Motivational interviewing with individuals at risk of sex trafficking

Motivational interviewing: A client-centered practice technique

As a directive and client-centered framework, motivational interviewing is a “collaborative conversation style for strengthening a person’s own motivation and commitment to change” (Miller & Rollnick, 2013, p. 12). Social workers frequently integrate motivational interviewing in client assessments, brief-focused interventions, or multiple ongoing sessions across mental health and health fields (Clarke et al., 2012; Field et al., 2016; Gaughran et al., 2013; Miller & Rollnick, 2013; Rollnick & Miller, 1995; Weir et al., 2009). There is strong support (including Cochrane reviews and multiple meta-analyses) for using motivational interviewing to successfully reduce substance use and sexual risk (Diclemente et al., 2017). For example, one meta-analyses found that motivational interviewing interventions for adolescents were effective across substance use behaviors, varying session lengths, different settings, and different levels of provider education (Jensen et al., 2011). Importantly, controlled research studies of motivational interviewing have demonstrated a 10–20% more effective than no treatment and that motivational interviewing can be learned optimally via a two-day interactive workshop followed by supervision and coaching (Lundahl & Burke, 2009). Sometimes motivational interviewing can be used as a pre-treatment before engaging in more intensive programs, such as inpatient programs or longer term cognitive behavioral therapy (CBT; Lundahl & Burke, 2009). As such, motivational interviewing should be implemented by social workers across settings who may encounter people working on changing behaviors (e.g. substance use, sexual risk behaviors, etc.), and sometimes used with other treatments such as CBT.

Motivational interviewing uses a client’s ambivalence to explore potential barriers and changes while supporting the client’s self-efficacy (their belief and capacity to control their own behavior and motivation). This approach is well suited to social work, which promotes clients’ socially responsible self-determination and works to enhance capacity and opportunity to address their own needs (NASW, 2019). Unlike confrontational practice approaches, motivational interviewing is neither authoritative nor a punitive or coercive in manner, which would leave the client in a passive role (Rollnick & Miller, 1995). Rather, motivational interviewing suggests that understanding a client’s values and providing feedback of risk and harm can help to strengthen the individual’s internal commitment to changing their own behavior (Miller & Rollnick, 2013). Motivational interviewing consists of four specific phases: engaging (relational foundation), focusing (strategic direction), evoking (preparing for change), and planning (bridging to change) (Miller & Rollnick, 2013). The engaging phases use a series of open-questions, affirmations, reflections, and summary statements (also known as OARS) to understand the nature of the person’s issue, motivation to change, and how change has been addressed in the past. Next, the client and practitioner focus on which direction is needed to address the problem or need. They may engage in agenda mapping to understand various options and goals, which must be narrowed. Importantly, the client likely knows the arguments both for and against the change so the service provider must be careful not to argue for the change while the client argues against it. Then, the client and practitioner engage in preparing for change, which involves assessing for readiness, importance, and feasibility of the change. Finally, planning for the change will occur, which will involve reinforcing public commitments, maintaining social supports, self-monitoring, and accessing resources. Motivational interviewing integrates social work values such as client self-determination and respecting the dignity and worth of a person by facilitating commitments to their self-identified goals.

Motivational interviewing as a possible intervention with individuals at risk of sex trafficking

Sex trafficking occurs when (1) a minor exchanges sex for financial compensation (known as a commercial sex act) or (2) an adult (over the age of 18) is induced through force, fraud, or coercion to perform a commercial sex act (22 U.S.C. §7102). Financial compensation for commercial sex acts can include food, money, clothing, housing, and drugs. Individuals at risk of sex trafficking inclusively refer to minors and adults who are vulnerable to participating in commercial sex acts in order to support themselves because of homelessness or poverty, or who are coerced or forced by abusive family members, partners, or, less commonly, acquaintances or strangers. Victims of sex trafficking often do not see themselves as such because of the circumstances in which sex trafficking occurs (Gerassi et al., 2018; Hoyle et al., 2011; Reid et al., 2017). For example, some individuals, mostly documented as young women and girls, are romantically involved with a trafficker (commonly known as a “boyfriend pimp”) and view their participation in the commercial sex industry as a choice made in the context of their relationship (Gerassi et al., 2018; Lloyd, 2011; Nichols & Heil, 2014; Raphael et al., 2010; Reid, 2010). Additionally, some runaway or throwaway LGBTQ+ youth experience rejection in their homes and begin sex trading (legally considered sex trafficking among minors) in order to support themselves (Curtis et al., 2008; Dank et al., 2015; Heil & Nichols, 2015). Some sex workers, who choose to sell sex as their profession, may also have circumstances that heighten the vulnerability (as described above), while other sex workers do not (Kurtz et al., 2005; Oselin, 2014). Because of associations with substance use, sexual risk behaviors, homelessness, poverty, and violence. social workers may encounter individuals at risk of sex trafficking in services that address homelessness, substance use disorders, intimate partner violence (IPV), mental health, and sex trafficking or prostitution. As such, social workers could explore the circumstances and motivations behind sex trading and other sexual risk/substance use behaviors and work with these clients to seek out alternative options, as needed or wanted.

To address the dynamics associated with sex trafficking (such as substance use, IPV, homelessness, etc.), motivational interviewing is recommended when discussing behaviors or contexts that may enhance one’s risk to sex trafficking, such as sex trading or a relationship with a potential trafficker (Cohen et al., 2017; ECPATUSA, International, S. H., The Protection Project, & John Hopkins University, 2013; Roe-Sepowitz et al., 2012). Motivational interviewing has often been utilized as a core part of programs aimed to serve this population, with the goal of increasing health outcomes (Burnette et al., 2008; Center for Substance Abuse Treatment, 2012; Gaughran et al., 2013; Wilson et al., 2015; Yahne et al., 2002). For example, the Magdalena Pilot Project used motivational interviewing in their outreach work to sex workers (who may be at risk for sex trafficking) and reduced frequency of drug use and HIV risk behaviors (Yahne et al., 2002). In a randomized control trial of women who experienced abuse and sexually transmitted infections (STIs), Champion and Collins (2012)found that using motivational interviewing as part of their intervention reduced STIs at the 12-month follow-up. Prostitution exiting programs similarly use motivational interviewing in order to increase therapeutic relationships and encourage clients to meet personal goals (Roe-Sepowitz et al., 2012). However, a randomized control trial of an adapted, brief motivational interviewing used with homeless youths showed no reductions of substance use, despite some initial promise in the pilot study (Baer, Garrett, et al., 2006). In these studies, motivational interviewing is implemented for individuals at risk of sex trafficking because of the overlap with substance use and sex trading risk; however, it is still not clear whether motivational interviewing is effective in reducing sexual and substance risk specifically with sex trafficked individuals and consequently remains an area of future study. In addition, whether and how motivational interviewing is used with individuals specifically at risk for sex trafficking to address sex trading or relationships with potential traffickers remains understudied.

While motivational interviewing is considered an integral, evidence-based practice model used in interventions designed to reduce sex trafficking risk and related behaviors, very little is known about how practitioners perceive using motivational interviewing with this population and the subsequent challenges that emerge in practice. Understanding the uses of and challenges with motivational interviewing in this context may help to strengthen service providers’ responses to individuals at risk of sex trafficking, and potentially enhance this population’s engagement with social services. As such, the purpose of this article is to understand whether and how social service providers in a Midwest region use motivational interviewing with individuals at risk of sex trafficking and explore the challenges that emerge in practice.

Participants

Twenty-four social service providers representing multiple social service organizations across a 17-county region in a Midwestern state participated in this study. Providers were purposively sampled in a two-phase process. First, the research team conducted a content analysis of websites from all organizations in the area that directly or indirectly addressed sex trafficking in practice (Gerassi & Skinkis, 2020; Graneheim & Lundman, 2004). This was an important first step because as regional CPS caseworkers identified individuals at risk of sex trafficking, they referred to social service providers at organizations that addressed homelessness, foster care, mental health, substance use, and IPV. In these cases, individuals included minors as well as individuals ranging from 18 to 24 who were aging out of services. In addition, sex trafficking prevention programs also worked with CPS to refer school-aged children at risk of sex trafficking to services. The content analysis allowed us to identify those organizations that directly or indirectly encountered sex trafficked individuals in the region, which were then discussed with DHS and CPS caseworkers to generate a list of key informants. These data were also compared to organizations most commonly utilized by community partners for case referrals. This process resulted in a list of approximately 28 social service providers from 25 organizations that were most likely to encounter sex trafficking in practice, all of whom were contacted for the present study.

Potential participants were contacted via email for recruitment. In most cases, the community partners introduced the first author to the potential participant via email. Collaboration with DFS was clearly stated in the email and informed consent documents, including information indicating that YFS would only receive summary and de-identified data from the study. Potential participants were asked to schedule an interview, either by phone or video conferencing (i.e. Skype). In order to participate, social service providers must have had direct practice experience with individuals at risk of sex trafficking or who had been sex trafficked.

Twenty-four social service providers participated in the study, the majority of whom identified as White/non-Hispanic women (n = 18). Other participants identified as White men (n = 2), Black/African American women (n = 2), and Latina or Hispanic woman (n = 2). Providers ranged in age from 25 to 70 years old (M = 42), but the majority of providers were in their 30s (n = 9) and 40s (n = 6). Providers had a range of education levels, ranging from graduate degrees (n = 13) to undergraduate degrees (n = 9) to having attended some college (n = 2). Social service providers provided services through foster care/youth (n = 7), counseling (n = 4), intimate partner/sexual violence (n = 7), awareness/prevention education (n = 3), trafficking specific services (n = 2), and job training support (n = 1). Eleven providers had less than five years of experience working with individuals at risk of sex trafficking, while nine indicated they had between 5 and 10 years of experience. The five providers who indicated they had 12–40 years of experience with encountering sex trafficking in practice indicated that they would not have labeled it as “sex trafficking” when they first encountered it but have come to know it as such. All participants had direct practice experience with this population, mostly as advocates/case managers (n = 11), counselors/therapists (n = 5), prevention educators (n = 3), or program coordinators/directors who also provided some advocacy work (n = 5), as is common in many small non-profit organizations.

Data collection

All interviews were conducted by the first author and ranged from 40 to 90 minutes, with the majority lasting approximately 1 hour. All participants chose to be interviewed by phone instead of video conferencing. The first author emailed informed consent documents before the interviews. After verbally reviewing the study information by phone, participants were asked for their permission to record and provided their oral consent to be interviewed. The interview guide explored practice strategies used with individuals at risk of sex trafficking and focused on their use, applicability, feasibility, and evaluation in services. If a research participant did not specifically name motivational interviewing, the researcher prompted him/her by asking about use with the particular technique. Other questions focused on strengths and challenges of providing services, such as motivational interviewing. When the interview questions were completed, the recording was terminated. Participants were then asked to complete a demographic questionnaire verbally or via email. Though the research team and community partners had discussed whether and how remuneration for participation would be appropriate, community partners indicated that they would likely use work time for the interview and therefore could not accept compensation. As such, no remuneration was offered and this was relayed in the informed consent process.

Data analysis

The research team, consisting of the first and second authors, conducted multi-phase independent co-coding, using a directed content analysis approach (Hsieh & Shannon, 2005; James Potter & Levine-Donnerstein, 1999). First, selective coding was used to identify manifest patterns from the interview guide, which related to direct practice strategy use, applicability, feasibility, and evaluation in services. Inductive analysis was used to identify latent, emerging themes, which were predominantly related to challenges in providing inclusive, evidence-based practices (including motivational interviewing) for diverse subpopulations of survivors. Key themes regarding motivational interviewing (e.g. use, challenges with use, positive experiences) were identified through independent, open-coding process and developed throughout the course of interviews. We determined that seven participants in the sample were not familiar with motivational interviewing at all. Focused coding developed from aggregating open codes under specific labels, primarily about motivational interviewing perceptions, positive engagement, disengagement, and discord. Of the 17 participants who were familiar with motivational interviewing, four indicated they could not comment on its use as it was not a central part of their practice. The other 13 participants described particular uses and practice examples of motivational interviewing in practice.

The team discussed any discrepancies among decision points that arose throughout coding, which were found to be minimal. For example, some providers described assessing for motivation without familiarity of motivational interviewing as a practice model. Codes for this were originally labeled as “no use” by one team member and “motivational interviewing misuse” by another. In accordance with the direct content analytic approach, we discussed our decision making process, such that we ensured that both coders independently would make the same decision about coding data as familiarity/unfamiliarity with motivational interviewing, whether something could be coded as positive or negative engagement, examples of discord (88% agreement on initial coding, arrived at consensus for the other 12%). We returned to the transcripts to confirm whether the participant had specifically indicated that they were unfamiliar with motivational interviewing as a practice model. Their descriptions of exploring the client’s motivation were subsequently coded separately as “being unfamiliar with motivational interviewing” and “assessing for motivation without model.” We compared these codes to previously collected data as well as new data and found that no new themes emerged, thus reaching saturation. When analysis was complete, we assessed the adequacy of the sample, in ensuring that participants held the relevant perspectives to understand how motivational interviewing is used and how positive and negative engagement manifest (Guetterman, 2015).

Providers’ use and applicability of motivational interviewing with individuals at risk of sex trafficking

Providers reported mixed familiarity with and use of the motivational interviewing. Some providers identified motivational interviewing as one of the core practice models used with their individuals, including those at risk for sex trafficking. For example, Alyssa, a case manager at a counseling/teen parenting organization, described motivational interviewing as one of the central techniques she used with her clients:

I would say we definitely use [motivational interviewing] a lot. We’ve done quite a bit of training in motivational interviewing so that again comes in to play when we are asking them, “What could you do differently next time? What are your thoughts on this? Why do you think this occurred? What do you think might occur in the future if this behavior continues?” So, it really is a lot of client-driven motivation. Trying to get them to realize and see what they could do. And hopefully that will aid in their success. So, a lot of it, in keeping clients is going to be based off of them feeling like they’re accomplishing things and making changes. (Alyssa)

Alyssa’s narrative contrasted from other providers, who were either unfamiliar with motivational interviewing or familiar but untrained and therefore unable to integrate it into practice. As Joanna, an IPV advocate described, “I’ve heard of [motivational interviewing] before. I couldn’t say specifically what that is, but I do know […]. We’re [at the organization] familiar with it.” Joanna’s response underscored that she knew of other colleagues who might be implementing motivational interviewing but, in her 12 years of working at the IPV organization, had never used it or been formally trained. Interestingly, Joanna went on to describe multiple conversations with clients in which she sought to understand the client’s motivation, values, and goals (without using motivational interviewing). For example,

Most of the people I work with, whether it’s DV [domestic violence] or trafficking, [I try to take], a strength based approach, you’re looking at what are the things that […]. What is this person really competent in? What do they hope for, for themselves? What are their core values? What do they want? What do they hope to do? I think that sometimes you can see that [hope and] glimmer sometimes when you’re talking to people about their life […]. About what they feel some of their strengths are and what they hope to work on some day in the future. (Joanna)

Alternatively, motivational interviewing was viewed as too formal of an intervention that could not be adapted to short-term settings, such as crisis counseling with individuals at risk of sex trafficking, or occur outside of a traditional, clinical setting like mental health counseling. For example, George, an advocate and program administrator at a homeless youth organization, reflected,

We have had, on a number of locations, training specifically around motivational interviewing […] sometimes our role within that system is more kind of day-to-day […] I know that motivational interviewing isn’t necessarily something that hasto be done in a [therapist’s]office […] But again, when you’re sitting in a car driving with a kid down the street and taking him to or from, or her to or from, an appointment. It’s more of a casual conversation. It’s more of a […] and out of those conversations, what gets revealed, what kinds of issues come up. The bulk of our staff, I would say probably 90% of the interactions with kids that we work with are more mentor-like kinds of relationships […] we have a few clinical staff, probably, I would say about a half dozen on our team. So, some of them would engage with the clients from time to time, or if recommended, in our specific providers that the kids speak with on a weekly basis. (George)

Engagement and discord in motivational interviewing with individuals at risk of sex trafficking

Providers’ experiences with motivational interviewing ranged from facilitating positive engagement to exemplifying disengagement, typically by describing examples of potential discord between client and practitioner.

Enhancing uses of motivational interviewing with individuals at risk of sex trafficking

Our findings suggest that some providers who encounter sex trafficked individuals may be completely unfamiliar with motivational interviewing. Despite its limitations, motivational interviewing is an evidence-based practice that can be used with many client populations among organizations that address homelessness, substance use, mental health, and IPV, including specifically individuals at risk of sex trafficking. Joanna, for example, underscored the need to assess for a client’s motivation, yet was not trained in motivational interviewing, and as such, was not implementing an evidence-based strategy in order to assess for and use the client’s motivation to enhance her safety. Situations like Joanna’s practice examples are conducive to using motivational interviewing and have been used in a wide variety of IPV related contexts as well (Saftlas et al., 2013). Social workers like her could strongly benefit from motivational interviewing trainings and efforts to adapt the formal model to their service population rather than informal conversations about client motivations. Social workers also can acknowledge the systemic, structural oppressions (such as racism, classism, etc.) that may impact the clients’ choices. Given the many challenges that most individuals at risk of sex trafficking face, such as poverty or violence, social workers have an opportunity to create systems of care that address the clients’ oppressive circumstances while also respecting their right to self-determination and dignity.

Another finding of this study suggests that those who work in short-term settings, such as providing crisis counseling or short-term case management to individuals at risk of sex trafficking, may not think that motivational interviewing is a relevant intervention for their work. This is an important finding for social workers, as they practice in diverse settings and people whose oppressive circumstances may be more conducive to short-term social work settings (such as homeless shelters). This may be problematic given the wide variety of professions such as counselors, educators, therapists, coaches, practitioners, clinicians, and nurses who have applied motivational interviewing to their work and improved clients’ outcomes (Miller & Rollnick, 2013). George’s narrative underscored a theme from some advocates who viewed their conversations as more informal, as they, for example, drove clients to appointments. This type of support is commonly provided to sex trafficked individuals in an effort to help clients meet their needs, such as attending appointments or job interviews (Gerassi & Nichols, 2017). Advocates who described the need to informally chat with clients may be falling into a “chat trap,” when only making small talk regarding comfortable subjects (Miller & Rollnick, 2013, p. 45). Although informal chatter may be helpful, a study of 23 counselors found that informal discussions had significant inverse correlations with client motivation to reduce substance use and client retention in treatment (Bamatter et al., 2010). It is possible that social workers who fall into chat traps are discussing informal subjects to appear non-judgmental and build rapport, but to the detriment of providing structured services to the client. Though informal conversations may be helpful for social workers to build rapport, keeping such discussions without use of structured interventions to a minimum may help avoid negatively influence client outcomes.

If used properly (without chat traps), motivational interviewing may be helpful when used with individuals at risk for sex trafficking, including those who are also homeless. However, the evidence supporting the use of motivational interviewing with homeless populations specifically appears mixed. For example, a meta-analytic review found that small but significant reductions of substance use were observed when motivational interviewing was used with adolescents and supports the use of motivational interviewing across varying session lengths, different settings, and differing education levels of the practitioners (Jensen et al., 2011). Thus, brief models of motivational interviewing may be more conducive to short-term settings that may provide services such as case management or crisis counseling to individuals at risk of sex trafficking, and helpful to advocates like George. However, a randomized control trial of an adapted, brief motivational interviewing used with homeless youths showed no reductions of substance use, despite some initial promise in a pilot study (Baer, Garrett, et al., 2006). Upon further investigation, Baer et al. (2008) found that specific statements about desire or reasons while using motivational interviewing for change revealed a significant reduction in substance use. Though Baer et al. (2008) emphasize that this study did not test the efficacy for motivational interviewing, they conclude that “youth verbalization about change may provide one method of assessment for likelihood of change, which could lead to tailored interventions” (p. 575). However, sex trading was not explored as a possible outcome, which may be important for future work. As such, this is an important area for further development in social work practice (to increase familiarity and use of motivational interviewing with individuals at risk of sex trafficking) and research (to evaluate its effectiveness with sex trading).

Taken together, it is possible that further adaptation of motivational interviewing may be important, particularly to adequately address subpopulations of individuals at risk of trafficking who are homeless. Our study adds to this body of literature by suggesting that practitioners who work with homeless populations may experience challenges in tailoring this approach to their work. Rather than opting not to use motivational interviewing, social service providers may need to receive training on how to appropriately tailor motivational interviewing with transient service populations, such as homeless populations. Future research should examine efficacy of motivational interviewing among individuals at risk of sex trafficking as well as homeless populations. Specifically, examining whether motivational interviewing can be tailored to reduce sex trading outcomes in addition to substance use outcomes may be important.

Enhancing positive engagement and reducing discord

Despite some examples of positive engagement, providers’ responses to sex trading disclosures may have contributed to practitioner–client discord. Guided by concerns for the health and safety, providers like Ericka and Elizabeth quickly dismissed their clients’ perceived benefits of sex trading and directed their clients against the behavior. These examples are inappropriate for use with motivational interviewing for, as Miller and Rollnick (2013)describe, “if you are arguing for change and your client is arguing against it, you’ve got it exactly backward” (p. 9). When giving advice, the authors recommend asking for permission and/or giving permission to disregard their advice, which in turn has the “paradoxical effect of making it more likely that the person will listen to and heed the advice” (Miller and Rollnick, 2013, p. 149). One possible way to have addressed the concerns raised by the clients in these examples would be to do what Miller and Rollnick describe as “agreeing with a twist,” because the “impact of a reframe may be increased by prefacing it with a reflection that acknowledges and essentially sides with what the person is saying” (p. 202). This would allow providers to explore the client’s perceived advantages, such as the positive aspects of a relationship with an intimate partner or self-sufficiency from abusive, heterosexist homes. Assuming the client identified the following advantages and disadvantages to sex trading, a social service provider could respond by suggesting something like,

So, what I hear you saying is on the one hand, you liked making money and you care a lot about your boyfriend and like making him happy. You also appreciate that he’s giving you some opportunities to make money. On the other hand, you’re now having to do things to keep making that money that you’re not as comfortable with. You feel like you have not been able to say no and that is making you feel unsafe. Is that right? Can we talk about that last part some more?