Creating Connections A Comparison of Two Treatment Models Addressing Parent-Child Relationships Dorothy Denny, MSW, LCSW

Welcome! Presentation overview: Description of PCIT and CPP Comparison of the two models Demonstrations Guidelines for selecting treatment modality Discussion and questions

Parent Child Interaction Therapy (PCIT) Developed for families with young children experiencing behavioral and emotional problems Therapists coach parents during interactions with their children to teach new parenting skills Skills are designed to enhance parent-child bond, reduce child negative behaviors, and increase parenting efficacy

Child-Parent Psychotherapy Developed for young children exposed to trauma, especially domestic violence Typically sessions conducted with child and parent or significant caregiver together Therapist aims to engage with parent/child dyad to create safety, promote attunement and change negative interactional patterns Parent and child create joint trauma narrative that identifies and addresses trauma triggers

Theoretical Underpinnings PCIT Behavior theory Attachment theory Social learning theory CPP Integrates psycho- analysis and attachment theory Includes developmental theory, cognitive- behavioral and social learning approaches

Target population PCIT Ages 2.5 to 6 Has been adapted for older kids (up to age 12) Presenting concerns Child disruptive behavior Parent coercive discipline CPP Ages Birth to 5 Presenting concerns Exposure to domestic violence Separation anxiety Emotional dysregulation Parental depression Chronic stress Bereavement Attachment “fit”

Treatment Length and Structure PCIT Clinic-based (has been adapted for home- based treatment) Average weekly sessions Highly structured Phase-based treatment: Child Directed Interaction Parent Directed Interaction CPP Clinic or home based Average: 50 weekly sessions Flexible Non linear 3 general treatment phases: Relationship /process building Targeting problem areas Recapitulation/termination

Client Constellation PCIT Parent and child Parents can be foster or kinship caregivers Parents must have daily access to child for home practice CPP Parent/caregiver and child Parents can be foster or kinship caregivers Can be implemented during supervised visitation for children in child welfare system

Therapist Role/ Alignment PCIT Therapist = Coach Therapist is aligned with the parent CPP Therapist = Facilitator Observer/Interpreter Therapist is aligned with the child-parent dyad

Necessary Resources for Implementation PCIT AV equipment Space Toys CPP Toys to evoke child’s memory or emotion about a traumatic event

Training/Supervision Requirements PCIT 40 hours of face-to- face training with a PCIT trainer 6 months phone consultation with trainer while seeing cases No specialized supervision required CPP Varies according to setting and need In-person training or learning collaborative models Consultation and reflective supervision

Assessment Process PCIT Clinical interview ECBI PSI DPICS observation Other standardized measures as appropriate CPP Observations across conditions Developmental history Caregiver perspective on child and family situation Caregiver history and psychological functioning Cultural “niche” Standardized assessment measures

Evidence Base PCIT Several RCTs showing long-term maintenance of treatment gains CEBC rating of 1 (“well-supported by research evidence”) on scale 1-5 CPP 3 RCTs with trauma- exposed young children CEBC rating of 2 (“supported by research evidence”) on scale 1-5

Adaptations PCIT Families and children with prenatal exposure to alcohol and other drugs Group treatment Children 8-to-12 years of age Children with medical conditions. Physically abusive families Native American families CPP Latino families African American families Native American families Asian families Recent immigrants Anxiously attached dyads Depressed mothers Chronically stressed families

Possible Barriers to Treatment PCIT Lack of home practice opportunities (e.g., when parents do not live w/ child) Inability to attend weekly sessions makes skill acquisition much more difficult Cognitive impairment of caregiver Lack of AV equipment CPP Parents unwilling to engage in emotionally laden and trauma focused work Cognitive impairment of caregiver Ongoing domestic violence or otherwise unsafe environment Lack of clinician access to reflective supervision

Therapist Anxieties PCIT Too manualized Degree of therapist direction Lack of comfort with time out procedures CPP Not manualized enough Alignment issues Reluctance to process traumatic material Less comfort or familiarity with psychodynamic theory Fewer family therapy skills Reflective supervision

Essential Elements-PCIT Coding Coaching Home practice

Essential Elements-CPP Developmental guidance Attunement Curiosity and empathy Ports of Entry Moments of meaning Reflective supervision

Domains of Intervention- PCIT Parent-child “special playtime” at home Weekly coaching sessions of parent utilizing skills in play situations Parent’s discipline of child Parent’s communication with child

Domains of Intervention-CPP Play Biological disruptions Child’s behaviors Child’s aggression Physical punishment Derogation, threats, criticism Relationship with absent parent/perpetrator Ghosts/Angels in the nursery

Treatment Goals-PCIT Improve parent-child attachment relationship Increase parent’s warmth and responsivity to child Reduce frustration/anger on part of both parent and child Help parent and child view one another more positively Increase child’s social skills, attention, and self- esteem

Treatment Goals-PCIT Decrease child’s disruptive behaviors Increase parent’s use of effective discipline skills Increase parent’s predictability, consistency, and follow through Enable parent to generalize discipline skills to other settings

How Treatment Goals are Achieved- PCIT PRIDE skills Daily parent-child “Special Time” at home Command training – giving good instructions Coaching parent to implement detailed discipline procedure Planned responses to Refusal to stayy in time-out Impulsive or dangerous behaviors Behavior disruptions in public settings Gradual generalization from clinic minding exercixes to “real life” discipline

Treatment Goals - CPP Return to normal development Respond realistically to threat Regulate levels of emotional arousal Re-establish trust in body sensations Restore relational reciprocity Normalize traumatic response Differentiate remembering from reliving Place traumatic experience into perspective

How Treatment Goals are Achieved - CPP Using child’s play and language to explore themes Conveying developmental guidance Modeling protection Interpreting feelings and actions Providing emotional support and empathic communication Offering material help

Determining best treatment option:PCIT or CPP?? Questions to Consider: Age of child Child’s relationship with caregiver CPS or Court priorities Trauma history of child Trauma history of caregiver Symptom presentation Safety concerns What else??

Questions & Answers

Bibliography Bodiford McNeil, C, & Hembree-Kigin, T. L. (2010). Parent-child interaction therapy 2 nd ed.) New York: Springer. Lieberman, A. (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant health. Infant Mental Health Journal, 25(4), Lieberman, A., & Van Horn, P. (2005). Don't hit my mommy: A manual for child-parent psychotherapy with young witnesses of family violence. ZERO TO THREE Press. And special thanks to our CASGSL staff and children for participating in the videos.