Parenting skills development in vulnerable families: Facilitating and supporting parental behaviour change

Warren Cann, Executive Director

CAFWAA 2007 National Symposium

WORKSHOP May 2007

AcknowledgementsStaff 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 multi- determined (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

CHILDPARENTPRACTITIONER

A KEY ISSUE IN PARENTING SUPPORT

Helping adults change

Low yield strategies

• Attitudes• Reassurance• Normalisation• Understanding• Support.

Understanding behaviour

change: Self-regulation

CUES REACTIONS

Automatic behaviour

CUESSELF-

REGULATORY PROCESSES

REACTIONS

• Thinking

• Planning

• Problem solving

• Decision making

(Kanfer & Schefft, 1988)

Self regulating

Problem behaviour: highly stereotyped, automatic and difficult to control

Action patterns adaptive,

and initially under high

control

Automatic adaptive patterns

(Kanfer & Schefft, 1988)

CHANGE PROCESS

Getting stuck

Stress

Self-regulation fails

Gets stuck

A habit forms(responses are automatic and

insensitive to outcome)

OR

Lacks an adaptive

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

1. Creating a collaborative relationship2. Developing commitment to change3. Contextual analysis4. Negotiating a program5. Program implementation and motivation

maintenance6. Monitoring and evaluating progress7. Generalization and maintenance

(adapted from Kanfer & Schefft, 1988)

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 the

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

• 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?

Assessing expectationof change

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

Incre

asin

g m

otiv

atio

n

Pre-contemplation

Contemplation

Determination

Action

Maintenance

Relapse

Program entry point

Exit

Stages of change

Prochaska & DiClemente (1982)

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?”

• 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

• Refining and quantifying client goals• ‘Day in your life’ strategy• ‘What do you want for your child?’• Magic wand question (O’Hanlon & Beadle, 1997)

• Turning problems into goals• Goals from values • Goals from expectations• ‘How will we know when to stop?’

Strategies for eliciting client goals

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

Do

RESPONSE OUTCOME

Emotional

Instrumental

PROXIMAL (close) CONTEXT

DISTAL CONTEXT

Think

Skills Social support

BiologySES

Culture

Feel

Settingevents

ENVIRONMENT

Settingevents Trigger

Act

INFLUENCE INCREASES

PREDICTIO

N INCREASES

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 Parent holds unrealistic expectations for the child

Stage 2 Child’s behaviour falls short of expectation (disappointment on part of parent)

Stage 3 Parent attributes a malevolent intention to child’s failure, i.e., wilful antagonism, deliberate provocation (anger on part of parent)

Stage 4 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 self-

monitoring 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

Assessm

en

t• 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 implementatio

n

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

Engagement behaviours

Efforts tochange

Actualchange

CO

UR

SE O

F T

HE

PR

OG

RA

M

Source: Unknown

Practitioner Praise

Insert intervention

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

1. Monitor and support client's motivation for change2. Enhance sense of confidence and personal belief that change is

possible (self-efficacy)3. Elicit and reinforce independent problem solving4. Maintain three way focus: working on child related issues

(parenting), coping and lifestyle5. Explore and counter thoughts and emotions that are blocking the

change process (acceptance/mindfulness strategies)6. Environment modification strategies7. 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

Example: High Risk Infant Practice Framework

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 fit3. Reinforce parent for use of skills4. Negotiate new goals, strategies or actions

as required5. 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