Motivational interviewing and child protection – the fit

Imagine someone knocks on your door and wants to talk with you about how you are treating your children. Part of you knows that lately you have not been managing well and that at times you just ‘lose it’, particularly when you are tired, stressed or out of it on alcohol or drugs. Now, this person is from a State agency responsible for investigating the care and protection of children. You want to know who ‘dobbed you in’, who is ‘nosey parking’ into your business. You have a belief that what happens behind closed door is private, family business and not anyone else’s concern. Your immediate reaction may be one of, ‘Who do you think you are telling me how to manage my kids, Bloody nanny state’, or a sense of relief as life has been really tough lately, or perhaps something in between.

This is the everyday reality for child protection workers whose role is to engage with families where the safety and protection of children is identified as a cause of concern. Where does motivational interviewing interface with this work? How might motivational interviewing assist in engaging families in the long game of safety, once the immediate acute risk concerns (the short game) are under control? And how might the spirit of motivational interviewing assist in building a working alliance with families to resolve issues they are facing? These are questions that we have been working with Department of Community Services staff from 22 sites throughout New South Wales during November as part of the Practice First initiative.  The conversations have been rich as workers have grappled with us to explore the places of alignment and where there are tension points. I thought I would take time to reflect on these issues and articulate the discussions we have had to date.

There are a number of clear areas of alignment which include :

• Building a partnership with families for long term outcomes. This is one of the key aspects of the spirit of MI and once the initial concerns around safety are managed, working with strengthening families and managing out of home care is where the early investment in building partnership really pays off.
• None of us like being told what to do, that we are not delivering on our skills as a parent, or that we cannot provide the basics of safety and security for our children. This is where joining with the concerns of the parent(s) and building a collaborative relationship focussed upon finding workable solutions to safety are consistent with MI practice. Agenda mapping is where the concerns of the parent and child protection staff have places of commonality which provides an excellent starting point.
• Where there are safety concerns then the relationship is generally ongoing over time given the multiple and complex issues (drug use, lack of parenting skills, housing issues, etc.) that are often present.  Having someone who can support motivation for change, who can evoke change talk, affirm effort and the direction of change creates an audience for change which can be absent in the client’s social world. This can often be barren in terms of change agents and turn round people.
• MI fits well with engaged clients who are at the point of recognition of the need for change. MI works in the space of ambivalence where the desire, ability, reason and need for change are evident on one side of the argument while on the other, the pattern of behaviour is entrenched.
• The philosophy of MI fits well with other strength based models (signs of safety, acceptance and commitment therapy, solution based approaches) and tools (scaling questions, values identification)
• Finally having people on your team who demonstrates compassion for your situation while holding a line on safety for vulnerable family members (children in particular) provides a place of accountability for effective ongoing work with families.

However alongside the obvious fit there are a number of challenging issues which include:

• Maintaining the boundary between an evidential role (gaining information around safety) and not going too far and ending up in a therapy role. I would make the argument that when we have an engaged interaction based upon the use of open questions, affirmations, complex reflections and summarising (the OARS skills of MI), this generates greater depth of information and as a result allows for more accurate information on which to base risk assessment on.  This also sets up the working relationship for those who will follow on with more ongoing involvement in families. This is the notion of through-care and that everyone has a place for the consistent and high quality work of helping families protect its members.
• Timeframes for investigating safety are important as none of us would condone leaving a child at risk. Being able to reflect on what it must be like to have people from outside the family coming uninvited into a person’s life will often create discord. MI is a great skill set to diffuse discord and join with the parents to find a solution. The key skill is to listen carefully for examples of change talk and amplify conversations around these ideas. Accepting that sustain talk will always emerge when we feel under threat and avoiding argumentation remains one of the key strategies to avoid discord within the relationship. MI is built upon social interaction theory which means that what happens between the parties is where change occurs. Avoiding reinforcement of sustain talk through generating the ‘righting reflex’ is one of the most important skills for the child protection worker. None of us want to entrench unsafe behaviour further – in fact that is unethical practice in my view.
• Some people think that in MI we don’t ask the ‘hard’ questions. Building dissonance is a core idea imbedded in MI practice and this is done through a number of strategies such as looking backwards, looking forwards, cost benefit tools, and exploring the most serious  things that have happened as a result of the behaviour. Engaging in these depth conversations go to the heart of safety issues through engaging with the persons own concerns for the wellbeing of their children.
• There is often a degree of anxiety in getting an intervention wrong by not acting in a timely basis. I would argue that using an MI consistent approach builds intrinsic motivation for change, which lasts longer than extrinsic, and so safety planning is more likely to have a better longer term outcome. MI is about behaviour change and planning for change is the fourth process in MI after engagement, focussing, and evoking.
• One of the key questions that often arises is how to tell the difference between true motivation and statutory motivation given the power that State agencies have in the lives of families. Encouraging change talk (DARNCAT) with attention to commitment, activation and taking steps, is a collaborative processes and a test of intrinsic motivation. If clients are merely going through the motions, then the follow through will often be inconsistent. Of course many of us start our process of change through extrinsic factors, but this often becomes intrinsic over time when we begin to see rewards for the efforts that we make.
• Conveying the bottom line is important for all interactions around safety. Transparency in dealing with clients is important as it conveys respect for the relationship and allows clients to explore what position they will take in relation to the issues raised. When safety is at stake then there is no room for compromise. There is room however for robust exploration of the issues which allows clients to exercise autonomy of response to decisions made. Motivational interviewing is not a magic answer to all issues and there will be times when workers have to act on behalf of children at risk and MI takes a back seat.
• The fact that sometimes home visits don’t allow enough time for in-depth conversations is  something often raised. In my experience it is amazing what can be achieved within a 30 minute interview window. Motivational interviewing is a directional conversation so once the focus is clear, then evoking from the client(s) and planning for an action towards a behaviour change, is the practice. All child protection services have as an outcome a plan of safety for children, so MI approaches are highly consistent with best practice in child protection.

It is my view that there is a very real place for motivational interviewing in child protection practice which as indicated is an important conversation for those engaging in safety of children. Moving practice from a forensic investigative approach to one of engaging in a relationship (while holding the line on safety) is what all of us would want to achieve within the work. These are my thoughts on the subject. Love to hear yours.

One Response to “Motivational interviewing and child protection – the fit”

1. Child protection and MI – results from the NSW project | HMA Blog says:

   February 24, 2013 at 2:01 am

   […] to engage parents in overcoming obstacles in  keeping children safe. As reported previously in our December blog, the Practice First model was trialled in 16 CSCs and one Child Protection Adolescent Team across […]