parent action: acceptance & commitment training for parents amy r murrell, jonathan schmalz, p r...
TRANSCRIPT
PARENT ACTION:PARENT ACTION:
ACCEPTANCEACCEPTANCE & &
COMMITMENTCOMMITMENT TRAINING FOR PARENTSTRAINING FOR PARENTS
Amy R Murrell, Jonathan Schmalz, P R Mitchell, Cicely T LaBorde
University of North Texas
Q: What is the sound of one hand clapping?
A: The sound of one hand clapping is the sound of one hand clapping.
A Little Question and Answer Session
Q: What is the sound of one child misbehaving?
A: The sound of one child misbehaving is the sound of one child misbehaving.
Q: What is the sound of “my” child misbehaving?
A: The sound of my failure, the sound of my lack of control, the sound of "I should have control", the sound of "I can't take another second of this, “ the sound of "I hate this child," the sound of "I shouldn't hate this child”, the sound of "what is wrong with me," the sound of “well, anyone would feel this way," the sound of "yeah, but I am the parent- I am supposed to love him," and on and on and on…
Behavioral Parent Training –Principles and Programs Behavioral parent training is a broad term
Set of structured activities targeted to parents Can be used to address general skills or child
behavior Has been used (efficaciously and effectively) for a
wide variety of issues ranging from prevention of child abuse and neglect (Smagner & Sullivan, 2005), to management of ADHD, CD (Patterson, Reid, & Dishion, 1992),
and anxiety with children (Diamond & Josephson, 2005). Many different sets/programs, by many names
PMT (Kazdin, 1992), Incredible Years (Webster-Stratton, 1994),
Triple-P (Saunders, Cann, & Markie-Dodds, 2003), Parents as Teachers …
All have in common – emphasis on antecedent control and management of consequences
Behavioral Conceptualization of
Parenting Classical Conditioning
Repeated pairings close in time
Behavioral Conceptualization of Parenting
Operant Conditioning
Treatment Approach for Directly Conditioned Responses
Extinction: Stop pairing the S and R Habituation: “Cue exposure” Response Prevention Counterconditioning Replace with Incompatible Behaviors Other Contingency Management
Basics of behavioral parenting interventions Consistency
Structure, organize, & plan clearly Set limits and delineate rules
Catch them being good and label it specifically
Reinforce “good” behavior with reward Use distraction Use planned ignoring and/or time-out Use appropriate consequences – fast,
reasonable, etc.
And they work!!
Shown to decrease: Abuse and neglect Delinquency, anxiety, and antisocial
behavior Evidence of increase in:
Positive parent-child interactions Child social skills Child coping skills
Except when they don’t…
Perhaps more easily said than done Most of them fail to address
Parents’ internal context (thoughts, feelings, etc.) External context factors like
Work stress or money problems Marital and broader family relationships
Research shows that treatment gains are not as robust or as long-lasting when there are complicating factors Need treatment that addresses these
contextual factors
Internal and External
Relational frames, or indirect conditioning Adds a contextual piece Adds a “meaning” piece
Provide in-home services, daycare, transportation, and other case management type services *This piece is difficult and expensive but
most of us do know how, given resources (the first point needs work)
More on internal context
Multiple ways to address this piece Kabat-Zinn’s Everyday Blessings work Singh’s Mindful Parenting work Wahler, Dumas, and Strand’s work Acceptance and Commitment Therapy
Greco’s findings Blackledge’s findings
ACT based on RFT
Relational Frames
“My child”
ME
CME
“Misbehavior”
Events acquire meaning through relational responding
Related events have same psychological functions (depending on context)
What Indirect Conditioning Gives Us
Good Ability to balance long- and short- term
contingencies Communication over time and distance Broad ability to evaluate, categorize, sort Broad ability to plan and execute based on
evaluations** Advantage in treatment and usually in life
Bad Can’t turn it off and may turn on you
No contact with contingencies Commands literal response (which is often avoidance)
What this might look like
Kids take on aversive qualities for parents Meaning
My child = A collection of misbehaviors Narrowing of behavioral repertoire
If you teach techniques alone Susceptible to falling back Goals, not values
Suggests the need to address indirect learning processes as well
Acceptance and Commitment Therapy
ACT is a behavioral treatment that specifically addresses indirect learning processes as well as direct conditioning.
Aim is to undermine these processes when they are ineffective and to increase psychological flexibility in the service of having richer, bigger, more meaningful lives
Six Core Components of ACT
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
EssentialComponents
of ACT
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
ACT Question
are you willing to have that stuff, fully and without defense
if the answer is “yes” that’s
as it is, and not as what it says it is,
Given a distinction between you and the stuff you are struggling
with and trying to change
AND do what takes you in the direction
of your chosen values
at this time, in this situation?
Psychological Flexibility
Acceptance
Allow self to have whole of experiences When doing so fosters effective action
No Dangerous, unhealthy, or unproductive
situations Emotional wallowing
Not tolerance Yes
Thoughts, emotions, memories, history, bodily states, behavioral dispositions
Hopelessness of struggle/control is the problem
Fusion & Defusion
Fusion is the process whereby certain verbal functions dominate over other directly and indirectly available psychological functions Cognition stands in for experience
Defusion is the process whereby other directly and indirectly available psychological functions become available
Defusion
ANYTHING that involves interacting with the aversive event that is not avoidance
Optimally, a wide variety of rich interactions As different as possible from the usual ways
of interacting (functionally, if not formally)
Contact with Present Moment
Contact with current contingencies Here and now Showing up
Appreciation without evaluation or defense Notice and label
Self-as-Context
Sense of self that is safe and consistent
Observe all changing experiences Without evaluation
Values/Valuing
Powerful reinforcement
What one wants to be about
Choose vs. decide
Talk in terms of importance and consistency
Committed Action
Making life about living values Not about eliminating pain
Defining specific goals Anticipating barriers
Changeability is important consideration
10 Session Protocol
Session one: Overview of ACT: Accept, Choose & Take Action
Basic introduction, group “rules”, etc. Discussion of why participants joined the group Basic introduction to ACT as an intervention
Suffering as normal part of being human (and being a parent)
Undermining the struggle How ACT may be used to improve parent
functioning Support “living out” of parenting values Effective management of adolescents’ behavior
10 Session Protocol
Session One: Overview Of Act: Accept, Choose & Take Action
The ways in which parent emotions, beliefs, social comparisons, etc. “show up” in role as caregivers How hard we struggle to “figure it out” Child relevant fears Create a space to find out what’s important
as parents, regardless of the “stuff” Falling in the hole metaphor
Commitment to catch each other from trying to “figure it out”
10 Session Protocol
Session Two: Parenting Values: Remembering What Matters Most
Behavioral skills training Contingencies and changes in the
environment Consistency
Discussion of how words can get us “spun out” Pen metaphor Can we notice how a word affects us Can we notice it without judgment
10 Session Protocol
Session Two: Parenting Values: Remembering What Matters Most
Sunrise/Sunset metaphor Note what values guide
relationships with children When heading toward and
away What obstacles are getting in
the way What the distance and being
“off-course” feels like Valuing
What really matters to you? What is vital?
Clarification of valuing vs. values
Parenting values worksheet
10 Session Protocol
Session Three: Is the Goal Control? Managing Content vs. Managing Behavior
Revisit Values Worksheets Visual Representation for Sunset Metaphor
Specific behaviors are markers for valued direction Discuss briefly the reasons for use of
metaphor/story Distributed flyer on managing child behavior
10 Session Protocol
Session Three: Is the Goal Control? Managing Content vs. Managing Behavior
Identification of what is in sunrise and what occurs as clouds and wind for each participant What negative thoughts/feelings do you have
about parenting? About your child? What about “yucky” bodily sensations or other
negative content? What do you do in response to this stuff?
How does that work?
10 Session Protocol
Session Three: Is the Goal Control? Managing Content vs. Managing Behavior
Normalize the difficulties associated with parenting an adolescent Fleeting nature of thoughts and feelings (but
how real they feel!) Vulnerabilities: “Looking good” vs. doing what
is best
10 Session Protocol
Session Four: Beginning to Let Go of Control
Moving across room toward sunrise with “mind” and chairs as obstacles It’s easier to take “stuff” along than to fight it
10 Session Protocol
Session Five: Mindfulness & Acceptance Write obstacles on physical representation of
clouds Process content “Milk, milk, milk” exercise with most powerful
content Clouds passing on horizon mindfulness exercise
Correlate of “Leaves on a Stream” metaphor Homework: Try exercise once during the next
week
10 Session Protocol
Session Six: Present Moment Awareness: Building a Responsive Relationship
Process mindfulness exercise from previous week and homework
Mindfulness exercise as a group (clouds in the sky)
Processing Do some things repeat, move faster, slower? Present moment awareness and observation without
reaction Behavioral skills like labeled praise (another
worksheet)
10 Session Protocol
Session Seven: Willingness and Committed Action: Standing Up for Your Child
Mindfulness exercise More behavioral skills, like grounding even when
unpleasant! The barriers to consistency and following up Normalizing difficulties with barriers
Willingness in the face of barriers Pen in the hand metaphor
Consistency with rewards People are sunsets, not math problems
10 Session Protocol
Session Eight: Common Challenges “Slips” are normal Mindfulness exercise: Noticing bodily sensations Ways of being your reactions
Ways I act in the moment Do these actions move me toward my valued direction?
Self as context piece Chessboard metaphor
Statement of one small concrete action to be taken in the following week; minding there may be “slips”
10 Session Protocol
Session Nine: Strategies for Dealing with Hot Button Issues that Many Parents Face
Discussion of how the one concrete action from week 8 went
Recognizing context and not just content
10 Session Protocol
Session Nine: Strategies for Dealing with or Hot Button Issues that Many Parents Face
Adolescents show tough behavior, in the face of it, we can use: Positive and negative reinforcement Behavioral shaping Appropriate use of directions and consequences Planned ignoring Token systems
This helps get us out of the content and into context!
10 Session Protocol
Session Ten: Exposure to Forgiveness and Generalization and Maintenance
“Big Steps/Bold Moves” Self and child- real and imagined failures
and imagined forgiveness Process consequences
Team building (asking for help) Reminders about “slips” Recommitments
Measures
Difficulties in Emotion Regulation Scale (DERS) Alabama Parenting Questionnaire (APQ) Acceptance and Action Questionnaire II (AAQ-II) Kentucky Inventory of Mindfulness Skills (KIMS) Behavior Assessment System for Children (BASC-2) Depression Anxiety and Stress Scales, Short Form
(DASS-21) Youth Outcome Questionnaire 30.1 (Y-OQ-30.1) Stress Index for Parents of Adolescents (SIPA) Participant Interviews
Emotion Regulation – Participant 1
Emotion Regulation – Participant 2
Emotion Regulation – Participant 3
Experiential Avoidance – AAQ-2
Mindfulness – Participant 1
Mindfulness – Participant 2
Mindfulness – Participant 3
Externalizing Bx – BASC-2
Internalizing Bx– BASC-2
Symptomology – DASS-21
Behavioral Outcomes – YOQ 30.1
Participant
Parenting Stress (SIPA) – Participant 1
Parenting Stress (SIPA) – Participant 2
Parenting Stress (SIPA) – Participant 3
Interviews – Participant One
Asked what her overall opinion of the group was at follow-up:
“I was at the end of my rope with my daughter… (She) is doing great and I think it’s [sic] because of some of the things I was able to use from the ACT program.”
Interviews – Participant Two
Q: Has anything been particularly helpful?
A: Learning more about discipline as opposed to punishment.
Q: Has there been anything that you felt like was a waste of time?
A: No, Amy has a master plan.
Interviews – Participant Three Q: Has the experience thus far been emotionally
difficult or distressing in any way? A: It’s emotional, but not difficult, realizing how tied
up in my son I am.
Q: Has there been anything that you felt like was particularly helpful?
A: There isn’t a perfect fix.
Q: Do you think that your situation with your kid has changed?
A: I’m calmer in situations, which facilitates more understanding.
Summary & Discussion
This pilot study using acceptance and mindfulness strategies in conjunction with behavioral parent training found:
Significant improvements with some key variables Though some predicted by ACT model not seen moving
as might be expected EA found in previous studies to worsen at first “Temporary mindfulness”
Most other variables moving in “right” directions, though not significantly Other studies have shown a lag effect in ACT processes
That participants report they found treatment useful
Summary & Discussion
Some confounds: Participant 2 missed a couple of sessions Participants 1 and 2 are married and
parenting the same child Follow-up necessary in future research
Where to?
Larger groups and more of them Recruitment troubles
Longer sessions Include follow up measures Further investigation of the use of ACT
and other acceptance and mindfulness based approaches with parents is warranted.