ERIC ED581432: The Promise of Motivational Interviewing in School Mental Health

2011·0.3 MB·English

by  ERIC

SchoolMentalHealth(2011)3:1–12
DOI10.1007/s12310-010-9048-z
REVIEW PAPER
The Promise of Motivational Interviewing in School Mental
Health
Andy J. Frey • Richard N. Cloud • Jon Lee •
Jason W. Small • John R. Seeley • Edward G. Feil •
Hill M. Walker • Annemieke Golly
Publishedonline:22January2011
(cid:2)SpringerScience+BusinessMedia,LLC2011
Abstract In recent years, the science of developing and legislators, and the general public have recognized the
implementing interventions addressing school-related risk social support and technical assistance needs of a sub-
factorshasproducedmanyadvances.Thisarticleaddresses stantial number of students who experience school, com-
thepromiseofacross-disciplinarypracticeapproachknown munity, and family risk factors jeopardizing the likelihood
asmotivationalinterviewinginschoolsettings.Specifically, of school success. These risk factors include parent–child
thesupportingevidenceaswellastheprocessandprinciples conflict; lack of bonding and social connectedness with
of motivational interviewing are described for those unfa- peers, teachers, and family; weak school engagement;
miliar with motivational interviewing nomenclature. A inconsistent classroom and/or family management prac-
description of recent school-based innovations using the tices; association with antisocial peers; bullying and
principles of motivational interviewing is then provided. harassment, and toxic school or classroom cultures (Frey,
Next, some potential applications for applying the motiva- Walker, & Perry, 2011). Without systematic interventions,
tional interviewing approach in educational settings to theseconditionsmay(a)disruptlearningandachievement,
enhancetheadoption,development,andimplementationof (b) place children at substantial developmental risk, and
effective school-based interventions designed to promote (c)createconcernsforthesafetyofteachersandclassmates
academicachievementandpreventoramelioratechalleng- (e.g., Burns & Hoagwood, 2002). In recent years, the
ing behavior are proposed. The article concludes with a knowledge base to guide educators and school mental
discussionoffuturedirectionsofmotivationalinterviewing health providers has increased exponentially, and at the
approacheswithinthecontextofschoolmentalhealth. same time our ability to effectively adopt and apply
effective practices with fidelity remains limited (Fixsen,
Keywords Motivational interviewing (cid:2) Naoom, Blase, Freidman, & Wallace, 2005).
Intervention research (cid:2) Fidelity Thisarticleexaminesthepromiseofacross-disciplinary
practice approach known as motivational interviewing
(MI) within school mental health (Miller, 1985; Miller &
Introduction
Rollnick,2002).Motivationalinterviewingisdefinedas‘‘a
client-centered, directive method for enhancing intrinsic
The field of mental health has recently developed a
motivation to change by exploring and resolving ambiva-
larger presence in schools as educators, policy makers,
lence’’ (Miller & Rollnick, 2002, p. 25). MI is founded on
thebeliefthathowoneinteractswithpeoplehassignificant
A.J.Frey(&)(cid:2)R.N.Cloud(cid:2)J.Lee
effectsuponintrinsicmotivationthatleadstobetterchange
UniversityofLouisville,Louisville,KY,USA
outcomes. The approach builds upon non-directive
e-mail:[email protected]
approaches developed by Rogers’ (1959) theory regarding
J.W.Small(cid:2)J.R.Seeley(cid:2)E.G.Feil the critical counselor skills necessary to facilitate change.
OregonResearchInstitute,Eugene,OR,USA
Specifically, Rogers advocated a client-centered approach
whereby the counselor provides an ideal atmosphere for
H.M.Walker(cid:2)A.Golly
UniversityofOregon,Eugene,OR,USA change by expressing empathy, warmth, and genuineness.
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2 SchoolMentalHealth(2011)3:1–12
MIisinfusedwithpositiveregardfortheclientalongwith treatmentapproaches,whichhighlighttheflexibilityofMI.
aspiritofcaringandconcern.MIexpandsRogers’stheory The majority of MI adaptations, including the Drinker’s
by adding directive strategies that target specific behavior Check-Up (Miller & Sovereign, 1989) and Project
and has demonstrated evidence for increasing motivation MATCH (Project MATCH Research Group, 1997) utilize
as a vehicle to behavior change in a variety of contexts. the principles and techniques of MI to guide communica-
Herein, the evidence supporting MI is presented, fol- tion and include a feedback routine in which assessment
lowedbyadescriptionoftheapproachforthoseunfamiliar resultsaresharedwiththeclientinanon-directivefashion.
with MI nomenclature, and a summary of recent innova- Adaptations have been applied to addictions (Miller,
tions in school-based mental health using an MI approach. Zweben, DiClemente, & Rychtaric, 1992), prenatal coun-
Next,somepotentialusesforthemotivationalinterviewing seling (Handmaker, Miller, & Manicke, 1999), diabetes
approachineducationalsettingsareexamined,followedby management(Smith,Heckemeyer,Kratt, &Mason,1997),
a discussion of the future directions of MI approaches in and relationship distress (Marriage Check-Up, Cordova,
school mental health. Warren, & Gee, 2001).
MI investigations have primarily centered on the study
of adults, with studies of its effectiveness for youth and
Evidence Supporting Motivational Interviewing children focusing on adolescent and pre-adolescent youth
rather than preschool or elementary aged children (e.g.,
Three systematic reviews of the efficacy of MI across Flattum, Friend, Neumark-Sztainer, & Story, 2009).
substantive domains have been published (Dunn, DeRoo, Lundahl et al. (2010) provide a plausible explanation for
& Rivara, 2001; Miller & Rollnick, 2002; Noonan & thelackofdirectstudywithyoungchildren;‘‘Considering
Moyers,1997).Inallthreereviews,evidencesuggeststhat developmental issues, MI is conducted within a cognitive
the use of MI, even in an abbreviated format (e.g., 1–4 medium and requires some degree of abstract reasoning
sessions),canencourageadultbehaviorimprovementsthat that should be present after the age of 12 years [based on
are significantly more favorable than no treatment, gener- Piaget’s (1962) model] and thus may not be as helpful for
ate gains that are maintained after the intervention and preteen children.’’ (p. 153). Atkinson and Amesu (2007)
sustainedovertime,andproduceeffectsthatareequallyas cautionagainsttheuseofMIwithyoungchildrenasMIis
effective as credible alternative treatments. Interestingly, largely language based, relying ‘‘on the ability of young
effectsizesforMIadaptationsfollowedbyanothertypeof people to express their feelings about a particular set of
treatmentweresimilartoofferingMIadaptationsasstand- circumstances’’ (p. 36). Studies that involve preschool and
aloneinterventions.Finally,theseresultsmustberegarded elementaryagedchildrensuggestthatMIcanbeusedwith
as tentative or preliminary given that the internal validity parents and teachers, who play asignificant role inthelife
of many of the studies was highly variable. ofthechild(e.g.,Channonetal.,2007;Freudenthal,2008;
This growing literature base has allowed for review of Freudenthal&Bowen,2010)andcontrolhomeandschool
the evidence from a meta-analytical standpoint, providing environments.Inthecontextofschoolmentalhealth,MIis
an aggregated view of MI effectiveness (see Burke, promising as a vehicle to change adult’s behavior, while
Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, mediating changes in the child’s behavior. However, the
2005; Vasilam, Hosier, & Cox, 2006). In the most recent study of MI with young children is only just beginning. It
meta-analysis, Lundahl, Tollefson, Kunz, Brownell, and may be plausible that MI could be utilized with young
Burke (2010) provide continued support for the use of MI children with some effectiveness (Nage, 2010). More
with many problem behaviors (alcohol, drug and tobacco likely, continued research in this area could reveal a con-
use,variousriskybehaviors,andmedicationandtreatment tinuumofMIrequisiteskillsthatareappropriateforcertain
adherence). developmental levels.
Within the substance abuse literature, several studies
have shown that adult clients who are exposed to MI as a
supplemental, ‘‘front-loaded’’ intervention (e.g., preceding The Process and Principles of Motivational
a standard intervention), are more likely to stay in treat- Interviewing
ment, put forth more effort during treatment, adhere more
closely to the intervention protocol or recommendations, Miller and Rollnick (2002) describe two phases of MI,
andexperiencesignificantlyimprovedoutcomesthanthose including a Phase 1, pre-commitment, in which ambiva-
whoreceiveidenticaltreatmentwithouttheMIcomponent lence is resolved, and a Phase 2, post-commitment, in
(Aubrey,1998;Bien, Miller, &Boroughs, 1993;Brown& whichintrinsicmotivationforchangeisactivatedtodrivea
Miller, 1993; Saunders, Wilkinson, & Phillips, 1995). collaborative change planning process. The MI environ-
These effects have been documented across diverse ment or treatment context is represented by three
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SchoolMentalHealth(2011)3:1–12 3
underlying constructs, and four motivational counseling (Miller & Rollnick, 2002): express empathy, develop dis-
principles that are skillfully combined to direct a client crepancy, roll with resistance, and support self-efficacy.
toward change. Empathy is demonstrated through counselor reflections of
During the pre-commitment phase, priority is given to client meaning that can clarify, reinforce, amplify, and
understandingtheclient’smotivesforchange—theclient’s produce change talk. In working with clients, counselors
primaryvalues,importantgoals,andidealsofselfandlife. often ‘take for granted’ the meanings embedded in their
These motives then become a central focus of the ensuing communications. Reflective listening, according to Miller
dialogue, based on the hypothesis that articulating the and Rollnick (2002), ‘‘is a way of checking, rather than
argument for change further clarifies these motives and assuming, that you already know what is meant’’ (p. 70).
moves the client toward change. Changetalk, asidentified Reflections are not questions but rather statements that
by Miller and Rollnick (2002), is the conceptual opposite indicate the counselor’s assumption of their meaning and
of resistance or client’s talk that sustains their current that ‘‘elicit more talk from the client, particularly change
condition. A primary task of the counselor is to produce talk’’(p.71).MillerandRollnicksuggestMIdivergesfrom
change talk. Change talk is defined as recognizing disad- classic client-centered counseling primarily because it is
vantages of the status quo, understanding advantages of directive; it intentionally attempts to direct a client toward
change,expressingoptimismaboutchange,andexpressing the resolution of ambivalence.
intention to change. To this end, counselors facilitate dia- Developingdiscrepancy,thesecondgeneralprincipleof
logue and avoid taking an ‘‘expert role,’’ instead empha- MI,isviewedasaneffectivewayto‘‘presentanunpleasant
sizing choice and responsibility for change to the client reality sothe person can confront itand be changed by it’’
who remains the resident expert on themselves. Further, (Miller & Rollnick, 2002, p. 38). Within the context of an
withinthemechanismofchangetheoryMIissupportedby intervention, discrepancy is the cognitive linkage between
an ethos consisting of three underlying constructs: evoca- a present behavior and the person’s important goals or
tion, collaboration, and autonomy. These constructs are in values. Festinger (1957) referred to this gap as ‘‘cognitive
place whether or not the counselor is using MI in a dissonance.’’ The theory suggests that when a behavior is
directive fashion (i.e., with a target behavior clearly iden- perceivedasconflictingwithimportantgoalsorvalues,the
tified) or not. person is more likely to change. Developing and amplify-
Evocationembodiesthecounselor’sactiveelicitationof ing discrepancy can create greater internal conflict or
the client’s personal reasons for change. The hypothesized ambivalence related to a status quo behavior. Increasing
mechanism of action is based upon self-perception theory discrepancy increases importance, which is one of two
that holds that the client’s arguing for change has a pow- critical requirements for change; the second critical
erful effect upon motivation. requirement is confidence, which is discussed below. Dis-
Collaboration is exemplified when the client takes a crepancyisthevehiclebywhichtheimportanceforchange
lead role in the dialogue and when the nature of the is increased. During the MI process, a counselor’s chal-
interaction is substantially influenced by the client’s ideas. lenge is to develop and increase discrepancy within the
AsdescribedbyMoyers,Martin,Manuel,Miller,andErnst context of MI without confronting, educating, or selling
(2007), ‘‘Clinicians [counselors] high in collaboration behavior change. This avoids creating a sense of being
appear to be dancing with their clients during an inter- coercedormanipulated.Theclientweighsprosandconsof
view—one moment leading, the next following—in change in a decisional argument and becomes convinced
seamless motion’’ (p. 6). This can only work when the thestatusquoistooinconsistentwiththeirmostimportant
behavior for change fits within the client’s ideals of self goals or values to be maintained. It is important that the
and life. client, rather than the counselor, be in the position of
The most pervasive theme is autonomy. Counselors evaluating the argument between maintaining the status
explicitlysupportclients’value-drivenchoice(s)whilealso quo or changing given that people are more likely to be
supporting the client’s control of the change process. intrinsically motivated, persuaded, and to invest in change
Working from a strength-based perspective, counselors bytheirowninternalvoicethanbythatofanyother(Miller
express their belief that the client is capable of change, & Rollnick, 2002).
while acknowledging the client’s agency to maintain the The third principle of MI, roll with resistance, is based
status quo (i.e., autonomous). ontheassumptionthatarguingiscounterproductive.Inthe
context of MI, resistance is viewed as ‘‘a signal of disso-
Motivational Counseling Principles nance in the counseling relationship’’ (Miller & Rollnick,
2002, p. 46). When a client resists change that is clearly
In addition to the three underlying constructs, four coun- congruent with important goals and values, the counselor
seling principles infuse the techniques and strategies used mustexercisegreatconstraintoverhimself.Thecounselor,
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who wishes to push a change agenda that is clearly in the tomorerecentapplicationsinthecontextofschoolmental
client’s best interest, must avoid the natural inclination to health.
educate or confront. Rather, the counselor must work to
remain within the spirit and principles of MI. The coun-
selor may be in touch with the human tendency to take up Motivational Interviewing Innovation
argument; however, in the context of change, this is a trap and Applications in School Settings
thatwillcreatetransparentorveiledbarrierstochange.The
counselor is encouraged to roll with the resistance by Shinn and Walker (2010) suggest that we are in the midst
maintaining equanimity without confrontation or any of the largest school reform effort of the past 30 years.
attemptto‘sell’change—evenallowingforadiscussionof Theseauthorsarguethatthisreform,largelydefinedbythe
the cons of change. These strategies work to affirm the adoption of a Response to Intervention approach, involves
challenges faced by the client, strengthen the relationship the creation of comprehensive, coordinated, and effective
between client and counselor, and lessen barriers that service delivery systems. These systems are defined by:
support open exploration of the decisional argument for (a) a foundation of prevention in which evidence-based
change. interventions represent primary, secondary, and tertiary
The fourth principle, support self-efficacy, is related levels; (b) data-based decision making; and (c) early
to the second critical requirement for change, which is intervention based on screening results. There are many
confidence. In support of a client’s self-efficacy, a coun- ways MI could be used by school mental health profes-
selor might rekindle memories of success from the past, sionals, several of which are directly related to the
while remaining within the spirit of MI by minimizing changing landscape of school reform efforts. Although the
authority and asking permission before educating or pro- use of MI in educational settings is limited, there is a
viding change plan options. growing literature base demonstrating its efficacy in
Embodiment of the three underlying constructs and addressingthemotivationofparents,teachers,andstudents
application of the strategies associated with the four prin- acrossavarietyofdomainsrelatedtoschoolmentalhealth
ciples described above are central to Phase 1, pre-com- services.
mitment,andbuildsascaffolduponwhichtheclientmoves
toward a commitment to change. Commitment to change Recent Innovations
marks the beginningofPhase 2,which includes: (a)build-
ing a menu of choices, (b) collaborating on the creation of Participation Enhancement Intervention
an action plan, (c) implementing and adhering to the plan,
and (d) sustaining the relationship. Within Phase 2, the In a series of articles, Nock and associates (Nock &
counseling environment is more relaxed and less strategic Ferriter, 2005; Nock & Kazdin, 2005; Nock & Photos,
withcounselorandclientworkingcollaborativelyonaplan 2006) developed and tested a conceptual framework for
for change. As such, the counselor usually enjoys open the Participation Enhancement Intervention (PEI; see
permission from the client to educate on change plan Nock & Kazdin, 2005), and the Parent Motivation
options. The counselor is advised to avoid the ‘‘expert Inventory(PMI).Theirpremiseforthedevelopmentofthe
trap’’ with excessive educating and confrontation that PMI was that treatment attendance and adherence to
violates the spirit of MI and which can erode rapport. treatment plans are the most basic necessities for effective
Notwithstanding this caution, the counselor can suggest treatment delivery. In regard to the treatment of youth,
andaidaclientinselecting anyintervention orcounseling this necessarily concerns the parent’s motivation to pro-
approach required to achieve change, even those that vide for their child’s attendance and to support adherence
contradictthespiritofMI,suchascognitiveandbehavioral to treatment plans. Until the development and subsequent
approaches. It cannot be overemphasized, that in the post- testing of the PMI, no tools existed to measure a parent’s
commitment phase of MI, it is critical that the counselor motivation for their children’s treatment. The PEI used
monitorthe interactions for signs ofresistance orreturn of elements of MI and the barriers to treatment participation
ambivalence. If sensed, the counselor should return to the model (see Kazdin, Holland, & Crowley, 1997) to provide
requisite phase 1 strategies as necessary. a very brief (5–15 min) intervention targeting parent
The flexibility with which MI can be utilized has led motivation at several points during their children’s treat-
counselors, as well as a variety of other mental health ment process. Along with MI elements, the PEI included
professionals from a wide range of disciplines, to adapt specific information about the importance of attending
these processes to various institutions, contexts, popula- treatments and staying on track with treatment plans and
tions,andawidevarietyoftargetbehaviors.Thefollowing helped parents develop plans for overcoming any barriers
commentaryincludesvariousMIinnovationsthathaveled they faced in attendance and adhering to the prescribed
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treatment. Using the PMI to evaluate the effectiveness of Classroom Check-up
the PEI, Nock and Kazdin (2005) found that increases in
parent motivation predicted parents’ rating of fewer bar- Building from the work of Miller and Rollnick (2002) and
riers to their participation in treatment and in turn greater DishionandStormshak(2007),Reinke,Lewis-Palmer,and
treatment attendance. Furthermore, both parents and Merrell (2008) recently developed The Classroom Check-
therapists reported greater adherence to treatment plans as Up (CCU), which is designed to increase the extent to
a result of the PEI. which teachers employ evidence-based classroom man-
agement strategies. The CCU consists of specific motiva-
tionalenhancementstrategiesincluding:individual(visual)
EcoFIT feedbacktoteachersonobservedclassroombehaviors(i.e.,
specific praise & reprimands), identification of strengths,
Dishion and Stormshak (2007) have developed the Eco- promotion of autonomy in the decision making process,
logical Approach to Family Interventions and Treatment direct guidance (when requested), encouragement of tea-
(EcoFIT) model, which includes an assessment-driven cher self-efficacy, and development of a menu of change
feedback component (Dishion, Stormshak, & Siler, 2010). options. Results from a single subject multiple baseline
A hallmark component of their model, the Family Check- designstudyacrossclassroomsindicatedincreasedteacher
Up (FCU), inspired by the Drinker’s Check-Up (Miller & use of specific praise and reduced reprimands and
Sovereign, 1989), is designed to increase parenting decreased classroom disruptive behavior (Reinke et al.,
behavior that promotes youth adjustment and competence. 2008).
The FCU consists of specific motivational enhancement
strategies including individual feedback to parents on First Step to Success
observed parenting practices, identification of strengths,
promotion of autonomy in the decision making process, Theauthorsofthisarticle,inspired,inpart,bytheworkof
and development of a menu of options based on effective the previously mentioned MI innovations in school mental
family management practices. The results of a recent health,havebeguntakingtheexistingFirstSteptoSuccess
clinical trial provided preliminary evidence for the effi- (Walker et al., 1998) intervention and infusing it with the
cacy of this intervention, as mothers in the intervention Family Check-Up (Dishion & Stormshak, 2007; Shaw
group showed increased involvement in their child’s et al., 2006), the wraparound planning process (Burns &
behavior and their children showed corresponding Hoagwood, 2002; Eber, Sugai, Smith, & Scott, 2002), and
decreases in conduct problems (see Shaw, Dishion, the Classroom Check-Up (Reinke et al., 2008). First Step
Supplee, Gardner, & Arnds, 2006). Dishion and Storm- consists of three modules applied in concert with each
shak (2007) recommend that the FCU precede evidence- other: (a) universal screening; (b) a school module called
based interventions to increase parental compliance with CLASS;and(c)ahomemodulecalledhomeBase.Thetwo
treatment protocols and regimens. Shaw et al. (2006) primarygoalsoftheFirstStepinterventionaretoteachthe
detailed the first in a series of notable studies of the FCU at-risk child to get along with others (teachers and peers)
program in early childhood. These studies demonstrated and to engage assigned schoolwork in an appropriate,
the positive longitudinal effects of the program on very successfulmanner.Theinterventionisdesignedtoachieve
young children who were identified as at-risk for early secondarypreventionoutcomes.ThethreemodulesofFirst
conduct problems (Connell et al., 2008; Dishion et al., Step are based on extensive research on school and home
2008; Gill, Hyde, Shaw, Dishion, & Wilson, 2008; Lun- intervention procedures with aggressive, antisocial youth
kenheimer et al., 2008; Moilanen, Shaw, Dishion, Gard- and over a decade of work related to the universal, pro-
ner, & Wilson, 2010; Shaw, Connell, Dishion, Wilson, & active early screening of at-risk children to provide early
Gardner, 2009). Those children of low-income families, detection(seeHops&Walker,1988;Patterson,1992).The
who were randomly assigned to the FCU condition, homeBase module of First Step consists of a series of six
demonstrated improvements in school readiness (inhibi- lessons designed to enable parents and caregivers to build
tory control and language development) through the childcompetenciesandskillsinsixareasthataffectschool
effects of the FCU on parents’ provision of increased adjustment and performance. The target skills that parents
positive behavioral support. Further study of the program areaskedtoteachtheirchildrenareasfollows:(a)Sharing
(see Gardner et al., 2009) demonstrated the program’s School, (b) Cooperation, (c) Limit-Setting, (d) Problem-
effectiveness for families ‘‘with very high levels of dis- Solving,(e)Friendship-Making,and(f)DevelopingConfi-
tress and disadvantage compared with those who were dence.HomeBasecontainslessons,instructionalguidelines,
more advantaged…’’ (p. 550). These effects were not as and parent–childgamesand activitiesfor directly teaching
strong in single parent families. theseskills.
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The First Step program has been extensively evaluated that has been infused into the school component (i.e.,
across a range of methodologies, including: single subject CLASS) to more effectively improve the teacher’s use of
(Carter, & Horner, 2007, 2009; Golly, Sprague, Walker, positive classroom management strategies. The First Step
Beard, & Gorham, 2000; Overton, McKenzie, King, & versionoftheCCUfocusesontheteacher’sperceptionsof
Osborne, 2002; Sprague, & Perkins, 2009), longitudinal the ‘ideal’ classroom and their beliefs in regards to
(Nelson et al., 2009; Walker et al., 1998), quasi-experi- behaviormanagementpractices,whicharegatheredduring
mental (Diken, & Rutherford, 2005; Golly, Stiller, & an initial interview. Exploring the teacher’s experiences,
Walker, 1998), and experimental designs (Walker, Golly, perceptions,valuesandgoalsassistsintheamplificationof
McLane, & Kimmich, 2005; Walker et al., 2009). These any discrepancies discovered within the information gath-
evaluations of the First Step program have demonstrated ering process. The information gathering process includes
strong, positive effect sizes for a majority of the at-risk an observational sampling of five teacher behaviors. The
preschool and primary level, elementary school children frequency of praise (both behavior-specific and general)
whoweretreated,andparents,teachers,andadministrators andreprimandsarerecordedacrossthreeagents:thetarget
have consistently reported high levels of satisfaction with child, any peer in the class, or the class as a whole.
theintervention.Whileeffectiveasasecondaryprevention Additionally, the frequency of positive student–teacher
program, First Step to Success (Walker et al., 1998) is interactions and negative teacher–student interactions are
generally not sufficient to substantially decrease challeng- recorded across the target child and any peer in the class.
ingformsofseverebehaviorandincreasetheprosocialand The teacher and interventionist meet again following the
adaptive behavior of students at the tertiary level. As the observations for data review (provided in the form of
parents of many young children with severe behavior graphs) and goal setting. During this meeting, teacher and
problemsalsoexperiencemultiplestressors,thehighlevels interventionist share their perceptions of the observations
of parental motivation and commitment necessary for andinterpretthedata.Thegoalistoinfluencetheteacher’s
change are often difficult to obtain. Additionally, while useofpositivebehavior-specificpraise.Theinterventionist
some teachers are motivated to adopt the classroom man- utilizes a directive MI approach to assess and manage
agementpracticesonwhichtheschoolcomponentisbased, resistance, cultivate importance and boost the teacher’s
teacher observation data suggests many do not. confidenceandfeelingsofself-efficacyforchange.During
TwoMIenhancementstotheFirstStepinterventionhave this process options are discussed, a plan of action is
beenaddedtobeginaddressingtheneedsofstudentsatthe developed and formalized (typically in writing), and
tertiary level. The first, a modified version of Dishion and commitmentstochangearemade.Theinterventionprocess
Stormshak’s (2007) FCU is completed with parents, with itself is self-selected and is also self-monitored by the
homeBase parent training offerings used in the event that teacher with support from the interventionist when
parents’deemthemrelevanttotheirchild’sschoolsuccess. requested. A menu of intervention options for teachers to
As can be seen in Fig. 1, the FCU begins with an initial facilitate a more positive climate through the use of
intake session to examine the parents’ perceptions of their increasedpositivebehavior-specificpraiseisofferedtothe
child’sschoolandhomefunctioninginrelationtotheirown teacher. In order to build a sense of ownership, reduce
values, goals, and ideals of self and life. Next, assessment complexity and support self-efficacy, teachers are encour-
data are collected from all intervention agents (parent, aged to create or utilize simple intervention strategies of
teacher,andtheFirstSteptoSuccessinterventionist)tohelp their own design. Often, the initial data review and feed-
identify strengths, potential discrepancies between child back cycle (discussed below) are all that is necessary for
and/or parent functioning, and family values, goals and teacher change. A feedback cycle of additional observa-
ideals. These discrepancies are amplified while parent tions of teacher behavior (twice per week for 2 weeks)
autonomy and self-efficacy are strengthened, and change follow the data review and goal setting process, allowing
talkisevoked.Ifappropriate,thefamilydevelopsaplanof the teacher to review progress and monitor the effective-
action that focuses on family management practices and is ness of their self-selected interventions. Data from each
tied to the parents’ goals and values. This enhancement to additional observation of the feedback cycle are added to
theFirstStepinterventionretainsmostfeaturesoftheFCU; the original visual and provided to the teacher without
however, a formal parent values identification activity has elaboration, unless requested.
beenaddedandtheassessmentprocesshasbeensimplified
toemployconceptsreflectingtheinterestsofeducators.The Potential MI Applications in School Mental Health
concepts also map onto the parent training content of the
First Step toSuccesshomeBase parent curriculum. Although the innovative applications of MI within school
The second MI enhancement to the First Step inter- mentalhealthhighlightedaboveinvolvetheinfusionofthe
vention is the addition of a modified version of the CCU MI approach into large-scale interventions, we believe MI
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SchoolMentalHealth(2011)3:1–12 7
Fig.1 Thefamilycheck-up
andchangeplancomponents.
*BasedonworkbyDishionand
Stormshak(2007)
has the potential to be used more generally. For example, Map allows those learning MI techniques to locate them-
McNamara (1996, 1998) has developed a system of MI, selves within an objective based hierarchy across the
used in the Canadian Public Schools, to guide teachers in pre-and post-commitment MI phases. The hierarchical
the development and implementation of pupil self-man- structureindicatesthatthesuccessfulcompletionofhigher-
agement skills. Additionally, Blom-Hoffman and Rose level objectives is, in part, contingent upon completion of
(2007)haveprovidedwrittencommentaryontheuseofMI those that precede them. The arrow on the side of the map
in school-based consultation, proposing that MI could be reflects the fact that although the process is linear in gen-
used effectively to enhance a consultees’ motivation to eral, lower level objectives should be revisited frequently.
change, and address common barriers to the successful Additionally, bold text in Fig. 2 represents the principles
implementation of change plans. Atkinson and Woods thatmakeuptheMIethos,locatedinshadedboxesnearthe
(2003) and Kittles and Atkinson (2009) suggested MI objectives in which these principles are emphasized,
might be used as an initial assessment tool for disaffected although not exclusively applied only in these areas. As
adolescents in schools. Utilizing a visual representation of can be seen in Fig. 2, autonomy, collaboration, and evo-
MI, the authors explicitly involved the children in the cation are emphasized equally across all objectives and
process. Counselors are allowed to establish the needs of phases. However, empathy is emphasized in the earliest
disaffected youth and identify suitable support strategies, stageofphase1,anddirectionduringthelatter.Thedotted
while gauging the children’s overall resistance to change. lines around empathy and direction have been added to
These authors report that the youth in their sample found highlight the fact that these principles may be applied to
the approach helpful in considering the implications of anyoftheeightobjectiveswithinthenavigationalprocess.
their own behavior, but that the intervention was most The specific interviewing techniques articulated by Miller
successful with children who were more ready for change and Rollnick (2002) can be mapped onto these objectives,
than those who were not. Additionally, Connell and and could guide school mental health professionals in
Dishion (2008) utilized a family-focused multilevel pre- conversations with students, parents, and teachers, in a
vention program delivered within public middleschoolsto general sense, to motivate them toward any specific
target parenting factors related to the development of targeted behavior.
behavior problems in early adolescence. The intervention
demonstrated collateral effects inhibiting the increase of Conversations with Students, Parents, and Teachers
depressive symptoms in high-risk youth over a three-year
period as compared with a control group. AlthoughanexhaustivelistoftheskillsassociatedwithMI
MI techniques could also be applied informally in practiceisbeyondthescopeofthisarticle,werecommend
conversations with students, parents, and teachers, used to school mental health professionals begin with the three
encourageteachersoradministratorstoembracepromising underlying constructs referred to by Miller and Rollnick
interventions,oremployedtohelpincreasethefidelitywith (2002): evocation, collaboration and autonomy. As school
which evidence-based interventions are implemented. In mental health professionals approach students, parents and
our work on training school mental health professionals to teacherswithconversationsaboutchange,theycanworkto
practiceinanMIsupportivefashion,wehavefoundFig. 2 elicit personal reasons for change, recognize values, ideas
(Cloud, Frey, Lee, Lyle, & Thompson, unpublished man- and intentions, and support—even encourage—personal
uscript) useful, which is based on the eight stages for- choice, while avoiding the expert role of educating or
warded by Miller and Moyers (2006). This Navigational attempting to sell a change process. These efforts will
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8 SchoolMentalHealth(2011)3:1–12
twist (Miller & Rollnick, 2002). These strategies are
illustratedinTable 1.ItisimportanttonotethatMIisonly
indicated when the subject of the conversation has a well-
developed sense of values, which typically develops in
adolescence. There are two specific strategies in which
schoolmentalhealthprofessionalsmaywanttoemployMI
practices:whentryingtogetateacherorparenttoembrace
promising interventions and when attempting to increase
the fidelity of implementation.
Embracing Promising Interventions
Fixsen et al. (2005) suggest that in all fields, but particu-
larlyeducation,thereisalargegapbetweenwhatisknown
to work and what is actually done. Maag (2001) suggests
that teachers are negatively reinforced for punitive disci-
pline practices, such as removing children from the class-
room or advocating in- or out-of-school suspension. Thus,
it is easy to see why school professionals may resist evi-
dence-based practices, which are typically proactive and
require changes in teacher behavior or the environment,
whichimpliestheproblemdoesnotresidewithinthechild,
but at the very least is shared (i.e., transactional) between
Fig.2 MInavigationalmap.1Establishandmaintainclientcentered the child and the adults who control the child’s environ-
environment for change: introduction, confirm autonomy, assure ment. In this case, it is quite clear that ‘‘buy in’’ among
competence;discoverimportantvaluesunderlyingidealsofselfand stakeholders is a critical ingredient across all stages of
life,findrelatednessofissuetolifeorvalues;affirmationwithopen-
implementation of evidence-based practices. The literature
endedquestions;transitionwithdoublesided?openendedquestion
as summary. 2Cultivate importance, raise discrepancy, elicit change supportingMIsuggestsitcanbeaneffectivemechanismto
talk by asking for the pros of change (desire, reason, need) then increaseambivalencebetweenone’svaluesordesiredstate
reinforceusingcomplexreflections.Gobackintime.Goforwardin and the status quo, which increases motivation and even-
time.Usetheimportancerulertoassessimportanceonascaleof1–10
tually commitment to an action plan—in this case the
thenelicitchangetalkasking‘‘whynota[lowernumber]?’’3Develop
adoption of evidence-based practices. In relation to the
confidenceasking‘‘howwouldyouchangeifyouweretodecideto?’’
Rekindlememoriesandrelivesuccessfulchangefromthepast,elicit navigation map (see Fig. 2), it may be that these profes-
vivid details of facts and emotions. Assess confidence on a scale of sionals are being asked to implement a plan of action
1–10 then elicit change talk asking ‘‘why not a [lower number]?’’
without an acceptable working alliance, or more likely
4Preventresistance:useparadox(rollwithresistance):remainneutral,
when they do not believe change is important, and/or that
minimizeeduc./neversellchangeorconfront.Iftense,transitionwith
consofchange(useresistanceresponse).Manageresistance:simple theydonotfeelconfident(i.e.,self-efficacy)intheirability
reflection:auniversalstrategy(leaserisk).Specialusereflections(in to implement the change plan. The principles of MI—
order of risk): double sided, emphasize power & control, amplify,
expressempathy,developdiscrepancy,rollwithresistance,
comealongside
and support self-efficacy—could be used to guide conver-
sations with key implementation agents, with the change
supporttheestablishmentofarelationshipbasedonrespect plan representing choice of relevant evidence-based
and can communicate a sense of trust in the recipient’s practices.
ability to change. From this foundation we recommend Inthisway,MIcanbeusedinavarietyofsettingswhen
schoolmentalhealthprofessionalsattempttoemploythose assessing an individual, group, or organization’s motiva-
skills used to respond to resistance as a general practice tion to change (Phase 1). For example, it could be used in
during their interactions with students, parents and teach- individualconsultationwithteachersorwhenfacilitatinga
ers.Itisimportanttonotethatresistancewithinthecontext group meeting (i.e., school- district- or state-wide positive
of MI includes arguments for sustaining the status quo or behavior support leadership team; IEP team; or student
arguments against change. The front line of defense in support team). What remains critical is that the school
these instances include: simple reflection, emphasizing mentalhealthprofessionalcorrectlyassessestheindividual
client-choice, double sided reflection, amplification, com- orgroup’sreadinesstocommittoachangeplan(Phase1in
ingalongside,shiftingfocus,reframing,oragreeingwitha Fig. 2)andmatchtheirapproachtothecurrentsituationto
123
SchoolMentalHealth(2011)3:1–12 9
Table1 Verbatimexemplifyingrespondingtoresistance
Speaker Text Strategyandrationale
Interventionist Again,thanksverymuchforyourobviouscommitmenttoAngela,andsupportingher Affirmation
hereathomesothatshecanimproveherbehavioratschool Summary
DuringourlastvisityousharedhowAngela’spoorbehavioratschoolcausedconcern
atyourjob,inyourrelationshipwithMs.SmithandevenwithAngelaherself.
BecauseofthisyouwerewillingtoexplorewhatitmighttaketosupportAngelain
changingherbehavioratschool.Thiswouldhelpyouatwork,inyourrelationship
withMs.SmithandwithAngela
Parent Yes,butIdon’tthinkanyoneatschoolwilllisten
Interventionist You’renotsureifMs.Smithwantstohelp? Simplereflection(respondingto
resistancewithnon-resistance)
Parent Well,Idothinkshewillhelp,butitwon’tbeeasy
Interventionist You’vealreadyshownagreatdealofcommitmenttoyourchild,Iknowyou’llmakea Affirmation
difference
Whatwerethemostimportantvaluesthatyoudiscoveredfromthevaluessorting Shiftoffocus
activity?
Parent Thatwasreallyhard,somanycardstosortthrough
Interventionist Thanksforhanginginthere—yourvaluesareveryimportanttothisprocess Affirmation
Parent OK—ButIdon’tknowhowthisisgoingtohelp
Interventionist Youthinkthisprocessmightbebetterifwedidn’tconsideryourvaluesandthevalues Amplifiedreflection
youwantforyourchild
Parent No,Iwantwhatisbestformychild.Honesty,hardworkandfamilyweremytopthree
Interventionist Whydidyoupickthesecards? Open-endedquestionsto
Whatdothesewordsmeantoyoupersonally,andforyourchild? encouragechangetalk
Whatdoyouseeinyourlife,andyourchild’sthatconvincesyouthisisimportant?
Howdoesthisrelateto[thetargetbehavior]?
Parent Ithinkthiswasawasteoftime
Interventionist Soononehandyouareacommittedparentwhowantsthebestforhis/herchild;buton Double-sidedreflection
theotherhandyoufinddiscussingthecorevaluesofyourfamilytobeawasteoftime
Interventionist Intheend,thisistotallyinyourcontrol.Ifyoubelievethatdiscussingthecorevaluesof Emphasizingpersonalchoiceand
yourfamilyisawasteoftime,let’smoveontosomethingmoreproductive control
accelerate their progression toward or through the post- present. Recent trends in school-based mental health, such
commitment phase, which addresses implementation asprogressmonitoring(Shapiro,Hilt-Panahon,&Gischlar,
fidelity. 2010)andclassroommanagementconsultationarelikelyto
be difficult for teachers, and applying MI techniques
Improving Fidelity of Existing Interventions associated with the pre-commitment phase may be bene-
ficial long after commitment to the change plan is
Too often implementation agents express motivation to established.
implement an action plan through a verbal commitment,
yet the resulting behavioral change necessary for effective
outcomes is substandard. Anyone who has worked with a Future Directions
teacher on a behavior intervention plan can certainly
appreciate this predicament, and research clearly demon- We anticipate MI within the context of school mental
strates that even when plans are well written, adherence to health will expand in the next decade due to the flexibility
the plan is often problematic (Conroy, Dunlap, Clarke, & of the process and its techniques along with the evidence
Alter, 2005; Van Acker, Boreson, Gable, & Potterton, base supporting its use. MI is a promising yet relatively
2005).However,poor adherence toa change plan isby no untappedapproachtopotentiallyenhancethedevelopment
means limited to behavior intervention planning, or to and implementation of effective school-based interven-
teachers for that matter. In relation to Fig. 2, this assumes tions. In this article, we have discussed the principles of
Phase2workhasstartedyetareturntoPhase1strategiesis MI,summarizedanumberofschool-basedMIinnovations,
often necessary because resistance to implementation is and highlighted how school mental health professionals
123
10 SchoolMentalHealth(2011)3:1–12
might adapt MI in educational settings to improve educa- alcoholism treatment. Psychology of Addictive Behaviors, 7,
tionaloutcomes.Wehavehighlightedthepossibilitieswith 211–218.
Burke,B.L.,Arkowitz,H.,&Menchola,M.(2003).Theefficacyof
regard to increasing parent involvement, building collab-
motivationalinterviewing:Ameta-analysisofcontrolledclinical
oration between home and school, addressing significant trials. Journal of Consulting and Clinical Psychology, 71,
educational and mental health problems with relatively 843–861.
brief intervention, and increasing the fidelity of interven- Burns, B. J., & Hoagwood, K. (2002). Community treatment for
youth: Evidence-based interventions for severe emotional and
tions that depends largely on changes in teacher or parent
behavioraldisorders.NewYork:OxfordUniversityPress.
behavior. Carter, D., & Horner, R. (2007). Adding functional assessment to
Based on our initial attempts to use MI, the outlook for First Step to Success: A case study. Journal of Positive
its use with children and families at the tertiary level is BehavioralInterventions,9,229–238.
Carter, D., & Horner, R. (2009). Adding function based behavioral
promising. Given the individualized, problem-solving nat-
support to First Step to Success: Integrating individualized and
ureofourapproachtotheenhancementoftheFirstStepto manualized practices. Journal of Positive Behavioral Interven-
Success intervention, it is imperative that counselors have tions,11,22–34.
well-establishedclinicalskillstoapplyMIindifferentiated Channon, S. J., Huws-Thomas, M. V., Rollnick, S., Hood, K.,
Cannings, J. R. L., Rogers, C., et al. (2007). A multicenter
environments(homeandschool),aswellasacrossmultiple
randomized controlled trial of motivational interviewing in
agents(parents,teachers).Thus,theinstructionaldesignof teenagerswithdiabetes.DiabetesCare,30,1390–1395.
training systems to adequately prepare school mental Cloud,R.N.,Frey,A.,Lee,J.,Lyle,&Thompson,C.(unpublished
health professionals for the implementation of MI with manuscript). Use of educational and memory sciences to
improve motivational interviewing learning outcomes: A case
fidelity and resourcefulness is critical to our current work
exampleofcurriculumdevelopment.
and should be a focus of future research. Future research Connell, A., Bullock, B., Dishion, T., Shaw, D., Wilson, M., &
should also examine how MI strategies can be used to Gardner,F.(2008).Familyinterventioneffectsonco-occurring
improve the reach and effectiveness of existing interven- early childhood behavioral and emotional problems: A latent
transition analysis approach. Journal of Abnormal Child
tions.Additionally,thefieldwouldbenefitfromsystematic
Psychology,36,1211–1225.
study of the barriers and facilitators to effectively imple- Connell,A.,&Dishion,T.J.(2008).Reducingdepressionamongat-
mentingMIapproacheswithinthecontextofschoolmental risk early adolescents: Three-year effects of a family-centered
health.Forexistinginterventions,attentionshouldbegiven intervention embedded within schools. Journal of Family
Psychology,22,574–585.
to process measures, such as social validity, feasibility of
Conroy, M. A., Dunlap, G., Clarke, S., & Alter, P. J. (2005).
high fidelity implementation, and satisfaction, as well as A descriptive analysis of positive behavioral intervention
more rigorous designs to assess efficacy and effectiveness. researchwithyoungchildrenwithchallengingbehavior.Topics
inEarlyChildhoodSpecialEducation,25,157–166.
Cordova, J. V., Warren, L. Z., & Gee, C. B. (2001). Motivational
Acknowledgments The research reported here was supported by
interviewing as an intervention for at-risk couples. Journal of
the Institute of Education Sciences, US Department of Education,
MaritalandFamilyTherapy,27,315–326.
through Grant R324A090237 to the University of Louisville. The
Diken, I., & Rutherford, R. (2005). First Step to Success early
opinionsexpressedarethoseoftheauthorsanddonotrepresentviews
intervention program: A study of effectiveness with Native-
oftheInstituteortheUSDepartmentofEducation.
American children. Education & Treatment of Children, 28,
444–465.
Dishion, T., Shaw, D., Connell, A., Gardner, F., Weaver, C., &
Wilson,M.(2008).Thefamilycheck-upwithhigh-riskindigent
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