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"A home for research and discussion about therapeutic community"
John Rivers
“Using Parents as First Therapists:
A reflective study of enabling parents through the use of parenting groups within a Child and Adolescent Mental Health Team to become first therapists.”
September 2004
Submitted in partial fulfilment for an
MA in Therapeutic Child Care
This reflective study firstly considers the national perspective of running parenting groups within a CAMHS provision and then moves on to consider why and how this intervention is used within the teams that I work in.
It also takes into account the feedback received from the parents that have been through the parenting programme.
Using a qualitative approach I reflect on my role as a leader of these groups, in holding parents in mind, the part other professionals play and the important contributions of the parents themselves.
I speculate as to why some parents are unable or will not attend these programmes and use my experiences to suggest what may be a way forward in supporting these parents to access these types of provision.
Title page Page 1
Contents Page 3
Chapter one :Introduction Page 7
Statement or rationale.
Statement of research purpose.
An analysis of my personal reflections.
A review of current literature.
Possible outcomes.
Chapter two: Methodology Page 14
Qualitative versus quantitative
The Weekly groups
Ethical considerations
Chapter three: Literature review Page 19
Introduction
The wider context
National Context.
Parenting Workers: The National Context
Parenting, some perspectives from the Health Services
Parenting issues and programmes within a CAMHS clinic setting
How ADHD has brought parenting within CAMHS to the fore
Support/parenting groups.
Evaluations of parenting programmes
Evidence of outcomes
Research Evidence from our local programmes
Conclusions
Chapter four: Reflections on running parenting groups Page 36
Introduction
The beliefs that I bring to parenting groups
The referrals to the programme
A brief overview of the Webster-Stratton programme I run Page 42
On going evaluation through pre and post group questionnaires
Reflections on co-ordinating and running the ten week programme Page 45
Engaging those that have chosen to come
The first two weeks
Weeks three and four
Week five
Weeks six and seven
Weeks eight and nine
Week ten
Chapter seven; Further thoughts on running the groups Page 65
Practical factors that help
Some concluding thoughts to running parenting groups
Conclusion
Chapter eight: Holding in mind and some group process Page 73
Modelling the experience
Containment and the beginnings of doing it for themselves
Chapter nine: Conclusions Page 77
The bigger picture
Workers
Parents
Appendices Page 92 [not included]
A: An evaluation of a group treatment program for parents of children with behavioural difficulties. A small scale study.
B: Group invitation reply form
C: Eyberg Child Behaviour Inventory
D: Parenting stress Index (Short form)
E: 10-Week Programme
Statement of rationale.
I have worked as a parenting group facilitator for 10 years in several settings, a Social Services Family Centre, the voluntary sector and currently in three Child and Adolescent Mental Health Teams. I am very aware of the central government’s current drive to increasingly endorse parenting programmes as a way of reducing unwanted challenging behaviour from children and adolescents.
There is also, within the three localities in which I work, a drive to reduce waiting lists in the over stretched Child and Adolescent Mental Health Service by offering group parenting programmes.
Much has been written and many studies made of the ability of such programmes to reduce unwanted behaviours in children and many have shown the effectiveness of this style of programme by evaluating the reduction in unwanted behaviours e.g. Webster-Stratton (1998), Scott (2002). Within our own team a small scale evaluation of the programme we run has also been carried out, which to some extent mirrors these findings, (Warnham 2004).
However it appears to me that most of these evaluations have concentrated on measuring reductions in unwanted behaviour, but it would also appear that there has not been this amount of thought given to what happens in these groups that may enable the parent/s to begin to build a different and more perhaps ‘therapeutic’ relationship with their children. What part does the group process play for parents attending these programmes or is it the programme content that helps? Are we effective in treating referred children by training their parents to offer that ‘therapy’? What is it that enables parents to better understand a child’s emotional needs, or is this merely changing behaviour by cause and effect?
Statement of research purpose.
It is my intention to reflect on my experience of running two parallel parenting programmes in two different localities, delivering the same programme to a total of twenty seven families.
During this ten week period I kept a journal not only of the programme content and group processes but also of my thoughts and feelings and those expressed by the parents.
My aim is to use this journal to reflect upon these two groups and to consider how therapeutic a tool this is for the treatment of children with significant behavioural problems that others have thought severe enough to refer into a Child and Adolescent Mental Health service.
What is it that helps us be effective in using parents as first therapists?
I feel that at this point it may be helpful to define what I am implying by first therapist.
The parent or primary carer is I believe the person in the most powerful position to make early interventions regarding emotional or behavioural difficulties, because that person should have the most complete understanding of the child, know his likes and dislikes, and is the one person who can have a consistent and ongoing and holistic relationship with the child.
An analysis of my personal reflections, focusing on-
The value of the process, for parents attending these groups and the impact, if any, on their children.
Holding parents in mind, that they may find the value in this for their children.
Have parents’ beliefs about the meaning of, or reasons for, their children’s challenging behaviour been challenged or changed by attending this style of programme?
Have parents’ beliefs about themselves as parents and their role in their children’s emotional development been challenged or changed? Is there at the end of the programme a different kind of relationship/empathy that could be described as therapeutic
A review of current literature, focusing on-
The national context in which parenting programmes have, and are, growing.
Outcomes of parenting programmes both short term and long term.
Winnicottian theories relating to ‘good enough’ parenting.
The purpose of the above would be to arrive at a greater understanding of what the additional factors are in the process of delivering this style of programme that are beyond the contents, and perhaps constraints, of the course manual.
I feel it may not be possible to include all these lines of research; however I would wish not only to use my reflections but also to be able to substantiate the analysis of these reflections by then linking them to available current thinking, research and theories.
Possible outcomes
I would hope that this pilot study would enable me to deliver further programmes in a more effective and empathetic way.
Also to challenge mine and others thinking when considering or delivering these programmes.
Perhaps also to inform thinking, about who and why we invite to attend these groups.
As I also always have new and inexperienced group facilitators working with me this would also be knowledge I would hope to be able to pass on to them.
I would also like a summary of my findings to be considered by The Parenting Education and Support Forum for possible publication, as at this time they appear to be the leading U.K. resource in disseminating materials and research relating to parenting programmes.
I also suspect that given the relatively small size and the time restraints of this study it is likely I will generate other questions that it will be outside of the scope of this study to consider.
Qualitative versus quantitative
As the thing I want to consider is about the richness of the experience, the many facets that go to make up the complete process, I have decided to use a qualitative approach to my research.
There are many papers, articles and other readings that have measured the outcomes of similar groups by quantitative analysis of the children’s behaviour before and after these programmes. Mostly they show an improvement to some greater or lesser degree in the children’s conduct problems. Indeed one such small scale study has been undertaken within our own service which mirrors these findings. Useful as this is it does not consider what has happened to make these changes possible. Nor does it consider the impact it has had on the parent or the relationship between parent and child.
As it is this richness, this quality of experience, that I want to consider I have decided on a qualitative approach to the analyses of my observations.
The adoption of a qualitative approach gives meaning to the experience as a whole and places the researcher as a participant within the field of study rather than an objective outside observer. This approach will allow me both to reflect on my participation, and assess my value as participant and narrator. The ability to scrutinize one’s own role, feelings and actions is fundamental to qualitative research and also as a group facilitator. Self scrutiny or active reflexivity recognises the inability of the qualitative researcher to remain ‘neutral’ of their conclusions.
I also believe that by using this approach and writing a journal I will be able to consider my role in the process. I will also be able to consider my own learning and development from within these groups, the immense amount the parents always teach me and also the impact that the two years of undertaking the MA in therapeutic child care has had on me and the way I now approach my work and facilitate these groups. “Exploring feelings through reflection can promote understanding and self awareness. As a manager I found that keeping a personal journal helped to bring clarity to my thinking, particularly when trying to face difficult issues in an honest way.” (Dacre in Ward and McMahon. 1998:196)
The Weekly groups
Over a ten week period of two parallel groups, and with the parents knowledge I have kept a reflective journal of the programme content, the group process and the thoughts and feeling expressed by the parents and those thoughts and feelings of myself.
I propose to use my journal to reflect on each week’s group process in turn in a systemic way, by this method I hope to come to a greater understanding not just of the processes within the group but also of myself and those other individuals that make up the group. “Leaning through refection is essentially a holistic process of knowing and transforming self, not a cognitive activity. We are who we are for reasons that cannot rationally be shrugged aside.” Johns (2002: 130) I will reflect on how I delivered the content and my perceptions of how this impacted on the parents at the time, both from my observations and from their feedback. Then to consider how that weeks intervention is then reported back to the group the following week, did it have a noticeable effect on the child and if so how did this effect the parent, how does the reporting of this impact on the group and subsequently on me as the facilitator delivering the next weeks intervention.
I will question what is my analysis of these considerations, holding in mind the learning from the taught aspect of the MA in therapeutic child care and Winnicottian theories of ‘good enough parenting’ and holding the child/parent in mind?
Ethical considerations
At the beginning of the two groups I talked to the parents about the MA course and that I hoped to write about my work in the groups, I explained that I would be keeping a journal and that it would not contain any body’s names, that it would be about the process and I would not be writing about their personal details. I also spoke to them about what I hoped to achieve and why I was doing this, all were in agreement that I could do this. I did remind them towards the end of the ten week programme about the journal and dissertation and still no one was in disagreement with this, in fact several asked that I let them know when and if I complete my MA.
Should it be useful to use examples I will use fictitious names and amalgamations of circumstances to completely protect anonyminity. However I intend to concentrate on the processes, themes, and patterns that I have noted appear to arise when parents have attended these groups and not the individuals that have attended them.
I will also not name the locality CAMHS teams where these groups took place, I will also use pseudonyms for my co workers should I need to refer to them and they are also aware of the work I am undertaking.
A small scale study has been undertaken within our service looking specifically at the pre and post programme child behavioural and parental stress questionnaires we use. I have asked the author of this paper for permission to draw upon her findings and will give her due credit within this research paper.
Her paper was prepared under the guidelines of her psychology department’s code of ethics.
My managers have given me verbal permission to write this dissertation on the parenting groups within our service.
.
Introduction
I aim in this literature review to set the wider national context of parenting education and then more specifically within a CAMH service. I believe it is important to consider the broader picture of how, and why, parenting education/support is developing in the United Kingdom and then to look at why there seems to be such a growth in this area of work within a child and adolescent mental health setting.
Secondly this review will think specifically about the parenting group education/support which the CAMH team of which I am a part offers locally, and the research on which these groups are based.
The wider context
Winnicott perhaps started to popularise the trend of educating parents in the role they play in their children’s social and emotional wellbeing back in the 1940s to 50s with his talks to parents and his radio broadcasts, collectively published as “The Child and the Family” (1957). Although the focus during that time was concerned with the relationship between mother and child we have now come to understand the broader implications for any main carer of children, and Winnicott’s work along with many others has informed the way we now, as professionals, think about the relationships within families.
Parenting programmes, as we have now come to know them, have been slowly gaining prominence in the UK for over a decade, and this has been reflected in, and to some degree led from, central government action as it starts to put the child, the family, parenting and social inclusion at the forefront of many of its policies and attitudes. This is not just in a mental health setting, but also within wider general health and primary health care settings. Parenting is also reflected in government thinking in education, for example, its drive towards ‘Parents as First Teachers’, its social services policies, as in the green paper ‘Every Child Matters’, and in the criminal justice system’s parenting orders.
Perhaps, just perhaps, those that decide policy are at last listening to those of us that try so hard to implement it in a way that will have a positive impact on those we work with. This may be because the current Labour Government sees the long term investment in the countries children and youth and parents as a means to pre-empting future expensive societal problems such as crime, family breakdown, mental health difficulties and social exclusion. “Helpfull Parenting” (2002:28) clearly raises these issues in its conclusions, stating that “the problems that result from unhelpful parenting- delinquency, violence criminality and mental health problems in adult hood- are problems for us all.”
As a result of this political interest there appears to be more and more funding, initiatives and projects, both within the statutory sector and the voluntary sector. This in turn has, I believe led to an increase in interest and research in the field of parenting programmes and parenting support.
There is an abundance of new publications, both books and shorter papers; in addition there has also been a growth in the development, production, promotion and sale of parenting programmes themselves. Some of which seem well grounded in research, others less so.
National Context.
The National Institute for Clinical Excellence (NICE) in collaboration with The Social Care Institute for Excellence are at present conducting an evaluation of Parent Training/Education Programmes for children with conduct disorders. They are researching all the available parenting programmes and the current published research and evaluations of them. This project aims to evaluate the effectiveness both of outcomes and financial costs. I am pleased to see that the family and societal costs of conduct disorders are also under consideration, but it is not altogether clear how these will be measured or what weight will be given to these areas in the final recommendations.
This body is due to publish its findings early in 2005 when it will then give guidelines around best practice for delivering these types of interventions within the caring professions i.e.; Health, Social Services. However, The Department of Health has just published “Supporting Parents, Messages from Research” (Quinton, 2004) which appears to put the socioeconomic and emotional support of parents before the more directed solution focused approach, thereby enabling parents more control and power over the interventions suggested or imposed.
The present Government’s Green Paper “Every Child Matters” (2003) will impact on those planning policy both at a national and local level. This is reflected in the recent Deputy Prime Minister’s office report “Mental Health and Social Exclusion” (2004) in which there is a whole chapter on supporting parents, both those suffering mental health difficulties of their own and those whose children are having these difficulties. Also, in “The New National Service Framework for Working with Children” (2004), recently published by The Department for Health there is great emphasis placed on supporting parents and family work.
The Public Policy Research Bureau on behalf of The Department for Education and Skills has just published its comprehensive and extensive research report titled “What Works in Parenting Support? A Review of the International Evidence” (2004). Throughout this report it is evident that parenting support/education has a part to play in the support of parents both in managing raising their children in a way that promotes the child’s wellbeing and also in supporting the parents themselves. It does however highlight significant gaps in the evidence, which include; an understanding of which groups benefit most from which different types of interventions. There is also very little longitudinal research into the effectiveness of these interventions over a longer period than the intervention lasts.
I have not been able to understand how the research publication due out in 2005 from NICE will differ from “What Works in Parenting Support? A Review of the International Evidence” (2004), except this appears to make no recommendations as to best possible practice. It does however highlight the need for further research in this country as most of the larger studies are from America, Australia or Europe and it has been difficult to establish how well these programmes work in a different cultural context.
The Royal College of Psychiatrists have also been looking at some of the available research and their publication “Parent-training programmes for the Management of Children with Conduct Disorders. Findings from research” (2002) has influenced which programmes have become the standard for use within a child mental health setting. This publication carefully looked at the types of programmes available and compared the differing theory basis behind these programmes; behavioural programmes, those with a relationship element, the Adlerian approach and Family Systems based approaches. Their conclusions appear to be that the behavioural approach, as long as it has a strong relationship element produced the best results. But again it was noted that there was a lack of longitudinal evidence and that most of the research was not from within the United Kingdom.
Parenting Workers: The National Context
There is also now more thought being given to those who provide these programmes. Until now there were very few, if any, dedicated parenting workers and very little dedicated parenting worker training. What there has been however, is specific training in the delivering the programmes, which tended to be provided, at a cost, by those that had developed the specific programme, so was usually quite narrow in its scope therefore parenting programmes were often delivered by professionals whose main responsibilities, although often closely related, lay elsewhere. Health Visitors, Social Workers and others in the child care professions will often undertake this work, usually in addition to their main responsibilities.
Currently The Parenting and Education and Support forum have published a draft of their proposed “National and Occupational Standards for Family Learning and Work with Parents” (2003). This will be a set of competencies that those delivering parenting interventions need to complete in a similar way to NVQs or Social Work Competencies.
Quinton’s “Supporting Parents” (2004), for the Department of Health, alongside the researched outcomes of a programme for training professionals to work with families in a more collaborative partnership, which his team have been delivering since 2001, indicates and perhaps reinforces the need for a more dedicated and specially trained workforce in delivering programmes and supporting parents.
The Royal College of Paediatrics and Child Health’s, “Helpful Parenting” (2002:28) supports these findings, and in their conclusions very clearly state “The need for an expansion of services will require training for professionals, parents and others who want to develop the skills to help parents, the development of standards of practice, and of accreditation, and better co-ordination of services at a local level”.
Parenting, some perspectives from the Health Services
As already stated, The Royal College of Paediatrics and Child Health have been thinking about how parenting can affect the general and emotional health of our country’s children Their report “Helpful parenting” (2002:4) comments “There is now a growing body of research which shows that our familiar assumptions about bringing up children are not always correct. The quality of care that babies and toddlers receive depends more on the sensitivity, insight, attitudes and resilience of the carers than the wealth or physical resources available to the parents.” They go on to discuss the interplay between a child’s physical health, mental health and quality of the parenting that a child receives.
Parenting issues and programmes within a CAMHS clinic setting
Open almost any child psychology or psychiatry journal from over the past two or three years and you are almost certain to find an article on parenting. CAMHS clinics have become much more inclusive of the family as a whole and this is reflected in the growth and diversity of teams across the country.
The new “National Service Framework for Children” makes recommendations for the team makeup and criteria, for team size and gives direction about the interventions offered, with family work and parenting taking equal precedence along with the more traditional psychiatric/psychology approaches.
How ADHD has brought parenting within CAMHS to the fore
In 2000 NICE directed that it was not enough just to prescribe medication for children with ADD, and ADHD but that there should also be some parental guidance offered as well, in order to lessen the impact these kinds of behavioural difficulties can have on the child, the family and on society in general. It was at this time that my post, community parent worker, and others like it, were thought about and set up. This has led to much more parenting/family work within CAMHS clinics and as a consequence many more people are now thinking about and researching how these clinical services can best meet these new demands on its scant resources.
Parenting, within the CAHMS clinics in which I work, is now offered as an adjunct for many of the other more traditional clinical interventions and for an increasingly wide spectrum of child behavioural, developmental disorders.
Support/parenting groups.
Adesida and Forman (1999) found that groups of parents, whose children had an ADHD diagnosis, meeting together, were empowering of each other. They also found that this safe environment enabled parents to express their feelings and emotions and with good facilitation this was seen as a complementary service that improved the effectiveness of the other services offered within their clinic.
Bradley et al (2003) look at a brief psycho-educational parenting programme and follow up a year later to discover significant improvements in child behaviour when compared with a control group who received only the basic clinic interventions
A more broadly focused approach was Golding (2002) whose review of parent training also took into account the socioeconomic circumstances of parents and the predictors for outcomes. This review highlights that models which address or at least acknowledge the extra-familial stresses on families, such as environmental and economic pressure, have an even greater success rate. Golding echoes Quinton’s findings and in practice these models are moving toward a holistic approach to parenting training within social contexts.
Scott and Sylva “The ‘Spokes’ Project: Supporting Parents on Kids Education” (2002) was a group work extended programme of parenting, parental/child literacy and then parent/child communication and problem solving run over three terms. This appears to show even better outcomes when compared with their control groups who received advice only. These studies reinforce that parenting training as a one off stand alone intervention is often not enough for many of the families that have been referred into a child health or social services type provision.
Evaluations of parenting programmes
Most of the larger scale evaluations of parenting programmes have predominantly been written by those that have also developed and marketed the programme. They have also mostly been conducted in very controlled university type clinic settings, and although for research to carry significant weight the intervention needs to be in its purest form, this does not reflect the reality of trying to then deliver that specific programme in the local community with all the myriad problems that families can face.
Quinton “Supporting Parents, Messages from Research” (2004) highlights the family centre model, especially where it also includes Health, Education and Parenting as well as a Social Services, Housing input, as a model that parents and workers alike feel has great value.
However it would be extremely difficult to clinically evaluate a model that changes for each set of given circumstances, and uses different components from various agencies for each individual family. I suspect that this has helped contribute to the slow but steady decline of Family Centres as a support for parents and parenting and their subsequent move towards child protection and assessment centres. It has always proved very difficult to really evaluate their performance in order to prove that their outcomes are of value.
I find it interesting to note that the three parenting programmes that carry the largest evidence base for their effectiveness are those that appear to have also the best marketing and financial back up. This has inevitably led to those programmes being used more extensively in clinical and statutory settings, and that in itself contributes towards the bias.
This in turn could influence organisations such as NICE when they conduct evaluations of available parenting programme research, they will inevitably end up biased towards those that are most used within the statutory sectors.
Evidence of outcomes
I have found it interesting to note that as of this time I have not found an evaluation that indicates a negative change or no change in parenting style for those parents that complete a programme. However I have also not been able to discover any studies of those parents that have dropped out of programmes before completion.
There is an abundance of evidence around well functioning families with a single issue such as child behavioural disorder, see Golding. (2000) Webster-Stratton. (1984). It is clear that behavioural style parenting group interventions with these families transfer well to other siblings and other behavioural difficulties within the family, although it is less clear if the positive changes transfer to other settings such as school.
Research Evidence from our local programmes
We were extremely lucky to have recently had a trainee Clinical Psychologist working within our clinic. She needed a research project and choose to look at our parenting group provision. (Warham 2004 unpublished)
We always ask parents to complete pre and post group questionnaires in order to measure each individual’s change. The trainee therefore had a wealth of data from a number of groups covering two years from which to draw her conclusions. (See appendix A) The groups from which Warham gathered her data take a behavioural approach with an emphasis on relationship building, an emphasis which Golding (2000), Bradley (2003), Webster-Stratton and Hammond (1997) and Webster-Stratton (1998) show to be positive.
Warham’s main conclusions reflect and reinforce those from the above literature review. Parents had a very high level of parental stress at the start of the programme; this was significantly reduced by the end of the ten weeks. However it was still above that which would be considered the clinical norm.
Children’s difficult behaviour was also significantly improved. But again the evidence indicated that it was still outside of the clinical normal range
Parents feed back was very positive about the course content and its impact on them and their children but a significant number indicated that it had not addressed the other issues that were impacting on their ability to parent in a positive way.
The rationale and structure of the groups used in Warham’s study and continue to be used within the CAMHS teams are discussed in the following chapter.
Conclusions
Parenting programmes as an intervention to change parenting styles and improve child behaviour and the projected outcomes for children have been growing at an increasing rate within the United Kingdom. This is to some extent being led by government in response to an increasing awareness that parents are most often those best placed to take the lead in making changes to difficult childhood behaviours. Also there does at last seem to be some understanding that these types of interventions, if delivered at an earlier age, can prevent much more serious and therefore costly difficulties at a later time. These costs are both at an individual level and at a cost to society.
There is an increasing move for those that are dictating policy to focus on that research evidence that is available. Although it is not clear how well these differing departments and organisations are co-ordinating their efforts. It would seem that some of the research is going to replicate that which has already been undertaken.
It appears, to a degree, that the increasing availability of these kinds of programmes is also being driven by the market, in as much as those that develop the programmes are the same people that are conducting the research and selling the product. So there is very little research into those parents that do not access the programmes or who drop out of them once started. Therefore although the evidence points to a positive outcome for those parents and therefore their children it should also be remembered that there are, from my experience, significant numbers of parents/children who are in need of these types of groups but do not or can not access them.
There is a need for much more independent research to be conducted within the United Kingdom. This would need to study carefully the differing styles of programmes, consider the differing cultural contexts of the home of the programme and also those of the different ethnicities of the UK population.
I devote the following chapters to all those parents I have worked with over the years; they have taught me so much.
Introduction
First I will give a summary of my beliefs regarding the groups that I run. I shall then give a brief description of the referral process to the programme and then of the programme as I run it. I will then go on to discuss the positive impacts that I have observed this programme to have on parents and their children. Finally, I will consider the issues that appear to stop parents using the programme to its full potential.
The beliefs that I bring to parenting groups
I have been running groups for parents whose children display difficult or destructive behaviours for many years, and over that time have observed recurring patterns, themes and issues that these parents bring to these groups.
When children and their families are referred into the Child and Adolescent Mental Health Team it is because they believe there is a significant difficulty and this belief is being supported by a professional other person, i.e. GP, Health Visitor, Paediatrician, someone from Education or Social Services.
There are many papers describing the behavioural change that children can undergo when parents attend these kinds of group programme. But very little about what it is that changes in the parent to enable this change in their children.
There is now a long history of writing regarding holding children in mind, containing their anxieties and the importance of the attachments between parents and children, Winnicotts thoughts and theories of “Good Enough Parenting”, holding and containing from the 1950s and 60s, Bowlby and Crittingdons work on attachment, through to the more recent books “Why Love Matters” (Sue Gerhardt 2004) and “What Mothers Do, especially when it looks like nothing” (Naomi Stadlen 2004) are perhaps just a small sample of the work that influences the way I believe parenting groups should be run.
First and foremost I have a belief that, if at all possible, the person/s best placed to offer support, build self esteem and self confidence, repair hurt and give comfort in times of despair and also ultimately change a child’s behaviour is that child’s parent or full time carer.
This is what drew me to the notion of parents as first therapists and having in mind the Green Paper “Every Child Matters” (2003) were reference is made to “Parents as First Teachers.” clearly giving the message that parents are those that start the learning process for children and also support their child’s ongoing more formal education. I see my work as an extension to this. Each parent is the expert on their own child, being the person with the most powerful relationship, my roll is to support and educate them in order to promote learning, change, emotional well-being and healing, when it is needed, in their children.
Of course it is equally possible for a parent to do the exact opposite and be a destructive or negative force.
I also believe that if a parent engages in this programme of work and also the group process, something happens that is bigger than the content of the course manual and therefore has a greater and more lasting impact on their relationship with their child than those parents that just mechanically follow the content.
It is this that I am setting out to consider. As Doubleday and Hay ask in the title of their very recant article on Webster-Stratton parenting groups within their local CAMHS service “Is Statistical Significance Enough” (2004) ?
The referrals to the programme
All of the parents that attend the group have already been assessed and are then passed on by referral to me by a doctor or clinician mostly from within the CAMHS teams; a few also come from paediatrics or paediatric psychology.
For each group I receive about fifty referrals. As the start date approaches I write inviting them to attend an information meeting. This is about two weeks before starting the group programme. I always send out the invitation together with a self addressed envelope and tick box reply slip (see appendix B) and get approximately a third reply, of that number most, but not all, will attend the information meeting. By the start of the programme I have between eight to fifteen families attending. As each parent is encouraged to bring their partner, friend or carer for support, this can add another third to the group size. When the group is run in the evenings the majority of parents’ attend as couples so these groups tend to be larger still.
I inform the referrer as to whether or not their patient has replied; if they have come to the information meeting and then if they attend the group. It is then up to the referring clinician to asses what to do about those that are not attending.
As there is a tick box on the reply slip that says ‘No thank you, I no longer wish to attend a parenting group’ those parents that do not even reply are the ones that I have most concern for. There may be many reasons for not replying but I suspect that most of these are negative.
There may be those parents that don’t read or write well and perhaps do not have the support to deal with these types of letters.
There may be those that I am not aware that English is not their first language.
There may be those that see the difficult behaviour as the child’s problem and can not see how this has anything to do with the way they interact with their child (these parents will often ask for individual counselling for their child)
There may be those whose life style is just so chaotic that the letter was probably lost within a very short time of receiving it and then forgotten about.
There may be those that fear they are admitting failure by attending such a group
There may be those families that it is always hard to reach and engage where all or many of the above apply,
Plus there maybe many other social, economic or mental health difficulties.
It is all these families that I feel I should be working at engaging, but given my limited time in each of the three localities, the systems that are in place, the large amount of referrals I receive and the understaffing of the CAMHS teams as a whole, I am ashamed to say that I rely on people not replying or attending in order to cope with the numbers of people in the group programme.
Within the CAMHS teams in which I work the Webster-Stratton Incredible Years parenting programme (1987) has been running for a number of years. This programme had been selected because of the large amount of evidence that it was effective, however as stated in my literature review chapter most of this evidence was from America and there was no hard evidence that it transferred well to the United Kingdom. Despite this it is the programme most commonly used within CAMHS teams.
My post was created in response to the NICE guidelines for ADHD and their advice that support for parents regarding managing difficult behaviour should be available to parents whose children had received a diagnosis of ADHD.
It was the main responsibility of the post to co-ordinate and lead this parenting programme rather than the ad hoc scramble to run the programme using whoever was available. Now that I run and lead the programme there is some consistency and co-ordination not only within each team but also across the three teams. I am able to call on workers from the CAMHS team who have some experience of running groups to co-facilitate, plus I try to have a third worker from outside of our agency. In the past I have had Health Visitors, Paediatricians, Child Welfare Officers, Trainee doctors, Psychiatrists and Psychologists, Social Workers and others from a Social Services background.
There are many advantages to bringing in others from outside agencies. They bring a different perspective to the group and stop it becoming stale for the regular leaders, they are receiving informal training and experience in the use of this model of parenting programme and although they are only in the parenting group programme they also get a wider picture and understanding of the CAMHS service and we of their service and obviously the more cross agency working we can imaginatively do, the better cross agency relationships we will develop.
On going evaluation through pre and post group questionnaires
Before the programme starts, two sets of questionnaires are given to the parents; “The Eyberg Child Behaviour Inventory” and “The Parenting Stress Index” (see appendices C and D). The parents are asked to complete these at home and bring them along to the first session. They are then asked to complete the same questionnaires again at the end of the programme along with a comprehensive satisfaction questionnaire which is aimed at the programme itself and their experience of it.(See appendix D)
These questionnaires are used to evaluate the groups effectiveness overall. In addition, along with our observations and other feed back they inform the reports we write at the conclusion of the ten week programme. These reports are addressed to the referring clinician, they are also copied to the parents, their GP and also to any other professionals involved with the family as long as consent has been given or the parent has requested me to do so.
The questionnaires have enabled us to see that overall the programme running within our clinics is successful; I will however describe these findings in more detail elsewhere in this paper
Engaging those that have chosen to come
I have struggled, for all of the time I have been co-ordinating these programmes, about how best to describe this to parents. Is it a course, a programme or classes? Am I teaching, facilitating, or leading? I have been told by numerous parents that when they have been referred to me they felt resentful and hurt. Being a parent and raising children is perhaps one of the most emotional and personal experience any adult can embark upon, by implication they feel they are being told they are no good at it, they are getting it wrong and their child is the way he is because of them, and to some degree this may be true but it is not a helpful or positive perspective of our relationship as we embark on a ten week programme of new learning together.
To try to lessen these feelings I hold an introductory meeting two weeks before the programme starts. I talk about the course being designed for, and aimed at, helping parents whose children may be more difficult to parent than most. That I believe all parents should be given the opportunity to access these types of groups- “you cant drive a car unless you have had lessons and this stuff is much harder to get right” There appears to still be some stigma about attending a parenting course, is it a sign of failure, should we be able to get it right instinctively? For most other difficult tasks or jobs most people would expect some form of learning or training before undertaking the task “if you buy a ------- washing machine it comes with a bloody instruction book and children are much more -------difficult, I mean ---- they don’t even have a bloody off switch” (Parent 2004). (Some expletives have been deleted)
I emphasise again and again that the only experts on their children are the parents themselves, not the psychiatrists or psychologists that referred them to me. I also try to stress that at no time will I be expecting them to do anything that they do not believe will work for them or that will not fit to their home, beliefs or lifestyle. I say that I will try to give them a few ideas but with twenty other parents in the room they collectively have much more expertise than I can muster.
Perhaps what has proved the most helpful is that I have started to ask two or three parents who have attended the previous group to come to these introductory meetings and I interview them about their experience of the programme, how did they feel when they where referred, were they nervous, resentful or angry? I also ask if the programme was difficult to complete. Interestingly they always stress that it is hard work that it is not a magic wand instant fix, but that the rewards are tremendous. One mother spoke about how when she started the programme she really did not like her nine year boy at all and that long before the ten weeks were over she had a very different and loving relationship with him. She stressed that his behaviour had not changed all that much, although there were improvements, she now felt in charge, more able to manage him when things did get tough. She told them that she could see that although the progress was not dramatically fast it was ongoing and over time she was going to be able to give him the skills to manage himself. This story was told with tears running down her cheeks and by the end it was not only her crying, and they call me a professional! It is these experiences that are so rewarding and keep me motivated to repeat the same programme over again. The new parents can then talk to them more informally over a cup of coffee at the end of the meeting.
During this meeting and with the help of my co-operating parents I try to sow the seed that it is possible for the group to carry on meeting once the programme has completed the ten weeks and that it is through this ongoing support that changes will be maintained and improved upon.
The first two weeks (see appendix E)
Parents are often disappointed that in the first weeks of the programme that we do not at first appear to be talking about difficult behaviour very much. After the initial introductions and formalities I ask parents to describe their ‘target’ child and describe the difficult behaviour they would like to change. This generates a list under each child’s name which I then do not refer to again until the last week.
The first weeks concentrate on how children learn through play, how they acquire their social skills and emotional literacy, and how parents can facilitate this learning. Parents at this stage really seem to want me to tell them how to discipline their children and it is quite hard to keep bringing them back to the task in hand, learning through play.
The whole foundation of my training has been in child development and the value of play. I started this type of work as a nursery nurse so know the value of play for children, together with positive interaction, regard and of course affection. It is the foundation of all I believe with regard to a healthy emotional development in children, but as I start to talk about the value of play it just feels almost frivolous after hearing how difficult life is for some of these parents, to then have to tell them to go off and play with their children for a set time each day and that this will be the beginning of a new relationship that will help them shape their child’s behaviour. They have come wanting answers, maybe new ways to exert control and I then tell them how much a child learns through play, how their whole world is made sense of through their games and imaginations.
We have a go at some role play of descriptive commentating on play, we concentrate on not asking questions and letting the child lead.
I believe although the learning about play is important, it is the group process that starts to come into play that has the biggest effect. Parents have seen that the others in the group are struggling with similar if not the same issues, a sense of, we are in this together, starts to develop.
At the end of each weekly meeting homework is set and in the first weeks they are asked to play with their child for a minimum of fifteen minutes a day, and to consider how they can use the things we have discussed to best effect. As I looked around the room I could see the one or two that were with me on this but also all those that that I perceived as thinking what is this fool talking about. It is at this point that I started to feel inadequate to the task, I try hard to remind myself that this programme works, that play is the right beginning and that almost every time I have run this programme I have felt this projection from the group. The feeling that however much I try it will not be enough. Even though I know all this intellectually these feelings of inadequacy are extremely powerful and it is with all my fingers and toes crossed that I close the group and send them off with their homework; Play with your child for a short time each day at a set time if possible, let your child take the lead but gently try to influence them into imaginative games or at least games that require conversation. Definitely no computer games! Eliana Gil when thinking about the more intensive use of play in play therapy cautions against using the kinds of toys that do not promote self expression, (1991: 28) and it is this principle and the principles of positive interaction that I was trying to promote to the parents in a less intensive way.
The first half of each week is dedicated to feed back, how has the week been, how did the home work go, was it easy or hard, if it was not done what made it difficult to do.
Time seems to be a huge issue for a lot of parents and this at first took me by surprise. Fifteen minutes a day did not seem a lot to me, but a father who works full time, maybe commuting, can be hard pushed just to see his children before they are in bed. A single mother with several children can find it hard to find any one to one time with a child. This comes up in all the groups and we usually get into a discussion of priorities.
Because I work within the NHS I have found it useful at times to describe what Im asking them to do as a treatment, if a doctor prescribed a course of physiotherapy for their child then I would hope they would find a way to do it.
I start to suggest that also by using play in a more constructive and perhaps structured way that the relationships may start to change. Often the best I can hope for is that the parent will acknowledge that both they and the child have started to value and enjoy the time together. There does however seem to be a significant number of parents that will openly say that they really do not find playing with their child enjoyable. I personally find this concept hard to comprehend as the time I spend both with my own children and those that I work with extremely rewarding and most of all just plain fun.
When asking questions about this it often transpires that some of the parents have never really experienced playing with an adult when they were children and they seem to find it hard to see it other than as a chore, they also feel that there are other more important things they should be doing.
There are others that find it all too frivolous. I suspect some of this is driven by the increasingly high demands that our education system is putting on our children. I feel that more and more they are being pushed to academic learning with no regard for their emotional development, I hear of four year olds having homework and five year olds having to sit for an hour or more each evening trying to learn spellings!
These parents do seem to start playing with their children if it is described as a part of a treatment package; I just hope that over time they also come to have fun doing it.
I also try to get them to think about power and control, what other aspect of a child’s life is not controlled in some way by an adult, in their play and through their imaginations they can be and do what ever they desire, they can rehearse and role play all those areas of life and relationships that we parents all hope they manage to negotiate in a positive way.
Weeks three and four
I have found time after time that these weeks are the hardest to get across to parents. The titles are “Praise” and “Rewards” and most parents believe that they already do this.
Praise seems to cause a lot of difficulty and I often wonder if this is something British, somehow stiff upper lip related, as those few parents I see that come from other cultures don’t appear to have quite as much difficulty with it. As parents arrive for this week I will greet them all with an over the top and very obvious compliment, it is very few of them that do not squirm or feel uncomfortable in some way and this gives us the starting point of our discussion, do they really want their children to feel as they themselves do when someone pays them a compliment. We do discuss the mechanics of giving compliments and praise to children, for instance being specific, naming that behaviour or deed they are being praised for, and mostly parents seem to be able to understand this.
What does seem to be almost impossible for a large number though is modelling accepting praise and giving self praise for a job well done.
I hold my hand up to being alongside of them in this, but the more I have run these groups and the more often I have received praise the less self conscious I feel about it. Discussing this at a personal level seems to help. Is it that we were not praised enough as children? Is it that our own self esteem leaves something to be desired? These issues and others often get talked about and that discussion seems to help them accept that they can do it, but also acknowledging that there needs to be loads of practice.
I feel it is so much harder for the single parent as often the only adult they have that can acknowledge their achievements is themselves, and self praise is perhaps the hardest of all to acquire and the easiest to let go of.
I have noticed a good indication of how well the group members are taking this on is if over the weeks if they have started to praise each other and maybe themselves, then it would appear something has started to change. A single mother that tells of how she managed to keep her cool, not shout, scream and smack at two in the morning when her three children are still running around and she can see and acknowledge this as a positive move forward on her part and not as a failure for not getting them to sleep at a reasonable time, then she is making great progress in my eyes. Often I do not get the first opportunity to say so because the group are all ready doing this, of course I will always reinforce it.
When we start to talk about rewards parents seem to automatically assume one of two things, either this is going to start to cost them a lot of money or they get stuck with the idea of star charts and say they do not work. It then seems to come as a surprise to them that I start by talking about praise as a reward, that their time playing with their child is a reward, that a hug, kiss or a ruffling of hair are all rewards and that these kinds of rewards are the ones that their children will remember and value when they are adults. My six year old son loves a bit of rough play and to say we can have a wrestle after he has done whatever task he was being difficult about will always get that task done. I try to stress that their time is perhaps the most important reward of all.
Social rewards just do not seem to be considered in the first instance and I wonder if this is because of similar issues to those that are brought up when the groups discuss play and praise, there seems to be no thought given to the connectedness of these aspects and how they affect us emotionally.
Rewards seem to mean money or other tangible things and most parents appear to be comfortable trying this, although they often call them bribes and it takes a little work to sort out the difference. We do discuss tangible rewards, how to use stickers, pocket money, and other tokens but I always keep coming back to how their time spent in a positive way is the biggest reward of all.
Week five
I have this week listed in the programme as a follow up week to “Praise” and “Rewards” and to some degree this is true but I have two other related agendas that I try to bring into the discussion.
First, how do we look after ourselves in order that we can look after our children, how do we value ourselves as an adult, a person in our own right as well as also being a parent. This always causes a lot of debate about how we have to put our children first; there is no time to even think about our own needs. How can we be the best parent we can be if we are so tired and run ragged by it all that we are struggling just to stay awake? I find it interesting to note that the following week often a few of the parents report that they have been to see their doctor for a variety of reasons.
Secondly I will bring into the discussion, in a more formal way, the links between how we were parented and how we parent. I always feel that I have to tread a careful path as I am not in a position to offer any counselling or therapy to those parents that have had difficult or abusive childhoods, but it also feels very important to acknowledge how big an influence our past experiences have on our relationships with our own children. I do try to have materials on hand that will signpost where and how to get additional help should anyone request or seem to need this, in each group that I have run there are always a few that will wait behind at the end to ask for help. I wonder how many just can not bring themselves to ask.
Always in this week we also have a quick review of where we have got too in the programme and somebody always makes the realisation that the play they started in weeks one and two, the praise they started giving in week three and the rewards system they set up in week four are all going to be ongoing, its not just for the programme or a few weeks, this is actually about a different way of doing it for ever, having a different relationship with their child and perhaps also with themselves.
Often parents suddenly start to feel terribly guilty, by what on the surface seems a few small changes in the way they do things and interact with their children, they have begun to notice changes in their child and also in the way they feel about their child and his behaviour, parents often start to beat themselves up for this, “why didn’t I do these simple things before”
Week five is perhaps the most difficult week for me to manage as the leader; there are often lots of tears and strong emotions to contain. I try to go back to how we learn to do these things, how impossible it is to always get it right and luckily as a parent I can always recount and tell a few stories of how I have got it wrong at times and then get them to think about why I might have done it the way I did.
Weeks six and seven
These weeks are dedicated to how children understand and learn the rules and boundaries, also how we as parents communicate what we want our children to do. Again I wonder if it is a cultural issue that we will often express our wishes or commands as questions, would you, will you, could you. There is often a lot of discussion about this and is there a difference between being firm and direct and being polite, can you be both. In my experience parents somehow feel that to give a command is insensitive and they tend to phrase all of these as questions. We get into debates about if ‘please’ is put at the end of a command does it then become a question or soften the impact somehow. We talk about the difference between giving a command as a parent and those given by somebody in authority over us, such as a Sergeant Major in the army or a Police Officer. Perhaps most importantly, we discus how many commands we give and if they are really necessary, if we only give those that we are prepared to follow up, what message do we give our children, and of course the reverse of this if we constantly give commands that we then do not follow up.
We move on to how clear are the rules, do our children really know what’s expected of them, how consistent are we at setting the limits and rules and again what messages are we actually giving. I also try to think about how well we role model these issues.
Weeks eight and nine
These weeks are the ones that the parents had hoped for at the start of the ten week programme. They cover time out, ignoring and logical and natural consequences.
These are often the most heated of discussions and cause the most disagreements within the group, should you try and ground a child with ADHD, should children have to pay the price at home for misbehaving at school. The one that I always bring up, If your child is able to dress themselves and they have had the warnings and know the rules but are still not dressed when it is time to leave the house, do you just take them as they are or do you dress them?
The parent’s most difficult dilemma seems to be about eating meals and this seems a very emotive issue for a lot of them as well as for some of the professionals I have had running the groups with me. When I have had a paediatrician or health professional working with me their view has mostly been, never try to force the child to eat but do not give them anything else, most young children will not starve themselves and will eat almost anything if they are hungry enough. So if a child misses a meal or two it is no big deal. Those that have come from a social services type background have tended to be more nurturing in their response and talk about letting the child have something like toast or fruit.
I believe there is, as with so many of these issues no real right or wrong, but being prepared to live with the consequences of what you decide to do is more the issue that needs to be considered.
Interestingly parents who are really working on the play, praise and rewards aspects often report that ignoring is the most powerful thing they can do with unwanted behaviour and it those parents that I try to bring into these discussions the most as this is such a powerful message, much better delivered by them than by me. However ignoring is often the most difficult strategy for parents to be consistent with and this is one of the areas we try to role play, I will get them to pair up and practice ignoring the other talking to them, they are often surprised at how hard it is to keep up a conversation when the other person is really ignoring you. I go back to, looking after yourself, praising yourself for getting it right and ask them to think of strategies to stop themselves being drawn in.
Week ten
This is the party week, but also the review of the programme. As stated before, parents are asked to complete post programme questionnaires. All of the lists of difficult behaviours that the parents described in the first week are posted on the walls and a significant number comment on how different things are now, those that have seen little change in the behaviours of their children usually comment that although the behaviour has not changed much, they have and they now handle it in a different and more positive way.
Once they have completed the questionnaires I have their original ones at hand so that they can make comparisons, I leave this open as an option should they want to and the majority do and have mostly been able to see significant positive changes.
I have an aversion to forms and form filling so it came as quite an eye opener that not only do some parents seem to enjoy doing this but that it is possible to use forms as a therapeutic tool, especially when there has been a positive change. It is often difficult both for the group leader and the parent to see the small gradual changes that happen within relationships and these forms do seem to be a powerful re-enforcer of the significant moves many of these parents have made and therefore is a good method of raising parent’s self-confidence in their ability to make positive changes.
The final form is a programme evaluation; (see appendix F) this is a part of the programme publication. This considers all the aspects of the course, through each weeks learning, what was difficult, what was found to be easy, what was useful and what was not. It also allows comment on the venue, the snacks provided and perhaps more difficultly what they thought of the course leaders, were they knowledgeable, did they feel that they took an interest in them as a person and did they like the leaders.
Almost all of the feed back on these forms is positive; the only exception is the video clips that are used each week to promote discussion, parents will often say they are dated and find the American accents difficult to understand and I would agree with this.
When I first started running these groups I thought that the parents would want to stay in touch with each other afterwards, however this did not seem to happen. More recently all of the groups that I have run are still meeting on a regular basis with most if not all parents attending. I have thought a lot about this and tried to discover what I am doing differently that has made this shift happen. I believe that there are several things that have helped, giving the message that this is possible, almost expected, right from the first meeting, talking about the other groups meeting and giving news of them and how they are doing throughout the ten weeks has also helped, but perhaps more importantly in week eight I am quite direct about how useful others have found this, but it that it takes somebody to organise it. I’m happy to photo copy lists of phone numbers, but someone from within the group needs to take on the organisation of it. It will not happen unless someone does, and so far someone always has, I’m not sure what I would do if nobody did?
There are very few people that drop out of the groups despite it being quite a large commitment of their time and there being very high expectations of them working hard over the ten weeks. The pattern seems to be that those that are still there on week three are there for the rest of the programme. I usually lose only one or two in the first two weeks, I suspect that this high attendance is a reflection of the referral process and that it is those that are really committed or desperate for change are those that attended from the start. It’s almost cherry picking by default.
Those that do drop out have tended to be the ones that have been directed to attend by someone in authority, social workers or education welfare officers or those that have other more pressing difficulties, their own mental health problems, housing or economic problems. All of my experience tells me that those that do stay despite experiencing these kinds of difficulties gain a lot not only from the programme itself but also from the support of the group and the group experience as a whole. However they do seem to do less well and the outcomes are not nearly as positive as those that were experiencing just the single difficulty of their child’s behaviour. This is reflected in all of the research; however there is very little additional support that these parents can access. If they are experiencing low level depression and are under their GP and then, as long as there is no immediate risk to the child, other than medication there is very little other support they can access. Cramped housing in run down, difficult and deprived areas usually meets all the required regulations and legal minimums so again further support is difficult to access. Earning a little extra to help pay bills could mean a reduction in benefit payments and it is extremely easy to get a doorstep loan which will take forever to pay back.
Practical factors that help
There are some practical things that can be done, which in my experience will not only help with engaging people but will also give the clear message that they matter and that they are valued. For the few short weeks that the parents are attending my groups I try to give them a small experience of being nurtured and cared for.
One of the basic rules for any type of therapeutic intervention is having a comfortable room that fits the requirements. having said this, one of the last evening groups I ran had far to many people for the size of the room, when the last two people arrived we had to close the door and put two chairs there, a worry in regard to fire regulations. When we used the TV people had to move and sit on the floor in order to see it. Somehow this seemed to be a part of the group experience, all mucking in together.
Refreshments can also play a vital role in making people feel welcome. If I’m running a morning group I will supply croissants, tea, coffee and fruit juice. A group that bridges lunch time will get sandwiches and drinks where as an evening group will get nibbles and drinks.
As far as possible midway between each of the weekly group meetings, each parent will receive a phone call from one of the group leaders. This serves several purposes, it helps parents stay on track with what ever the home work for that week was and can help trouble shoot any difficulties or reinforce that they are doing OK. It gives parents the opportunity to offload any difficulties that might not be all that relevant or maybe difficult within the group setting, thereby we are able to more closely concentrate on the task in hand at our next meeting. But for me the most important aspect of these phone calls is that it gives a very clear message that we are keeping them in mind, we are thinking about them and it matters to us how they are doing.
Should someone miss a week they will get a phone call at the earliest opportunity after the group meeting and all of the handouts together with a hand written note will be put in the post immediately.
The sum of all these little practical things appears to have a great impact on some of the parents I work with. This maybe the first time that anyone has shown a real interest in them as a person in their own right. It may just be that they receive the message that someone cares about them. For some of the dads this may be a new message that it is ok for a man to care but more importantly it is also ok to show it.
One area I do have to hold in mind is that I often work with vulnerable single mothers and I might be the first man that has cared about them. It is at these times that I need to rely on my co-workers to keep me safe.
Some concluding thoughts to running parenting groups
Sending a parent off to one of these style groups can often be seen as the wonder cure for all that is difficult in their relationship with their child. All of the research tells us that these programmes are useful and work. However they should only be seen as a part of the solution, yes parents get a lot from them, relationships do change, but they do not change the other circumstances that a parent has to manage whilst still trying to raise their child. They can also only ever touch on the personal underlying issues for the parent that they have to try and manage within themselves.
I found it interesting that, in the case of the parents who were attending as couples, the men seemed to defer to the women, choosing not to talk or at best saying something like “I agree”, “One of the considerable difficulties is that, while there are plenty of ‘rules’ laid down for motherhood, fathers rarely know what is expected of them in any concrete way (Burgess. 1997:141).On reflecting about this over several groups I have realised it is better not to let them off the hook, so I now usually comment that we have heard from all the mums but still do not really know what the dads think or feel and I then put them on the spot by going around the group again just asking them, by week three most if not all are contributing much more voluntary.
Finally, one father said to me as he was leaving for the last time at the end of week ten, “saying thank you and goodbye doesn’t seem enough, you feel like my best mate at the moment. You have saved me, my relationship with my wife and children, well my life really”, that’s why I keep running these groups.
Conclusion
Having worked with so many groups of parents I have seen the positive impact that attending these groups has on the majority of them. In very general terms there appears to me to be three broad categories that these parents fall into.
First, there are those that are competent parents who are working hard at the job and thinking about what it is they are doing, however they have tricky or difficult children to raise, these children may have ADHD or at least have an attention or impulsivity problem, or they may fall within the autistic spectrum or have a similar communication or behavioural difficulty. For these children there is only a very small, if any, change in their behaviour over the course of the ten week programme. What does change in a very positive way is their parent’s belief in themselves and their abilities to manage these difficulties.
Secondly there are those parents that although well meaning are not quite getting it right, they may have fallen into an overly punitive approach and forgotten the need for some fun, joy and positive interaction, or in fact they may be the exact opposite and be much too relaxed believing the child will find their own way in the end, but generally letting the child rule or dictate the home. It appears that these parents are the ones who see the biggest change, not only in their children but also in themselves at the end of the ten weeks.
Lastly there are those that, in a very broad sense, have an underlying issue, they may have mental health problems or social, economic difficulties or other unresolved difficulties/issues as adults in their own right that need to be addressed before we can address their difficulties parenting. For this group of parents the being in a group is itself a supportive experience and if the course content is followed and worked at there may be some positive changes in the child’s behaviour, however the underlying issues may not have been addressed or challenged for the adult so I do not believe the change is easily sustainable for either parent or child without some additional support.
Modelling the experience
The emotional strings that hold all of the difficult inter-related concepts together within a relationship are not something that I believe can be taught, let alone in ten weeks. I have however seen this connectedness start to grow from the seeds that are sown within parenting groups, some of this is the content and structure of the programme, i.e. Play, Praise and Rewards, and by asking each week that the parents feed back how they have put the learning into practice, but an equal and just as important part is the modelling on the part of the group leaders, holding the Parent in mind, nurturing them, caring for and about them and ultimately acknowledging and containing their anxieties.
As Winnicott says “It should be noted that mothers who have it in them to provide good enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of their task. (1960: 49) Murray and Andrews (2000: 133) describe how the care and support of a parent can influence directly how much a young baby cries, “The kind of care a baby needs is more easily given if the parents themselves are well supported.” “Having a baby who cries a great deal and is highly sensitive, can leave parents feeling demoralized and depressed.”
They go on in further chapters to describe how those caring for babies need care themselves.
Although by the time parents attend one of my parenting groups the children are much older, the parents need to feel cared for and supported can be no less strong given the onslaught of difficult behaviour the parents can feel they are receiving from their children.
Containment and the beginnings of doing it for themselves
Just as important is the modelling of how the rules and boundaries decided on in the very first week make the experience of attending a group feel safe enough to share some very personal and emotive experiences. There is a need for containment, Ward (1998: 15) when discussing Winnicott and Bions work on the holding environment and containment for children, describes how the child projects their unmanageable feelings and anxieties into the parent, who then having felt them, hands them back in a more manageable form “there: that’s what you were worried about. I think you’ll find you can cope with this now.” These principles apply equally to the running of a parenting group, the parent shares, describes and discusses their fears anxieties and feelings of despair and hopelessness, these at first need to be managed by me as the group facilitator and fed back in a more manageable form. Sometimes it is possible to reframe these feelings as a positive strength. A father who had started to feel inadequate because he realized his ten year old sons ADHD type behaviour was just the same as his as a child and to some degree is still the same, can be given the message that he is indeed the expert role model for his son. Who else would have the expertise to help his son learn how to manage his feelings and behaviour? At other times it is just a case of holding those feelings and handing them back in smaller pieces so that the whole can be managed over time. A little of this is managed by the structure of the programme; we do not consider consequences until there is some positive interaction, each stage being broken down into manageable chunks and building on the stage before. The rest needs to be managed and held by the facilitator at least temporarily.
But then slowly the group becomes more able to do this for each other and themselves. It is the facilitators role to get this group process happening as soon as possible, there is much more power in messages received from your peers than from someone outside of your circle. This is also very empowering in another way in that the members of the group become the same people that are helping, they are no longer there just to receive help, they have also become the ‘therapists’ for each other and therefore ultimately these skills will transfer home to their children.
The bigger picture
As I have highlighted there is still very little research into parenting programmes that has been based here in the UK and what there is has been mostly conducted within small clinical teams looking at their own service provision in a similar way to that which has been conducted within our own provision.
There is an abundance of evidence from the USA and Australia and the most frequently used programmes have been imported from there, it would appear with little regard as to the cultural differences. I wonder if there is a belief that if it’s from a predominantly white, English speaking country it will transfer without any consideration or adjustment.
As there is increasingly more and more government interest in parents and parenting I would hope that larger scale evaluations of particular programmes may be undertaken, perhaps more of the universities will become interested as it becomes politically interesting.
On a positive note I have just been approached to participate in a national evaluation of a new programme that is being launched. However it is again being evaluated by those that are publishing and marketing the programme.
Workers
There is a growing trend for parenting workers to be employed as a part of CAMHS teams and in my experience an increasingly wide variety of professions are becoming interested and involved in this growing area of work. In addition more local authorities are employing parenting co-ordinators to look at the provision of groups and other supports at a local level.
Unfortunately there is not yet any dedicated training other than that provided by those selling the programmes and although Health Visitors, Social Workers and similar professionals may have a wealth of experience to bring to this work there is also the need for dedicated training to focus on parenting in its own right. Group dynamics, co-working, group facilitation and to a certain degree co-ordination and management are also some of the vital components to this work and this is without considering the vast amount of administration that running these groups can generate. At present training in all of these areas would seem to be a bit piecemeal at the best or is nonexistent in most cases.
Parents
In my experience all of the parents that attend and complete the programmes I run, say that they value the experience and report that they have learnt a great deal from the course content and this is indeed reflected in the small scale study undertaken within our service. This has highlighted that although there has been a significant change both in parental stress and difficult child behaviour there is a need, in a lot of cases, for ongoing support of some kind.
Indeed those children that have a recognised diagnosis of ADHD, ashbergers, autism or similar, will of course need ongoing interventions/medications and these needs will change as each child grows and develops both physically and emotionally. Parents will also need continuing support to manage these changes, especially perhaps at the significant milestones or times of transition that all children experience. It will never be enough to measure success by counting those cases that we discharge or close as this will not measure the quality of the experience or intervention.
I am concerned that continued funding for posts or projects seems too often to be linked to numbers or output as in industry. Because most of my work is with groups of people and I receive many more referrals, my ‘output’ figures are extremely high; however it is extremely difficult to measure success in relation to the emotions, feelings and positive relationships that are the very reasons for running these groups.
“All parents, regardless of material possessions, culture, ethnic origin, and religious beliefs can experience difficulties in caring for their children. Some demonstrably unhelpful parenting practices are very common. There is good evidence to suggest that services to support parents and enable them develop skills and insights into helpful parenting, delivered in an empathic and respectful way, can be effective diverse social circumstances.” (Royal College of Paediatrics and Child Health, 2002:28)
So in answer to the question can we be effective in using parents as first therapist? Yes all of the research tells us so and as I have demonstrated, this is echoed in my experience and the responses of the parents that I have worked with.
Parenting is becoming an important political agenda and we must use this momentum to promote not only the acceptance of parenting programmes as a right for all, delivered at the appropriate level, but also to promote the training of those delivering it.
The parenting programmes are useful tools to facilitate, concentrate and promote this change but it is through the quality of the facilitation of the groups and the hard work of the parents, that parents experience the most support. It is the sum of the parts, the formal manualised programme, the group experience, the nurturing and the care and interest in the parents as people that allows the real changes to happen and parents to become first therapists.
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