Overview of the study
Local authority social workers for children and their families deal with large numbers of parents who have alcohol problems. Research shows that they have particular difficulties when trying to work with parents who deny or minimise the amount they drink. Motivational interviewing is a counselling method developed for working with people who have a drink or drugs problem. A particular focus of motivational interviewing is on working with “denial”, so it seems likely to be helpful for social workers in their work with parents who misuse alcohol.
However, there are challenges involved in training social workers motivational interviewing. Firstly, we do not know much about the process of training social workers in such skills. Thus, there are questions about the starting level of their skills, the best format for improving their practice and the relative impact of training and follow-up input such as consultations or supervision. Secondly, while motivational interviewing is of proven effectiveness in a range of settings, there are particular challenges in child protection social work that make using counselling skills difficult. For instance, how can motivational interviewing skills be used to when one is telling a parent that one believes a child should be removed or assessing whether their drinking is harming their child’s welfare? There is remarkably little research on how these difficult conversations can be managed, and we therefore can not be confident about how motivational interviewing might be used in such situations.
The study explores these areas. It is interested in three main questions:
- Does input around motivational interviewing make a difference to social workers’ skills?
- What helps and what hinders skill development?
- What is the impact of using motivational interviewing skills in practice?
The study provided a Z-day training workshop for 35 social workers and 5 managers from seven London local authorities. Before and 3 months after the training participants’ skills and attitudes were measured through:
- Asking participants how they would respond to various casework situations and rating the answers.
- Standardised measures of attitudes to working with alcohol misuse.
- Social workers’ descriptions of the cases that they were currently working with.
- Qualitative descriptions of current work and the impact (if any) of the training.
- In addition, after the training we recorded a session with a “simulated client” (i.e. someone acting as a parent with an alcohol problem) and rated participants for skill in motivational interviewing. This was undertaken for 34 social workers.
We were also interested in the contribution of additional supervision and/or group discussions in promoting skills development, as previous studies have found this to be particularly important. We therefore randomly assigned half of the group to receive extra input; the others received no support between the workshop and the follow-up interview.
- A key finding was that prior to training social workers had remarkably confrontational ways of talking to clients with few demonstrating even relatively basic listening skills.
- Overall the 2-day training workshop had a statistically significant positive impact. The most important changes were that participants:
- Demonstrated more empathy and less confrontation in simulated practice vignettes.
- Reported greater confidence in their knowledge of alcohol misuse and their ability to work with alcohol problems.
- Reported being less stressed in their work.
- Most participants felt that increased empathy and reduced confrontation seemed to be linked to better relationships with parents and possibly to better outcomes in some cases.
- The level of skill in motivational interviewing varied widely. Of the 34 participants who had an interview with a simulated client rated 10 appeared to have some competence, 15 had some indication of basic listening skills and 9 demonstrated little or no skill in listening.
- The additional supervision and consultations made little appreciable difference to the practice of most participants, though they may have helped some of those who achieved the highest levels of skill. There was a low level of participation in these.
- Participants received very little support in the development of their practice skills in their workplace between training and follow-up. Whether managers attended the course with workers or not appeared to make no difference to this.
- From the accounts of workers who achieved competence, it appeared that many of the skills of motivational interviewing can be used with apparent success in even very challenging discussions with parents.
Implications of the findings
- Improving the communication skills of social workers in working with parental alcohol misuse is an urgent priority. The poor listening skills and high levels of confrontation demonstrated by most participants prior to training were a surprising and striking finding.
- The confrontational style identified pre-training points to the possibility that social workers may inadvertently be contributing to the resistance that they describe as such a problem in their work with this client group. It is always likely to be difficult to talk to someone about the impact of their alcohol problem on their child; if workers have not been taught how to listen empathically it is likely to make the discussion even more fraught.
- A 2-day workshop in motivational interviewing had a significant positive impact on the practice, knowledge and confidence of participants. This is an important positive finding. Some significant improvements in listening skills and reductions in confrontation can be achieved through even a brief training intervention.
- The lack of support for skills development in workplaces was surprising. In particular the lack of involvement of line managers in developing the skills of practitioners was of concern, as this group appear key in supporting the transfer of skills learnt in training into practice.
- The provision of telephone supervision and group consultations was not effective, and participation was poor. Further work on what might help social workers in transferring skills from training into practice is needed. A programme of follow-up days and/or training for supervisors are possible approaches to this issue.
- The study provided evidence that USing listening skills improved social workers’ relationships with clients and their satisfaction with their work. This did not need to be as high level a skill as “motivational interviewing”: for many participants it was relatively simple skills, such as using open questions or reflections, that seemed to help improve relationships.
- There was nonetheless some encouraging evidence for the potential contribution that motivational interviewing might make as a method to be used by child and family social workers. However, more research is required on how participants can achieve skilfulness, on how skilful practitioners negotiate practice dilemmas and on whether outcomes for parents and children are improved.
Donald Forrester, Jim McCambridge, Stephen Rollnick, John Strang and Clara Waissbein.