The application of motivational interviewing techniques for engaging "resistant" families

The application of motivational interviewing techniques for engaging "resistant" families

Marie Iannos and Greg Antcliff

CFCA Practitioner Resource— May 2013

Practitioners of intensive family support programs may frequently encounter parents who present as ambivalent and "resistant" to engaging with the service. Motivating parents to make the necessary changes required to increase safety and to provide an adequate standard of care for their children therefore poses a challenging task for workers. This paper explores the application of motivational interviewing principles (Miller & Rollnick, 2004) as a promising approach that family support workers may apply to engage, motivate and support parents to enhance the safety and wellbeing of their children.


The goal of intensive home-based support programs for vulnerable families is ensuring that children stay safe and remain within their family, and aim to reduce re-notification or re-substantiation risk, close the case without court involvement, prevent the removal of children into alternative care, or facilitate family reunification. These programs are usually of long-term duration (up to 12 months) and require frequent weekly worker contact with families.

Families referred to these intensive programs often have multiple and complex needs, and it is not uncommon for workers to face parents who are ambivalent about addressing their issues and resistant to engagement with services. This may be particularly so if the family has a history of negative experiences with child protection authorities and mistrust towards workers.

The application of motivational interviewing in child protection work

Motivational interviewing is a client-centred directive counselling approach that seeks to enhance an individual's capacity to change (Miller & Rollnick, 2004). Central to motivational interviewing is developing an empathic relationship with the client which seeks to resolve the ambivalence about the behaviours which are preventing change. Originally developed as an approach for problem drinkers, motivational interviewing has been shown to be particularly effective in facilitating change in the field of substance misuse and a variety of health-related behaviours, and the majority of its solid evidence base comes from these areas (e.g., Carroll, 2001; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010).

In recent years, motivational interviewing has been touted as a promising approach for working with families with substantiated abuse or neglect (Morrison, 2010; Watson, 2011), and as a useful additional component to "standard" cognitive-behavioural and social learning based parenting therapies when these are not working (Scott & Dadds, 2009). Although at present motivational interviewing has not been used extensively in the child protection field, promising data are emerging demonstrating the effectiveness of such strategies with substance abusing pregnant mothers (May et al., 2008); in group therapy with abusive fathers (Crooks, Scott, Francis, Kelly, & Reid, 2006; Scourfield et al., 2012); and with non-offending mothers of children who have been sexually abused (Corcoran, 2002). Overall, motivational interviewing has been put forward as:

A possible strategy for enhancing parental motivation to engage with services and also an approach that could be used to help parents consider making changes in the way they care for their children. (Watson, 2011, p. 472)

Several studies have also shown benefits of training child protection workers in motivational interviewing techniques. In particular, workers developed a less confrontational and more empathic communication style, which resulted in less resistance from families (Forrester, Kershaw, Moss, & Hughes, 2007; Forrester, McCambridge, Waissbein, & Rollnick, 2008; Forrester, McCambridge, Waissbein, Emelyn-Jones, & Rollnick, 2008).

Principles of motivational interviewing

Motivation to change

Understanding the context, meaning, strength and flux of conflicting motivations is essential in engaging and assessing the protective motivations of parents (Morrison, 2010).

Morrison (2010) pointed out that "motivation" is a complex process that should be understood within a broader context, taking into account the interaction between a parent's core beliefs, values, feelings and behaviour, goals, and their personal resources, opportunities and constraints. He suggested that changing behaviour, especially if it is long-standing and embedded in underlying belief systems, is less likely to happen unless the worker has some appreciation of the underlying context and drivers of the behaviour. It may not be helpful to think of parents as being either motivated or unmotivated to change, but rather as continually dealing with motivational conflict between their desire to maintain the status quo and the desire for change. For example, a mother's desire to protect her child from a violent partner may be in conflict with her need to avoid loneliness. Understanding the meaning and strength of these conflicting motivations is essential to engaging and facilitating a parent's readiness to change.

Stages of change

Understand which stage of change parents are in, and tailor response accordingly.

Motivational interviewing is an approach which has often been used together with principles of the Stages of Change Model (DiClemente & Prochaska, 1998) which identified five elements of the change process: pre-contemplation, contemplation, determination, action, and maintenance. The model has been described as a useful framework to assist child protection practitioners conceptualise the processes of change in families with complex needs (Horwath & Morrison, 2001; Morrison, 2010). It is important for the worker to first recognise the stage the parent is at. In reality, the change process does not occur in a linear fashion, but rather parents may move forward and back between stages. Ideally, workers should aim to support parents move towards the action and determination stages to facilitate real change in their parenting practices.

How do workers identify which stage the parent is in and how do they facilitate and support the parent to make necessary changes to keep the children safe and in their care? The practical application of the model has been demonstrated in Bragg's (2003) manual for working with parents with substance disorders. However it is feasible that these could be applied to at-risk families in general. A description of the stages of change, and corresponding key tasks for child protection workers as illustrated by Bragg (2003) and further described by Morrison (2010) are described below and summarised in Table 1.

Pre-contemplation

Families who are initially referred to involuntary statutory child protection services are frequently seen at this stage. Parents are in denial that there is a problem, and may minimise the concerns raised for their children's safety. They may feel fearful of losing their children and angry of the intrusion of external agencies, and therefore present as defensive and blaming, resistant to engage, or alternatively as passive and helpless to respond. The workers main task in this stage is to raise the parent's awareness that there are concerns about their children's safety and increase their understanding of their risky behaviours by providing information and feedback. Workers are advised to avoid a confrontational or "lecturing" style and giving prescriptive advice.

Contemplation

Workers may find that the majority of families referred to intensive family support programs find themselves in the contemplation stage. At this stage, parents acknowledge that a problem exists in their care of the children; they want to change, but at the same time do not want to, or believe that they can't. Parents may therefore present as ambivalent and appear "stuck". For some families, particularly where their child has been subject to multi-agency protection plan, this may be the beginning of a journey in recognising and coming to terms with the existence of a problem. This most challenging stage is characterised by parents thinking about how to prepare for change, and exploring how their situation will be better if change occurs and the negative consequences of not changing (e.g., child removed). The key task for workers is to address ambivalence by helping the parent "tip the balance" in favour change, so that they can "argue for" their own change.

Determination

At this stage, motivation for change has been identified. The parent has decided to change and wants to do something about the problem. This is an opportunity for real change to occur. Workers are encouraged to seize this opportunity. Their main task is to support the parent to identify the most appropriate actions they can take to facilitate change, no matter how small, and helping them develop a change plan which is realistic, acceptable and effective.

Action

The parent takes action and makes steps to change. This may be related to specific goals they have set in particular areas of their change plan. The key task for the worker is to support and advocate for the parent to undertake the change behaviour. This could involve a number of interventions (e.g., parenting class, attending drug rehab). At this stage, care should be taken that families with multiple problems are not overwhelmed with too many tasks or appointments, and that the interventions are matched to the parent's readiness, willingness and capacity to change and the available resources to support them

Maintenance

At this stage, parents consolidate and sustain any the changes they have already made. New stresses however, can quickly overwhelm the parent's fledgling confidence and skills and increase their risk of relapse. Therefore the key task for workers is relapse prevention, aimed at anticipating stresses and triggers that may undermine the parents newly acquired coping skills. A significant component of relapse prevention involves supporting the parent to identify their triggers to relapse into problem behaviour patterns and to develop appropriate coping strategies.

Table 1. Stages of change and worker tasks
Parent's stage Indicator Key worker task
Pre-contemplation

Denial there is a problem. See no need to change.

Minimisation, blaming and resistance are most commonly present.

Raise parent's awareness of the problem and the possibility of change

Do not give prescriptive advice. Avoid confrontation.

Contemplation

Acknowledge a problem exists. Parent considers change, but also rejects it.

Parent is ambivalent and may often feel "stuck". Can argue for and against change.

Address ambivalence.

Discuss reasons and benefits for change and the risks/consequences of not changing.

Help the parent tip the balance in favour of change.

Determination

Parent has decided to change and wants to do something about the problem.

There is now a window of opportunity for change.

Help the parent identify best actions to take for change. Support their motivation for change.

Help them find a change strategy that is realistic, acceptable, accessible, appropriate and effective.

Action

Parent takes steps to change.

Parent engages in specific actions to bring about change.

Help parent implement a change strategy.

Support and be an advocate for the parent. Identify available sources of support.

Maintenance/relapse prevention

Parent actively works on sustaining changes made.

Challenge during this stage is to prevent relapse.

Help parent identify the possibility of relapse.

Support parent to identify their triggers to relapse. Develop coping strategies to prevent relapse.

Adapted from Bragg (2003) and Morrison (2010).

Facilitation of change using motivational interviewing principles and skills

Focus on engagement before change. Use a strengths based collaborative approach.

Useful mnemonics to remember are REDS principles to work with ambivalence, OARS micro-skills, and questioning strategies to elicit change talk.

Engagement

Motivational interviewing is "conducted in a collaborative spirit that motivates parents to engage in the change process which enables them to identify their strengths whilst feeling to take ownership of their difficulties" (Morrison, 2010, pp. 321-322). It is important for the worker to focus on engaging the family by developing trust and rapport before working towards change. This can occur by listening empathically and reflectively to understand the parent's issues from their point of view, and avoiding argumentation and conflict, which may serve to strengthen the parent's resistance and place the children at further risk.

Apply "REDS" principles

Given our understanding of the Stages of Change Model (Prochaska & DiClemente, 1998), how do workers achieve the tasks to support parents make changes? What skills are useful? The Motivational Interviewing website, describes four basic principles which can be remembered using the REDS acronym. These basic principles are described below, together with how they could be applied in relation to working with parents as suggested by Morrison (2010).

Roll with resistance

Resistance occurs when the client experiences a conflict between their view of the "problem" or the "solution" and that of the clinician, or when they experience their freedom or autonomy being impinged upon. These experiences are often based in the client's ambivalence about change. (Motivation Interviewing Resources [MIR], n.d., p. 3)  

Try to sidestep resistance by avoiding confrontation and argument, lecturing or "righting" the parent. Instead, connect with the parent to move in the same direction.

Express empathy

Empathy involves seeing the world through the clients eyes ... This approach provides the basis for clients to be heard and understood, and in turn are more likely to honestly share their experiences in depth. (MIR, n.d., p. 3)

Express empathy in the face of resistance. Make a genuine effort to understand the parent's perspective and convey this understanding.

Develop discrepancy

Motivation for change occurs when people perceive a mismatch between where they are and where they want to be ... a counsellor practicing Motivational Interviewing works to develop this by helping clients examine the discrepancies between their current circumstances/behavior, and their values and future goals. (MIR, n.d., p. 4)

Identify the parent's ambivalence by listening for and identifying the discrepancies between their core beliefs, values and behaviour. For example, the parent may express that it is important to them to be a responsible parent (values), but they are struggling with a heroin addiction and cannot attend to the children's needs when they are drug-affected (behaviour). The inner "discomfort" created by facing this discrepancy can create a shift to motivate the parent to reach their own realisation that something must change. The worker can then elicit change talk, which guides the parent to argue for (rather than against) their own change.

Support self-efficacy

[Motivational interviewing] is a strengths-based approach that believes that clients have within themselves the capabilities to change successfully. A client's belief that change is possible (self-efficacy) is needed to instil hope about making those difficult changes. (MIR, n.d., p. 3)

Support the parent's hopefulness that change or improvement is possible by identifying and actively affirming their personal strengths and previous successes. Searching for exceptions to the problem gives the parent opportunities to demonstrate that the problem is not occurring the whole time, and the strengths in their parenting (e.g., "can you tell me what good days in your family look like?"). Explore also how they have successfully dealt with past problems and the resources they used which were helpful (e.g., social support networks, services). This will help to increase their level of self-efficacy and confidence and their readiness to change.

Motivational interviewing micro-skills: "OARS"

There are four micro-counselling skills and techniques which workers can apply to facilitate the REDS principles with parents. Four of these micro-skills - open-ended questions, affirmations, reflective listening, and summarise - can be remembered using the acronym "OARS" (MIR, n.d., p. 4).

Open-ended questions

Open-ended questions are those not easily answered with a "yes/no" or short answer containing only specific information. Open-ended questions invite elaboration and thinking more deeply about an issue. (MIR, n.d., p. 4)

Open-ended questions encourage the parent's response to questions from his or her own perspective. In contrast, closed questions require a yes/no response and give the parent very little room to move. An example of an open ended question would be "what makes you think you should make a change?" whereas an example of a closed question is "don't you think you drink too much?".

Affirmations

Affirmations are statements that recognize the client's strengths. They assist in building rapport to help the client see themselves in a different, more positive light. (MIR, n.d., p. 4)

This suggests actively listening for the parent's strengths and values and reflecting these back in an affirming manner. For example, if the parent discusses their many previous efforts to change a particular behaviour from the position of feeling like they are a "failure" or hopeless, reframe what they have said from negative to positive. For example: "What I am hearing is that it is very important for you to change this behaviour. You have made numerous efforts over a long period of time. It seems that you have not yet found the way that works for you". This reframe accomplishes both affirmation of the parent's efforts and perseverance, and establishes a basis to finding a solution that will work for the parent.

Reflective listening

Reflections bring to life the principle of expressing empathy as well as guiding and supporting the client towards change. By careful listening and reflective responses, the client comes to feel that the counsellor understands the issues from their perspective (MIR, n.d., p. 5).

Respond to what the parent is saying by using more reflective statements than questions. Reflections can be simply repeating, or more complex reflection of the parent's implicit meaning and feelings. Follow the parent's ideas making every effort to convey understanding. This process can help the parent discover what their behaviours or lack of action may be about. Facilitate the parents to focus on his or her knowledge and resources.

Summarise

Summarising is a special type of reflection where the therapist recaps what has occurred in all or part of the session. Summaries communicate interest, understanding and call attention to important elements of the discussion. (MIR, n.d. p. 5)

It is a useful way to clarify what has been discussed so far, and can reinforce parents change talk, highlight realisations, identify themes, transitions or progress that may have occurred in the session.

Eliciting change talk

Further to the OARS skills, a key skill in motivational interviewing is questioning strategies to elicit change talk. Change talk can be defined as:

statements by the client revealing consideration of, motivation for, or commitment to change. In motivational interviewing, the therapist seeks to guide the client to expressions of change talk as the pathway to change. (MIR, n.d. p. 5)

A range of questioning strategies have been suggested to elicit change talk and a sense of readiness to make changes. Table 2 describes the key questioning strategies for evoking change talk and some examples of how they could be applied to discussions with at-risk parents.

Table 2: Strategies for evoking change talk
Strategy Example
Ask evocative open questions: the answer to which is likely to be change talk.
  • In what ways does this problem concern you?
  • How important is it for you to make this change? What/who needs to change?
  • So what do you think you'll do?
Ask for elaboration/examples: when a change talk theme emerges, ask for more details. Ask the parent to give specific examples.
  • Tell me more about how you would manage Billy's tantrums?
  • In what ways do you show Billy you are upset?
  • When was the last time you had a good day with Billy?
  • Give an example of what a good day looks like?
  • What do you notice about Billy/yourself/the family when are having a good day?
Explore decisional balance: ask for the pros and cons of both changing and staying the same.
  • What are the pros and cons of making changes in your family?

Parent may respond " if very little changes I will probably lose my children and end up in jail" or "if a good deal of change occurs I will have a good relationship with my children, and I will have a job".

Looking back questions: ask about a time before the problem emerged. How were things better, different?
  • How were things better/different before John (violent partner) moved in with you?
Looking forward questions: Ask what may happen if things continue as they are (status quo). Invite the parent to address their ambivalence and highlight the benefits of change and the negative consequences of not changing.
  • How would you like your family to be 5 years from now?
  • How would things be better/different if you made changes?
  • If you were 100% successful in making the changes that you want, what would be different in your family?
Query extremes: explore the advantages and disadvantages of not changing.
  • What are the best things that might happen if you do make this change?
  • What are the worst things that might happen if you don't make this change?
Use change rulers: to explore readiness to change
  • On a scale of 1 to 10, how important is it to you to change [the specific target behaviour], where 1 is not at all important and a 10 is extremely important?
  • Follow up with: And why are you at a __and not a __ [higher number]? What might happen that might move you from a __ to a __ [higher number]?
Explore goals and values: ask what the parent's guiding values are.
  • What do you want from life?
  • What does being a "good parent" mean to you?

Ask how this fits in with the parent's goals or values.

Come alongside: explicitly side with the negative (status quo) side of ambivalence to invite the parent to argue for change.
  • Perhaps [being in a violent relationship/drinking alcohol to cope] is so important to you that you won't give it up, no matter what the cost.

Adapted from "Strategies for Evoking Change Talk" (MIR, n.d. p. 6) available from the Mid-Atlantic Addiction Technology Transfer Center, Motivational Interviewing Website

Conclusion

Families with multiple complex needs referred to family support programs can often present as "resistant" and difficult to engage. When considering parent's motivation to change, it may be more helpful to think of parents as being neither "motivated" nor "unmotivated", but rather as continually dealing with motivational conflict between their desire to maintain the status quo, and the desire for change. Motivational interviewing is an approach which has shown promising applications to working with this resistant population of families. Morrison (2010) comprehensively described an application of this approach in families where children have been mistreated. The approach works alongside the Stages of Change Model (Prochaska & DiClemente, 1998), which encourages workers to identify the parent's stage of readiness to change and to explore the issues around the parent's ambivalence. Central to motivational interviewing is the importance of avoiding confrontation and working in a collaborative spirit, in a manner that can motivate parents to engage in the process and enable them to identify their strengths whilst feeling supported to take ownership of their difficulties. The REDS principles, OARS micro-skills and questioning strategies to evoke change talk may be useful. These emphasise the need for the worker to adopt an empathic style that supports the exploration of ambivalence and to elicit change talk, whilst at the same time building the parent's sense of self-efficacy and hope that change is possible. It is also important for workers to support parents who manage to make changes by helping them to prevent relapsing to unsafe parenting practices. Overall, motivational interviewing approaches may help families argue for their own change, so they can take the necessary steps to develop positive parenting and coping strategies to ultimately build safer stronger families.

Additional reading and resources

Further information can be found on the Motivational Interviewing website, hosted by Motivational Interviewing Resources, LLC and the Mid-Atlantic Addiction Technology Transfer Center.

References

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Publication details

CFCA Practitioner Resource
Published by the Australian Institute of Family Studies, May 2013.

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