Module 4D: PERSPECTIVES ON CHANGE IN OUTREACH

To help participants understand the basic principles of how people change and to learn effective approaches to motivate people experiencing homelessness to make decisions to change.

The learning activities in this section are designed to engage participants with the subject material using informative and interactive approaches. Instructors will need to determine which, if not all, of these activities to carry out depending on a) participants’ learning needs and interests, b) the focus of the training, and c) time available.

Instructors are encouraged to prepare for each activity by reviewing the handouts to be given to participants and by reading the recommended resource papers and materials that are listed. These papers and materials, along with other relevant resources, will provide useful background information to assist in fulfilling the purpose of this section. The amount of time suggested for each activity should be adjusted as needed.

Introduction

How do outreach workers understand the need for behavioral change in the context of relentless poverty and homelessness? How do we deal with personal conditions and disorders so severe and chronic that the prospect of change seems all but hopeless?

Outreach workers go out on the streets and into shelters to make connections with people experiencing homelessness in order to help them better their lives and living situations. The ultimate hope is that their homelessness will be ended and they might be restored in body, mind, and spirit.

Workers offer help by reaching out, listening, providing material assistance, assessing, and attempting to prompt others to make change efforts towards certain goals. They aid this process by providing access to the necessary resources and support to do so. These changes may be as small as persuading someone to accept a cup of coffee or as significant as facilitating someone’s entry into treatment for an addiction.

Central to the role of the outreach worker is to be an "agent of change." Workers are like modern day peddlers who, instead of selling shoes and toothbrushes, "sell" the possibilities and opportunities for homeless people to improve their lives. Of course, as experienced workers know, this can be a hard sell especially given the multiple systemic barriers and personal vulnerabilities that interfere with transitioning from the street to stability.

There is an old adage that you can lead a horse to water but you can't make it drink.  This is indeed true, despite our human tendency to persist otherwise.  It is this notion of "leading to water" that is fundamental to outreach work.  Workers do this by conveying empathy, proving themselves to be trustworthy and demonstrating that they have the ability and expertise to help.

In addition it is the function of effective outreach to help create favorable conditions for clients to move in the direction of change and to fully support those efforts.  Madeline Hunter, author, adds this twist to the adage:  "They say you can lead a horse to water, but you can't make him drink. But I say, you can salt the oats."  Outreach workers in fact do what they can within the relationship and through advocacy efforts to "salt the oats" so as to promote client change and use of needed resources.

People who experience chronic homelessness face daunting obstacles in their quest to change and improve their lives. Often there are significant internal emotional and psychological hurdles to be overcome. Deep fears, mistrust, and a lack of self-efficacy related to past experiences are often present. Some people have essentially given up all hope.

In addition, a lack of available and/or appropriate external resources such as training programs, work, income, housing, social support, medical and mental health care present all-too-familiar barriers.

Various social and psychological theories have been put forth as to why and how people change. What they seem to have in common is that certain conditions must be met for people to decide to change their behaviors, attitudes or beliefs. Human beings don’t embrace change readily. In fact, we tend to resist it, even when change seems to be in our best interests.

Martin Fishbein, in Developing Effective Behavior Change Interventions, suggests that across these theories there appear to be common variables that underlie one’s ability to initiate and sustain change efforts. He states that "generally speaking, it appears that in order for a person to perform a given behavior one or more of the following must be true:

• The person must have formed a strong positive intention (or made a commitment) to perform the behavior;

• There are no environmental constraints that make it impossible to perform the behavior;

• The person has the skills necessary to perform that behavior;

• The person believes that the advantages (benefits, anticipated positive outcomes) of performing the behavior outweigh the disadvantages (costs, anticipated negative outcomes);

• The person perceives more social (normative) pressure to perform the behavior than to not perform the behavior;

• The person perceives that performance of the behavior is more consistent than inconsistent with his or her self-image, or that it’s performance does not violate personal standards that activate negative self-actions;

• The person’s emotional reaction to performing the behavior is more positive than negative; and

• The person perceives that he or she has the capabilities to perform the behavior under a number of different circumstances …"

Considering these variables, it is not surprising that people facing unremitting poverty, homelessness, and illness often find it difficult to initiate and sustain changes in their lives. And yet, many do succeed in making positive changes.

In this module we will examine three distinct but interconnected change concepts that have been found to be particularly relevant and useful in the Health Care for the Homeless approach to care.

• The Stages of Change model provides a framework to understand the change process on a continuum (or spiral).

• Motivational Interviewing is a client-centered, directive approach focused on resolving ambivalence in the direction of change.

• Harm Reduction is a client-centered approach that recognizes that change is often incremental and that any positive change which results in reducing the negative impact of a behavior is seen as significant.

Purpose: To provide an overview of three change concepts – stages of change, motivational interviewing, and harm reduction – and their relevance and application to outreach with people experiencing homelessness

Time: 60 minutes

Materials:

• Handout: Motivating Change in Outreach (Download the PowerPoint presentation, Motivating Change in Outreach, and print out six slides per page = total 8 pages)

• Optional: Additional selected handouts from Activities 2, 3 and 4 below

• Optional: LCD projector, projection screen, downloaded PowerPoint presentation from laptop computer or overhead projector with transparencies of individual slides

Preparation: Download and preview the PowerPoint (PP) presentation or review the handout that contains printed copies of the presentation slides. Choose the method by which you will make this presentation. Options include:

1. download the PP slides and use an LCD projector and screen

2. use overhead projector in which case you will need to make transparencies/overheads for each slide

3. use printed copies of the slides only.

Whichever method you use, plan to provide a handout of the PowerPoint slides to each participant.

Prepare notes and illustrations for your presentation. It may be useful to review the handouts and resources listed in Activities 2, 3, and 4 in this section for background information. In addition, books such as Motivational Interviewing by Miller & Rollnick and Changing for Good by Prochaska, Norcross and DiClemente are valuable to read. Also, you might browse the Internet for additional information about these change concepts.

Procedure:

1. Make a presentation to the group using the slides/transparencies/handouts as a basis for your teaching. Use illustrations as much as possible. Invite participants’ questions and comments.

It is recommended that you devote time during this presentation or some other time to practice some of the basic skills of motivational interviewing as outlined in the OARS handout: Open-ended questions, Affirmations, Reflective listening, and Summaries. See Module 3 Listening with All Six Senses for practice activities specific to reflective listening and summarizing.

Purpose: To explore the process by which people make change decisions in their lives

Time: 20-25 minutes

Materials:

• Handout: Stages of Change

• Resource Paper: Five Stages of Change

Preparation: Review the resource paper and the handout. The resource paper provides a more detailed description of the stages of change than the handout. If desired, the resource paper could also be used as a handout.

For additional reading, refer to the book Changing for Good by Prochaska, Norcross and DiClemente, 1994, or look up web-based resources on this topic.

Procedure:

1. Summarize and briefly discuss with the group the five stages: pre-contemplation, contemplation, preparation, action and maintenance. Also comment on the concept of relapse. Include the following key points:

• Behavioral change may involve starting, ending, increasing, decreasing or altering a particular behavior. Behavior is defined broadly, not only referring to physical behaviors, but also to thoughts, attitudes and beliefs.

• The change process is not necessarily linear. It’s often more like a spiral than a straight line. Sometimes it is "two steps forward, one step backward."

• The stages are not totally distinct from one another. They operate more like run-on sentences that merge and tangle with one another.

• Stages cannot be skipped in general. One must move through each one eventually.

• People move through the stages at their own pace and timing. For example, some linger for years in one or more of the pre-contemplative, contemplative or preparation stages. Others move quickly through them into the action phase.

• Each stage (and relapse) requires a different stance and response by the care provider.

2. Next, give an example of a simplified change process in which one advances through the various stages in a brief and linear manner, for the purpose of illustration. Use the following example or make up your own.

Pre-contemplative: All of your clothes are dirty and in need of laundering, but you ignore this and basically choose not to think about it.

Contemplative: You run out of clean clothes and come to the realization that you probably ought to clean them, especially since someone made a comment about it today. Still, you have a tempting thought that surely you could get by a few more days!

Preparation: You make a mental note that you have to buy more laundry detergent at the store. You sort your clothes into piles and decide you’ll do one pile each evening until you’ve completed the job.

Action: You wash your clothes over the course of several days.

Maintenance: You decide that rather than letting your laundry pile up until you have nothing to wear, you’ll do one load of laundry each week to make the task more manageable.

3. Now ask participants to come up with their own examples either true to life or imagined. Have participants share their examples with someone else or the whole group. This exercise helps give a clearer sense of what each of the stages entails.

4. As a final step, present a case of an outreach client with whom you have worked over time (or have a group member provide a case example). Choose a particular issue illustrating the client’s movement through the five stages of change from pre-contemplation to maintenance. For example, persuading the client to receive medical or mental health care, to apply for financial entitlements, to seek treatment for chemical dependency, or to access housing. Discuss the various barriers that had to be overcome. Also, note the movement back and forth between the various stages that occurred.

Purpose: To become familiar with the basic tenets of motivational interviewing and its usefulness in outreach

Time: 30-40 minutes

Materials:

• Handout: What is Motivational Interviewing?

• Handout: Motivational Responses Based on Stages of Change

• Handout: GRACE: Five Principles of Motivational Interviewing

• Handout: OARS: The Basic Skills of Motivational Interviewing

• Handout: Open-ended Questions & Affirmations

• Handout: Reflective Listening

• Handout: Summaries

Preparation: Review the various handouts above related to motivational interviewing. Prepare a presentation that provides a basic primer on this topic using the handouts as a guide.

For additional reading, refer to the book Motivational Interviewing by Miller and Rollnick , 1991 or 2^nd edition 2002. There are various useful web-based resources on this topic as well.

Procedure:

1. Distribute the seven handouts to participants.

2. Give a didactic presentation on motivational interviewing using the handouts as supporting material. Allow ample time for questions and clarification.

3. Continue the activity by taking time to practice the skills of asking open-ended questions, using affirmations, listening reflectively, and summarizing. For guidance, refer to Activities 4 and 6 in Module III, Section C on "Listening with all Six Senses." If the group practiced these skills previously in the training, consider moving on to the next step.

4. Break into groups of three for a role-play exercise in which there is a designated outreach worker, a homeless client, and an observer in each group.

• The client assumes the role of a homeless person living on the streets. He or she assumes a certain persona with various concerns or problems common to those experienced by homeless people. For example, the person might have a heroin addiction, an abscess that is getting worse, is feeling hopeless, or needs medical and addictions treatment but doesn’t trust "professionals."

• The outreach worker has had some contact with the individual in the past and has established some rapport and trust. On this contact there seems to be an opening to talk in greater detail about the homeless individual’s situation.

• The observer listens in on the interchange between the worker and client without making any comments or directly participating in any way.

5. Instruct the outreach worker and client to enter into a "typical" conversation. The worker is to listen for what stage of readiness for change a client might be at given a particular problem that the client raises. The worker thus responds accordingly using the basic skills of motivational interviewing. The worker should try to use each basic skill (open-ended questions, affirmations, reflective listening, and summaries) as often as possible during the interaction.

6. During the role-play the observer is to note, preferably in writing, in what manner and how frequently the outreach worker uses each of the four skills.

7. At the completion of the role-play, the interviewer and client discuss what the experience was like from each person’s perspective. The observer reports on the results of her or his observations of the worker and adds other comments or insights as appropriate.

8. If time permits, conduct three different role-plays in which each participant is given an opportunity to play all three roles.

Purpose: To develop a basic understanding of the concept of harm reduction and its applicability to change in the outreach context

Time: 20 minutes

Materials:

• Handout: Principles of Harm Reduction

Preparation:

The concept of harm reduction is variously referred to as 1) a philosophy of care, 2) a set of public health interventions, and 3) a grassroots advocacy effort. The primary focus for this activity is on harm reduction as a philosophy of care based on the principles noted on the handout.

Harm reduction as a philosophy of care is a client-centered approach that acknowledges that behavioral change is often uneven and incremental. In this approach, the client determines the pace and steps toward change. The role of the worker is to help motivate the person in the direction of change using the stages of change concept to identify the client’s readiness for change. Any step in a positive direction towards change is considered significant in the harm reduction philosophy.

The notion of reducing harm or risk is not a new idea. Human beings have practiced it since the beginning of time. Virtually all of our routine activities of moderation, self-care, and self-protection are intended to decrease risk or harm. It seems that the controversy that surrounds harm reduction is related to its application to certain controversial behaviors than to the concept of harm reduction itself.

Review the handout and prepare a brief presentation on the concept of harm reduction with an emphasis on the definition, goals, and principles of harm reduction as a philosophy of care.

Suggested background reading:

• Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors by G. Alan Marlatt. Guilford Press, 1998. 

• Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions by Patt Denning, Guilford Press, 2000. 

• "Harm Reduction: Concepts and Practice" www.ccsa.ca/docs/wgharm.htm

Procedure:

1. Begin by asking the group to name as many examples of harm reduction practices in everyday life that they can think of. Encourage them to think broadly in regard to personal behaviors as well as public health interventions. Some responses you might expect to hear:

E.g. seatbelts, bike helmets, brushing teeth, bathing, eating non-fatty foods, filtered cigarettes, nicotine gum/patches, drinking moderately, condoms, methadone, bleach kits, needle and syringe exchange, education, sewage systems, fluoride in drinking water, vaccinations, health screening, garbage pickup, alcohol server training, etc.

2. Distribute the handout. Give a brief presentation about harm reduction, drawing from the comments in the preparation section above, the handout, your own expertise and other reading. Provide examples from your own outreach experience in which you employed a harm reduction approach.

3. Facilitate a group discussion asking participants to share their own thoughts and questions about using a harm reduction approach in outreach. Encourage them to share examples from their own outreach experience. Acknowledge that this issue remains a controversial one for some providers. Explore these varying opinions within the group.

4. Close the activity by summarizing the connections between the concepts of stages of change, motivational interviewing, and harm reduction and their applicability to outreach to people experiencing homelessness.

Back to Top

This project was funded through a Cooperative Agreement with the Health Care for the Homeless Branch, Division of Programs for Special Populations of the Bureau of Primary Health Care/HRSA January 2002.