobilized for long periods (Chronic contemplation).

26. The Stages of Change • Preparation Stage • Initial Movement away from ambivalence and toward action (making a decision). • Statements reflect the beginnings of motivation. • Person considers strategies for change. • Action • The person takes steps to bring about change. • The stage at which clients are most likely to benefit from active treatment.

27. The Stages of Change • Maintenance Stage • The person sustains the change accomplished by previous action. • Steps for maintaining long-term change are different from steps for initial change. • Triggers – Expectations – Social Context • Relapse Stage • Long-standing change often involves setback. • Person may relapse into previous problem behaviors. • Goal: return to process of change as soon as possible.

28. Practitioner’s Motivational Tasks

29. Ambivalence “Working with ambivalence is working with the heart of the problem.” (Miller and Rollnick, 1991)

30. Understanding Ambivalence Costs of Status Quo Benefits of Change Costs of Change Benefits of Status Quo Contemplation: cost-benefit balance Source: Miller and Rollnick (1991)

31. Precontemplation • Raise doubt-increase the client’s perception of risks and problems with current behavior. • Increase awareness about possibilities. • Create dissatisfaction (The Confrontation Within) . • Explore Consequences. • Explore desirable options/alternatives.

32. Contemplation • Explore reasons to change and the risks of not changing. • Reinforce any decisions/steps for positive change from person’s past. • Explore rather than prescribe – don’t give solutions. • Address decision making imbalances: (Intuitive – Dependent – Rational).

33. Preparation (Decision) • Respond positively to statements of intention. • Tip the balance from ambivalence toward taking action. • Person-Centered Treatment Planning. • Goals setting that accounts for client preferences and environmental options.

34. Action • “Stage matched therapists want to help, but will only encourage clients to take steps when they are most ready to succeed.” (James O Prochaska) • Work as partners on a plan for recovery. • Build skills & coping strategies • Connect to supports

35. Maintenance • Help the client to identify and use strategies to prevent relapse. • Develop knowledge and skills to support progress: • Biological – Psychological – Social Triggers • Expectations that helped motivate the person to take action. • Use peers to provide models of recovery, serve as guides, and to help create an experience of community.

36. Relapse • Help the client to renew the process of contemplation, preparation (decision making) and action. • Help client recognize relapse as a normal part of achieving goals that will endure. • Focus on learning and positive reinforcement rather than punishment.

37. Motivational Interviewing Process

38. Exercise: Negative Practice • Experience first-hand how responses that are not reflective listening can obstruct motivation and change.

39. Exercise: A Taste of Motivational Interviewing • Experience the basic approach and “feel” of motivational interviewing.

40. Motivational Interviewing Process We evoke from the person the reasons and best steps to make a change through the following: • Matching our activities to the person’s stage of change. • Asking questions to facilitate a conversation about potential changes: (Listen for/Evoke Change Talk). • Desire: “Why do you want to make this change? • Ability: “How would you go about doing it to succeed?” • Reason: “What are the three best reasons to do it? “ • Need: “How important is it to you to make this change?” • Commitment: “So, what are you willing to do now?”

41. Motivational Interviewing Process • Facilitate conversation by using O-A-R-S • Open-ended questions • Affirmation • Reflections • Summarize • Manage Commitment to the Status Quo (Often referred to as resistance) • Assist with Change plan

42. OARS: The Basic Skills of Motivational Interviewing • Open-ended Questions • Affirming • Reflective Listening • Summarizing

43. Forming Open Questions “Did you know that crack use during pregnancy put you baby at risk for serious health problems? “What do you know about the health effects crack use during pregnancy” “Do you want to go the treatment program?” “How would you feel about going to the treatment program?” “Are you thinking about getting clean?” “How do you feel about getting clean right now?

44. Open-Ended Questions • “How can I help you?” • “Would you like to tell me about_______?” • “How would you like things to be different?” • “What are the positive things and the less good things about_________?” • “What will you lose if you give up_______?” • “What have you tried before?” • “What do you want to do next?”

45. Open Questions to Promote Change Disadvantages of the Status Quo • How do you feel about your weight? Advantages of Change • What would the benefits be for you, if you were to lose weight ? Optimism for Change • What makes you feel that now is a good time to try something different? Intention to Change • What would you like to see happen? • How might things be different for you, if you did make a change?

46. Affirmations • Statements of recognition of client strengths. • Reinforces person’s participation • Builds rapport • Build confidence in ability to change • Enhances feeling of self efficacy • Must be congruent and genuine.

47. Reflective Listening “Reflective listening is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn’t. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen” (Miller and Rollnick, 1991)

48. Reflective Listening Is a process of… • Hearing what the speaker is saying, • Making a “guess” at what he/shemeans, • Verbalizing this “guess” in the form of a statement. Purpose: to check out and convey your understanding of what the patient is trying to communicate.

49. Levels of Reflection • Simple Repeating, rephrasing and staying close to content. • Amplified Paraphrasing – respond to the meaning/beliefs being expressed. • Feelings Respond to emotional dimension. Need for a “feelings vocabulary”.

50. Forming Reflections For starters… • It sounds like you are not ready to…… • It seems that you are having a problem with…. • It sounds like you are feeling .... • So you are saying that you are having trouble…….. As you improve, you can shorten the reflection…. • You’re not ready to…. • You’re having a problem with .... • You’re feeling that….. • You are having trouble with….