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Introduction

Motivational interviewing is a way for medical professionals to have a constructive conversation with their patients about change. Motivational interviewing involves a collaborative approach where the patient is the expert on their own life in effecting change and the medical professional helps to reduce ambivalence through this intervention (Miller & Rollnick, 2013). Behaviors that individuals who are homeless might want to change include:

• Increasing employment opportunities
• Medication adherence
• Alcohol use and abuse
• Management of comorbidities

Occupational therapists can use motivational interviewing to help individuals who are homeless engage in these behaviors and have more success in their daily lives.

Theory

The transtheoretical model can be used to measure a patient’s status on changing. The patient can move through the stages and go from not being ready to change, being ready, planning different strategies to continue changed behaviors, and to maintaining the behavior change (Brown, 2012). Occupational therapy practitioners must note what stage of change the patient is currently in, in the transtheoretical model. When considering the stage their patient is in, we can further develop change in the individual by helping them progress to the next stage.

Evidence

A chronological account found motivational interviewing to be significantly effective in improving motivation for change in urban homeless population (Crouch & Parrish, 2015). They reviewed health surveys for improved health status, decreased recidivism, and housing retention.

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness. While adhering to Fitzroy’s prescribed medication, he successfully lived with roommates and began work training.  Shortly after, however, he reported the use of an herbal remedy, described as a “cure” for schizophrenia, was a better alternative to taking his prescribed medications to manage his symptoms.   Consequently, Fitzroy began to engage in aggressive behaviors toward his roommates and experienced increased difficulties with work training tasks.  Fitzroy was referred to an occupational therapist at The Fountain House to address his recent difficulties with medication management and minimize aggressive behaviors.

Intervention Plan

Problem Statement

Fitzroy demonstrates a lack of consistency in taking his schizophrenia medications daily, thus affecting his ability to maintain employment.

Long Term Goals

1. Fitzroy will identify three positive reasons for being compliant with his medications to increase adherence in medication management within 4 months.
2. Fitzroy will adhere to medication prescriptions for medication management 6 out of 7 days a week within 4 months.

Short Term Goals

1. Fitzroy will identify 1 positive reason for being compliant with his medications to increase adherence in medication management within 2 months.
2. Fitzroy will adhere to medication prescriptions for medication management 4 out of 7 days a week within 2 months.

Intervention Format

Individual

Setting

Fitzroy will participate in occupational therapy sessions at the Fountain House for 15 minutes 5x a week.

Supplies

None

Agenda

• Meet Fitzroy and begin developing therapeutic relationship and trust (5 min)
• Assess Fitzroy’s readiness for change (2 min)
• Engaging in motivational interviewing focused on medication management (18 minutes)
  • Potential open-ended questions
    • • • “How have you been feeling recently?”
        • “What are you doing to help manage your symptoms?”
        • “Explain to me how you feel when you take your medications?”
        • “What do you think is preventing you from being compliant with your medications daily?”
  • Provide affirmations
    • “It sounds like you know how important it is to take care of your body”
    • “You have been doing a great living with your roommates.”
    • “You are a motivated member of the Fountain House”
  • Provide reflections
    • “I hear it didn’t work out with your roommates, what has changed from last week to this week?”
    • “It sounds like you are unable to control some of your symptoms, primarily your aggression towards others. What do you think is the cause of this?”
    • “Do you think it is important to maintain a job? If so, why?”
  • Provide a summary of the discussion (5 min)

Documentation

S: “I want to live in the Fountain house and work, but no one gets along with me.”

O: Client presented for 15-minute session focusing on medication management using a motivational interviewing approach. Client reported that he was unable to adhere to his medications 4 out of 7 days a week. Client explained his frustration towards other members of the Fountain House and how demonstrated an interest in managing his symptoms. Client does not have a regimented schedule for medication management and does not have any routines or habits to maintain adherence or compliance. Client reported that he wants to remain living in the Fountain House. With permission, the therapist helped the client identify 2 pros and cons of taking the herbal remedy versus his prescribed schizophrenia medication.

A: Client presents with a lack of medication management strategies and insight resulting in a decreased ability to maintain employment and having positive relationships with roommates. Client is currently in the precontemplation stage of change and would continue to benefit from skilled OT services to help client to continue advancing in medication management.

P: Client would benefit from additional therapeutic discussions using a motivational interviewing approach to improve his understanding of the consequences of his aggressive behaviors and the importance of adhering to his medication. Client to see OT 5x/week for 15 minutes each session.

References

Brown, C. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: AOTA Press. ISBN-13: 978-1-56900-331-2

Crouch, C., & Parrish, D. E. (2015). Implementing Motivational Interviewing in an Urban Homeless Population: An Agency-University Collaboration. Research On Social Work Practice, 25(4), 493-498

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing, Third Edition : Helping People Change. New York, NY: The Guilford Press. ISBN 978-1-60918-227-4