Motivational interviewing seeks specific solutions
Interventions shift responsibility to the clients
The key to a four-session HIV prevention for positives program targeting Latinos, called Positively Latino, is the adaptation of the theoretical model of motivational interviewing, which is a different approach than the traditional case management model.
"Motivational interviewing allows the client to make a decision based on his or her own motivations," says Deanna McPherson, MPH, CHES, capacity building coordinator for PROCEED Inc. in Elizabeth, NJ. "It’s the interviewer’s responsibility to try to find ways to motivate the client to try to make a change in risk behaviors."
This approach works particularly well with HIV-positive clients because it shifts the responsibility for preventing HIV transmission to them without shifting blame for the epidemic, she says.
McPherson explains how the Positively Latino program, which mostly is conducted in Spanish, works:
First session: This includes a pre-test and obtaining the client’s consent for videotaping the session, she says. It lasts 90 minutes.
The counselor or case manager, who has been trained in motivational interviewing will discuss the concept with the client. The counselor also will talk with the client about HIV prevention methods and the person’s own responsibility, McPherson says.
The counselor discusses the client’s motivation for change and emphasizes that the counselor is not there to try to change him or her because that is up to the client, she adds.
"Then they’ll spend time looking at the client’s point of view of the problem," McPherson says. "The counselor, using skills of motivational interviewing, asks open-ended questions with affirmations. For example, the client might say, I don’t use condoms all the time, but I use them with my main partner.’
"Then the counselor will reply, It’s good that you’re using them with your main partner and perhaps using condoms with your other sexual partners is something that you can think about working on or that you might like to work on,’" she continues.
The client will fill out a questionnaire that asks how many sexual partners the client has had and whether the client knew his or her partners’ HIV status. The questionnaire also asks about alcohol and substance use and how that might impact sexual risk. There also are questions about depression and whether a client feels threatened by a partner, McPherson says.
The form also inquires about whether clients feel responsibility for protecting partners or themselves from sexually transmitted diseases (STDs), she adds.
"Then after they fill out the feedback forms, the counselor spends some time with them on commitment to change, and the counselor would see whether the client is ready to make a change, and what the roadblocks are to thinking about making a change," McPherson says.
Second session: This is held a week later. The counselor asks what has changed in the person’s life and then re-emphasizes what was discussed in the first session, she says. Then the counselor returns to the idea of a change plan and discusses developing it or reviewing a change plan if one had already been made, McPherson explains.
A change plan worksheet is available as a template, and it includes open-ended statements, such as the following:
- "The changes I want to make are . . ."
- "The most important reasons I want to make these changes are . . ."
- "The main goals for myself for making these changes are . . ."
- "I plan to do this to reach my goals . . ."
Then the client may list a plan of action, a target date, and steps that he or she may take to make a change and what might interfere with that change, McPherson notes.
It’s also important that the client identify other people in his or her life who can assist with the change and the specific ways those people can help.
Clients and counselors then discuss the goal of positive results and how the client will know whether the plan is working, she says.
"What we found and some preliminary results found was that often clients were using condoms when they were having sex, but their main problem was depression and dealing with being positive and disclosing their HIV status to friends and relatives, McPherson recalls. "Their social network was small, and the stigma of being a Latino who was HIV-positive was difficult."
Third session: During this session, clients complete a second questionnaire that is more specific to the drug and alcohol abuse. It asks how long the person has known his or her HIV status, whether the client is taking HIV antiretroviral drugs, and what the last viral load count was, McPherson says.
The client is asked whether in the last six months he or she used alcohol, poppers, crystal methamphetamines, downers, party drugs, marijuana, or other substances, she notes.
The third session also reviews the two previous sessions, and counselors spend time talking about the client’s progress and barriers to change, she adds. "Counselors attempt to ask for a commitment or reevaluate the plan if one has been made.
"The session ends with a summary of what was transpiring in session two and provides a summary of change plans for risky sex or other problems identified in that session," McPherson says.
Fourth session: A introduction and review of the previous three sessions are held, and the counselors return to the theme of change plans, she says.
"The counselor and client review the change plan to see what the barriers or challenges are," McPherson explains. "What happened with many counseling sessions is clients went into a whole realm of family issues and drug and alcohol issues, and it took some time to get back to the reason for their being in that session."
Counselors then will discuss sexual behaviors and whether the client has used condoms in recent days, she adds.
"The fourth session evaluates the work done and looks at future work and then assesses the client’s commitment to change," McPherson says. "Then the counselor will make referrals."