a framework for engaging resistant parents in child welfare

Rebecca Mirick, PhD, LICSW Adjunct FacultySimmons School of Social [email protected]

Reactance and the Child Welfare ClientA Framework for Engaging Resistant Parents

September 18, 2012

[email protected] FamiliesInSociety.org alliance1.org

A Framework for Engaging Resistant Parents

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GoalsDevelop an understanding of psychological reactance

and how to use it as a framework to understand resistance in child welfare services

Identify client responses to feelings of reactance

Utilize the reactance theory framework to assess for reactance and identify interventions with “resistant” child welfare clients

September 18, 2012 ● Alliance for Children and Families

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Children in Child WelfareWho is impacted by child welfare services?

675,000 children became involved with child welfare services in 2010

Approximately 400,000 children were in foster care in 201155% of children in foster care have been there for more

than 1 year31% of children in foster care have been there for more

than 2 years

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U.S. Department of Health and Human Services, 2010; www.acf.hhs.gov


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Characteristics of Child Welfare ServicesWhat is expected of parents in child welfare work?

Participation

Compliance

Demonstration of “deference to the authority of the worker”

Task completion

Parents are often resistant to child welfare servicesAlpert & Brittner, 2009; Altman, 2005; Altman, 2008; Reich, 2005; Smith, 2008


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Resistance in Child WelfareAngerDefensivenessAggressionArguingInterrupting or ignoring the workerChallenging the workerBlaming others for problemsMaking excuses for behaviorsMinimizing/denying the problemBeing unwilling to make changes or engage in the workArriving late to services or not attending at allPassive resistance

Rooney, 1992/2009


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Impact of Resistance and NoncomplianceParental lack of participation (noncompliance) and resistance impacts decision making.

Noncompliance is associated with:Longer stays in foster careHigher rates of child removalHigher rates of future maltreatment reportsGreater chance of termination of parental rights

Atkinson & Butler, 1996; DePanfilis & Zuravin, 2002; Jivanjee, 1999; Karski, 1999; Rittner & Dozier, 2000; Reich, 2005


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Examples of Resistant Clients

Suzy (23) is a Caucasian mom of two small children involved with child welfare services for the first time; the

baby (5 weeks old) broke her leg while her dad was watching her. She is very angry and frustrated that the

children are in foster care—she yelled at the worker in a planning meeting. She does not like two of the goals

(admitting that the boyfriend intentionally hurt the baby & getting a restraining order ) and believes the baby’s

injury was an accident. She has been told not to contact her boyfriend; while her children are living in foster

care, she secretly sees him. As a result, overnight visits with her children were postponed for 6 months. She is

now pregnant.

Jenna (28) is an African American mom living in an urban public housing development. She is polite and

respectful to the worker, but is often not at home, even when visits were scheduled ahead of time. She has a

history of substance abuse issues. She has missed multiple sessions of substance abuse treatment. She is

always regretful about missing services and has a reason why she missed (e.g., car wouldn’t start, boss

wouldn’t let her off of work, etc.) and promises not to miss any more…and yet always does. The worker told

her that she has to attend all treatment services and meetings for the next month or the worker will

recommend that she not regain custody of her little boy.

Maria (35) is a Latina mom with a history of substance abuse; her children’s school filed a 51-A for neglect.

She is angry that CPS is back in her life, and that she has mandated drug testing and substance abuse

treatment. Although she was attending AA regularly a few months ago, she has now stopped. She blames the

school for CPS involvement—they just don’t like her. Maria’s children remain with her at present, but the CPS

worker has said that the children may need to live with a family member if she cannot cooperate with services.

Maria’s been asked to do anger management treatment, a substance abuse program, attend AA regularly, do

drug testing, and attend a parenting class.


Why Don’t Parents Participate?Conventional Explanations


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Explanation #1: Family Characteristics

There are family characteristics or problems that negatively impact participation.

Substance abuse/major mental illnessShameDomestic violencePovertyCultural issues/disconnectLack of access to transportation or ability to get

time off of workLack of access to health insurance

Resistance: These issues interfere with parents’ engagement in services or access to services.

Ayon & Aisenberg, 2010; Reich, 2005; Staudt, 2007


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Explanation #2: Lack of Motivation

Lack of motivation to change or motivation to parent can impact participation.

They do not care enough about their child to make changes or participate in treatment services

They are in denialTherefore, lack of participation is a predictor of whether the

parent can parent the child safely

Resistance: The parent is not motivated enough by the love of the child or desire to parent, the parent is in denial.

Altman, 2008; Reich, 2005; Smith, 2008


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Explanation #3: Mistrust

A lack of trust that the worker or agency is there to help can impact participation in services.

Mistrust is common particularly in poor, urban neighborhoods of color

Child welfare agencies often have negative reputations (“baby snatchers”)

Resistance: The parent does not trust the worker or the agency.

Anderson, 2000; Reich, 2005


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Explanation #4: Readiness to Change

There are mutually exclusive stages of change that clients cycle

through in a non-linear manner.

Precontemplation

Contemplation

Preparation

Action

Maintenance

Resistance: Clients are pushed to change in the

precontemplation or contemplation stage.

Girvin, 2004; Littell & Girvin, 2004; Prochaska & DiClemente, 1984


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Explanation #5: Worker/Client Relationship

A motivational interviewing approach suggests that worker’s behavior in the relationship can impact resistance.

Resistance: Occurs when there is dissonance in the relationship between worker and client. The worker should address this by changing her/his approach.

Hohman, 1998; Miller & Rollnick, 2002; Mullins et al., 2004


Psychological ReactanceAn Alternative Explanation


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What is Reactance?

Take a minute and think about a situation where you were forced to do something you really did not want to do.

What did you think?

How did you feel?

What did you do?

Rooney, 1992


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Psychological ReactanceA normal, expected motivational drive to regain a lost or threatened freedom a person had assumed would be available to him/her.

The magnitude of the reactance depends on:

1. The importance of the lost/threatened freedom to the person

2. The presence of an implied threat to other freedoms

3. The strength of the person’s assumption that this freedom would be available to him/her

4. The proportion of freedoms threatened/lost versus those available to the person

Brehm, 1966; Brehm & Brehm, 1981; Rooney, 1992/2009


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Threatened or Lost FreedomsThreatened/lost freedoms in child welfare include:

Decisions about who to date/ live withLiving arrangementsDecision to leave a partner or to obtain a restraining

order against a partnerCustody of a child Parenting decisionsAlcohol or drug useAA/NA attendance/ treatment attendance

Altman, 2008; Reich, 2005; Smith, 2008


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How Is Reactance Expressed?Responses to reactance can be viewed as attempts to decrease intolerable affect (reactance) and regain feelings of power and control.

How do clients express reactance?

1. Attempt to regain the lost/threatened freedom

2. Search for loopholes to restore the lost/ threatened freedom

3. Express hostility or aggression towards the person who restricted/threatened the freedom

4. Value the lost/ threatened freedom more than before it was lost/ threatened Brehm, 1966; Brehm & Brehm, 1981; Rooney, 1992/2009


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1. Attempts to Regain the FreedomPeople often respond to reactance by trying to regain the lost freedom directly.

Examples:Arguing with the child welfare workerDenying the abuse occurred Demanding the return of the child/ childrenDefending parent’s behavior

Rooney, 1992/2009


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2. Search for Loopholes

Parents respond to the feeling of reactance by trying to regain the freedom—not outright, but indirectly through a loophole in the limit.

Examples:If children are placed with family members, the

parent may try to visit there, instead of at the supervised, scheduled visits

A mother who has lost custody of a child may get pregnant again

Rooney, 1992/2009


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3. Anger

Parents express reactance as anger, hostility, or aggression toward the limit-setter. This occurs even when the expression of anger will not restore the lost or threatened freedom.

Examples:Parent gets angry and frustrated in a team meeting Parent spends half of a treatment session

expressing anger and frustration about CPS involvement

Rooney 1992/2009


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4. Restricted Behaviors Become More AppealingSometimes reactance is not expressed either directly or indirectly and must be tolerated instead. The prohibited behavior can become more desirable.

Examples:The unsafe partner becomes more desirableAlthough a parent with substance abuse issues had

been contemplating about change—the mandate to attend treatment services and label of “substance abuser” decreases her desire to enter treatment services

Rooney, 1992/2009


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Example #1Suzy (23) is a Caucasian mom of two small children involved

with child welfare services for the first time; the baby (5 weeks old) broke her leg while her dad was watching her.

She is very angry and frustrated that the children are in foster care—she yelled at the worker in a planning meeting. She does not like two of the goals (admitting that the boyfriend intentionally hurt the baby and getting a restraining order ) and believes the baby’s injury was an accident.

She has been told not to contact her boyfriend; while her children are living in foster care, she secretly sees him. As a result, overnight visits with her children were postponed for 6 months. She is now pregnant.


24

Example #2Jenna (28) is an African American mom living in an urban public

housing development. She is polite and respectful to the worker, but is often not at home, even when visits were scheduled ahead of time.

She has a history of substance abuse issues. She has missed multiple sessions of substance abuse treatment. She is always regretful about missing services and has a reason why she missed (e.g., car wouldn’t start, boss wouldn’t let her off of work, etc.) and promises not to miss any more…and yet always does.

The worker told her that she has to attend all treatment services and meetings for the next month or the worker will recommend that she not regain custody of her little boy.


25

Example #3Maria (35) is a Latina mom with a history of substance abuse;

her children’s school filed a 51-A for neglect. She is angry that CPS is back in her life, and that she has mandated drug testing and substance abuse treatment. Although she was attending AA regularly a few months ago, she has now stopped. She blames the school for CPS involvement—they just don’t like her.

Maria’s children remain with her at present, but the CPS worker has said that the children may need to live with a family member if she cannot cooperate with services. Maria’s been asked to do anger management treatment, a substance abuse program, attend AA regularly, do drug testing, and attend a parenting class.


How Can Reactance Theory Be Used in Child Welfare Work?


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Benefits of Reactance

Can be predictedClient-centered approachSome approaches are supported by

preliminary researchIs congruent with social work valuesSeparates client behavior from client

motivation/ desire to parentNot client blaming

Rooney, 1992/2009


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Assess for Reactance

Signs of reactance: Anger, refusal to participate in services, denial, interrupting, getting off task easily, making negative comments, questioning the worker or treatment provider’s expertise, missing appointments or visits.

Formal measures of reactance:Hong Psychological Reactance ScaleTherapeutic Reactance Scale (Dowd)

Beutler et al., 2011; Dowd, Milne & Wise, 1991; Hone & Page, 1989


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Approaches With Reactant Parents1. Use the lens of reactance theory to interpret the

parent’s behavior

2. Use interventions likely to reduce the reactance versus increase it

Interventions to Reduce Reactance1. De-emphasize the power differential

2. Use nondirective approaches

3. Limit restrictions


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Intervention #1: Limit Use of Power

Parents in child welfare services are sensitive to the power issues inherent in the work.

Examples: ○ Mandates○ Threats○ Unscheduled home visits○ Asking parents to “jump through hoops” to

demonstrate motivation ○ Persuasion○ Coercion

Altman, 2008; Berg & Kelly, 2000; Diorio, 1992; Dumbrill, 2006; Smith, 2008


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What Does It Look Like to De-Emphasize Power?

Avoid threats, coercion, or persuasionAvoid unnecessary requirements or mandatesBe respectful of client’s space particularly when in

their home (e.g., ask permission to look in the kitchen or talk to the child—if the response is no, then have a conversation about what that might mean)

Focus on a collaborative, empathetic approach versus one that highlights power differential

Berg & Kelly, 2000; Dumbrill, 2006; Rooney 1992/2009


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The Cycle of Reactance andUse of Power

Reactance behaviors expressed

Social worker responds with use of power &

authority

Increased reactance

Increased use of power & authority

Increased reactance

G. D. Rooney, 2009


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Example #1Suzy (23) is a Caucasian mom of two small children involved

with child welfare services for the first time; the baby (5 weeks old) broke her leg while her dad was watching her.

She is very angry and frustrated that the children are in foster care—she yelled at the worker in a planning meeting. She does not like two of the goals (admitting that the boyfriend intentionally hurt the baby & getting a restraining order ) and believes the baby’s injury was an accident.

She has been told not to contact her boyfriend; while her children are living in foster care, she secretly sees him. As a result, overnight visits with her children were postponed for 6 months. She is now pregnant.


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Intervention #2: Non-Directive Approaches

Directiveness is how much the practitioner is in control of the work

This intervention for high-reactant clients has the most empirical support

Practitioner directiveness is negatively correlated with outcomes for high reactant clients

Beutler & Clarkin, 1990; Beutler & Harwood, 2000; Beutler et al., 2011; Karno & Longabaugh, 2005


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What Are Non-Directive Approaches?Directive approaches Non-directive approaches

Cognitive behavioral therapy Supportive therapy

Traditional, disease model-based substance abuse treatment

Motivational interviewing

Practitioner as expert Client as expert in his/her own life

Giving advice, confrontation, interpretation, providing information, initiating topics

Active listening, collaborative goal setting

Limiting choices, using persuasion or coercion, taking the lead

Offering choices, letting the client take the lead, avoiding persuasion or coercion

Avoid practitioner-directed interventions

Use client-directed interventions (like bibliotherapy)

Beutler & Clarkin, 1990; Karno et al., 2009; Karno & Longabaugh, 2005


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Example #2Jenna (28) is an African American mom living in an urban public

housing development. She is polite and respectful to the worker, but is often not at home, even when visits were scheduled ahead of time. She has a history of substance abuse issues. She has missed multiple sessions of substance abuse treatment.

She is always regretful about missing services and has a reason why she missed (e.g., car wouldn’t start, boss wouldn’t let her off of work, etc.) and promises not to miss any more…and yet always does.

The worker told her that she has to attend all treatment services and meetings for the next month or the worker will recommend that she not regain custody of her little boy.


37

Intervention #3: Limit RestrictionsTheoretically, decreasing the number of restrictions on personal freedoms should decrease the reactance response.

Examples:Keep goals as specific as possibleEmphasize the freedoms which remain available to

the clientClarify “silent mandates”

G.D. Rooney, 2009; R.H. Rooney, 1992/2009


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What Does It Look Like to Limit Restrictions? If the parent is mandated to attend substance abuse treatment

services, offer the parent a choice of programs; thus, the main limit still remains, but the freedom to choose which one remains

Emphasis specific, not global, goals; and clarify that the parent needs to stay away from a violent partner, not stop dating; the issue is the violence, not the dating

Help a parent manage losses associated with the required loss of an unsafe partner—find new childcare, if he cannot watch the children, or apply for financial assistance since he is no longer helping to pay the bills

Avoid restrictions or requirements that are only present to determine how motivated the parent is

Smith, 2008


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Example #3Maria (35) is a Latina mom with a history of substance abuse;

her children’s school filed a 51-A for neglect. She is angry that CPS is back in her life, and that she has mandated drug testing and substance abuse treatment. Although she was attending AA regularly a few months ago, she has now stopped. She blames the school for CPS involvement—they just don’t like her.

Maria’s children remain with her at present, but the CPS worker has said that the children may need to live with a family member if she cannot cooperate with services. Maria’s been asked to do anger management treatment, a substance abuse program, attend AA regularly, do drug testing, and attend a parenting class.


Future ResearchWhat Is Needed?


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Future ResearchDoes the use of reactance theory have the potential to improve child welfare

outcomes?

How open are child welfare agencies to the use of reactance theory? Workers themselves versus administration? If barriers to the adoption of this approach are present, what are they?

What is the impact of the context of child welfare work (e.g., federal legislation, timelines, safety concerns for both child and self, lack of treatment services)?

How can child welfare workers effectively assess for reactance?

How many parents are experiencing reactance? How many are resistant for other reasons? What are these reasons?

Does the use of reactance-based interpretations of parent-behavior improve parent attendance and increase engagement in services? Is this associated with more positive outcomes?


[email protected] FamiliesInSociety.org alliance1.org/intellectual-capital-division

Dr. Rebecca G. [email protected]

Additional Alliance ResourcesPRACTICE• Practice & Policy Focus:

http://alliance1.org/ppf • Alliance for Children and Families Annual Conference (Innovation Track):

http://www.alliance1.org/nc/workshops-innovation-implementation• START and Family Outcomes: Collaborative Strategies That Work (Webinar):

http://alliance1.org/webinar/start-and-family-outcomes-collaborative-strategies-work

POLICY• Washington Insider: http://www.alliance1.org/policy/insider

• Reactance and the Child Welfare Client: Interpreting Parents’ Resistance to Services Through the Lens of Reactance Theory (2012) Families in Society, (93)3, doi:10.1606/1044-3894.4224

• Presentation references available in handout file.

Presentation Resources

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ReferencesAdministration for Children & Families. Retrieved from www.acf.hhs.gov/programs/cb/stats_research/afcarsAlpert, L.T. & Britner, P.A. (2009). Measuring parent engagement in foster care. Social Work Research, 33, 135-145. doi:

10.1093/swr/33..3.135.Altman, J.C. (2005). Engagement in children, youth & family services. In G.P. Mallon & P.M. Hess (Eds), Child welfare for the 21st

century: A handbook of practice, policies and programs (pp. 72-86). New York: Columbia University Press. Altman, J.C. (2008). Engaging families in child welfare services: Worker versus client perspectives. Child Welfare, 87, 31-63. doi:

0009-4021/2008/030841-61Altman, J.C. & Gohagan, D. (2009). Work with involuntary clients in child welfare settings. In R.H. Rooney (Eds.), Strategies for

work with involuntary clients (224-247). New York: Columbia University Press.Anderson, D.G. (2000). Coping strategies and burnout among veteran child protection workers. Child Abuse & Neglect, 24, 839-

848.Atkinson, L. & Butler, S. (1996). Court-ordered assessment: Impact of maternal noncompliance in child maltreatment cases. Child

Abuse & Neglect, 20, 185-190. doi: 10.1016/S0145-2131(95)00146-8 Ayon, C. & Aisenberg, E. (2010). Negotiating cultural values and expectations within the public child welfare system: A look at

familismo and personalismo. Child and Family Social Work, 15, 335-344. doi: 10.1111/j.1365-2206.2010.00682xBarth, R.P. (2008). The move to Evidence-Based Practice: How well does it fit child welfare services. Journal of Public Child

Welfare, 2, 145-173. doi: 10.1080/15548730802312537Berg, I.K. & Kelly, S. (2000). Building solutions in child protective services. New York: Norton.Beutler, L.E. & Clarkin, J. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York:

Brunner/Mazel.Beutler, L.E. & Harwood, T.M. (2000). Prescriptive therapy: A practical guide to systematic treatment selection. New York: Oxford

University Press. Beutler, L. E., Harwood, T. M., Michelson, A., Song, X., & Holman, J. (2011). Resistance Level. In Norcross, J. C. (Ed),

Relationships that work: Therapist Contributions and Responsiveness to Patient Needs (2nd ed.). New York: Oxford University Press.

Brehm, J. (1966). A Theory of Psychological Reactance. New York: Academic Press.

Brehm, S. & Brehm, J. (1981). Psychological reactance: A theory of freedom & control. New York: Academic Press.

Bundy-Fazioli, K., Briar-Lawson, K. & Hardiman, E.R. (2009). A qualitative examination of power between child welfare workers

and parents. British Journal of Social Work, 39, 1447-1464. doi: 10.1093/bjsw/bcn038

DePanfilis, D., & Zuravin, S. J. (2002). The effect of services on the recurrence of child maltreatment. Child Abuse & Neglect,

26(2), 187–205. September 18, 2012 ● Alliance for Children and Families

http://www.larrybeutler.com/wp-content/uploads/2009/01/Resistance-Norcross-r.doc

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References (continued)Dowd, E., Milne, C., Wise, S. (1991). The Therapeutic Reactance Scale: A Measure of Psychological Reactance. Journal of Counseling &

Development, 69, 541-545.

Drake, B., Jolley, J.M., Lanier, P., Fluke, J., Barth, R.P. & Jonson-Reid, M. (2011). Racial bias in child protection? A comparison of competing

explanations using national data. American Journal of Pediatrics, 127, 471-478. doi: 10.1542/pes.2010-1710

Diorio, W. D. (1992). Parental perceptions of the authority of public child welfare workers. Families in Society, 73(4), 222-235.

Dumbrill, G. (2006). Parental experience of child protection intervention: A qualitative study. Child Abuse and Neglect, 30, 27-37. doi:

10.1016/j.chaibu.2005.08.012

Gelles, R.J. (1996). The book of David: How preserving families can cost children’s lives. New York: Basic Books.

Girvin, H. (2004). Beyond 'stages of change': using readiness for change and caregiver-reported problems to identify meaningful subgroups in a child

welfare sample, Children & Youth Services Review, 26, 897-917. doi: 10.1016/j.childyouth.2004.04.001

Hohman, M.M. (1998). Motivational Interviewing: An intervention tool for child welfare case workers working with substance abusing parents. Child

Welfare, 77, 275-291.

Hong, S. & Page, S. (1989). A psychological reactance scale: Development, factor structure and reliability. Psychological Reports, 64, 1323-1326.

Jivanjee, P. (1999). Professional and provider perspectives on the family involvement in therapeutic foster care. Journal of Child and Family Studies,

8(3), 329-341.

Karno, P.M., Beutler, L.E. & Harwood, M. (2002). Interactions between psychotherapy process and patient attributes that predict alcohol treatment

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Karno, P.M. & Longabaugh, R. (2005). Less directiveness by therapists improves drinking outcomes of reactant clients. Journal of Consulting &

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Karno, P.M., Longabaugh, R. & Herbeck, D. (2009). Patient reactance as a moderator of the effect of therapist structure on post treatment alcohol

use. Journal of Studies on Alcohol & Drugs, 70, 929-936.Keller, J. and McCade, K. (2000). Attitudes of low-income parents toward seeking help with parenting: Implications for practice. Child Welfare, 79,

285–312.Littell, J.H. & Girvin, H. (2004). Ready or not: Uses of the stages of change model in child welfare. Child Welfare, 83 (4), 341-366. doi: 0009-

4021/2004/040341-26Miller, R.M. & Rollnick, S.P. (2002). Motivational Interviewing: Preparing people for change. New York: Guildford Press.Mullins, S.M., Suarez, M, Ondersma, S.J. & Page, M.C. (2004). The impact of motivational interviewing on substance abuse treatment retention: A

randomized control trial of women involved with child welfare. Journal of Substance Abuse Treatment, 27, 51-58. doi: 10.1016/j.jsat.2004.03.010


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References (continued)Prochaska & DiClemente (1984). The transtheoretical approach: Crossing the traditional boundaries of change. Homewood, IL:

Dow Jones/Irwin.Reich, J.A. (2005). Fixing families: Parents, power and the child welfare system. New York: Rutledge.Rittner, B., & Dozier, C. D. (2000). Effects of court-mandated substance abuse treatment in child protective services cases. Social

Work, 45(2), 131-140. Rooney, R.H. (1992). Strategies for work with involuntary clients, 1st edition. New York: Columbia University Press. Rooney, R. H. (2009). Strategies for work with involuntary clients, 2nd edition. New York: Columbia University Press. Rooney, G.D. (2009). Oppression and involuntary status. In R.H. Rooney (Eds.), Strategies for work with involuntary clients (349-

387). New York: Columbia University Press.Smith, B.D. (2008). Child welfare service plan compliance: Perceptions of parents and caseworkers. Families and Society, 89,

521-533. doi: 10.1606/1044-3894.3818Staudt, M. (2007). Treatment engagement with caregivers of at-risk children: Gaps in research and conceptualization. Journal of

Child and Family Studies, 16, 183-196. doi: 10.1007/s10826-006-9077-2US GAO. (July 2007). African American children in foster care. GAO-07-816. Retrieved March 23, 2012 from

www.gao.gov/cgi-bin/getrpt?GAO-07-816.U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2010

(Washington, DC: U.S. Government Printing Office, 2010).


http://www.gao.gov/cgi-bin/getrpt?GAO-07-816

a framework for engaging resistant parents in child welfare

Education

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small children

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treatment services

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