Parenting skills development in vulnerable families Facilitating and

Parenting skills development in vulnerable families: Facilitating and supporting parental behaviour change Warren Cann, Executive Director CAFWAA 2007 National Symposium WORKSHOP May 2007

Acknowledgements Staff of the Parenting Research Centre Partners in the C-Frame Consortium > Tweddle Child and Family Health Service (Lead Agency) (VIC) > The Queen Elizabeth II Family Centre (ACT) > Tresillian Family Care Centres (NSW) > Ngala Family Resource Centre (WA) Funding provided by the Department of Families, Community Services and Indigenous Affairs & Victorian Government Department of Human Services

Parenting: Basic assumptions • Parents are the primary architects of their children’s world • Effective parenting is critical for optimal development in children • The style and nature of parenting is multidetermined (history, culture, environment and context are important) • Parenting occurs in a reciprocal context

Parenting (cont. ) • Parents’ greatest influence is through daily interactions • Social expectations of parents are very high • Parenting is simple and hard • Parenting is learned and parents are learners • Parents are powerful change agents

Parenting intervention logic PRACTITIONER PARENT CHILD

A KEY ISSUE IN PARENTING SUPPORT Helping adults change

Low yield strategies • • • Attitudes Reassurance Normalisation Understanding Support.

Understanding behaviour change: Self-regulation

Automatic behaviour CUES REACTIONS

Self regulating CUES SELFREGULATORY PROCESSES • Thinking • Planning • Problem solving • Decision making (Kanfer & Schefft, 1988) REACTIONS

CHANGE PROCESS Problem behaviour: highly stereotyped, automatic and difficult to control (Kanfer & Schefft, 1988) Action patterns adaptive, and initially under high control Automatic adaptive patterns

Getting stuck Stress Self-regulation fails A habit forms (responses are automatic and Lacks an adaptive OR insensitive to outcome) Gets stuck response

Intervention approach • Assist client to assume responsibility for change • Create conditions required for initiating and maintaining behaviour change (enhancing motivation) • Re-establish self-regulatory processes associated with effective living and autonomous problem solving (enhance coping) • Weaken self defeating habits and increase flexibility in the client’s response repertoire (building sensitivity). • Develop more adaptive responses where necessary (skill development).

Process Model (C-FRAME) • Based on a model of adult behaviour change • Provides a logical and structured sequence for the process of engagement and assessment • Specifies a framework for action (process), but does not prescribe activity (content) • Allows for systematic attention to issue of ‘how’ we work with parents • Provides shared conceptual basis and a common language.

Phases of intervention (adapted from Kanfer & Schefft, 1988) 1. 2. 3. 4. 5. 6. 7. Creating a collaborative relationship Developing commitment to change Contextual analysis Negotiating a program Program implementation and motivation maintenance Monitoring and evaluating progress Generalization and maintenance

Phase 1: Creating a collaborative relationship

Collaborative approach • Not so much a matter of technique, as it is a way of being • Relationship built on the basis of respect and acceptance (Miller & Rollnick, 1991) • Begins by finding something that the client wants to work on (Madsen, 1999) • Seeks to understand the relevance of the work to the client’s life, rather than the relevance of the client to the practitioner’s work (Madsen, 1999) • Ensures that intervention goals are consistent with the client’s core values and desired future.

Collaborative approach (cont. ) • Rejects confrontation, coercion and manipulation • Highlights strengths and resources rather than deficits • Does not give advice on how to do anything unless authorised to do so (Madsen, 1999) • Assumes the client is an active agent in their life (O’Hanlon & Beadle, 1997) • Empowers client by facilitating access to ideas and resources (Dadds, 2003) • Emphasises choice and maximises client control (Webster-Stratton & Herbert, 1994) • Leaves decision making to the client (Kanfer & Schefft, 1988)

Collaborative attitudes • No such thing as a ‘bad parent’, just as there is no such thing as a ‘perfect parent’ • Parents try their best, sometimes under difficult circumstances • Parents have reasons for behaving in the way they do • Wanting the best for the child is the shared ground between parent and practitioner • Parenting is learned, and parents can learn • Parent has expertise

Creating a collaborative relationship Phase 1: Goals • Establish a genuine partnership between parent and practitioner • Clarify respective roles and expectations • Gain clarity about the presenting issues, concerns and distress • Foster the commitment of the parent to therapeutic relationship and the process • Assist the parent to develop an adaptive stance to the problem • Develop positive expectations of outcome • Model talk and interaction consistent with the model of change that underpins the process

Creating a collaborative relationship PHASE 1: Tasks • • • Exploring the help-seeking context Clarifying roles Cultivating and protecting engagement Establishing a preliminary strengths list Developing an issues list and setting some initial priorities • Obtaining a background history

Assessing expectation of change • You have tried lots of things to address this and it appears you are still unhappy with your progress. How are you feeling about that? • Why haven't things got better? • What do you expect will happen now that you have come here? • What is the likelihood that positive changes will occur now? • On a scale of 1 -10, where 1 is absolutely no hope and 10 is extremely hopeful, how hopeful would you say you are that there will be a positive outcome here? • How hard/easy do you think it will be to achieve the outcome you want? • What happens next if this does not work?

Personal investment and threats • What would it mean about you if the situation does change for the better? • Can you imagine any negative consequences if this problem is fixed? • Lets consider for a moment the other side of the coin; what would happen if this program is not successful? • What is the worst thing that could happen if the problem was not solved? Could you live with that? /cope with that? • Would it be possible to move forward even if the problem gets no better?

Strategies for finding strengths (O’Hanlon & Beadle, 1997) • Explore previous changes the client has made • Explore times when the problem is not occurring • Find exceptions to the problem (when the problem was expected but did not occur) • What worked for them in the past (what worked for other people) • Amplify competence (skills) • Promote the transfer of competence from one life area to another • ‘How come it didn’t get worse? ’

Phase 2: Building commitment to change

Rationale • All clients are ‘involuntary’ • Many clients will be struggling with subjective incompetence • Change is difficult, demanding and stressful • Clients are more likely to be motivated to achieve their own goals • Practitioner invitation to change is not enough • Client must have opportunity to explore fully the benefits of change and assess the level of effort required to achieve a change • Need for a clear up front strategy for monitoring progress

Stages of change Pre-contemplation Increasing motivation Exit Contemplation Determination Action Maintenance Relapse Prochaska & Di. Clemente (1982) Program entry p

Developing a commitment to change Phase 2: Goals • Maintain the collaborative working relationship established in Phase 1. • Reduce parent demoralization • Motivate the parent to consider positive consequences of change and develop new incentives for change • Establish connections between goals, actions and the parent's values and beliefs • Explore available options and their limits Based on Kanfer & Schefft (1988)

Developing a commitment to change PHASE 2: Clinical tasks • Making core values explicit • Identifying goals that are linked to core values • Deepening commitment to goals • Selecting success indicators • Commencing small actions intervention • Collaboratively evaluating preliminary change efforts

Questions to elicit values • ‘In a world where you could choose, what direction would you take your life? ’ (Wilson, 2003). • ‘I’d like to get a sense of what you see as the most important things in life—that is, what you want your life to mean. ’ • ‘Can we look at the bigger picture for a moment. I bet on your gravestone, you are unlikely to want the epithet to read: ‘She finally got him to sleep through the night’. So what is the most important thing to you - what kind of parent are you aiming to be? • How would you like your children to think of you as a mother or a father? How does that compare to you now? • Why is this issue important to you? What would it mean if you were to be successful? • Funeral exercise

Strategies for eliciting client goals • Turning problems into goals – ‘Ok, so you want to fix the problem of Sarah waking up through the night. What do you want instead of Sarah waking up and calling out for you? ”

Strategies for eliciting client goals • Turning problems into goals • Goals from values: – ‘Imagine for a moment that you are the kind of parent who was living their life fully consistent with their values. What would you be doing differently from what you are doing at the moment? ’

Strategies for eliciting client goals • Turning problems into goals • Goals from values • Goals from expectations – 'What is your greatest hope for what will happen as a result of being involved in this program? '

Strategies for eliciting client goals • • Turning problems into goals Goals from values Goals from expectations ‘How will we know when to stop? ’ • • Refining and quantifying client goals ‘Day in your life’ strategy ‘What do you want for your child? ’ Magic wand question (O’Hanlon & Beadle, 1997)

Countering demoralization (Kanfer & Schefft, 1988) Helping the parent to find the answers to 5 questions: • • • What will it be like if I change? How will I be better off if I change? Can I change? What will it cost to change? Can I trust this practitioner and setting to help me get there?

Phase 3: Contextual analysis

Contextual analysis • All behaviour has a purpose (or function). • Functional analysis is a way of understanding behaviour by examining the components of behavioural events • It views behaviour in context (the relationship between behaviour and environment) • Any behaviour can be analysed for its function. • Purpose is pragmatic: Functional analysis provides a focus for change efforts

IN FL UE NC EI N C DISTAL CONTEXT RE Culture AS ES PROXIMAL (close) CONTEXT RESPONSE ENVIRONMENT OUTCOME Do Act Setting events Trigger Emotional Think Instrumental Feel Skills S Social support E AS SES E R C I ED R P I T C ON IN Biology

Contextual analysis: Example A father is walking a toddler through the shopping centre when they pass a donut shop. The child points at the shop and says, "Donut". The father says, "No, it's nearly lunch time. You can't have a donut. " The child asks again and is refused. The child starts screaming loudly and flailing about on the floor. An embarrassed father says, "Ok, if you are going to be like that you can have a donut…but just one, otherwise you'll spoil your lunch". The child's screaming and flailing stops.

Four stage process of child abuse (Morton et al. , 1988, p. 90) Stage 1 Stage 2 Stage 3 Stage 4 Parent holds unrealistic expectations for the child Child’s behaviour falls short of expectation (disappointment on part of parent) Parent attributes a malevolent intention to child’s failure, i. e. , wilful antagonism, deliberate provocation (anger on part of parent) Parent overreacts and delivers severe punishment

Cognitive assessment • • • Analyzing client narratives Interviewing for cognitive content Assisted recall Role play Thought monitoring

Goals of Phase 3 • Refine the Parent's problem definition further • Identify how the Parent’s current behaviour is functional, encourage insight • Promote the development of effective selfmonitoring and self-evaluation • Identify new or more adaptive skills and behaviours, and assess the Parent's entry level on these skills • Identify Parent resources and strengths • Identify potential constraints on behavioural change • Continue to motivate the Parent towards specific changes

Contextual analysis Phase 3: Clinical tasks • Conduct functional analysis (behaviours, cognition, attitudes, emotions) • Conduct skill analysis • Explore resources and strengths

Skills Assessment • Is there something that could be done differently that would improve the situation? • Does the client have such a skill currently in their repertoire? • If so, what is stopping them using it? (resources and opportunity) • Is a suggested skill likely to be helpful? • What does the client expect would happen if they were to behave in this way? (expectancies) • Could the client do this? (self-efficacy) • Would the client do this? (beliefs and values) • What would be needed before the client could do this? (level of training) • What would get in the way and how could those problems be avoided? (obstacles)

Phase 4: Negotiating a program

Negotiating change and intervention Phase 4: Goals • Seek agreement on target areas • Establish priorities for change and explore specific strategies • Assist parent to accept responsibility for engaging in planned change or intervention program

Negotiating change and intervention Phase 4: Clinical Tasks • Share assessment findings • Seek agreement on targets for change or intervention • Revisit goals and values • Identify and trouble shoot potential obstacles to change • Assess actual constraints in the parent’s life and the appropriateness of suggested strategy

Phase 5 Intervention implementation

Promoting active processing: Getting clients to think and solve problems for themselves • Adopt an intensely interested and curious approach to client’s life • Be task focussed • Avoid small talk and politeness • Talk less (no statement over 20 seconds) • Spare the client your opinions • Use questions more than statements • Be slow to give advice • Maximise choice and options • Do not make decisions for your client

Promoting active processing (cont. ) • Prompt client to be specific • Gain clear and firm commitments • Use praise strategically

COURSE OF THE PROGRAM Practitioner Praise Source: Unknown Engagement behaviours Efforts to change Actual change

Insert intervention • Evidence based program/strategy • e. g. , Multisystemic Therapy

Example: High Risk Infant Practice Framework 1. Monitor and support client's motivation for change 2. Enhance sense of confidence and personal belief that change is possible (self-efficacy) 3. Elicit and reinforce independent problem solving 4. Maintain three way focus: working on child related issues (parenting), coping and lifestyle 5. Explore and counter thoughts and emotions that are blocking the change process (acceptance/mindfulness strategies) 6. Environment modification strategies 7. Skills training (child, coping, lifestyle) 8. Self-management training (self-monitoring, self-evaluation, problem solving, self-reinforcement) 7. Identify potential obstacles and develop plans to overcome them. 9. Identify environmental and social supports for change

Skills development • • • Provide clear explanations and rationales for strategies Link rationales with parental goals Hold open discussions about benefits and drawbacks Actively solicit disagreement and concerns Assess entry level skills and build on and enhance strengths Utilise effective teaching strategies Identify obstacles to the effective use of skills Prepare the parent for frustration and set backs Develop back up plans.

Coaching Parents • • Introduce skill/strategy Provide a clear rationale Model the skill Practise the skill Provide feedback Select homework: practice and self-monitoring In vivo training (with child, home or clinic)

Phase 6 Monitoring and evaluating progress

Monitoring and evaluating progress 1. Monitor and evaluate change from contact to contact 2. Assess goodness of fit 3. Reinforce parent for use of skills 4. Negotiate new goals, strategies or actions as required 5. Identify and develop plans to manage issues that may have arisen as a result of the client's change.

Phase 7 Maintenance, generalisation and termination

Maintenance, generalisation and termination • • Foster the use of self-regulation skills in other (and future) areas of life, including problem identification, analysis and problem solving. Teach parent to identify early signals of distress in order to activate constructive problem solving or help-seeking Anticipating and avoiding triggers for relapse Phasing out practitioner involvement

• For a copy of this presentation or to request a copy of C-Frame, email me at wcann@parentingrc. org. au • To stay in touch with the work of the Parenting Research Centre, subscribe to PRC news from the homepage of our website www. parentingrc. org. au • For more information on working with parents who have an intellectual disability, visit our website www. healthystart. net. au • For parenting resources, visit our websites www. raisingchildren. net. au and www. abcdparenting. com. au