Is motivational interviewing a sound technique in child protection?

Motivational interviewing should and could have a bigger role to play in child protection work argues social worker Mel Ashton, a substance misuse specialist

We know that substance-using parents and carers – of whom there are many in the average child protection caseload – do not necessarily respond positively or immediately to social work methods and interventions. They experience them as coercive, not collaborative; the velvet glove coming off revealing an iron fist.

A battle of wills can often ensue, where the parents or carers retreat into a psychological stance which a professional will view as a reluctance to change despite mounting concerns.

While there are some substance-using parents and carers for whom the pull of their alcohol and illicit drug use is greater than the drive to achieve positive change; there are others who are simply stuck in their own ambivalence about change.

The aim of motivational interviewing (MI) is to resolve this ambivalence in people whose behaviour may well be causing them, and others, problems, but who have not changed their behaviour as a result. Clearly, child protection concerns would fall under this category, yet MI appears to be rarely used in child protection work.

However, if we are interested in evidence-based practice then we have seen MI tested in clinical trials and been found to be efficacious.

In making these observations, I am not being critical of children’s social workers or their practice – they do an extremely demanding and sometimes thankless job. However, social work education has long lacked a focus on substance misuse as an important feature of child protection work and, arguably, has not equipped practitioners to work effectively with parents and carers who exhibit such problems.

In my view, this needs addressing – and in a way that enables practitioners to demonstrate competence. It is worth noting that research seems to show that single, attendance-only training events are inadequate for this kind of learning.

Described as a “quiet and eliciting approach” MI explicitly avoids confrontation and instead, “rolls with resistance”. This, and the use of open questions and selective reflections, enables practitioners to develop a therapeutic or empathic relationship with a client that is much more likely to result in the client recognising their own problems. Developing this and the motivation to change then becomes the focus of the intervention.

Even if clients are not ready or unwilling to change – exhibiting a confrontational approach and increasing resistance – MI is still recommended but with the more modest goal, at least initially, of planting a seed which may bear fruit down the line.

Children’s social workers could adopt MI approaches more than they do and earlier in the process, while keeping one eye clearly fixed on the welfare of children. For example, the worker could decide to conduct a session(s) that, even for a limited period, focuses differently on the problem, by exploring how the client sees and describes it. This may yield a glimmer of discomfort about the conflict between one or more aspects of their substance use and their role as a carer. In that event, we are seeking to explore and develop that discrepancy in a way that leads to further problem-recognition statements.

I’m aware that many parents involved in child protection proceedings may exhibit what is known as “disguised compliance” and no single approach will ever be able to combat this, but it’s worth noting that even if a parent says all the right things, they still have to translate this into practice. One would expect that a parent who says they want to change to be doing something that backs this up. Actions may speak louder than words but both are pre-requisites for genuine change attempts.

It is important to address the question of whether MI, which entails practitioners conveying a sense of optimism about change, sits comfortably with the realities and challenges of child care social work. You may think it does not, in which case, rely upon other methods for evoking change. If you think that it is broadly compatible, but requires a change of approach – one worth attempting – then it may offer you another tool in your social work kit-bag. In my view, it is at least worthy of discussion.

CareSpace: practitioners debate motivational interviewing

Contributors to Community Care’s CareSpace forum for social workers discuss their use of MI. Join this discussion at CareSpace

Republican: Motivational interviewing is a powerful tool to use to facilitate change when people are in contemplation or precontemplation. However, it relies on building and enhancing motivation for change. Where people are locked in denial it has little use. The problem in child protection is that you are often dealing with people with a very formed world view which might not be open to change. On the face of it, it is a simple technique but in actuality requires great skill. Think of the ineptness of the manager who tried to use solution-focused working in the Baby P case.

DonaldF: MI is not confined to people in any particular stage of change. It is probably the most strongly evidenced supported way of working with alcohol problems, and there is increasing evidence that it can be used to help people with a range of behaviour change issues (from eating more fruit to taking anti-psychotic medication).

For social work a particularly attractive feature of MI is that it has a focus on understanding and working with client resistance. Far too many of the approaches we use are imported from therapeutic settings where people want help. That is not necessarily true in child protection work.

MI has also been adapted to be used in a wide variety of ways – from 15-minute GP consultations to the way prison warders talk to prisoners. Again, this suggests it might be useful for social work.

On the other hand it is important that we explore through research the opportunities and challenges of using MI in child and family work. There is one study about this which had promising findings. We at the Tilda Goldberg Centre are undertaking a larger scale study now, which will be finished next year.

There are a lot of reasons for thinking MI may be useful in child protection work – but let’s not swallow it whole. Let’s look at what MI should be like in working with families where there may be serious concerns and develop a form of MI fit for social work practice.

StevieNicks67: I have used MI in substance misuse and found it to be helpful in initiating change. But solution-focused therapy would be more beneficial in a child protection environment because it focuses on family strengths and initiating change. It enables parents to use their own tools in initiating change and is less oppressive.

Anthony_Hertford: I have trained probation staff in motivational approaches and am very keen to explore motivational approaches in my new field of work in children’s social care. Motivational approaches, when used properly, hold others to account for thinking and behaviour, provide a strategy for searching out disguised compliance as well as a model for enabling others to identify the specific choices and tasks required for change. I am certain there are likely to be limitations. Motivational approaches do assume (as do most approaches) time to change and, of course, there may be tensions where changes may be required immediately.

Also published in Community Care 21 July 2011 under the headline Intervention with Optimism (picture credit: Alamy)

More information on motivational interviewing and child protection work will be presented at Community Care’s conference on Drug and Alcohol Misusing Parents, 15 September, London

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