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Integrating Motivational Interviewing into Home-Based Child Maltreatment Prevention and Family Preservation Services
Posted By admin On February 2, 2009 @ 1:26 pm In Issue 8,Right Column | Comments Disabled
Jane Silovsky, Ph.D. -Â University of Oklahoma Health Sciences Center
Thad R. Leffingwell, Ph.D. – Oklahoma State University
Debra B. Hecht, Ph.D. – University of Oklahoma Health Sciences Center
Please address correspondence to:
Thad R. Leffingwell
116 North Murray
Stillwater, OK 74078
Multiple pathways to child maltreatment exist with historical, social, individual (parent and child), biological, situational, and cultural factors interweaving to form potentiating and protective factors (Belsky, 1993). The factors that contribute to the onset and maintenance of neglectful and physically abusive parenting practices are complex and interconnected (Erickson & Egeland, 2002; Kolko, 2002; Milner, 1998). In response, child maltreatment prevention and family support and preservation services typically include multiple components designed to identify and address risk and protective factors (DePanfilis & Dubowitz, 2005; Littell & Schuerman, 2002; Lutzker, 1984; Whittaker & Tracy, 1990).
Unfortunately, intervention and prevention programs for child maltreatment have struggled with high attrition rates and treatment noncompliance (Chaffin, 2004; Harder, 2005; Lau & Weisz, 2003). Parents may drop out of services even when services are court ordered and there are clear negative consequences such as the risk of losing custody of their children (Chaffin et al., 2004; Gelles, 2000; Mullins, personal communication). Attrition rates as high as 70% have been reported with child welfare populations (Lundquist & Hansen, 1998). Program attrition remains high despite responses to overcome external barriers to services which include providing services in the home, arranging for child care, providing transportation, flexible scheduling, and even compensating parents for their time spent participating in programs (Gomby, 2000; Lundquist & Hansen, 1998; Prinz et al., 2001; Wells, 1997). Service developers have shifted foci to directly address internal barriers to services, targeting parents’ low motivation to change their behaviors as well as parents’ limited beliefs in their own ability to execute changes (Chaffin et al., 2004).
Motivational Interviewing (MI) is a client-centered directive counseling method designed to reduce resistance to change and elicit commitment for change. Integrating MI in the context of home-based services with multi-need families may reduce service attrition and improve responsiveness to behavior change strategies (Rullo-Cooney, 1995 cited in Littell & Girvin, 2004). This article describes potential applications of MI with intensive home-based, child family preservation services. Challenges to the implementation of MI and ethical issues are also addressed. The term “parent” will be used throughout the paper to describe the primary caregiver and client with whom the home-based service provider is working.
Motivational Interviewing (MI) is a broad approach designed to build commitment, promote decisions for change, increase self-efficacy, and strengthen desire and drive to change (Miller & Rollnick, 2002). MI has been used primarily for substance abuse, but also with health behaviors such as weight loss and smoking cessation. More recently, MI has been found to enhance participation when applied to parents in clinic-based parent behavior training programs, including parents involved in child welfare (Chaffin et al., 2004) and parents of children with behavior problems (Nock & Kazdin, 2005).
Implementation of MI by child welfare case workers to address parental substance abuse has been advocated (Hohman, 1998). Research with families involved in child welfare suggests that MI techniques may enhance the likelihood of follow up with substance abuse treatment (Carroll, Libby, Sheehan, & Hyland, 2001). However, the risk of child maltreatment is multifaceted and the desired behavioral changes can range beyond substance abuse to include parenting practices and conflict resolution behaviors as well as actions of the parents to change their living situations, education, employment, and medical and mental health status.
Since motivation impacts parents’ compliance with all these service areas, lack of motivation to change may limit the efficacy of home-based services. It thus makes sense to broaden the application of MI from substance-use related problems to other problems where motivation, ambivalence, and resistance pose challenges (Miller & Rollnick, 1991; 2002; Wahab, 2005). An overview of the principles and approach of MI is provided, followed by information about its application to a range of potential issues in family preservation and support services.
Fundamentals of MI
Miller and Rollnick (2002) have described three fundamental characteristics of motivational interviewing: (a) a collaborative, rather than authoritarian or prescriptive, relationship between the service provider and parent, (b) an eliciting, evocative approach versus a persuasive or educative stance, and (c) a commitment to the ultimate autonomy of the parent to make decisions about change and to marshal personal resources for change. These characteristics respect parents’ freedom of choice and competence and represent the fundamental spirit of MI. This philosophy is consistent with the family-centered foundation of family preservation services (Wahab, 2005). Four fundamental principles – express empathy, develop discrepancies, roll with resistance, and support self-efficacy – translate the spirit of MI into a set of behavioral strategies (Miller & Rollnick, 2002).
The first principle, express empathy, borrows from classic work by Carl Rogers (1951, 1961) and assumes that acceptance of parents as they are facilitates change. Reflective listening communicates empathy to the parent and helps build a strong collaborative relationship. Understanding the nature of ambivalence is a key to demonstrating empathy in motivational interviewing. Ambivalence about behavior change is a normal and natural part of the behavior change process (Prochaska, DiClemente, & Norcross, 1992). Change is difficult, and the status quo is often comfortable in some ways, even if it may be dysfunctional in other ways. If one sees ambivalence about change as normal and natural – rather than as a sign of pathology or immorality – it becomes much easier to develop and express empathy.
The second principle, develop discrepancies, involves amplifying differences between the parent’s current behavior and his or her own goals, values, or self-image (Miller & Rollnick, 2002). Parents are rarely satisfied with all aspects of their current situations and often have hopes and dreams for improvements. If parents perceive their own behavior as inconsistent with other important values they hold, the probability for behavior change increases. The task for MI is to tip that balance of conflicting behaviors, goals, and values in the direction of healthy, adaptive change.
The third principle, rolling with resistance, is a key principle that separates motivational interviewing from other approaches. In MI, resistance is viewed as the product of the interpersonal process between service provider and parent rather than as a characteristic of the parent themselves. From this perspective, interactions can reduce or create resistance. Service providers can alter their own behavior to minimize or prevent resistance. With MI, when resistance is encountered in the interview, the service provider should change strategies and avoid confrontational or persuasive approaches.
The final principle, supporting self-efficacy, refers to communicating a belief in parents’ ability to be an agent of change on their own behalf. This principle is often enacted subtly by the service provider’s implicit belief in the parent’s role in the process of change. Demonstrated respect for parents’ autonomy and choice and as a collaborative partner in exploring change implies a belief in those parents’ ability to change. Also, when service providers inquire in a sincere way how a parent might go about making a change, it implies a belief in the parent’s own resources and ideas. A number of explicit strategies can be used including reviewing past successes or models, amplifying personal strengths, brainstorming new ideas, or even occasionally providing direct advice with permission to do so (Miller & Rollnick, 2002).
Applications of MI in Intensive Home-Based Services
The philosophies of many family support and family preservation programs which may include respecting family members’ expertise in understanding their situation and needs, viewing family’s perceptions and behaviors as changeable, and recognizing the complexities of strengths and vulnerabilities (Child Welfare League of America, 2005) are consistent with the basic principles of MI. Parents referred for intensive home-based services have often experienced life circumstances which have been destructive to their motivation. Repeated failure experiences, limited early childhood educational enriching experiences, and multiple contextual barriers (e.g., violent neighborhoods, limited job opportunities, no models of a different course of life) negatively impact beliefs that life could change for the better. Further, the referral to home-based services through child welfare may have been experienced as confrontational by the parents. When beliefs and behaviors are challenged a common response is to hold stronger and defend one’s own initial belief (Silvia, 2005).
Focused use of empathy and reflective listening early in the process of working with families is designed not only to enhance the strength of the relationship, but also to facilitate identifying areas of ambivalence about change. MI strategies then can be used to assess the parents’ (a) desire for the situation to remain the same, (b) belief that situations can be different and that they have the ability to make the changes, (c) values and goals, and (d) competing goals and motivations (DePanfilis, 2000).
Often parents may hold a wide range of thoughts and opinions that reflect different degrees of motivation about the same topic, and thus are ambivalent about change. Ideal opportunities for MI arise whenever (a) clients are ambivalent about behavior changes, (b) there is evidence that the current behavior is leading to maladaptive outcomes, (c) a clear choice or choices is/are available that serves the best interests of the family, and (d) an opportunity for change is realistically available. Remembering that these desires, beliefs, and motivations are fluid and can change rapidly even over the course of a single interaction is critical in the implementation of MI.
To apply MI there must be a specific target behavior and a specific identifiable desirable change. MI cannot be applied with a very generic goal such as “motivating an unmotivated client”. Several examples of specific behavior change targets follow. Families commonly have multiple needs and challenges, and home-based providers can easily become overwhelmed with the breadth of concerns. To effectively use MI, home-based providers require the ability to step back and focus on individual challenges and avoid getting bogged in the morass of complex, overlapping issues. Families may vary greatly in their motivational readiness to change different behaviors – for example, they may be ready to learn new parenting skills but unwilling to discuss changes in substance use. Each behavior change challenge must be assessed and may require different types of intervention (Hohman, 1998). The following sections describe areas in which MI may be applied.
Substance misuse. Substance abuse and dependence has been found to be an important risk factor in families involved in child welfare (Chaffin, Kelleher, & Hollenberg, 1996). Addressing parental substance use that has detrimental impact on their children is perhaps the most obvious opportunity for using MI skills to facilitate change (Hohman, 1998). Parents may be resistant to admitting to substance-related problems or discussing change. MI can be used to create an optimal opportunity for change to be considered and pursued by the user, particularly when evidence of problems associated with substance use is present. Changing substance use behavior is the strongest evidence-based application of MI (Dunn, Deroo, & Rivara, 2001; Burke, Arkowitz, & Dunn, 2002; Burke, Arkowitz, & Menchola, 2003; Burke, Dunn, Atkins, & Phelps, 2004; Hettema, Steele, & Miller, 2005).
Parenting practices. Often the primary goal for home-based services is to change a pattern of ineffective and/or coercive parenting practices including harsh physical punishment and inadequate supervision (Gomby, Culrose, & Behrman, 1999). However, it is not uncommon for parents to be defensive about current discipline strategies when confronted directly. Motivation to changing parental behaviors is hindered by self-protective attributions, lack of experience with readily available models for praise and non-punitive discipline strategies, and limited faith that alternative methods would result in improved child behavior. Demonstrating openness in discussing the pros and cons of a variety of parenting strategies, developing an understanding of core parenting values and beliefs, and avoiding confrontations on corporal punishment may facilitate reducing defensiveness (Chaffin et al., 2004).
Knowledge and beliefs about child development. Parents may be less likely to react with frustration and abusive acts if they have an accurate understanding of child development and appropriate expectations for behavior (Gomby et al., 1999). However, preconceived ideas about development are often closely held and based upon advice from family elders or other parenting role models. For example, parents may hold inappropriate assumptions about a child’s ability to control impulses, sustain self control, or remember and perform multiple or complex directives. Direct education and correction can be anticipated to be met with defensiveness, reducing the potential positive impact of the information. MI strategies may be helpful for generating openness to new information by encouraging parents to identify areas where gaps in their knowledge may exist.
Employment and education. Poverty is a significant risk factor for child neglect and physical abuse (Slack, Holl, McDaniel, Yoo, & Bolger, 2004; Willis, Holden, & Rosenberg, 1992). Families at risk for child maltreatment often struggle with issues related to unemployment, underemployment, or limited education. They may become ambivalent, unable to generate motivation to make positive behavior changes. Reengaging in job searching, educational opportunities and/or pursuing a rehabilitative job skills program or college degree are all areas where ambivalence and resistance may be encountered. MI may be useful for eliciting employment and education achievement values that, when contrasted with the status quo, will lead to motivation to change when realistic options exist.
Resource utilization. Many families can benefit from pursuing any number of community and social resources and yet many are reluctant to do so. Most programs require significant initiative on the part of the family to complete paperwork and provide documentation which inadvertently cause significant behavioral barriers. In addition, some families do not pursue resources for which they qualify because to do so conflicts with important values related to self-sufficiency and privacy. MI skills may be used to explore these areas of value dissonance and elicit ways in which not pursuing appropriate resources may be dissonant with other values related to provision for family needs.
Medical and mental health care. Families often have significant medical or mental health needs that have gone untreated or otherwise unaddressed due to a lack of available health providers or insurance, health-related fears, or other reasons affecting readiness to address these issues (Arkowitz & Westra, 2004; Koenen, Goodwin, Struening, Hellman, & Guardino, 2003; Mojtaai, Olfson, & Mechanic, 2002; Murphy, Rosen, Cameron, & Thompson, 2002). Significant health concerns and mental health issues may also provoke anxiety, which can trigger avoidance. MI skills could be used to explore ambivalence about seeking medical care and complying with recommended treatment or prevention strategies.
Family planning. One of the most important decisions families face is whether or not to have more children. While home-based service providers may frequently have opinions about the wisdom of conceiving additional children, ethical concerns arise regarding the potential use of MI in family planning decisions – a subject which is discussed in more detail later. Certainly, reflective listening and assistance with problem-solving are always appropriate in these situations, since neither requires the service provider to advocate for one particular choice as is required for MI. However, MI may also be appropriate and helpful in situations where the parents have expressed an autonomous desire, such as wanting effective birth control to prevent future conceptions, yet they continue to struggle with implementing the behavioral changes necessary to achieve this goal. For example, despite a desire to utilize effective birth control, parents may remain ambivalent about discussing it with a physician or potential sexual partners, or about adhering to a method requiring daily medication.
Relationships. Another problem frequently contributing to the troubles of at-risk families is unstable, unhealthy, and potentially dangerous interpersonal relationships. Similar to decisions about birth control, home-based providers may often have opinions about the desirability of parents’ chosen partners. MI may be useful when discussing partners who have demonstrated a tendency to be verbally or physically abusive, or whose behavior is otherwise so dysfunctional as to create a hazardous situation in the home (e.g., drug or alcohol dependence). In these cases, MI can be employed for exploring the pros and cons of the relationship for the parent, and perhaps eliciting a commitment to make adaptive changes in those relationships.
If a commitment to change is elicited from the parent, the professional must recognize that change may be dangerous for a mother and child and additional support would be necessary. Appropriate steps to mitigate this danger including safety planning and immediate referrals to community resources would most likely be necessary. The professional must keep in mind that MI is a useful tool for dealing with a specific challenge – client resistance to change – but does not replace all other necessary professional skills and standards of care including case management and effective use of community resources.
Ethics of Motivational Interviewing
Applications of MI principles and techniques by home-based service providers raise ethical questions about the appropriateness of the method. This issue may arise when the worker sees an opportunity or need for a behavior change and the family disagrees with this perception. In some situations, professionals may rightly pause before proceeding with a directive intervention like MI that will advocate for preferred choices. In some situations, the needed behavior change may be so clearly adaptive that the ethical complexity is low. For example, a parent who uses excessively harsh and cruel punishment causing physical and emotional harm to their child and yet refuses education or referrals for assistance with parenting may likely be an appropriate opportunity to use MI. Other situations, however, are more complex. In these situations, values and agendas may be in conflict and one must take special care in such situations.
Miller and Rollnick (2002; Miller, 1994) have written extensively on the topic of ethics and MI. They highlight three aspects that contribute to the complexity of the ethical use of MI: (a) dissonance between provider and parent about choices that are in the parent’s best interest, (b) personal investment of the provider in parent choices, and (c) possible coercive power of the provider upon parent behaviors (Miller & Rollnick, 2002). These three issues must be considered when making decisions about the ethical application of MI.
Miller and Rollnick (2002) argue that due to MI’s focus upon intrinsic motivation derived from a discrepancy of the status quo with client values, MI cannot be used to coerce families into choices that are inconsistent with their values. The question of discrepancy in regards to the family’s best interest may often not be a conflict of what is ultimately best for the family, but a difference in the prioritization of competing values. In the example above, the family may share their value of child happiness and well-being with the provider, but the decision to pursue noncoercive parenting practices competes with other values or motives of the moment. In these situations, using MI to help families make decisions consistent with all of their values and goals would be appropriate.
Complexity increases when adding the other two considerations (Miller & Rollnick, 2002). Home-based service providers often experience a personal investment in a parental behavior change because of the provider’s concern for the well-being of the children involved. Sometimes the alternatives may create conflict between what is best for the parent and what is best for the children. Further, Miller and Rollnick (2002) advise that if the provider possesses ultimate power to coerce a behavior change, MI would not be inappropriate, and research suggests it may be less effective (Ashton, 2005). In most jurisdictions, home-based service providers are mandated reporters of suspected child maltreatment. However, the home-based provider is not the ultimate arbiter of any consequences that may arise from a mandated report, reducing the coercive power of that relationship. In many states, mandated reporting laws apply to any citizen who suspects abuse or neglect. If mandating reporting requirements alone were enough to make MI inappropriate, that it would be inappropriate for any professional to use MI. We do not believe this would be an accurate interpretation. A primary responsibility of providers is to continuously assess risk to the children. Ethically, the home-based service providers must clarify their role and responsibilities at the onset of services.
As with most ethical dilemmas and decisions, clear-cut answers are rarely found. When home-based professionals encounter questions about the ethical use of MI with families, consider the three issues (agreement on parents’ best interest, personal investment of the provider, and possible coercive power) raised by Miller and Rollnick (2002) in consultation with professional peers and supervisors.
Barriers to MI
In attempting to integrate MI into traditional home-based services in real-world settings, challenges and barriers may be encountered. The following section describes some barriers as well as suggestions for overcoming these barriers.
Hesitation to use counseling techniques. Some home-based service providers express reservations about using techniques they feel may extend beyond their scope of practice or expertise. They are usually not therapists and often initially perceive MI to be therapy. MI applications have been successfully developed and used by physicians (Rollnick, Heather,& Bell, 1992; Rollnick, Mason, & Butler, 1999), nurses (Bennett et al., 2005), midwives (Tappin et al., 2000), public health workers (Thevos, Quick, & Yandulli, 2000), and even non-professional peers (Larimer et al., 2001), therefore, advanced education in counseling techniques is not required. Education and supervision in basic counseling skills may enhance comfort with use of client-centered listening and other MI skills.
Chaotic context of home visits. While home-based services include many advantages, one of the disadvantages is the lack of control over the intervention environment. Home-based service providers frequently have to contend with noise, televisions, children, unexpected visitors, and even pets, all of which can interfere with the engaged conversation that is typical of MI. Planning ahead and working with the families to reduce environment barriers prior to MI conversations may be helpful.
Conflict with traditional approach. For some home-based providers, the nature of MI runs counter to their traditional professional approach as either (a) nondirective support or (b) active problem-solvers for families. We would emphasize that MI is best thought of as a supplement to other directive strategies. When families are ready and willing to change, offering them resources, education, opportunities, and creative solutions will likely have substantial impact. However, for those families who are more ambivalent about change, an MI approach could be an effective alternative to meet parents where they are and elicit greater readiness to change.
Difficulty recognizing behavior change targets. Previous studies have found that home-based providers may find it difficult to reliably identify needs and problem behaviors (Duggan et al., 2004). Skillful use of MI in the home-based context requires providers to not only recognize potential behavior change targets but also to accurately assess whether MI might be appropriate. Providers for child abuse prevention programs have been found to be poorly equipped to recognize and respond to parental alcohol and drug use/abuse, mental health issues, and intimate partner violence, which in turn interfered with their ability to link families to services (Duggan et al., 2004; Littell & Schuerman, 2002). The ability to assess and make accurate judgments regarding risk factors is critical, such as examining use versus abuse of substances and relationship problems versus intimate partner violence. Training in the risk factors and in identifying resistance and ambivalence using behavioral indicators is recommended. Teaching the use of “readiness ruler” scaled questions to assess the importance of a behavior change, confidence in making changes, and motivational readiness may also be of assistance (Rollnick, Mason, & Butler, 1999). Readiness rulers are simple assessment devices that involve asking parents to “rate on a scale of 1-10″ (or similar metric) their readiness to make a behavior change.
Providers and parents may also have different beliefs about prioritizing areas of change. Experiencing success in an area that the parent is motivated to change may enhance later motivation in areas that the provider believes is a greater priority. However, some issues may be too critical to delay. Direct intervention can be utilized to address issues prioritized by parents, and MI can be integrated in the same sessions to address issues in which there is more ambiguity regarding change.
External barriers to behavior change. Families often have many external barriers to change (e.g., lack of transportation) that make it difficult for family decision-makers to contemplate change. Home-based providers can become overwhelmed in the face of seemingly insurmountable obstacles. Families who are low in internal motivation to change will see only barriers and are unlikely to participate in creative and persistent problem-solving to overcome the barriers (Ryan & Deci, 2000). However, if MI strategies can successfully elicit internal motivation, families will be more likely to collaborate with the home-based provider in problem-solving.
Impact of court involvement. Family preservation services are often provided within the context of potential or actual court involvement. In such situations, the potential threat of court action may make it difficult to effectively employ MI. Indeed, an autonomy-supportive position can be a difficult stance with regard to coercive parenting practices, when the role of the home-based service provider is, in part, the care and protection of children and given that service providers are required to report any suspected maltreatment to authorities (Ashton, 2005). Effectiveness of MI with coerced populations has been questioned (Mullins, Suarez, Ondersma, & Page, 2004). Providers can emphasize choice and control to the extent that parents’ can choose (or not choose) to make the behavior changes necessary for child safety.
Determination of the behavior to change and goal to be reached. Use of MI requires identifying a specific behavior to change and a goal to reach. Internal motivation to change behavior and to reach set goals will be enhanced by flexibility and independent choice. However, families who are court-ordered to services may have specific requirements on their treatment plan (e.g., must successfully complete program X) rather than flexibility and choice in reaching the goal (e.g., eliminate violence in the home). When another reasonable plan to reach the same goal is developed with the family, part of the home-based service provider activities may also be facilitating the parent’s self-advocacy for the behavior change. Further, an important factor for effective use of MI is evidence that the current behavior is problematic. MI is less likely to be effective in cases when there is no clear evidence to justify the court-ordered services (e.g., requiring substance abuse treatment for someone who possessed an illegal substance but does not have problematic substance use or dependence) (Ashton, 2005).
Summary and Conclusions
Service attrition and resistance to change behaviors is common in work with families involved in child welfare or considered to be at risk for child maltreatment. Intensive home-based services were designed in part to reduce many of the external barriers to services. Integrating MI into home-based services can address the internal barriers that often coexist with the families. MI is most effectively used when there is evidence of maladaptive outcomes related to current behavior or when the parent is ambivalent about change, and alternatives exist that can be realistically implemented if the parent is motivated to make the change. Areas in which to utilize MI include substance misuse, parenting practices, employment and educational changes, interpersonal conflict and partner choices, and resource utilization.
Practitioners are cautioned against viewing MI as a panacea for changing parental behavior with intensive home-based services. A family-centered approach, empathy, flexibility, and focus on the end goal rather than on a specific path toward that goal, are needed for MI to be successful. Some amount of parental ambiguity about change is essential and there is some question about MI’s effectiveness if services occur within a potentially coercive environment.
Home-based service providers without previous experience or education in assessing families or counseling skills may initially be hesitant in implementing MI. Further, home-based service providers whose philosophy is solely nondirective or have limited belief in the ability of the families to make adaptive decisions may struggle with accepting the MI approach. Chaos of home environment, perceived coercion from the courts, and limitation of truly realistic change opportunities in the community complicate the use of MI. Suggestions for overcoming these potential barriers and implementing MI with parents in intensive home-based services are consistent with traditional philosophies of family preservation services. Treatment outcome and services research is required to inform training, implementation, and efficacy of MI integrated in intensive home-based services.
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