MOTIVATIONAL INTERVIEWING WITH A TWIST:
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1 MOTIVATIONAL INTERVIEWING WITH A TWIST: Facilitating Communication & Change with Policymakers Barbara DiPietro & Matthew Bennett
2 MERGING MI & ADVOCACY HCH turns 30 in 2015 & we are still in business Clinicians work in a larger context where homelessness & poverty are prevalent Upstream thinking: need to address systemic issues Ask ourselves: What causes the problems we see at the individual level? Overlap of mission and skills: clinicians are fundamentally problem-solvers We can t end homelessness by ending homelessness
3 FIRST, A DISTINCTION A FOCUS ON Identifying mutual values & goals Raising awareness Defusing tension Developing relationships Sharing concerns & ideas Facilitating change NOT A FOCUS ON Engaging in clinical work with policymakers
4 WHAT IS ADVOCACY? The act of requesting, supporting, or recommending Raising awareness Educating Facilitating Note: Advocacy is different from lobbying
5 HRSA & ADVOCACY HRSA PAL 99-12: Program Goals The goal of the HCH Program is to improve the health status and outcome of care for homeless individuals and families by improving access to primary health care and substance abuse services. Access is improved through outreach, case management, and linkages to services such as mental health, housing, benefits, and other critical supports. Providers in HCH programs seek ways to create new approaches to deliver comprehensive care, unite providers through collaboration, decrease fragmentation of human services, and advocate on behalf of homeless people. Available at:
6 HARM REDUCTION IN ADVOCACY Sometimes you can t make it better, but you can keep it from getting worse Relapse is part of recovery Human behavior & resistance to change is largely the same at the macro level Find agreement on some issues & set others aside Change is nearly always incremental
7
8 THE POLICY MAKING PROCESS Identify Problem Evaluation Identify Solutions Implementation Select Solution(s)
9 CHALLENGES TO ENGAGING Polarization and tension in politics Lack of time (personally & professionally) Lack of relationships with policymakers Lack of mandate within organization Lack of direct cause-effect between problems and policy solutions Don t know where to begin Don t feel like an expert Intimidated Similar to clinical engagement barriers in people?
10 WHAT POLICYMAKERS WANT To be re-elected (or re-appointed) & to make changes Legislators most likely to represent constituent interests when: They know precisely who their constituents are They interact with them frequently Their political futures depend on gaining and keeping constituent support.
11 Source: Pew Research Center, October 22, 2013.
12
13 ALL POLICY IS LOCAL Prohibition Slavery Voting laws Single payer Minimum wage Marriage (race/gender) Equal pay Gun laws Nuisance crimes Abortion Capital punishment Labor laws Immigration Housing eligibility Covered health services Drug laws Criminal sentencing Tax law
14 + THE BRIDGE TO MI
15 TEACHING ELEPHANTS TO DANCE Rider = Logical Brain Hope Change is Possible Self-confidence I can make it happen Needs a destination and the small steps needed to get there Elephant = Emotional Brain Empathy through personal connections motivates the elephant Sympathetic paralysis Will charge if it think it is in the them vs. us dynamic
16 MANAGING THE ELEPHANT Spirit of MI
17 SPIRIT OF MI (MI VS. MANIPULATION!!) Compassion Support verse confrontation Empathy for another s point of view and journey to get that view Acceptance The person and their view has some inherent worth Autonomy: The person has the right to their own decision Partnership Guiding (avoiding directing or following) You do less than half the talking Help person voice of change Evocation Person is the expert on the their position and point of view Person holds the wisdoms on how change works in their world
18 Open Ended Statements/ Questions OARS Affirmations Empathy Summaries Reflections
19 OARS Reflections Stay in the back seat Simple vs. Complex Affirmations Keep it positive Elicit past successes with difficult changes Keep the problem separate from the person Open Ended Questions and Statements Open vs. Closed 1:2 Ratio Do not use to direct Summaries Reflections that bring together several things the person stated Opportunity to state ambivalence Tool to build cognitive dissonance
20 DIRECTING THE RIDER Partnering to create a path forward
21 SHARED AGENDAS Person Shared Agenda Clients You
22 PERSON S AGENDA Always start with what the person wants to accomplish around the issue Person Understand barriers to action If you want the person to care about your agenda we must care about theirs Clients Shared Agenda You
23 YOUR AGENDA Connect your aspirations with the person s aspirations Person Make your goals personal Stories Pictures Your experiences Bring controlled passion to the table Clients Shared Agenda You
24 CLIENTS NEED Find the Us and avoid the Them Person Connect the person s aspirations for the future with meeting needs of your clients Clients Shared Agenda You
25 Ambivalence Focus Change Ambivalence Wanting more than one thing at the same time The desired things are incompatible with each other The committee inside the mind Which side has the majority? What needs to happen to change votes? Voting for the status quo = Sustain talk Sustain talk is natural Resistance is a result of the relationship Voting for new behaviors = Change talk Talk about the new behavior Research: Increase in change talk predicts actual change Your goal: Increase change talk
26 MI MOUNTAIN (Pre-) Contemplation Preparation Action
27 ZONE OF TOLERANCE We can tolerate some discrepancies, but the larger the gap the more stress it causes When stress becomes too great, we look for paths forward that bring us back into the zone This is one of most fundamental drivers of change A n x i e t y Research helps show think/actions are not inline with values or goals Cognitive Dissonance Zone of Tolerance Action in Line with Values
28 RESEARCH: ELICIT PROVIDE ELICIT Elicit Measure interest in the information you can provide Explore person s knowledge Provide Get permission REALLY important with expertise! Provide information building on what the person already knows Present information without interpreting its meaning for the person Elicit Discuss person s reaction (thinking/feeling) to the information Ask the person if they see anyway you can help them reach THEIR goals
29 VALUES: THE WONDERFUL WORLD OF COGNITIVE DISSONANCE Your objective: Find values that the person has voiced that support the change If you know something about the person s background (religion, family, history) utilize that to connect them personally to change GENTLY reflect back any discrepancies between values, research and past thinking/actions if the person doesn t see it on their own Do not make it personal Use shared agenda to find a way forward
30 TRANSITION TO PLANNING Transitional summary State that you would like to summarize what you have heard from the person Give a gentle recitation of the person s own change talk Planning Question What can I do to help you tackle this difficult problem? Do you see a way we can work together to improve the quality of lives for those in our community? Avoid commitment questions during transition What are you going to do? So are you going to do anything about this or not?
31 MI AT A LARGER LEVEL
32 MI & ADVOCACY: COMMON CHARACTERISTICS Possessing patience, compassion, partnership, acceptance Creating safe space & avoid confrontation Focusing on goals & aspirations Finding us and avoiding them Developing a shared agenda Working through ambivalence & resistance De-escalating tense issues and situations Understanding change processes
33 DISSONANCE AMONG POLICYMAKERS Political objectives & policy objectives often at odds Inconsistent viewpoints between subjects Seemingly irrational decision-making or sudden changes in positions Full understanding of impact of decisions may not be seen or understood
34 CHALLENGES ONCE ENGAGED Channeling emotions constructively & focusing on outcomes Defusing tension and preventing polarization Creating safe space that encourages ideas Recognizing difference between public and private persona Focusing on long-term relationship rather than short-term progress Remembering today s rival is tomorrow s ally, progress is slow/intermittent/erratic/unexpected
35 ADVOCACY ISSUE BREADTH
36 INFLUENCES Top factors that determine what health issues state legislators work on: 1. Constituent need or opinion 2. Evidence of scientific effectiveness Source: Dodson, et al. (2013.) State Legislators Work on Public Health-Related Issues: What Influences Priorities. J Public Health Management Practice 19 (1):
37 COMMON GOALS & VALUES GOALS Reduced homelessness Cost-savings Public health Public safety Individual well-being Healthy communities Productive citizenry Freedom Equity Liberty Patriotism Opportunity Choice VALUES
38 ADVOCACY OUTLETS
39 ADVOCACY AS SELF-CARE Engagement helps take back control & empower Greater awareness builds confidence & knowledge Change is possible and happens every day.
40 TAKE-AWAY POINTS Changes in people and systems have cycles that depend on engagement MI & HR clinical skills easily transfer to policy environment for macro-level change Facilitating needed change depends on relationships & effective communication Many issues & venues are available and policymakers are eager for your input.
41 CONTACT Barbara DiPietro, Director of Policy National Health Care for the Homeless Council Baltimore, MD or Matthew Bennett, Chief Innovation Officer Coldspring Center for Social & Health Innovation Nederland, CO or center
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