There are varying levels of Motivational Interviewing (MI) proficiency, and it is particularly challenging for outreach workers in homeless services to conduct advanced MI with fidelity. MI is a collaborative, person-centered approach to elicit and strengthen motivation to change. It offers providers a useful framework for interacting with people who are experiencing homelessness and struggling with mental and/or substance use disorders or trauma. MI is rooted in an understanding of how hard it is to change learned behaviors, many of which have been essential to survival on the streets.
MI’s central principle is that “motivation to change should be elicited from people, not imposed on them,” according to S. Rollnick and J. Allison in The Essential Handbook of Treatment and Prevention of Alcohol Problems. Rollnick later suggested that MI is “a person-centered form of guiding to elicit and strengthen motivation for change” in a 2009 article on ten things that motivational interviewing is not.
Imagine trying to elicit change talk when approaching a person living on the street who struggles with the use of alcohol. Strangers quickly pass by, or perhaps, a few acquaintances crowd in and interrupt a potential conversation mid-sentence. It just doesn’t work this way.
“Even well-trained professionals will struggle with practicing MI in the field, especially without coaching or feedback,” advises Mr. Steven Samra, a MI trainer and homeless outreach expert. Clarifying this comment he adds, “The challenge with street outreach is that change talk doesn’t happen until mutuality is built through a period of engagement.”
This is not to say that the spirit of MI is not a vital part of outreach. In fact, it is. Samra advises that reflective listening should be prioritized in street outreach, and this can lead to change talk. The ability to conduct advanced MI increases as engagement increases. Advanced MI becomes even more essential as people move into housing and receive wraparound services. “Keeping people in housing is the tricky part,” Samra added.
Since MI was first described in print in 1991, 25,000 articles and 200 randomized controlled trials have been published, according to W.R. Miller and S. Rollnick in Motivational Interviewing. SAMHSA’s Evidence-Based Practices Resource Center describes MI as a practice with key outcomes in alcohol use, negative consequences or problems associated with alcohol use, drinking and driving, alcohol-related injuries, drug use, and retention in treatment.
As a person-centered practice in homeless services, MI is particularly relevant and its roots can be applied well. Research suggests that the prevalence of alcohol and drug use disorders among people experiencing homelessness is high. A 2014 study on alcohol and drug use among homeless veterans found that 60% of program entrants had a substance use disorder and 54% of those with a substance use disorder had both alcohol and drug use disorders. In another study on mental health conditions, service use, and barriers to care, 500 people experiencing homelessness were interviewed, and 83% met the criteria for alcohol or substance use disorders.
The outcomes specific to MI in homeless services have been quite positive. Research has found that MI improved alcohol and drug treatment entry among veterans experiencing homelessness, and MI has been effective in reducing alcohol and drug risk among adolescents experiencing homelessness.
Yet, it’s important to note that practicing MI with fidelity requires feedback and coaching. It’s difficult to do this in the field where providers can easily fall into a pattern of repeating approaches that are inconsistent with MI, particularly approaches that have worked in the past. Feedback and coaching is often not available. However, it can be in other environments.
“In a formerly homeless individual’s home, you are on their turf, and they may let their guard down a little. At home, they often have time, safety, and solitude to reflect upon the conversation after you leave. This isn’t always the reality for those living on the streets or in a camp,” Samra said.
Samra offers the wisdom of his experience. As an outreach worker in Nashville, Tennessee, he regularly visited a local park in which one gentleman reliably resided on one of many benches. Only a few words between Samra and the man were exchanged over the course of many visits. It turns out that before engaging, this man meticulously watched Samra and studied how he interacted with other people. He paid particular attention to whether Samra followed through with his word. After three weeks, he told Mr. Samra that other outreach workers had promised him the sky and nothing had happened. He said, “I’ll give you three strikes and after that I’ll take what you offer but not what you promise.” Eventually, Mr. Samra was able to help him find housing.
Looking back on this experience, Samra said, “There is no way I could have used change talk before then.” Listening first worked. After that Samra could plant seeds for real change.
This article was published to highlight the April 2014 theme of Alcohol Awareness.
SAMHSA published a PATH Spotlight on Motivational Interviewing – 2010 (PDF | 2.6 MB) to assist grantees. Access more behavioral health and homelessness resources.