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Motivational Interviewing: Drawing Out the Homeless

The sight of a bag lady or man pushing a grocery cart carrying their few worldly possessions is unnerving and all too common. On any given night in cities and towns across the U.S., the estimated number of individuals living on the streets is nearly 672,000. In the course of a single year, an estimated 1.5 million people use the homeless shelter system. Who are these people and why can’t they get off the streets? What’s being done to help them or get them to help themselves? The issue is a complex one and involves not only outreach but considerable effort to help draw out the homeless. One technique that is particularly effective is motivational interviewing.

Who Are the Homeless?

Looking at the bag lady, it’s easy to jump to conclusions or make snap judgments – many of which turn out to be false. This person must be lazy, a bum, mentally ill, a criminal – the list goes on. The fact is that the homeless population in America includes individuals from all backgrounds. They include entire families, elderly individuals, youth, single adults, and veterans. Among all homeless adults, an estimated 23 to 40 percent are veterans. Homelessness is not confined to the big cities, but occurs in small towns, suburbs and rural areas as well.

Besides being homeless, these individuals often suffer from substance abuse and/or mental health disorders, or have a disability or are in poor physical health. According to the National Coalition for the Homeless (NCH), 20 to 25 percent of the homeless population in the U.S. suffers from some form of severe mental illness. This compares to only 6 percent of Americans with a severe mental illness (National Institute of Mental Health, 2009). In fact, mental illness, says the NCH, is the third largest cause of homelessness for single adults.

Homeless individuals may have lost their job, home, car, experienced bankruptcy, or had a severe trauma. Domestic violence is often an immediate cause of homelessness for women and children. Chronic homelessness, although representing a small percentage of the total homeless population, nevertheless consumes more than 50 percent of the available services. About 9 percent of the homeless live in rural areas. There is no single “face” of the homeless, and addressing the problem of what to do for the homeless requires understanding the complexity of the problem.

Risk Factors for Family Homelessness

Research has identified the lack of affordable housing as the primary cause of homelessness among families. The threat of homelessness is a constant pressure among poor families who are struggling to meet monthly mortgage payments or to pay the rent. According to the National Alliance to End Homelessness, there are other factors or predictors, characteristics that homeless families tend to share. These include:

  •  Extremely low incomes
  • Tend to have young children
  • Headed by a younger parent
  • Homeless children have high rates of anxiety, depression, behavioral problems and poor school performance
  • Homeless poor families have high incidences of domestic violence and mental illness

What is Motivational Interviewing?

Motivational interviewing (MI) is a person-centered, empathic guiding approach that can lead people to make significant changes in their lives. This is the definition of MI used by Ken Kraybill and Steven Samra in a recent webcast, Guiding People toward Change: the Spirit of Motivational Interviewing, available through the Homelessness Resource Center, part of the Substance Abuse and Mental Health Services Administration (SAMHSA).

The practice of MI involves a unique and creative approach of combining spirit and technique. Some have referred to it as a means of practicing “kindness with skill.” During the webcast, the presenters explored what is meant by MI, why it’s essential, and how it can be more useful in providing care for people who are experiencing homelessness. In other words, MI is an approach utilized to reach and draw out the homeless, to get them ready to accept change and to become motivated to change their circumstances.

The presenters know what they’re talking about, having had a great deal of experience in the field. Kraybill, who works as a technical assistance specialist for the Homelessness Resource Center, has worked in the behavioral health, health, and homelessness arena for the past 27 years. He has developed curricula, research guides and workshops to help inform others and equip them to work in the field. He currently provides training nationally on topics that include motivational interviewing, outreach and engagement, supervision, and personal and organizational wellness.

Samra recently joined the HRC as a recovery specialist and is also a veteran’s service coordinator with Operation Stand-Down in Nashville, Tennessee. After spending more than 30 years in and out of homelessness and battling addictions, Samra pulled himself together and received his BA and MPA at Cal State in Chico (in 2000). His life since then has been dedicated to helping pull others out of the street. He currently assists homeless veterans in and around Nashville.

How MI Works

In essence, MI works because it is a collaborative relationship between the counselor (provider) and the homeless individual. To be most effective, trust must first be established. Kraybill and Samra describe the relationship as being more like a partnership than being in an expert or recipient role.

The spirit of MI involves a counselor showing genuine interest in the homeless individual, believing in him, encouraging him to think creatively, and thus making learning interesting and fun for the homeless individual.

It is important to note at this point that motivation is elicited from the client (the homeless person), and not imposed upon him by the counselor. The chief task of the counselor, then, is to help facilitate expression (verbalization) by the client and guide him towards a resolution that triggers change. This often takes a non-linear approach, as direct persuasion is not an effective tool to resolving ambivalence. You can see this at work by thinking how trying to talk people into change rarely works. While it may be seen as helpful, it is just as likely to backfire as you meet resistance from the person you’re trying to persuade to change. In contrast, the counselor in MI quietly helps the person to examine the source of his ambivalence, and directive in the sense that he guides the client.

An individual’s readiness to change, then, is not a trait. It comes about as a direct result of interpersonal interaction. Denial is feedback regarding the counselor’s behavior. It is resistance. You cannot overcome resistance by bulldozing through it. A more empathic approach is needed.

Many homeless individuals have lost hope – hope in the system that has failed them, hope in themselves, hope that there’ll ever be a more promising future. Experts in treatment know that without hope, there can be no lasting change. There is no motivation without hope for the future. The spirit of MI is such that the counselor infuses hope to the client. By refusing to give up on the client and by providing a lifeline of hope, spirit, and belief that things can be changed, the counselor carries hope for the client. Kraybill and Samra liken it to being a “hope lender” for the client. The counselor believes in the client even when the client can’t believe in himself. One of the beautiful aspects of MI is that when clients do change, they will often make statements like, “I was only able to do this because someone believed in me.”

  • Each partner has expertise – An interesting way of looking at MI is that each person in the partnership has some type of expertise and/or wisdom. A collaborative partnership or relationship is side-by-side, not face-to-face. Side-by-side implies collaboration, whereas face-to-face is confrontational.
  • Goals are set collaboratively – Instead of a top-down approach, in MI, goals are set collaboratively. Once mutually agreed-upon, the client is given a menu of options as to how to achieve those goals.
  • Approach matches readiness with personal choice – The type of approach takes into consideration the client’s readiness to change and emphasizes personal choice and autonomy. Ambivalence is seen as a normal part of change. It just means that a slightly different approach may be needed to counter the ambivalence and help the client to soften his resistance to change.
  • MI requires responsiveness – In order to draw out the homeless, the counselor needs to come from a place of quiet and reflection. He needs to be responsive, mindful of the present, grounded and centered. He cannot be reactive. Reaction is fear-based and all about defense.
  • Two main areas to eliciting change – One of the key elements in MI is to use skills to elicit change. Two main areas to helping people change is to establish a strong relationship of trust and safety, and to get the client to talk about change.

Talking about their lives, telling their “stories” is often very difficult and painful for the homeless individual. Mental illness, intoxication, neurological and developmental disorders, and brain injuries can often deprive the individual of the capacity to relate their stories or to locate themselves in the real world. Their narrative, thus, may take on bizarre or extreme dimensions. In order to get the client to a place where a coherent story can be shared, especially if the homeless person also has a disability or illness, may involve exercising great patience and a careful approach on the part of the counselor.

When the counselor invites the client to share his story, it’s a non-threatening way to gain the person’s trust and to form a picture of the individual’s life. Sharing a little of the counselor’s own story builds confidence and common ground. The shared “humanness” helps solidify the trust and encourages the client to proceed further toward goals.

Living on the street often builds estrangement. The individuals are literally alone and to themselves, being estranged from society, separated from ordinary activities, relationships, and a sense of place and purpose in the world. The longer homelessness persists, the deeper this sense of isolation and estrangement becomes. Reaching out to the client with MI allows hospitality – an invitation to relationship.

Hospitality implies no strings attached. There are no rules to follow, no judgment and no demands. The counselor is giving of his heart in order to help the client. Within this spirit of hospitality, the trust that builds allows the client to freely tell his story. Once the story is shared – past, present, and future – self-reflection and restoration can begin. The fertile ground for hope and change to sprout and take form can follow.

How does hospitality work? Imagine the first encounter by a counselor with a homeless individual. This may have been a referral or a chance meeting. The variations are endless, but the specifics are simple. Hospitality could be sharing a cup of coffee, a smile, acknowledgement, listening without interruption, offering a word of encouragement, or just being with the person in silence. To be effective, the counselor has to see the big picture, and not an instant fix. In MI, there is no quick fix. It is all about the big picture, the long-term desired results, always emphasizing the client’s personal choice and autonomy.

  • Reflective listening is important – The counselor using MI needs to listen reflectively. This means eliciting and selectively reinforcing the client’s self-motivational expressions of problem recognition, concern, desire and intention to change, and ability to change.
  • No jumping ahead – Gauging the client’s ability to change in MI means the counselor cannot jump ahead. If the client is not yet ready to change, jumping ahead of his ability to do so will only bring about resistance.

Future for MI in Drawing Out the Homeless

As for the future use of MI in drawing out the homeless, it would seem that the effectiveness of the technique to-date bodes very well for its continuation. As many MI proponents have contended, there is no win-win in a confrontational approach. Thus, the use of the collaborative, empathic MI approach is more effective in helping to build trust and guide the homeless client toward a willingness to change. MI is grounded in mutual trust, and an emphasis on the client’s personal choice and autonomy.

MI works not only with homeless individuals, but also with those who may be concurrently suffering from alcohol or other substance abuse, mental disorder, and disabilities. It is a more human technique, the so-called means of “practicing kindness with skill.”

As more MI counselors are trained, perhaps the great isolation and walls of resistance of thousands more of the currently homeless can be bridged and removed. This will allow an open pathway upon which to build and create a blueprint of change for the future.

There is still hope.

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