Training Matters

 

Vol. 10, No. 2 • June 2009

How Do People Change?
In child welfare work, change is at the heart of things. Every day, we find ourselves in the difficult position of asking families to change—to break old patterns and learn new ways of behaving to ensure the safety, permanence, and well-being of their children.

Historically, child welfare agencies attempted to bring about behavioral change in families through a command and control approach: we would tell them what to do and expect them to comply to avoid negative consequences.

Unfortunately, this isn’t very effective. When we use a confrontational style, we often provoke a high level of resistance, which makes it even harder for us to support families and keep children safe. This traditional approach isn’t aligned with what research has shown about the way change actually occurs.

Six Stages of Change
According to Prochaska and DiClemente (1982), behavioral change is a gradual process involving six stages:

  1. Precontemplation: The person is not considering change. They may not be aware a problem exists or that they need to make changes.

  2. Contemplation: The person becomes aware a problem exists and that there are reasons to change. However, the person may both “want to change” and “not want to change” at the same time.

  3. Preparation: The person perceives the benefits of change and the adverse consequences of continuing the present behavior. As they think about the risk versus the benefits, the balance tips in favor of change. Commitment to change begins.

  4. Action: The person chooses a strategy and begins to take steps to alter habits and modify the environment to make significant life change. At this stage they may face serious challenges in relationships, employment, etc., that create barriers to change.

  5. Maintenance: The person has learned ways to sustain their gains and knows how to identify and avoid things that may trigger a return to problem behavior.

  6. Lapse / Relapse: The person returns to previous problem behavior for a time.

People move through these six stages at different rates. Progression is not linear: it is normal to move back and forth between stages.

No matter what type of change you want to accomplish (start an exercise program, weight loss, help a client with substance abuse, etc.) motivation is critical.

Motivation Is Key
Up until the 1980s, motivation—that is, the probability a person will be ready to enter into and adhere to a change strategy (Miller & Rollnick, 1991)—was seen as something people either had or didn’t have. In therapy and other helping relationships, if the client didn’t have it, “lack of motivation” was used to explain clients’ failure in treatment.

Research over the past 20 years has improved our understanding of motivation considerably. We now know that the amount of motivation a person has fluctuates daily. We also know that motivation can be created and is strongly influenced by our relationships with other people (Miller, 1985). For example, research has revealed that:

  • Helping professionals get better outcomes when they show more empathy. Concern facilitates change more effectively than confrontation and consequences.
  • Providing feedback to people about their problems can elicit change-related behavior.
  • Helping people set clear, realistic, attainable goals facilitates change.
  • Providing a choice among alternatives improves compliance and outcomes (Miller & Rollnick, 1991).

Implications for Child Welfare
This information makes it clear that the old way of telling families what to do and then sitting back and calling them “unmotivated” when they don’t comply is not legitimate child welfare practice. Although families are ultimately responsible for their own change, we cannot expect them to come to us ready and motivated to change. As child welfare professionals it is our job to enhance families’ motivation to change and to support them throughout the change process.

To succeed in this challenging task we must use what we know about motivation and the change process. As a regular part of their work with families, child welfare workers should tailor what they do and say according to where the families are in the change process. The box below identifies the goals child welfare should have at each of the six stages.

A key strategy for helping parents move from one stage to another is using open-ended questions that help parents state for themselves the risks and benefits of changing or not changing. (For example, “What makes you think you need to do something about this? What do you like about the way things are now?”) Practitioners would then respond with statements that reflect back both the content and the emotion of what was said. (“It sounds like the time with your friends helps you deal with the stress of being a single parent. Is that right?”) Another important strategy is to identify and affirm any signs of motivation or strength in the parent. (“I can tell by how much you’ve thought about this that you really are concerned for your kids and want them to be safe.”) Perhaps most importantly, avoid arguing, threatening, or convincing: if the parent expresses resistance to change, trying to talk them into it only creates more resistance (Miller & Rollnick, 1991).

Fortunately, as a state we are already creating an atmosphere in child welfare that is conducive to the motivational approach. The family-centered principles of partnership North Carolina has embraced (e.g., “everyone needs to be heard,” “judgments can wait,” “partners share power”) are what’s needed to build the relationships that empower families and support positive behavioral change.

Goals for Child Welfare Staff at Each Stage of Change
Parent’s Stage
Goals for Child Welfare Staff
Sample Questions to Ask
Precontemplation Increase the parent’s perception of risks and problems with current behavior; raise parent’s awareness of behavior How would you know if this was a problem? How does this behavior help you? What problems does it cause for you or your family?
Contemplation Foster and evoke reasons to change and risks of not changing; help parent see that change is possible and achievable What do you think will happen if you keep doing things the same way? What would be the advantages of changing?
Decision to Change Help parent identify best actions to take for change; support motivation for change What do you want to happen? When else have you followed through on an important decision?
Action Help parent implement strategy and take steps Which option sounds like it fits you best? What would make it easier for you?
Maintenance Help parent identify triggers and use strategies to prevent relapse What feelings, people, or places make you want to do this again?
Lapse or Relapse Help parent re-engage in the contemplation, decision, and action stages See questions for contemplation, decision, and action stages above
(Adapted from National Center on Substance Abuse and Child Welfare, 2004; Miller & Rollnick, 1991)

Motivational Interviewing
To apply information about motivation to your work with families, learn more about Motivational Interviewing (MI). Developed by Miller and Rollnick, MI began as a treatment for substance abuse but has been applied successfully to many other issues, including CPS referrals. Many studies demonstrate MI’s effectiveness. For example, in a study involving child welfare clients, when only one session using Motivational Interviewing was done with clients, the rate at which they entered substance abuse treatment doubled (Hattema, et al., 2005).

To learn more about Motivational Interviewing, consult the following resources:

References

Hettema, J., Steele, J. & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.

Miller, W.R. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98, 84–107.

Miller, W.R. & Rollnick, S. (1991, 2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.

National Center on Substance Abuse and Child Welfare. (2004). Understanding substance use disorders, treatment and family recovery: A guide for child welfare professionals . Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. <ncsacw.samhsa.gov>

Prochaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19 , 276–288.

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