Acparian APA C THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION The e-journal of the Australian Clinical Psychology Association ISSUE 7: SEPT 2013 ACPARIAN ISSUE 7: SETP 2013 Child and Family Therapy Issue In this issue Family therapy: a history Ethical issues Critical factors in therapy with Indigenous children Family therapy for children with emotional and behavioural problems: Anxiety Callous-Unemotional traits Autism spectrum disorder Parent-Child Interaction Therapy
Transcript
AcparianA PACTHE AUSTRALIAN
CLINICAL PSYCHOLOGYASSOCIATION The e-journal of the Australian Clinical Psychology Association
ISSUE 7: SEPT 2013
ACPARIA
N ISSU
E 7: SETP 2013
Child and FamilyTherapy Issue
In this issue
Family therapy: a history
Ethical issues
Critical factors in therapy with Indigenous children
Family therapy for children with emotional and behavioural problems:
n this edition of The ACPARIAN there is a special focus on child and family therapy. Current practices in improving the mental health of vulnerable children, and some of the latest developments in therapy, are addressed by experts
in their field. Differing clinical approaches are considered and implications for clinical practice are highlighted. A brief history of family therapy by Paul Rhodes provides an introduction in explaining the evolution of some of the differing models of family therapy, current influences, and application to family dynamics. An internationally recognised authority on Parent Child Interaction Therapy, Cheryl McNeil, along with colleagues Meredith Norman and Nancy Wallace, presents a description of this influential therapy for young children with emotional and behavioural problems. Aimed at improving the parent-child relationship, emphasis is placed upon parents as the catalyst of change, with parenting skills and interactions shaped by the therapist. The training of parents in therapy is also underscored by David Hawes, offering cutting-edge recommendations for clinicians helping families of children with specific callous-unemotional traits, a new specifier for conduct disorder. The benefits of parental involvement in the treatment of children with anxiety are outlined by Vanessa Cobham. Outcome studies comparing child-focused cognitive behavioural therapy interventions with parent-child interventions are examined, and the advantages of the latter highlighted. Michelle Curran discusses the experiential difficulties facing a child on the autism spectrum, and outlines the beneficial effects upon the child of having the therapist engage the parents in an extension of the Applied Behavioural Analysis program. The benefits of clinical intervention for a mother and child on the autism spectrum are provided in a personal account by Ryan and his mother. It is timely to have a paper focusing upon our Indigenous population, as many Indigenous children are the most disadvantaged within our society, and research is limited. The crucial factors to consider when engaged in psychological therapy with Aboriginal and Torres Strait Islanders are comprehensively explicated by Sarah Mares and Gary Robinson. Practical approaches to engagement and intervention by clinicians within a familial, community, and cultural framework are detailed.
The unique ethics and legal complexities, such as informed consent and confidentiality, associated with the involvement of more than one person in the therapeutic process, are highlighted by Giles Burch in the Ethics and Legal section. Finally, some brief personal reflections, by a number of clinical psychology students, of engagement in therapy in their first practicum makes for fascinating reading in the Student and Training Matters section. I hope you enjoy our selection of papers.
CONTENTS 2 Editorial
3 From the President
5 A brief history of family therapy
9 Parent-Child Interaction Therapy
14 Clinical practice recommendations for children with callous-unemotional traits
18 Childhood anxiety disorders: Involving parents in treatment
22 Opinion piece: An extension of traditional Applied Behavioural Analysis treatment for children with an autism spectrum disorder
24 Client perspective – Ryan
26 Working with Aboriginal and Torres Strait Islander children and families
33 Ethics and legal dilemmas: Ethical issues in family therapy
34 Student and training matters: The experience of the first practicum
he election of a new Government has brought new opportunities and challenges for Australians facing mental health issues and for ACPA. On its website
(http://www.liberal.org.au/latest-news/2013/08/30/coalitions-policy-improve-mental-health), the Coalition Government has determined to:
task the National Mental Health Commission to assess the effectiveness of all existing mental health programmes across both government and the non-government sectors. The goal of this comprehensive review will be to ensure services are being properly targeted at patients, that services are not being duplicated and that programmes are not being unnecessarily burdened by red tape.
We are very aware of major gaps in services for patients with more serious, comorbid, and chronic conditions that require more than the 10 sessions of treatment available under Medicare, and greater expertise than is often provided under the ATAPS program, given that many Local Health Districts employ generalist psychologists and other professionals who do not have accredited training in mental health. Such individuals are currently either being poorly serviced or are reliant entirely on medication to keep their problems manageable. Relief from underlying psychosocial factors that impact their condition is withheld. We are also very aware of the angst created by the difficulty in obtaining consistent and clear advice about compliance with requirements that impact those working in the Medicare system. While ACPA and the Department of Human Services have attempted to address this, advice given has continued to be inconsistent and anxiety provoking; however, the responses to questions put by ACPA give support to members following these guidelines in the event of an audit. In recognition that "Seventy-five per cent of all mental illness manifests itself in people under the age of 25 and one in three young people experience moderate to high levels of psychological distress at some point," and that "suicide is the leading cause of death for young Australians aged 15 to 24", the Coalition is extending research and services to youth, which is to be applauded. These services are much needed and will, hopefully, alleviate the suffering of our youth, while
providing them with the means to successfully negotiate the pathway to adulthood. Mental illness is founded early in life, not only on genetic vulnerabilities, but also on familial stress. Providing additional services for children and families suffering psychosocial stress has thus far been largely overlooked. Increasing services under Medicare to offer couple therapy and parenting skills with family therapy would enhance the quality of life of children nationally. The Coalition also plans to develop a Mental Health Workforce Training Institute. There is a strong training role here for qualified clinical psychologists, and we would like to be able to offer our expertise to the nation in training the mental health workforce, and in the ongoing provision of consultation and supervision as required. In terms of education, ACPA has been very active. The 2013 Annual Conference held in Brisbane in July, featuring Professor Nancy McWilliams presenting on working with the Self-Defeating Personality, was well attended and a great success. The 2014 Annual ACPA conference will be held in Christchurch from 10 – 13 April in conjunction with the New Zealand College of Clinical Psychology (NZCCP). The theme is: My strength does not come from me alone but also from others: Ehara taku toa i te toa takitahi, engari he toa takitini ke. This theme is very apt, given the ongoing support and encouragement offered by NZCCP to ACPA from before its inception, for which we will forever be grateful. Other Continuing Professional Development events have also been offered nationally. Western Australia has presented a seminar series looking at different approaches to treatment involving Schema Therapy, given by Dr Chris Lee, and a Jungian approach, offered by Ms Susan Thorman. This event too was very popular and very well received. Dr Lee will be presenting a Schema Therapy Master Class in Melbourne in March 2014. As ACPA continues to grow, develop, and strengthen, our voice is being increasingly heard where we want to make an impact. One of the more difficult issues we face is the imminent loss of specialist recognition in Western Australia and the consequent downgrading of psychology in a State that has traditionally protected the public by ensuring that appropriately qualified psychologists working in specialised areas of psychology are clearly recognised. The challenge for ACPA, and psychology generally, is now to reinstate this protection nationally to enable the public and referrers to identify those psychologists with qualifications in the area in which they are endorsed to specialise. I would like to thank all ACPA members for their support and encouragement over the past quarter and for the vote of confidence in the leadership at the Annual General Meeting. ACPA is fortunate to have a cohesive and active Board that will enable us to consolidate further and strengthen, and thereby carry us forward to respond to the challenges ahead.
A Brief History of Family Therapy Paul Rhodes, MClinPsych PhD Senior Lecturer, Clinical Psychology Unit, University of Sydney Paul Rhodes is Senior Lecturer in the Clinical Psychology Unit, University of Sydney, Honorary Senior Clinical Psychologist at the Department of Psychological Medicine, Children's Hospital Westmead, and former Editor of the Australian and New Zealand Journal of Family Therapy. Please address all correspondence to: Email: [email protected] Phone: 0415 039 389
n the past two decades family therapy has made its mark in clinical psychology, particularly in terms of the recognition of manualised models of intervention for complex problems built from an integration of schools from the
tradition of family therapy. The Maudsley model of family-based treatment for anorexia nervosa (Lock, Le Grange, Agras, & Dare, 2001), multisystemic therapy for juvenile justice work (Henggeler, Clingempeel, Brondino, & Pickrel, 2002), and multidimensional family therapy for adolescents with behaviour and substance abuse problems (Liddle, 2009) has established itself within clinical psychology as a trusted approach for very challenging presentations. Less is known in clinical psychology circles, however, about the tradition from which these have been sourced, a rich history of innovative and contextual practice that continues to develop to this day. The aim of this essay is to introduce clinical psychologists to the main schools of practice in family therapy, namely structural, systemic, strategic, solution-focussed, and narrative therapies, as well as more recent developments. While the latter two models also serve as individual therapies, they are included because they are central to contemporary family therapy. Bateson "Information is a difference that makes a difference"- Gregory Bateson
Family therapy has its origins in the work of anthropologist Gregory Bateson and the group of therapists working in Palo Alto in the United States. This group set the foundations of systems theory, including the notion that the behaviour of each family member is determined by the patterns of interactions that connect them (Bateson, 1972, 1979). Messages between individuals in the family were not always seen to be communicated directly, but to involve more complex levels, where what is spoken is at odds with the actual message delivered. These patterns implied that abnormal behaviour in a patient could be circular, rather than linear, in causality, and maintained through interactions between people rather than as the product of internal pathological states. For Bateson (1972) the role of the therapist was to introduce new information into the system; this would help families adapt, rendering the symptom unnecessary. These developments had, and still have, significant implications for the understanding of human psychological problems. When Bateson started in the early 1950s and 60s, individual behavioural and psychodynamic therapies prevailed with a focus on the intra- rather than inter-personal. This approach had obvious limitations when working with children, where changes made in the individual could be easily undone by interactions in the home setting. For this reason (and others), many family therapists remain highly sceptical about the ethics of diagnosis. The 1960s to the 1990s saw a prodigious number of schools of family therapy emerge, each with its own charismatic leaders, some highly consistent with systemic theory and others reacting against it. In this brief summary I will focus on four main schools, each used by contemporary family therapists: structural, Milan-systemic (and post-Milan), brief solution-focussed, and narrative. Each of these can be seen as looking at family dynamics from a different lens, focussing on hierarchy, patterns, strengths, and stories in consecutive order. In this sense, despite the politics, each simply works with different phenomena. Hierarchy "Change is seen as occurring through the process of the therapist's affiliation with the family and his restructuring of the family in a carefully planned way, so as to transform dysfunctional transactional patterns" - Salvador Minuchin Minuchin (1974) developed his structural practice from his work with delinquent boys in New York in the late 1950s and 1960s, boys who responded poorly to the passive stance of the therapist in psychoanalytic therapy. Minuchin was most concerned with how behaviour problems are the product of problems in the familial organisation, particularly when the boundaries between parental and sibling subsystems were not maintained. For Minuchin, healthy family organisation involved a clear parental executive, as opposed to a coalition between one parent and a child. These types of coalitions were seen as a means of conflict avoidance in the couple, who detoured arguments through the child so as to avoid the difficulty in making adaptive changes to their own functioning. Families were also seen to encounter problems when they were either too disengaged
or too enmeshed in the face of changes, with one involving too little support and the other preventing autonomy. In terms of style, the structural therapist could not be more different to the passive analyst. The structural therapist was a director of family interactions, coaching the family, asking them to move chairs in the room, and unbalancing interactions to get members to do things differently. One of Minuchin's most innovative methods was his enactments/re-enactments. Enactments involved the therapist observing the family attempting to resolve an issue in the therapy room, thus revealing any structural restraints to change. In the re-enactment, the therapist takes charge, coaching the family to reorganise. Patterns "If we define the family as a self-governing system based on rules established through a series of trials and errors, then its members become so many elements of a circuit in which no one element can be in unilateral control over the rest" - Mara Selvini-Palazzoli While Minuchin was certainly heavily influenced by Bateson, four clinicians working in Milan, headed by Mara Selvini-Palazzoli, were to develop the model that was arguably most theoretically consistent with his systemic theory. This model, known as Milan systemic, centred on the concept of homeostasis (Selvini-Palazzoli, 1985). Families were seen to become stuck in their interactions with each other in the face of developmental milestones or specific stressors. This rigidity would lead to increasingly vicious cycles that could only be resolved when the pattern was broken. Selvini-Palazzoli and her team devised an innovative five-step intervention for this purpose (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1980), one where the perspective of a team was used to help the therapist identify and challenge these patterns. The team and therapist first met to hypothesise about family functioning, developing a neutral and curious stance towards therapy. The therapist would then meet with the family, with the aim of developing, confirming, or disconfirming hypotheses. The therapist would use circular questions in this endeavour, asking family members to guess as to the feelings, intentions of relationships of others so as to introduce new information and possible flexibility into the system. After an hour or so, the therapist would then consult with the team to prepare feedback for the family. This feedback would include a positive connotation of the presenting problem (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978), ascribing noble intentions to the identified client as an invitation for family members to change their interactions with one another. Paradigm shift So far, in this brief history I have focussed on Minuchin and Selvini-Palazzoli, representatives of the two most influential schools of family therapy during this period. There were, of course, many other proponents of family therapy, including the Palo Alto Mental Research Institute (MRI) brief therapy (Watzlawick, Weakland, & Fisch, 1974), Bowen's (1978) transgenerational model, the strategic approach (Haley, 1976), and more. The 1980s, however, saw the development of a number of important critiques of these
schools, all of which came to be seen as 'first-order' therapies (Hoffman, 1985; Mackinnon & Miller, 1984). Proponents of these schools were criticised for positioning themselves as objective outsiders who could effectively diagnose family dysfunction using theories that were seen as 'true'. A social constructionist approach, however, saw models as lenses rather than truths. Pathologising conceptualisations of families was rejected and the therapist was required to become more transparent about their own beliefs, biases, and blind spots. One of the significant implications of this critique was the reconfiguration of Milan systemic practice into what became known as post-Milan (Jones, 1993), spearheaded by two members of Selvini-Palazzoli's original team (Boscolo, Cecchin, Hoffman, & Penn, 1987). The most influential developments in this regard, however, were the development of interventive interviewing (Tomm, 1985), a sophisticated approach to asking therapeutic questions, and the modification of the reflecting team to allow greater transparency (Andersen, 1987). Tomm's articles are a goldmine for any clinician hoping for a practical description of what to actually do in the room when working systemically with families using questions. Anderson's reflecting team requires the team to discuss their feedback while the family watches from behind the screen, supporting the development of formulations that must focus not only on explanation but also on empathic understanding (Sadler & Hulgus, 1989). Strengths "Find out what works and do more of that" – Steve de Shazer The history of family therapy can, to some extent, be seen as a progressive reaction against the dominance of psychoanalysis in the first half of the 20th century. Minuchin and Selvini-Palazzoli's response was to situate problems between individuals, rather than within them, a fundamental ethical shift when it came to pathologising children who came to be seen more as the product of their interpersonal context. Post-Milan went one step further, positioning therapy as the co-construction of meaning between therapist and client, mediating against the more directive and less transparent approach of the first order schools. Steve de Shazer's (1985, 1988) solution-focussed therapy, however, made another significant, even quantum, leap in terms of opposition to the determinism of psychoanalysis. For the first time, a model emerged that was disinterested in exploring problems but focussed exclusively on the mobilisation of solutions and strengths. Arguably, the origins of solution-focussed therapy can be in prior models, particularly strategic therapy. de Shazer was unique, however, in basing therapy exclusively on a faith in the client's potential to find their own hidden resources at the expense of any notions of personal or interpersonal pathology. Of particular interest is the fact that solution-focussed therapy emphasises the future rather than the obsession with the past that characterised psychoanalysis. The iconic 'magic wand' question is used to help families imagine their life in the future without the problem and then support them to discover and amplify similar events, that they have failed to notice, in the present.
Stories "As alternative stories become available to be performed, other sympathetic and previously neglected aspects of the person's experience can be expressed and circulated" – Michael White & David Epston The last model in this brief history represents an Australian and New Zealand contribution in White and Epston's (1989, 1990) narrative therapy. While de Shazer was certainly influenced by social contructionism, White and Epston wore it on their sleeve, developing a model heavily inspired by the work of Foulcault and Derrida (Fish, 1993). Many psychologists may be familiar with White's (1984) early work with 'sneaky poo', where encopresis was externalised to foster personal agency in the child and family. Later narrative work, however, was less behavioural and more insight-oriented and more clearly differentiated from the influence of systemic and strategic therapies. Narrative therapy is, to some degree, political in nature, conceptualising the problems of the individual not as a product of their relational context but rather a product of dominant problem-saturated stories embedded in the culture. The role of the therapist is to explore contradictions to these definitions, unique outcomes that allow for the externalisation of preferred and liberative stories. These stories can be 'thickened' (Geertz, 1983), by what White (1995) called "outsider witness practices", the inclusion of people in therapy, real or metaphorically, that can support the 're-membering' of these narratives. Integration In presenting this history in temporal order, the aim has not been to suggest progress from less to more ethical models of therapy. While each new model grappled with epistemological questions and sought to develop a greater respect for the hidden expertise of the family, all four models are still clearly represented in contemporary family therapy. Family therapy can best be seen as 'the art of lenses' (Hoffman, 1990), with each model revealing a different phenomenon to the observer. Many of the developments in family therapy since the 1990s have concerned themselves with the integration of models (Breunlin, Schwartz, & Mac Kune-Karrer, 1992), a process that allows for the different schools to balance each other out when it comes to their strengths and weaknesses in regard to particular presenting problems. For instance, consider the Maudsley model of family-based treatment for anorexia nervosa (Lock et al., 2001). This approach relies heavily on Minuchin's structural approach to the disorder (Minuchin et al., 1978), whereby the parents are united to tackle their behavioural responsibilities at home, and any triangulation with the patient is broken. The inclusion of White's externalisation of anorexia, however, places the pathology squarely on the illness and any apparent familial dysfunction is seen in its result rather than as pathogenic. In Minuchin's original conceptualisation the anorexia was actually caused by family dysfunction. The Maudsley model retains the assertive and united behavioural stance taken by the parents but any notions of criticism and resulting disempowerment is catered for by the integration with White. In addition, the Maudsley model also includes the circular questioning techniques taken from Post-Milan
systemic therapy. The therapist refrains from giving advice but guides parents through interventive interviewing. This allows them to be further empowered in their battle against the anorexia, making their own decisions and preventing a reliance on professionals and the cycle of readmissions that can result. Evidence The primary preoccupation of family therapists over the past fifty years has been the development of innovative and contextual approaches to human problems. To a large extent developments have been guided by ethical and philosophical concerns rather than by the results of science. In the past 20 years, however, there have been many significant changes in this regard. Family therapists have maintained a degree of scepticism about the predominance of the randomised control trial as the source of evidence and advocated for a much greater role for process research and qualitative methods (Rhodes, 2012a). Many have also resisted the influx of branded manualised treatments, especially given the significant role that the therapeutic relationship has been found to play in the efficacy of treatment (Hubble, Duncan, & Miller, 1999). Nevertheless, a significant body of evidence in support of the efficacy of family therapy has been established for a wide range of presenting problems (Carr, 2000). These include conduct and oppositional problems in children, (Serketich & Dumas, 1996), substance abuse in adolescence (Rowe & Liddle, 2003), the management of expressed emotion in psychosis (Pharoah, Mari, & Steiner, 2000), depression in systemic couple therapy (Baucom, Shoham, Meuser, Daiuto, & Stickle, 1998), and more. Many of those conducting these studies have been family or clinical psychologists, well versed in science but still enamoured with the creative potential of family therapy techniques. Conclusion In 1999 Paul Gibney suggested that family therapy had been dominated by heroic figures, preoccupied with always being 'the new kid on the block' and poorly engaged with other disciplines. A strong engagement with psychology, however, has served family therapy well, particularly in the development of an evidence-base for family therapy. The demonstration that family therapy techniques are effective on empirical grounds represents a maturing of the field and willingness, previously missing, to hold itself to account in this respect (Rhodes, 2012b). I do believe, however, that this process of influence can be two-way and that family therapy practice can serve to inspire clinical psychologists working at the coalface with children, adolescents, and their families. The models available provide a host of creative lenses and skills that can support families who may be "stuck" in their interactions with each other or disempowered in the face of significant obstacles. One of the potential critiques of the scientist-practitioner model in clinical psychology is that the resulting reliance on manuals and branded treatments has taken the art out of our practice. An engagement with the tradition of family therapy can contribute towards reminding us to continue to remain creative in our work.
Andersen, T. (1987). The reflecting team: Dialogue and meta-
dialogue in clinical work. Family Process, 26, 415-428. Bateson, G. (1972). Steps to an ecology of mind: Collected
essays in anthropology, psychiatry, evolution, and epistemology. Chicago, IL: University of Chicago Press.
Bateson, G. (1979). Mind and nature: A necessary unity (Advances in systems theory, complexity, and the human sciences). New York, NY: Hampton Press.
Baucom, D., Shoham, V., Meuser, K., Daiuto, A., & Stickle, T. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology, 66, 53-88.
Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York, NY: Basic Books.
Bowen M. (1978) Family therapy in clinical practice. New York, NY: Aronson.
Breunlin, D., Schwartz, R., & Mac Kune-Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco, CA: Jossey-Bass.
Carr, A. (Ed.). (2000). What works with children and adolescents? A critical review of psychological interventions with children, adolescents and families. London, England: Routledge.
de Shazer, S. (1985). Keys to solutions in brief therapy. New York, NY: Norton.
de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York, NY: Norton.
Fish, V. (1993). Post structuralism in family therapy: Interrogating the narrative/conversational mode. Journal of Family Therapy, 19(3), 221-232.
Geertz, C. (1983). Local Knowledge. New York, NY: Basic Books. Haley, J. (1976). Problem solving therapy. San Francisco, CA:
Jossey-Bass. Henggeler, S., Clingempeel, W., Brondino, M., & Pickrel, S.
(2002). Four-year follow up of multisystemic therapy with substance abusing and dependent juvenile offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 868-874.
Hoffman, L. (1985). Beyond power and control: Toward a "second order" family systems therapy. Family Systems Medicine, 3, 381-396.
Hoffman, L. (1990). Constructing reality: The art of lenses. Family Process, 29, 1-12.
Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association.
Jones, E. (1993). Family systems therapy: Developments in the Milan-systemic therapies. Chichester, England: Wiley.
Liddle, H. A. (2009). Multidimensional family therapy for adolescent drug abuse: Clinician's manual. Center City, MN: Hazelden Publishing Co.
Lock, J., Le Grange D., Agras, W., & Dare, C. (2001). Treatment manual for Anorexia Nervosa: A family-based approach. New York, NY: Guilford Press.
MacKinnon, L., & Miller, D. (1984). The new epistemology and the Milan approach: Feminist and socio-political implications, Journal of Marital and Family Therapy, 13(2),139-145.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Minuchin, S., Rosman, B., & Baker, L. (1978). Psychosomatic families: Anorexia Nervosa in context. Cambridge, MA: Harvard University Press.
Pharoah, F., Mari, J., & Steiner, D. (2000). Family intervention for schizophrenia. Cochrane Database System Review, 2: CD000088.
Rhodes, P. (2012a). Why clinical psychology needs process research: An examination of four methodologies. Clinical Child Psychology and Psychiatry, 17(4), 495-504.
Rhodes, P. (2012b). Nothing to fear? Thoughts on the history of family therapy and the potential contribution of research. Australian and New Zealand Journal of Family Therapy, 33(2), 171-182.
Rowe, C. L., & Liddle, H. A. (2003). Substance abuse. Journal of Marital and Family Therapy, 29, 97-120.
Sadler, J., & Hulgus, Y. (1989). Hypothesising and evidence gathering: The nexus of understanding. Family Process, 28, 255-67.
Selvini-Palazzoli, M. (1985). Self-starvation: From individual to family therapy in the treatment of anorexia nervosa. New York, NY: Aronson.
Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox. New York, NY: Aronson.
Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing circularity-neutrality: Three guidelines for the conductor of the session. Family Process, 19, 3-12.
Serketich, W., & Dumas, J. (1996). The effectiveness of behavioral parent training to modify antisocial behavior in children: A meta-analysis. Behavior Therapy, 27, 171-186.
Tomm, K. (1985). Circular interviewing: A multi-faceted clinical tool. In D. Campbell, & R. Draper (Eds.), Applications of systemic family therapy: The Milan approach. London, England: Grune & Stratton.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York, NY: Norton.
White, M. (1984). Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles. Family Systems Medicine, 2(2), 50-60.
White, M. (1995). Reflecting teamwork as definitional ceremony. In M. White (Ed.), Re-authoring lives: Interviews and essays. Adelaide, Australia: Dulwich Centre.
White, M., & Epston, D. (1989). Literate means to therapeutic ends. Adelaide, Australia: Dulwich Centre.
White, M., & Epston, D. (1990). Consulting your consultants: The documenting of alternative knowledges. Dulwich Centre Newsletter, 4, 23-25.
Parent-Child Interaction Therapy Cheryl McNeil, PhD West Virginia University Meredith Norman, BA West Virginia University Nancy Wallace, BA West Virginia University Cheryl McNeil is a licensed clinical psychologist and full professor of psychology at West Virginia University. She has extensive clinical and research experience in disruptive behaviour disorders of children, assessment methods for behaviour problems among children, and treatment outcomes - particularly treatment outcomes of Parent-Child Interaction Therapy (PCIT). Currently, Cheryl is one of only 15 Certified PCIT Master Trainers in the world, and is a nationally-renowned authority on PCIT. Meredith Norman is a second year doctoral student at West Virginia University currently working with Cheryl McNeil as a member of her PCIT laboratory. Meredith has primary clinical and research interests in childhood externalising disorders, evidence- based behavioural parent training programs, and treatment dissemination. Nancy Wallace is a first year doctoral student at West Virginia University currently working with Cheryl McNeil as a member of her PCIT laboratory. Nancy's primary clinical and research interests lie in the areas of childhood disruptive behaviour disorders, emotion regulation, the parent-child relationship, and empirically-based behavioural parent training programs. Please address all correspondence to: Cheryl McNeil, PhD West Virginia University Email: [email protected]
Theoretical foundations
arent-Child Interaction Therapy (PCIT) is an evidence-based treatment for young children with behavioural and emotional problems. It was originally developed as a treatment for children with disruptive behaviour
problems, including those associated with Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in children ages 2 to 7 years. The theoretical framework of PCIT is based on attachment and social learning theories as well as Diana Baumrind’s theories of parenting. Specifically, PCIT incorporates the Hanf model approach to dyadic interactions in order to teach authoritative parenting skills (Eyberg, 1988). Parents are taught to be responsive and provide nurturance to their child, which is characteristic of parent-child dyads with a secure attachment style. Parents are also taught to provide firm consequences for misbehaviour using specific behaviour management techniques based on social learning theory. The combination of warmth and firm control is the foundation for authoritative parenting which is associated with numerous positive child outcomes in the literature. Key features PCIT differs from many existing treatments for child emotional and behavioural problems in several important ways (McNeil & Hembree-Kigin, 2010). First, PCIT therapists work with a parent and child together as a dyad rather than individually. This allows therapists to shape parenting skills in the context in which they are meant to be implemented, parent-child interactions. By teaching parents to provide selective attention and predictable consequences for child behaviour, parents become the agents of change for their child's behaviours. Second, parenting skills are taught through direct coaching of parent behaviours during parent-child interactions. Immediate feedback on skill use from the therapist helps parents learn the skills more quickly. Direct coaching also allows therapists to identify and correct errors in parent use of skills before errors become well ingrained. Typically, therapists coach parents from behind a one-way mirror and provide immediate feedback to the parent on skill use through a "bug-in-the-ear" (or Bluetooth) device. Another unique feature of PCIT is that treatment is driven by data. Data are gathered at the start of each session in the form of a short questionnaire and observational coding of parent-child interactions. These assessments are then used to individualise the treatment for each child and family. Behavioural observations also determine family progress towards mastery of skill use and guide the coaching for each session. These key features are present throughout the two treatment phases of PCIT, Child Directed Interaction (CDI) and Parent Directed Interaction (PDI). Structure Child directed interaction The first phase of treatment, CDI, is based on the primary goal of building a strong, secure, warm relationship between the parent and child (McNeil & Hembree-Kigin, 2010). Given that many families who enter PCIT have experienced some disruption in the parent-child relationship, CDI works to repair these bonds through the use of play therapy skills and behavioural techniques. The solid base that is built in CDI
fosters qualities such as trust, mutual respect, and love between the parent and child, increasing the child’s motivation to please the parent and engage in appropriate behaviour. Throughout CDI, selective attention is used to increase such positive child behaviour, while decreasing inappropriate, negative attention-seeking behaviours. As is reflected in its name, CDI is child-led; in other words, the parent is instructed to follow the child’s lead during play as long as the play is appropriate. Parents are encouraged to be a “play therapist” for their child, abiding by the basic principles of child-centred play therapy that include following the child’s lead and providing a safe and supportive atmosphere of positive regard. At the beginning of CDI, parents are taught a set of “do” and “avoid” skills that become the basis for the parent-child interaction (Eyberg & Funderburk, 2011). The “do” skills include five key skills, referred to by the acronym, PRIDE: Praise, Reflection, Imitation, Description, and Enthusiasm/Enjoyment. Parents are also taught to avoid asking questions and issuing commands, as well as to avoid using any negative, critical, or sarcastic talk. Parents are coached to mastery of these skills which include 10 specific, labelled praises, 10 behavioural descriptions, 10 reflections, and fewer than three questions, commands, and negative statements during a 5-minute period. The mastery criteria are set at an extremely high level to over-train parents in the use of these effective skills such that they become a natural part of everyday parent-child interactions. Positive skills, such as labelled praise and imitation, increase children’s self-esteem as well as serve to prevent negative behaviour. Reflective statements allow parents to listen attentively to their children’s talk, encouraging positive communication and improving children’s grammar and vocabulary. Behavioural descriptions can be used to increase appropriate, on-task behaviour. When using behavioural descriptions, parents are often amazed by children’s improved focus and ability to concentrate on a single activity for long periods of time. The final “do” skill, enjoyment, is used to encourage positive and mutually rewarding interactions between the parent and child. "Avoid" skills, such as questions and commands, serve to take the lead away from the child, recognising that critical/sarcastic statements may actually increase problematic behaviour and inspire negative emotion between the parent and child. Therapists code parent-child interactions during a 5-minute play observation at the beginning of each session. For this, they use the Dyadic Parent Child Interaction System (DPICS), an empirically-based and manualised coding system developed to evaluate the quality of parent-child interactions (Eyberg, Nelson, Duke, & Boggs, 2005). In addition to in-session coding and live coaching, parents are assigned five minutes of daily homework, often referred to as “special time,” in which they are instructed to play with their child by concentrating on implementing the PRIDE skills. This time-limited interaction is an intentionally short, therapeutic period in which parents simultaneously improve their play skills and strengthen the parent-child relationship. Parent directed interaction
Following mastery of CDI, parents and children move forward to the second phase of treatment, PDI (Eyberg &
Funderburk, 2011). In PDI parents are encouraged to issue commands, followed by a specific discipline procedure if the child chooses to exhibit defiant behaviour. During this procedure, children are instructed to sit on a time-out chair for three minutes (plus five seconds of silence). If the child exhibits dangerous behaviour or leaves the chair before the three minute period is up, the child is led to a back-up area where he or she must remain for one minute (plus five seconds of silence). Within the first session, both the parent and child are introduced to, and taught, the specific steps involved in the time-out procedure. In contrast to CDI, PDI is led by the parent; however, CDI skills are interwoven throughout PDI in order to keep the interaction positive and enjoyable for the parent and child. Consistency and predictability are key facets of PDI as children learn appropriate boundaries, consequences of negative behaviour, and emotion regulation skills. Parents are taught how to issue positively stated, specific, effective commands that increase the chances of child compliance. Following compliance, parents immediately issue a specific, labelled praise. Command practice begins with the use of in-session play commands that pose little demand upon the child. As parents become more confident in issuing effective commands, they are instructed to increase the number of demands upon the child through the use of “real life” commands. As in CDI, generalisation of in-session skill change to the home setting is promoted by having parents practise skills during daily, 5-minute PDI homework sessions that begin with instructions to the child about the expectation that the child will be “practising listening” during the session. Referred to as compliance training, parents are told to issue a high rate of commands during this period of time such that child compliance can become automatic with repeated practice over time. Compliance is reinforced consistently by the parent using enthusiastic labelled praise and child-led play. In order to generalise the procedure further, later PDI coaching sessions typically include practice in public settings and inclusion of siblings. PDI mastery is met when parents are able to issue at least 75% effective commands with at least 75% correct follow through (i.e., labelled praise or time-out procedure). To graduate from PCIT, children must score within normal limits on the Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999) according to parent report, and parents must feel that they can manage their child’s behaviour effectively and consistently and in multiple environments (Eyberg & Funderburk, 2011). Research The initial research on PCIT provides support for its efficacy in reducing disruptive behaviour problems in young children (Eyberg & Robinson, 1982). Additional research suggests that the effects of PCIT generalise to the school setting (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991) and to untreated siblings (Brestan, Eyberg, Boggs, & Algina, 1997). Furthermore, the treatment effects of PCIT have been found to maintain for several years following treatment (Boggs et al., 2004; Eyberg et al., 2001; Hood & Eyberg, 2003).
The efficacy of PCIT has been demonstrated with families from diverse cultural backgrounds and children with a variety of behavioural and emotional problems (McNeil & Hembree-Kigin, 2010). Research suggests that PCIT is efficacious with Latino (Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; McCabe & Yeh, 2009; McCabe, Yeh, Lau, & Argote, 2012), Netherlander (Abrahamse et al., 2012), African American (Fernandez, Butler, & Eyberg, 2011), Chinese (Leung, Tsang, Heung, & Yiu, 2009), and Australian families (Phillips, Morgan, Cawthorne, & Barnett, 2008). PCIT has also been used to treat behavioural and emotional problems associated with Autism (Solomon, Ono, Timmer, & Goodlin-Jones, 2008), Mental Retardation (Bagner & Eyberg, 2007), Major Depressive Disorder (Luby, 2009), Separation Anxiety Disorder (Pincus, Santucci, Ehrenreich, & Eyberg, 2008), trauma (Pearl et al., 2012), chronic illness (Bagner, Fernandez, & Eyberg, 2004), and traumatic brain injury (Cohen, Heaton, Ginn, & Eyberg, 2012). Finally, PCIT has been found to reduce behaviour problems in children who have experienced maltreatment, as well as reduce child abuse recidivism (Chaffin et al., 2004; Chaffin, Funderburk, Bard, Valle, & Gurwitch, 2011). Taken together, the current literature suggests that PCIT is appropriate for families from diverse cultural backgrounds, children with a wide-range of behavioural and emotional problems, and parents who are physically abusive. Future directions Further research on family, therapist, and training factors that potentially influence family progress through PCIT would improve understanding of this intervention. One area in which more research is needed is the effectiveness of PCIT in community mental health centres. Initial research suggests that PCIT is an effective treatment for child disruptive behaviour problems for multi-problem families (Lyon & Budd, 2010; Pearl et al., 2012); however, the rates of premature dropout are quite high in this population. Therefore, more research is also needed on factors that contribute to PCIT attrition such as barriers to treatment, family factors, and individual differences in therapist techniques. An additional direction for future research is greater examination of the way in which PCIT is disseminated, including therapist training models. Of particular interest is the influence that individual therapist coaching techniques have on family progress through treatment. Finally, PCIT would benefit from additional studies examining the application of the model outside the United States, including in Australia. Yet, when the existing research is considered in its totality, PCIT appears to be a robust early intervention approach, with strong and lasting positive effects on child and family functioning, that can be considered a promising resource for Australian therapists.
References
Abrahamse, M. E., Junger, M., Chavannes, E. L., Coelman, F. J. G., Boer, F., & Lindauer, R. J. L. (2012). Parent-child interaction therapy for preschool children with disruptive behaviour problems in the Netherlands. Child and Adolescent Psychiatry and Mental Health, 6, 24. doi:10.1186/1753-2000-6-24
Bagner, D., & Eyberg, S. M. (2007). Parent-child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child & Adolescent Psychology, 36(3), 418-429.
Bagner, D., Fernandez, M., & Eyberg, S. M. (2004). Parent-child interaction therapy and chronic illness: A case study. Journal of Clinical Psychology in Medical Settings, 11(1), 1-6.
Boggs, S. R., Eyberg, S. M., Edwards, D. L., Rayfield, A., Jacobs, J., Bagner, D., & Hood, K. H. (2004). Outcomes of parent-child interaction therapy: A comparison of treatment completers and study dropouts one to three years later. Child & Family Behavior Therapy, 26(4), 1-22.
Borrego, J., Anhalt, K., Terao, S., Vargas, E., & Urquiza, A. J. (2006). Parent-child interaction therapy with a Spanish-speaking family. Cognitive and Behavioral Practice, 13(2), 121-133.
Brestan, E. V., Eyberg, S. M., Boggs, S., & Algina, J. (1997). Parent-child interaction therapy: Parent perceptions of untreated siblings. Child and Family Behavior Therapy, 19, 13-28.
Chaffin, M., Funderburk, B., Bard, D., Valle, L., & Gurwitch, R. (2011). A combined motivation and parent-child interaction therapy package reduces child welfare recidivism in a randomized dismantling field trial. Journal of Consulting and Clinical Psychology, 79(1), 84-95. doi:10.1037/a0021227
Chaffin, M., Silovsky J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., … , Bonner, B. L. (2004). Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72(3), 500-510.
Cohen, M. L., Heaton, S. C., Ginn, N., & Eyberg, S. M. (2012). Parent-child interaction therapy as a family-oriented approach to behavioral management following psychiatric traumatic brain injury: A case report. Journal of Pediatric Psychology, 37(3), 251-261. doi:10.1093/jpepsy/jsr086
Eyberg, S. M. (1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child and Family Behavior Therapy, 10, 33-46.
Eyberg, S. M., Funderburk, B., Hembree-Kigin, T., McNeil, C. B., Querido, J., & Hood, K. (2001). Parent-child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23(4), 1-20.
Eyberg, S. M., & Robinson, E. A. (1982). Parent-child interaction training: Effects on family functioning. Journal of Clinical Child Psychology, 11, 130-137.
Fernandez, M., Butler, A., & Eyberg, S. M. (2011). Treatment outcome for low socioeconomic status African American families in parent-child interaction therapy: A pilot study. Child & Family Behavior Therapy, 33(1), 32-48.
Hood, K. K., & Eyberg, S. M. (2003). Outcomes of parent-child interaction therapy: Mothers' reports of maintenance three to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32(3), 419-429.
Leung, C., Tsang, S., Heung, K., & Yiu, I. (2009). Effectiveness of parent-child interaction therapy (PCIT) among Chinese families. Research On Social Work Practice, 19(3), 304-313. doi:10.1177/1049731508321713
Luby, J. L. (2009). Early childhood depression. American Journal of Psychiatry, 166(9), 974-979.
Lyon, A. R., & Budd, K. S. (2010). A community mental health implementation of parent-child interaction therapy (PCIT). Journal of Child and Family Studies, 19(5), 654-668. doi:10.1007/s10826-010-9353-z
McCabe, K., Yeh, M., Lau, A., & Argote, C. (2012). Parent-child interaction therapy for Mexican Americans: Results of a pilot randomized clinical trial at follow-up. Behavior Therapy, 43(3), 606-618. doi:10.1016/j.beth.2011.11.001
McCabe, K. M., & Yeh, M. (2009). Parent-child interaction therapy for Mexican Americans: A randomized clinical trial. Journal of Clinical Child & Adolescent Psychology, 38(5), 753-759.
McNeil, C., & Hembree-Kigin, T. L. (2010). Parent-child interaction therapy (2nd ed.). New York, NY: Springer Science + Business Media.
McNeil, C. B., Eyberg, S. M., Eisenstadt, T. H., Newcomb, K., & Funderburk, B. W. (1991). Parent-child interaction therapy with behavior problem children: Generalization of treatment effects to the school setting. Journal of Clinical Child Psychology, 20, 140-151.
Pearl, E., Thieken, L., Olafson, E., Boat, B., Connelly, L., Barnes, J., & Putnam, F. (2012). Effectiveness of community dissemination of parent-child interaction therapy. Psychological Trauma: Theory, Research, Practice, and Policy, 4(2), 204-213. doi:10.1037/a0022948
Phillips, J., Morgan, S., Cawthorne, K., & Barnett, B. (2008). Pilot evaluation of parent-child interaction therapy delivered in an Australian community early childhood clinic setting. Australian and New Zealand Journal of Psychiatry, 42(8), 712-719. doi:10.1080/00048670802206320
Pincus, D., Santucci, L., Ehrenreich, J., & Eyberg, S. M. (2008). The implementation of modified parent-child interaction therapy for youth with separation anxiety disorder. Cognitive and Behavioral Practice, 15, 118-125.
Solomon, M., Ono, M., Timmer, S. G., & Goodlin-Jones, B. (2008). The effectiveness of parent-child interaction therapy for families of children on the autism spectrum. Journal of Autism & Developmental Disorders, 38, 1767-1776.
Clinical Practice Recommendations for Children with Callous-Unemotional Traits David J Hawes, PhD School of Psychology, The University of Sydney David Hawes is a Senior Lecturer in Clinical Psychology in the School of Psychology, University of Sydney. He maintains a program of ARC/NHMRC research into developmental (including neurobiological) aspects of aggressive and oppositional behaviour, and the translation of this evidence into family-based interventions. This research was recently cited as a basis for revisions to the DSM-5 diagnosis of conduct disorder. He is involved extensively in the training of clinical psychologists in postgraduate and community health settings, and is a consulting editor of the Journal of Clinical Child and Adolescent Psychology. Please address all correspondence to: David J Hawes, PhD School of Psychology, University of Sydney Sydney NSW 2006 Australia Email: [email protected]
he most significant revision to the disruptive behaviour disorders in DSM-5 reflects the value of callous-unemotional (CU) traits as a marker for childhood conduct problems that appear to follow a distinct
developmental trajectory, associated with distinct clinical indications. It is important to note that while it is only the diagnosis of conduct disorder (CD) that incorporates CU traits (rebranded ‘limited prosocial emotions’) as a diagnostic specifier, there is extensive evidence that CU traits operate in much the same way across both CD and oppositional defiant disorder (ODD).
What are callous-unemotional traits? The term ‘CU traits’ was first coined by researchers quoting the language used by parents when describing children seen to be characterised by an enduring lack of guilt and empathy. However, this term is not merely descriptive. When applied in clinical science and practice, the term provides a theoretical reference to a phenotype, or specific cluster of features that covary in stable patterns across time and context. Conceptualisations of CU traits have drawn heavily on the personality literature, with early research establishing that they demonstrate a similar structure to that seen in psychopathic personality. As such, CU traits are not simply another feature of antisocial behaviour – they may or may not occur in individuals with conduct problems, but, when they do, a very different presentation of conduct problems is seen in terms of symptom pattern, developmental history, and prognosis. Children with CU traits are relatively good at reading people’s emotions (i.e., ‘cognitive’ empathy), yet emotional cues fail to elicit in these children the same kind of spontaneous mirroring of affect that characterises healthy ‘affective’ empathy. Problems recognising emotional cues are also characteristic, but these are somewhat specific to expressions of fear and distress. These deficits have been referred to as ‘fear blindness’, and appear to be in part accounted for by atypical allocation of attention to emotionally salient information. Callous-unemotional traits and the treatment of child conduct problems At the time I began conducting research in this area, there was no existing evidence regarding treatment outcomes or processes related to childhood CU traits. It was only in 2005 that clinical data were available to suggest that current treatments for conduct problems are less effective for children with these traits (Hawes & Dadds, 2005). At that time we found that boys (aged 4-8 years) with high levels of CU traits were those most likely to retain a diagnosis of ODD 6-months following parent training for conduct problems. Observational and monitoring data showed that this poor response was apparent even when controlling for the greater severity of pre-treatment conduct problems among these boys, the quality of parents’ implementation of the prescribed parenting strategies, and treatment dose. This finding has since been replicated across a range of ages and treatment modalities by groups around the world (e.g., Haas et al., 2011; Kimonis, Bagner, Linares, & Blake, in press; Manders, Deković, Asscher, van der Laan, & Prins, in press). Evidence regarding the factors that characterise children with CU traits and their families has also grown considerably. On the basis of this evidence I would argue that the clinicians who stand the best chance of success in treating children with CU traits are those with the best understanding of the unique parenting processes that operate on the adjustment of these children, and of the interplay between those parenting processes and child characteristics that would appear to be more biologically based. Heritability estimates from numerous twin studies suggest that CU traits are under moderate-to-strong genetic control. Data on the molecular genetics of CU traits have also begun to emerge, with colleagues and I recently finding childhood CU traits to be associated with epigenetic processes in oxytocin receptor
genes (Dadds et al., in press). Neuroimaging research has further identified various structural and functional differences in the brains of primary-school-aged children with CU traits, compared to healthy peers, across regions implicated in emotion processing and the encoding of associations between actions and consequences (see Viding & McCrory, 2012). Clinical practice recommendations
My aim here is to consider how the emerging evidence base for CU traits may inform clinical practice and decision-making with the families of children referred for conduct problems. I would suggest that at least six practical recommendations can be made to clinicians on the basis of the evidence currently available. These are presented as follows, alongside some of the key findings upon which they are based. 1. Collect data on callous-unemotional traits as part of initial clinical assessment It has previously been reported that approximately one third of children with conduct problems also show high levels of CU traits, and, as noted already, such traits appear to identify children at risk for poor treatment outcomes. I hasten to add that research has at no time suggested that children with CU traits are untreatable, but rather that the outcomes seen for these children typically fall short of the gains that can often be achieved. Colleagues and I have found that while only 12% of children with low levels of CU traits still show diagnosable levels of ODD six months following treatment, this figure is 27% for children with high levels of CU traits (Hawes, Dadds, Brennan, Rhodes, & Cauchi, 2013). Clinical data on CU traits collected as part of an initial assessment, therefore, have prognostic value, identifying children with unique clinical needs who warrant additional attention and resources. Measurement research to date has demonstrated that CU traits can be measured reliably from the preschool years using the reports of parents and other informants familiar with a child. The measure I use most frequently (see Hawes & Dadds, 2007) includes questions that index the extent to which a child is “unconcerned regarding others' feelings”, “inconsiderate of other people’s feelings”, and “unhelpful if someone is hurt, upset, or ill”. One of the questions I have often been asked is whether a parent’s answers to such questions may simply reflect distorted perceptions of their child. Although multi-informant reports on CU traits should be collected whenever possible to guard against this, the evidence suggests that this is not the case. For example, in a study I recently published with colleagues, we found that mothers’ ratings of CU traits were just as predictive of poor treatment outcomes as a multi-informant index that combined the ratings of CU traits provided by each child’s mother, father, and teacher (Hawes et al., 2013). 2. Utilise the core components of social-learning based parent training for conduct problems Notwithstanding the apparent limitations of existing parent training interventions for children with CU traits, the value of such interventions for these children should not be
dismissed. Importantly, studies indicate that social-learning based parent training may be an effective means of reducing the expression of CU traits in young children. Evidence published in 2007 was the first to suggest such effects (Hawes & Dadds, 2007). In that study, we saw that children showed a drop in CU traits, in the order of a medium-effect size, following receipt of parent training, which was maintained across the 6-month follow-up. This effect has since been replicated, most impressively in an RCT design. McDonald, Dodson, Rosenfield, & Jouriles (2011) found that preschoolers with conduct problems exhibited a reduction in magnitude of CU traits following parent training, with this reduction mediated by decreases in harsh and inconsistent discipline. Such findings suggest that rather than aiming to meet the needs of children with CU traits by replacing current parent training programs outright, or even omitting components that appear to be less effective for these children (e.g., time out), the core components of current parent training programs are best retained as a foundation upon which to build. 3. Prioritise a focus on positive reinforcement ‘reward’ strategies In addition to associating CU traits with relatively poor outcomes following parent training for conduct problems, research suggests that such outcomes may be accounted for, in part, by distinct affective and behavioural responses to specific components of such interventions among children with these traits. For example, we have found that compared to boys without CU traits, those with high levels of CU traits express less affect when being disciplined with time-out. Their behaviour also appears to be less responsive to this consequence. Alternatively, children with high levels of CU traits appear to be just as responsive as those without CU traits to the positive reinforcement ‘reward’ strategies used in parent training (Hawes & Dadds, 2005). This is consistent with experimental evidence of punishment insensitivity in individuals with CU traits (see Viding & McCrory, 2012) and suggests that interventions that prioritise an emphasis on reward-based contingencies may have the strongest impact on the behaviour of such children. 4. Establish the promotion of parental warmth as a key goal of treatment There is now considerable evidence that the influences of family environment on child conduct problems are moderated by CU traits. Early research showed that while negative (harsh and inconsistent) parenting practices explain the conduct problems of children without CU traits, the conduct problems of children with high levels of CU traits are less directly related to negative parenting (e.g., Wootton, Frick, Shelton, & Silverthorn, 1997). This effect has been replicated numerous times. However, the more that researchers have distinguished between distinct dimensions of parenting, and between parenting practices versus qualities of the parent-child relationship, the more that the question has shifted from “Does parenting just not matter for children with CU traits?” to “Are some domains of parenting even more critical for children with CU traits?”. Colleagues and I have found that while negative parenting shows relatively little association with conduct problems in children with CU traits, parental warmth may be even more proximal to behavioural adjustment among these children than
among children without CU traits (e.g., Pasalich, Dadds, Hawes, & Brennan, 2011). This evidence would suggest that intervention components that operate to enhance parental warmth may be those most likely to translate into behaviour change among children with CU traits. 5. Anticipate that parents of children with CU traits may require additional support to maintain changes in quality of parenting There is now research to show that part of the risk process associated with childhood CU traits is the impact those traits have on parents. The first evidence of this was seen in longitudinal research published by colleagues and me, looking at change in parenting practices over a 12-month period (Hawes, Dadds, Frost, & Hasking, 2011). The parents of children with high levels of CU traits showed increased levels of both harsh and inconsistent discipline. Indeed, it makes sense to consider that parents who find that their child does not respond to discipline may be compelled to escalate the severity of punishments. Likewise, it is easy to see how such experiences might lead parents to feel there is little point attempting to implement such discipline consistently. Our research also showed that CU traits predicted deterioration in levels of parental warmth over time. Once again, it is not hard to speculate why. If a child were to show little interest in his/her parents’ feelings, while failing to reciprocate their expressions of warmth, a gradual decline in such warmth would not be surprising. Importantly, we found that the influences of child CU traits on quality of parenting were independent of other child and family factors that are known to disrupt parenting, including the actual conduct problems of the child. These dynamics have been conceptualised in terms of an evocative gene-environment correlation, whereby genetically-based child traits elicit the kind of family interactions that feedback into those traits, amplifying them over time. For clinicians, it is important, therefore, to keep in mind that when working to achieve gains in parenting practices in the family of a child with CU traits, child-driven effects in that family may well also be working on parents to undo those gains. 6. Include child empathy and emotion-recognition as therapeutic targets Only one study to date has provided support for a novel intervention that may improve the treatment outcomes of children with conduct problems and CU traits (Dadds, Cauchi, Wimalaweera, Hawes, & Brennan, 2012). Based on the neurocognitive evidence concerning emotion-processing deficits in children with CU traits, colleagues and I conducted an RCT to test whether the effects of parent training could be enhanced by combining it with an empathy training component. This was found to be the case. The intervention itself borrowed heavily on emerging work in the field of autism, and was delivered to families through a combination of child and family-based sessions involving interactive computerised modules and parent-child homework in the form of emotion-focused games. However, what was surprising about our findings was that while this empathy training was associated with changes in children’s emotion recognition, those changes did not appear to mediate the superior treatment response seen for children with CU traits who received the combined intervention. As such, it remains somewhat unclear why this intervention was more effective
than standard parent training alone. We have speculated that in addition to acting on emotion recognition capacities, the emotion-focused activities undertaken by these families may have inadvertently acted on warmth in the parent-child relationship. Ongoing research is currently being conducted to better understand these effects. Conclusion
Developmental models of conduct problems have evolved rapidly in recent years, and translational research has struggled to keep up. Put simply, data on the causes of child conduct problems has been coming in at a much faster rate than data on how clinicians can improve the effectiveness of family-based interventions in the field. In my view, the emerging evidence base for CU traits represents the most promising avenue for translation research in child conduct problems, and already has much to offer clinicians.
References Dadds, M. R., Cauchi, A. J., Wimalaweera, S., Hawes, D. J., &
Brennan, J. (2012). Outcomes, moderators, and mediators of empathic-emotion recognition training for complex conduct problems in childhood. Psychiatry Research, 199(3), 201-207.
Dadds, M. R., Moul, C., Cauchi, A., Dobson-Stone, C., Hawes, D. J., Brennan, J., & Ebstein, R. (in press). Methylation of the oxytocin receptor gene and oxytocin blood levels in the development of psychopathy. Development and Psychopathology.
Haas, S. M., Waschbusch, D. A., Pelham, W. E., King, S., Andrade, B. F., & Carrey, N. J. (2011). Treatment response in CP/ADHD children with callous/unemotional traits. Journal of Abnormal Child Psychology, 39, 541-552.
Hawes, D. J., & Dadds, M. R. (2005). The treatment of conduct problems in children with callous-unemotional traits. Journal of Consulting and Clinical Psychology, 73(4), 737-741.
Hawes, D. J., & Dadds, M. R. (2007). Stability and malleability of callous-unemotional traits during treatment for childhood conduct problems. Journal of Clinical Child and Adolescent Psychology, 35(3), 347-355.
Hawes, D. J., Dadds, M. R., Brennan, J., Rhodes, T., & Cauchi, A. (2013). Re-visiting the treatment of conduct problems in children with callous-unemotional traits. Australian and New Zealand Journal of Psychiatry, 47(7), 646-53.
Hawes, D. J., Dadds, M. R., Frost, A. D. J., & Hasking, P. A. (2011). Do childhood callous-unemotional traits drive change in parenting practices? Journal of Clinical Child & Adolescent Psychology, 40(4), 1-12.
Kimonis, E. R., Bagner, D. M., Linares, D., & Blake, C. A. (in press). Parent training outcomes among young children with callous-unemotional conduct problems with or at-risk for developmental delay. Journal of Child and Family Studies.
Manders, W. A., Deković, M., Asscher, J. J., van der Laan, P. H., & Prins, P. J. (in press). Psychopathy as predictor and moderator of multisystemic therapy outcomes among adolescents Treated for antisocial behavior. Journal of Abnormal Child Psychology.
McDonald, R., Dodson, M. C., Rosenfield, D., Jouriles, E. N. (2011). Effects of a parenting intervention on features of psychopathy in children. Journal of Abnormal Child Psychology, 39, 1013-1023.
Pasalich, D. S., Dadds, M. R., Hawes, D. J., & Brennan, J. (2011). Do callous-unemotional traits moderate the relative importance of parental coercion versus warmth in child conduct problems? An observational study. Journal of Child Psychology and Psychiatry, 52, 1308-1315.
Viding, E., & McCrory, E. J. (2012). Genetic and neurocognitive contributions to the development of psychopathy. Development and Psychopathology, 24, 969-983.
Wootton, J. M., Frick, P. J., Shelton, K. K., & Silverthorn, P. (1997). Ineffective parenting and childhood conduct problems: The moderating role of callous-unemotional traits. Journal of Consulting and Clinical Psychology, 65, 301-308.
Childhood Anxiety Disorders: Involving Parents in Treatment Vanessa Cobham, PhD School of Psychology University of Queensland Vanessa Cobham completed her clinical PhD in the field of child and adolescent anxiety disorders at the University of Queensland in 1997. Since that time, she has worked as a researcher at the School of Psychology, University of Queensland and as a senior Clinical Psychologist within the Mater Child and Youth Mental Health Service. Vanessa has published and presented widely in the area of childhood anxiety disorders. Most recently, she has also worked in the field of posttraumatic mental health in children and adolescents, particularly in the aftermath of natural disasters. Vanessa has recently ended a 2-year secondment as the Deputy Chair of the Statewide Child and Youth Recovery and Resilience team following the 2011 Floods in Queensland. She is currently the Director of the beyondblue Child and Adolescent Bushfire Response in Tasmania, in addition to her University of Queensland and Mater roles. Please address all correspondence to: Dr Vanessa Cobham School of Psychology University of Queensland Email: [email protected] The purpose of this paper
his paper aims to review briefly the significance of childhood anxiety disorders, provide an overview of the treatment outcome research literature in this field (with a specific focus on the role of parents in treatment), and
describe a family-focused intervention used by our group at the University of Queensland. The significance of childhood anxiety disorders Anxiety disorders are the most common psychological complaint reported by children, with a point prevalence of 5-10% and a lifetime prevalence of approximately 20%
(Cartwright-Hatton, McNicol, & Doubleday, 2006). These disorders impact negatively on academic and social performance, and problems with physical health and social isolation are common (e.g., Wood, 2006). Untreated, childhood anxiety has a poor prognosis, often persisting into adulthood. In addition, anxiety disorders in children predict the presence of other forms of pathology (e.g., depression and substance abuse) in childhood, adolescence, early adulthood, and later adulthood (e.g., Bittner et al., 2007). The above points focus on the impact of anxiety on the individual child. However, the significance of these disorders goes far beyond individual children. Thus, families of children with anxiety disorders have been found to report worse levels of family functioning (Hughes, Hedtke, & Kendall, 2008) and more problematic familial relationships compared to families of children without anxiety disorders. It has also been found that the sibling interactions of anxious children were characterised by more conflict and control, and less warmth, when compared with those of non-anxious children (Fox, Barrett, & Shortt, 2002). It is suggested, therefore, that there is enormous clinical benefit (both for an identified anxious child and their whole family) in a treatment approach which keeps in mind at all times the entire family of an anxiety-disordered child. Moving beyond children's families, there is also a significant societal cost associated with untreated childhood anxiety disorders. Although we have efficacious interventions for treating these disorders, most anxiety-disordered children never receive treatment (Essau, Conradt, & Petermann, 2002). Essau (2005) reported that, of a representative school sample of 1035 German adolescents aged 12 to 17 years, only 18.2% of youth meeting criteria for an anxiety disorder received mental health treatment. This is consistent with an Australian child and adolescent population sample (Sawyer et al., 2001). This issue of poor reach, combined with the poor prognosis of childhood anxiety when untreated, is extremely significant. In Australia, anxiety and depression are the leading causes of incident, non-fatal burden of disease in both male and female adults (Begg et al., 2007). Untreated, childhood anxiety disorders have the potential to have a long-term economic and societal impact. The treatment outcome research: A brief review In the past, treatment outcome research has focused on child-focused cognitive behaviour therapy (CBT). However, as the role of parenting in the aetiology of child anxiety has become clearer (e.g., Rapee, 2012), attention has moved towards the development and evaluation of parent + child CBT protocols. There is a growing consensus that child-focused CBT is an evidence-based treatment for anxiety in children (Seligman & Ollendick, 2011). A recent systematic review of child-focused CBT interventions noted the average remission rate to be 56.5% (Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004). Child-focused CBT (with 10 sessions being the most common duration) is regarded as the international "gold standard" in the treatment of childhood anxiety disorders. Importantly, child-focused CBT protocols do not target family members other than the identified child.
However, Khanna and Kendall (2009) note that all child-focused programs involve parents to some degree. Several studies have evaluated CBT protocols incorporating parental involvement and reported positive outcomes. Few studies, however, have directly compared a child-focused intervention with a parent + child-focused intervention. In one of the few studies to have examined this comparison over the longer term, it was reported that, three years post-treatment, anxiety disordered children whose parents had been actively involved in treatment were significantly more likely to be free of any anxiety diagnosis compared to anxiety disordered children who received a child-focused intervention (Cobham, Dadds, Spence, & McDermott, 2010). Overall, however, the findings have been inconsistent (Barmish & Kendall, 2005). In a meta-analysis, In-Albon and Schneider (2007) reported no differences in outcomes between child- and family-focused interventions. However, in their review of this literature, Cresswell and Cartwright-Hatton (2007) concluded that involving parents in treatment does provide an additional benefit, although the effects may be small. In other words, empirically speaking, 'the jury remains out' on the issue of whether or not involving parents in the treatment of anxiety disordered children enhances outcomes. Involving parents: How and why? Although the scientific evidence is equivocal when it comes to anxiety disorders, clinically, it seems to make sense to involve parents in the treatment of almost any kind of emotional and/or behavioural difficulty experienced by a child. Siqueland and Diamond (1988) summarised the argument in favour of parental involvement in treatment in general:
Parents can help their child practice the skills taught them in [session] … and generalize learning to other contexts … [as] maintenance of gains … will depend on the child's continuing ability to use these coping skills on new challenges and opportunities. Second, parents' beliefs and attitudes about their child's abilities, their own abilities to cope, and the safety of the world may impede progress. Third, changes in the child may threaten parents by destabilising familiar, though uncomfortable, family dynamics. (p. 82).
A recent study underscored the potential for parents to be involved in their anxious children's treatment. Cobham (2012) randomly assigned 55 anxiety disordered children and their parents to either a waitlist (WL) control group or one of two different delivery modalities of the same family-focused intervention. The two delivery modalities were therapist-supported bibliotherapy (where parents implemented the intervention at home) and individual, clinic-based therapy. Compared to children in the waitlist control condition, at post-treatment, children in both active intervention conditions had improved significantly … and equally. The percentages of children who were anxiety diagnosis free at post-treatment were as follows: 0% in the WL condition; 95% in the therapist-supported bibliotherapy condition, and; 78.3% in the individual therapy condition. The difference between the two active interventions was not significant.
Treatment gains were maintained in both conditions across the follow-up period of six months. The family-focused intervention used in the above study consisted of a 6-session intervention for parents ("Do as I Do"; Cobham, 2006a) and a 6-session intervention for children ("Facing your Fears"; Cobham, 2006b). This integrated intervention, used by our group at the University of Queensland (e.g., de Groot, Cobham, Leong, & McDermott, 2007; Leong, Cobham, de Groot, & McDermott, 2009), represents one end of the continuum in terms of involving parents or not – in this intervention, literally half of the sessions are spent just with parents. The intervention is described in greater detail in the Cobham (2012) paper, from which the following summary is taken:
Both programs are manualized, with parents and children each receiving workbooks that are used in session and for home-based tasks. Each program consists of 6 weekly sessions, with the parent program being completed first. The parent program focuses on: (1) increasing parents' awareness of the role they may play in the development and maintenance of their child's anxiety disorder; (2) teaching parents the principles of effective anxiety management in order that they can provide the best possible model to their children; and (3) teaching parents effective parenting strategies for managing their children's anxiety. The child program aims to teach children a two-step plan for overcoming anxiety, "Helpful Thoughts" and "Brave Behaviors." Helpful thoughts involves learning to identify thoughts; understanding the role of thoughts in anxiety; learning to apply a "scientific approach" to evaluate thoughts; and learning to generate alternative, more realistic thoughts. Brave behaviors involves learning about the role of avoidance in maintaining anxiety, and the completion of parent-assisted exposure tasks. (p. 468).
As noted, the intervention described above represents a high level of parental involvement. This is not always going to be either possible or desirable. Fortunately, there are many other ways to involve parents in the treatment of childhood anxiety. For instance, even when we run child-focused interventions (for research purposes), we typically ask parents to attend the beginning of their children's sessions in order to: provide feedback to the clinician in relation to how things have been going at home from their perspective, and; hear about the content their children will be covering in session. Similarly, at the end of their children's sessions, parents are invited back into the therapy room in order to hear from their children about what they have learned and what homework tasks have been set for the week. Parental support of homework tasks is a particularly important element to parents' involvement – particularly tasks such as in vivo exposure, which is unlikely to occur without parental involvement and support. In summary, although recent, preliminary studies have provided strong support for the intervention described above, it is important to keep in mind that in terms of the research, it remains unclear as to how necessary it is to
involve parents in the treatment of childhood anxiety. It is also clearly important to keep developmental and relationship issues in mind when deciding how, and to what extent, to involve parents in treatment. Thus, an anxious adolescent may be less tolerant of the same level of parental involvement than an anxious 8-year-old child might be. Similarly, children and adolescents with less secure, more troubled relationships with their parents may be less willing to have their parents involved in their treatment compared to children and youth with more secure and settled parental relationships. As always, a case-by-case approach, in combination with a therapeutic framework that is both developmentally and systemically attuned, is essential.
References
Barmish, A. J., & Kendall, P. C. (2005). Should parents be co-clients in cognitive-behavioral therapy for anxious youth? Journal of Clinical Child and Adolescent Psychology, 34(3), 569-581.
Begg, S., Vos, T., Barker, B., Stevenson, C., Stanley, L., & Lopez, A. (2007). The burden of disease and injury in Australia 2003. Australian Institute of Health and Welfare. AIHW cat no. PHE82. Canberra, Australia: AIHW & ATSB.
Bittner, A., Egger, H. L., Erklanli, A., Costello, J., Foley, D. L., & Angold, A. (2007). What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry, 48, 1174-1183.
Cartwright-Hatton, W., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26, 817-833.
Cartwright-Hatton, W., Roberts, C., Chitsabesan, P., Fothergill, C., & Harrington, R. (2004). Systematic review of the efficacy of cognitive behaviour therapies for childhood and adolescent anxiety disorders. British Journal of Clinical Psychology, 43, 421-436.
Cobham, V. E. (2006a). Do as I do programme: Parents' workbook – Revised edition. Brisbane, Australia: University of Queensland.
Cobham, V. E. (2006b). Facing your fears programme: Children's workbook (2nd ed.). Brisbane, Australia: University of Queensland.
Cobham, V. E. (2012). Do anxiety-disordered children need to come into the clinic for efficacious treatment? Journal of Consulting and Clinical Psychology, 80(3), 465-476.
Cobham, V. E., Dadds, M. R., Spence, S. H., & McDermott, B. (2010). Parental anxiety in the treatment of childhood anxiety: A different story three years later. Journal of Clinical Child and Adolescent Psychology, 39(3), 410-420.
Cresswell, C., & Cartwright-Hatton, S. (2007). Family treatment of child anxiety: Outcomes, limitations and future directions. Clinical Child and Family Psychology Review, 10, 232-252.
de Groot, J., Cobham, V. E., Leong, J., & McDermott, B. (2007). Individual vs. group administered family-focused CBT for childhood anxiety: A pilot randomized control trial. Journal of Australian and New Zealand Psychiatry, 41(12), 990-997.
Essau, C. A. (2005). Frequency and patterns of mental health services utilization among adolescents with anxiety and depressive disorders. Depression and Anxiety, 22(3), 130-137.
Essau, C. A., Conradt, J., & Petermann, F. (2002). Course and outcome of anxiety disorders in adolescents. Journal of Anxiety Disorders, 16(1), 67-81.
Fox, R. L., Barrett, P. M., & Shortt, A. L. (2002). Sibling relationships of anxious children: A preliminary investigation. Journal of Clinical Child and Adolescent Psychology, 31(3), 375-383.
Hughes, A. A., Hedtke, K. A., & Kendall, P. C. (2008). Family functioning in families of children with anxiety disorders. Journal of Family Psychology, 22(2), 325-328.
In-Albon, T., & Schneider, S. (2007). Psychotherapy of childhood anxiety disorders: A meta-analysis. Psychotherapy and Psychosomatics, 76, 15-24.
Khanna, M. S., & Kendall, P. C. (2009). Exploring the role of parent training in the treatment of childhood anxiety. Journal of Consulting and Clinical Psychology, 77(5), 981-986.
Leong, J., Cobham, V. E., de Groot, J., & McDermott, B. (2009). Comparing different modes of delivery: A pilot evaluation of a family-focused, cognitive-behavioural intervention for anxiety-disordered children. Journal of European Child and Adolescent Psychiatry, 18, 231-239.
Rapee, R. M. (2012). Family factors in the development and management of anxiety disorders. Clinical Child and Family Psychology Review, 15, 69-80.
Sawyer, M. G., Arney, F. M., Baghurst, P. A., Clark, J. J., Graetz, B. W., Kosky, R. J. …, Zubrick, S. R. (2001). The mental health of young people in Australia: Key findings from the child and adolescent component of the national survey of mental health and well-being. Australian and New Zealand Journal of Psychiatry, 35, 806-814.
Seligman, L. D., & Ollendick, T. H. (2011). Cognitive behavior therapy for anxiety disorders in children and adolescents. Psychiatric Clinics of North America, 20, 217-238.
Siqueland, L., & Diamond, G. S. (1998). Engaging parents in cognitive behavioral treatment for children with anxiety disorders. Cognitive and Behavioral Practice, 5, 81-102.
Wood, J. J. (2006). Effect of anxiety reduction on children's school performance and social adjustment. Developmental Psychology, 42, 345-349.
www.acpa.org.au
Look for the ACPA Member logo
The Australian Clinical Psychology Association (ACPA)PO Box 1242 BROADWAY, NSW, 2581
Does your psychologist have
accredited qualications in clinical psychology?
The Australian Clinical Psychology Association (ACPA) represents only clinical psychologists who have obtained the accredited qualications set down by the Psychology Board of Australia for recognition as a clinical psychologist.
These are:
AAn accredited Masters (two year) or Doctoral (three year) degree in clinical psychology;
and
A post-degree period of supervision to bring the total of post-graduate training to four years.
IIn choosing an ACPA Member you are ensuring that your clinical psychologist has completed this established standard of training.
Accredited Masters and Doctoral-level training in clinical psychology:
Provides the highest levels of training currently offered within the psychology profession in Australia Facilitates the development of high-level, specialised skills in mental health assessment, diagnosis, and evidence-based treatment planning and implementation
Not all psychologists who are permitted to use the term clinical psychologist in Australia have completed this level of training. Indeed, some have not completed any post-graduate qualications in clinical psychology.
International standards require post-graduate qualications in clinical psychology for all clinical psychologists.
Ask the psychologist providing your mental health treatment what accredited post-graduate qualications they have in clinical psychology.
To nd a clinical psychologist who is a member of the Australian Clinical Psychology Association go to:
www.acpa.org.au and search:
Clinical psychologists are specialists in theassessment and evidence-based treatment of a wide range of mental health problems, including:
• Addictions• Attention Decit and Hyperactivity Disorders• Autistic Spectrum Disorders• Bipolar Disorder• Depression & Mood Difficulties• Drug & Alcohol Abuse•• Eating Disorders• Emotional & Behavioural Problems in Children• Fears, Phobias, Anxiety & Panic Attacks• Grief, Loss & Bereavement• Obsessions & Compulsive Behaviour• Pain and Somatic Symptoms• Personality Disorders•• Post-traumatic Stress Disorder• Psychotic Illnesses• Recovery from Childhood Trauma• Schizophrenia• Separation Anxiety• Social Anxiety• Sleep Disorders
An Extension of Traditional Applied Behavioural Analysis Treatment for Children with an Autism Spectrum Disorder Michelle L. Curran, PhD University of the Sunshine Coast Michelle Curran is a consultant and parent practitioner working with children on the autism spectrum. She was awarded her PhD in Psychology in 2012 from the University of Southern Queensland. In conjunction with Dr Dixie Statham, she is cofounder of the autism spectrum disorder (ASD) support group1 run by the University of the Sunshine Coast Psychology clinic. Michelle has recently joined the clinical team at the University of the Sunshine Coast, extending the potential research possibilities in the field of ASD. Please address all correspondence to: Michelle L. Curran, PhD Psychology Clinic University of the Sunshine Coast Phone: +61 7 5456 5074 Email: [email protected]
1 The ASD support group supports parents and the extended family to develop understanding of individuals on the autism spectrum. It is an inclusive group involving individuals on the spectrum, parents of children on the spectrum, couples on the spectrum, and their partners and children. Meetings are held monthly on the University of the Sunshine Coast campus; Michelle has found that shared communication between parents of young people and adults on the spectrum has increased knowledge, understanding, and awareness of autism spectrum disorders. The group also involves education from professionals in the field and education for students in the Master of Psychology (Clinical) program, furthering the growth of knowledge for future professionals in the field.
utism Spectrum Disorder is characterised by impairment in functions, including, but not limited to, communication, social interaction, and cognition that are related to central nervous system maturation
(World Health Organisation [WHO], 2013). These impairments are consistent with the requirement for problems in the domains of behaviour and social interaction that DSM-5 has established for the diagnosis of an autism spectrum disorder (American Psychiatric Association, 2013). It is acknowledged by WHO that, in addition to personal limitations of individuals on the spectrum, there is an emotional and economic burden on families and caregivers. WHO estimates a global median prevalence of one in 160 children; however, the true figure may exceed this because of underreporting. Considering these high prevalence rates, and an anticipated lifetime cost in the United Kingdom, Northern Ireland, and the United States of America as between $1.4 and $2.4 million US dollars, it is understandable that the political and personal focus is on the least cost, emotionally effective treatment plan. Maglione, Gans, Das, Timbie, and Kasari (2012) undertook a systematic review to develop consensus guidelines for non-medical interventions in ASD. It was identified that children on the spectrum “should have access to at least 25 hours per week of comprehensive intervention”, marking Applied Behavioural Analysis (ABA), among others, as an example of an intervention that has shown efficacy. The intervention areas identified by the technical expert panel as essential for a comprehensive intervention program included: language, play skills, maladaptive function and behaviour, and an ongoing parent education component in the specific intervention used (Maglione et al., 2012). Finally, it is outlined that, once educated in the intervention, the parent role in the child’s therapy is to assist the child in extending skill acquisition to home and community settings. Consistent with Maglione and colleagues’ findings, this article conceptualises an alternative course of treatment that extends traditional ABA. That is, it provides the therapist with a carefully guided clinical intervention that empowers the parent and, most importantly, improves treatment outcomes for the individual. It is of note that this proposed conceptualisation is not limited to the field of clinical child psychology, but can extend to adult therapy where a willing partner is able to embrace the process outlined. Common to individuals on the autism spectrum are difficulties with social interaction, emotional regulation, theory of mind, and general linguistic abilities (from mild to severe). Imagine if, as therapists, we could extend the therapeutic process from the consulting room outwards to encompass every minute of our client’s existence. If we take terms like chunking, breaking information down into smaller pieces, and compartmentalising that are used in ASD interventions, and find a mechanism in which to extend them into the individual’s everyday life and being, then we have the potential to provide cost effective interventions. As Maglione and colleagues suggest, engaging the parent in the child’s therapeutic process not only allows for the transference of skill outside the therapy setting but enables them to feel as though they are part of the solution rather than just the “therapy taxi service”.
What does this look like for the therapist? To date as a clinician, I have found that most parents do not fully understand the difficulties faced by a child with ASD trying to navigate the world in contrast to the ease with which a neurotypical child (i.e., an individual who is not on the autism spectrum) does. Therefore, the first step involves comprehensive psychoeducation for parents. As a therapist, I would anticipate that it is rare to find a parent who is fully aware of their child’s every limitation of understanding. Because their child is their child, and they know no difference, parents and their family system learn to adapt and compensate for and with the child who has ASD. Thus, when the parent presents at their initial clinical interview, whether it be for assessment or therapy, you are presented with a highly adaptive individual who may be somewhat “blind” to the intricacies of their child’s processing of information. This is particularly pertinent when working with a parent who has all children on the autism spectrum as they essentially are unaware of how to raise a child without these traits. It is the role of the therapist to tease out the knowledge base of the parent and not to assume that they have read every book pertaining to autistic spectrum disorders or that they have fully engaged the material to a level of understanding capable of application. In addition, the parent needs to be engaged and involved in their child’s therapeutic learning process to facilitate transfer to the home and wider community. What does this look like for the parent? This reflective approach teaches parents how to verbalise their own thoughts, feelings, and behaviours to their children. Now we see the link. Once again, cognitive behaviour therapy (though often perceived as too rudimentary) comes to pass as the potential gold standard for treatment across presentations. Through this process the parent helps the child to recognise their own thoughts, feelings, and behaviours. Subsequently, this plays the role of normalising the child’s psychological experiences, potentially preventing the emotional difficulties that are common among individuals on the spectrum (i.e., worries and metacognitions that dysregulate the individual). At times, neurotypical children can find it difficult to negotiate their environment. Imagine the world of ASD children. They live in an environment in which they are continually overstimulated. People around them speak essentially another language (e.g., lacking detail, too much generalisation, incomprehensible pitch and tone), their behaviour is not considered acceptable by others (e.g., lack of tonal awareness, self-stimulatory behaviours, melt downs), and the world is generally confusing for them to navigate. When this occurs with neurotypicals, we attempt to bring “order” to our world or situation. An individual on the spectrum does not always have the tools to bring this order. However, through this dual process of engaging the child in therapy and providing the parent with psychoeducation and skill development, the child can eventually “break the code” and improve their methods for processing their environment.
What does the child learn? This process enables the child to learn that their thoughts, feelings, and behaviours are, in fact, normal. Through parental modelling and verbalisation of emotional conceptualisation of what is normal, the child is able to better build an emotional repertoire. Innate neurotypical skills of behaviour management, social norms, and rules can be learnt through the daily explanation of a parent’s experiences in the world. In conclusion, as therapists, we have the ability to broaden the perspective of the parent regarding their role in their child’s skill development. What we must recognise is that we are with the child for one hour a week. The parent is with the child 24/7, with the exception of time spent in formal education settings. It is integral that these skills are taught on a daily basis, not just in the hour a week in the therapeutic environment. ABA therapy can be completed on average at a rate of 25 hours per week, but this is financially prohibitive for most families. So why not “train-the-trainer” in the provision of effective modelling to enhance therapeutic outcomes in our clients?
References American Psychiatric Association. (2013). Diagnostic and
Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.
Maglione, M. A., Gans, D., Das, L., Timbie, J., & Kasari, C. (2012). Nonmedical interventions for children with ASD: Recommended guidelines and further research needs. Pediatrics, 130, s169. doi:10.1542/peds.2012-09000
World Health Organisation. (2013, April). Comprehensive and coordinated efforts for the management of Autism Spectrum Disorders. Executive Board, 133rd session, Provisional Agenda Item 6.1. Retrieved from http://apps.who.int/gb/ebwha/pdf_files/EB133/B133_4-en.pdf
Ryan The benefits of clinical intervention with a mother and child on the autism spectrum are provided in a personal account by Ryan1 and his mother. Ryan, an 11-year-old boy who attends a government primary school in Sydney's inner west, was referred to a community health centre with behavioural and peer difficulties at school. He lives, and has good relationships with, his mother, stepfather, and his stepfather’s 15-year-old son. Ryan has inconsistent contact with his biological father, who is described by his mother as being similar in personality to Ryan. After a comprehensive, multimodal assessment by a clinical psychologist at the centre, Ryan was given a diagnosis of Asperger’s Disorder. Ryan and his mother share their experience of how a clinical psychologist in a community health centre has made a vast difference to their lives. Mother’s perspective
yan was born on 23 March, 2002. On the third day after his birth, when we stayed in the hospital, Ryan was quiet while other kids were crying loudly. At the time this did not seem to be of importance; however, it is
something that that has always stuck with me. Though Ryan would not cry loudly like other infants, we did notice that he seemed irritable. We later found out that he was allergic to milk powder and that being fed soy milk powder was the cause of his distress. When he started to drink fresh milk, his irritability stopped. Ryan grew into a very quiet toddler who seemed content in his own company. He was never noisy and his father and I thought that he simply had a quiet nature. He was enrolled in childcare when he was 2-years-old. Teachers noticed, and commented to me, that he preferred his own company to that of other children and never played with others. At home, he liked to watch cartoons and movies, watching the same episodes or movies over and over. When Ryan was 3-years-old, my husband and I divorced and I started to raise him on my own. While I went to work every day, I would leave him to be looked after by different friends, so he was always staying at different places during the week. My friends who looked after him liked him very much because he very rarely spoke and was very quiet; he never caused any trouble for anyone. When Ryan started to go to primary school, he disliked playing with his classmates, always staying in the corner to read alone. He didn’t have any friends at school, didn’t seem to be interested in making friends, and would get angry 1 "Ryan" is a pseudonym for the subject of this article.
easily. He would get particularity angry when he came across something that he found hard to understand, and sometimes he would even hit his head against a wall. This really worried his classroom teacher so the school did some tests, with the result being that his EQ level was very low, whist his IQ level was extremely high. When he was in Year 2, it was noticed that Ryan would become grumpy easily, and would get angry very quickly over small things, but then seemed to return to normal just as quickly. We took Ryan to see a children’s psychologist. They asked him questions such as "Do you have friends?" and "Are you happy being alone?". Ryan’s answer was "I have no friends, but I am happy being alone". We all thought that Ryan was just very introverted and that this was just his nature and personality. Based on this session, a report was submitted to the school but intervention was not suggested or offered and his difficulties continued. Ryan did the test for the Opportunity Class when he was in Year 4 and he was accepted to start the following year. After half a year of Year 5, the teacher found him to be a bit different from the other students and I was called to school. The teacher discussed concerns that she had about Ryan, such as his difficulties socialising with other students, some of the type and content of the conversations that he had had with teachers, and his quickly changing moods. It was at this point that we were referred to our local community health centre for help. The first time we met our clinical psychologist she asked questions, such as "What problems is he having at home, at school, and generally?". She asked for specific examples and asked a lot of questions about his development and how the family functioned in general. She spoke with the school and asked us to fill in measures. After a few sessions, she explained that Ryan suffers from something called Asperger’s Disorder, and she made a plan to treat Ryan. She also coordinated this plan with the school. Based on this plan, Ryan was taught, in weekly sessions, different methods to overcome his difficulties. Between appointments, he was given skills and techniques to practice. After a few weeks and lots of practice, a noticeable change occurred. Ryan went from playing alone to making friends, from rarely talking to being more talkative, and to being able to have more control over his responses and reactions. Ryan’s school and I noticed that he was hardly getting angry at school and home anymore. Now, Ryan is starting to get close to his classmates and his communication with me and other people has improved, and continues to improve; this surprised me the most. We even recently went on a trip to the snow with two of his classmates. I deeply appreciate the great help he received from his clinical psychologist and his classroom teacher. I see the positive changes that he has been making and I hope that he continues to get better each day so that he will be able to successfully and happily get through high school and have the skills to deal with other challenges he may encounter there.
Ryan’s perspective With the help of the clinical psychologist I have improved greatly in understanding others and dealing with difficult situations. Before, I did not talk to other people at school or interact with them, and I did not know how to solve problems that others seemed to know how to solve. I now have skills to manage arguments, debates, and even misunderstandings that occur either at home or at school.
I feel as if I now know how to end unpleasant situations the appropriate way, whereas before I would have reacted aggressively, which is not okay. The sessions with my clinical psychologist have also helped me understand about feelings. For example, how to tell if a person is feeling a certain emotion before I start talking to them, or while I’m talking to them, by recognising cues.
Working with Aboriginal and Torres Strait Islander Children and Families Sarah Mares, BMBS FRANZCP CertChildPsych MMH(Inf) Senior Research Fellow Centre for Child Development and Education Menzies School of Health Research Darwin Gary Robinson, PhD Associate Professor and Deputy Director Centre for Child Development and Education Menzies School of Health Research Darwin Sarah Mares is a child and family psychiatrist with an established clinical and academic interest in the peri-natal, infant, and early childhood periods and in prevention and intervention with highly disadvantaged populations. She is currently Senior Research Fellow at the Centre for Child Development and Education, Menzies School of Health Research in Darwin and, prior to this, was Senior Staff Specialist in the Alternate Care Clinic for children in Out of Home Care at Redbank House in Western Sydney. She is an experienced multidisciplinary educator, supervisor, and consultant. Gary Robinson is an anthropologist and, over many years, has been engaged in research into household and family patterns among Indigenous people of northern Australia. In partnership with communities and government, he has conducted large scale interventions in health, literacy education, and early childhood services. He was a program leader, Social-Emotional Wellbeing for the Cooperative Research Centre for Aboriginal Health, and has led the development of school- and community-based parenting and early intervention programs in remote communities. He is Associate Professor and Deputy Director of the Centre for Child Development and Education in Menzies, where he leads a program of research into Indigenous parenting and families. Please address all correspondence to: Sarah Mares, PhD Email: [email protected]
Background
here is such diversity in the circumstances, composition, aspirations, and functioning of Australian Aboriginal and Torres Strait Islander1 families that this topic would better be addressed in a designated text or series of
papers rather than this brief overview. Further diversity exists because practitioners engage with Aboriginal families in a range of service contexts from urban mental health, school based and private sector settings, to fly in fly out services to communities. Despite the diversity, it is clear that some criteria for good practice are common to all therapeutic and supportive work with vulnerable children and families, including Aboriginal families. Equally the very particular history of Australia's first peoples and the continuing impact of colonisation and successive government interventions, including that associated with the Stolen Generations, need to be acknowledged. There can be a tension between identifying the strengths inherent in a culture that has ensured the survival and adaptability of children over thousands of generations and the undeniable adversity and poor developmental trajectories currently faced by many Indigenous children. Although many Aboriginal and Torres Strait Islander children make a successful transition to healthy adult lives, a substantial proportion (around 50%) are being raised in community and family environments where they are exposed to multiple and cumulative developmental and health factors. These are strongly associated with adult chronic disease, addictions, psychiatric disorders, and suicidal behaviour (Afifi et al., 2008; Felitti & Anda, 2010; Shonkoff et al., 2012). There are few published evaluations of mainstream family and parenting programs, delivered to scale with Aboriginal families. Little has been written about the necessity or otherwise for adaptation, delivery, and evaluation of these interventions in culturally diverse and often remote settings. There are also few papers on the assessment of social and emotional wellbeing of Aboriginal children, including the use of standardised measures and assessment tools (Bamblett, Frederico, Harrison, Jackson, & Lewis, 2012). Professionals experienced in mainstream settings can feel that there is little to guide them in their communication and interaction with Aboriginal parents and children, despite increasing requirements for what has been called cultural competence or cultural safety (Downing, Kowal, & Paradies, 2011; Price-Robertson, McDonald, Lewis, & Bamblett, 2011). This paper will provide a brief overview of the cultural, historical, demographic, and practical factors that require consideration in the development and delivery of therapeutic interventions with Aboriginal children and families. We will outline principles that can inform practice, resources that practitioners may find valuable, and an approach to engagement that is a prerequisite to any form of family or parenting intervention.
1 For the purposes of this paper the terms Aboriginal and Indigenous are used interchangeably to refer to Australia's first peoples, the Aboriginal and Torres Strait Islander peoples.
Approaches to practice must be informed by clear therapeutic models that are evidence-based, but sufficiently flexible to take into account the specific needs and circumstances of families in their own particular context. Time needs to be given to engagement and building trust if retention of families and, therefore, effective intervention is to occur. This is particularly so for families where a history of 'welfare' involvement and/or child removal is current or recent. Insufficient time spent listening and building engagement, and/or a crude emphasis on, or stereotypes about, culture can impede the development of a useful therapeutic relationship. A simplistic single approach to what are often complex and diverse difficulties may provide initial comfort to the practitioner but is likely to be of little benefit to the family or child. It is important to remember that there is often far more individual and family variation within a given cultural or community group than there is between community or cultural settings. Provision of therapeutic services alongside preventative and universal programs is essential. This requires well-trained and supported professionals, working in partnership with community services and resources (for example, Aboriginal Medical Services or Aboriginal Health Workers), to engage families. Demography and family composition Australian Indigenous cultures are founded on practices of child rearing dating back many thousands of years. The strength of traditional approaches, including involvement of kin and community in child rearing, continues to influence family life, even for those living in urban environments. The historical adversities faced by Australia's Indigenous peoples, including the Stolen Generations, and their intergenerational impacts on families and individuals are well documented (Human Rights and Equal Opportunities Commission, 1997; Silburn et al., 2006). These are compounded by social disadvantage, poverty, rapid social change, and, in some areas, the development of dysfunctional community environments where there are few resources and inadequate and uncoordinated service provision. The Aboriginal and Torres Strait Islander population comprises around 2.5% of the Australian population and this figure is increasing, with the largest number living in New South Wales (Australian Bureau of Statistics, 2012). Over half of the national population are urbanised. However, in contrast, over 30% of the population of the Northern Territory are of Aboriginal descent, and at least half live in remote or very remote communities where variants of traditional languages, cultures, and practices continue to be observed, and access to basic services is often very limited. Australia's Indigenous population is much younger than the non-Indigenous population (median age 21 years vs. 37 years), and nationwide approximately 36% of the Indigenous population are aged 0-15 years. Aboriginal and Torres Strait Islander women also have a higher birth-rate and are more likely to have children at a younger age (Australian Institute of Health and Welfare, 2012a). One effect of this is that, in addition to parents being younger, children vastly outnumber adults in many Aboriginal families, and many of
those adults suffer a substantial burden of chronic disease (Australian Medical Association, 2012). The Indigenous ratio of adults to children is around one third that of the non-Indigenous population, a very different family context for child-rearing and a commonly overlooked non-cultural factor shaping the reliance of many Indigenous families on extended families and kinship networks. This supports anecdotal reports of Indigenous grandparents and aunties feeling overburdened, and is one aspect of the difficulties in recruiting sufficient Indigenous foster carers (Higgins, Bromfield, & Richardson, 2005; Silburn et al., 2013). Culture, parenting, and family functioning No culture is static or homogeneous; rather, culture is continuously evolving with great variation in patterns of childrearing and family functioning. Traditional Aboriginal rearing practices have been subject to pervasive change in response to the direct and indirect effects of European settlement. These include Government policies specifically targeting Aboriginal families and communities, and the rapid social and multicultural transformations impacting on all families and contributing to the great diversity in contemporary Australian family life. Family functioning and parenting quality are shown to be core determinants of children's health, development, and physical, cognitive, social, and emotional outcomes, mediating the impact of genetic as well as environmental risk factors, including poverty. There is little agreement in the literature about what constitutes optimal family functioning or how this should be measured objectively (Walker & Shepherd, 2008). Core dimensions of parenting and family functioning can be defined as: (a) care (meeting the child's needs for physical, emotional and social wellbeing, and safety); (b) control (setting and enforcing appropriate boundaries); and (c) development (realising the child's potential in various domains) (Hoghughi & Long, 2004). Family functioning cannot be considered in isolation from a wide range of other social and economic factors. Chronic adversity, parental physical and mental illness, current substance abuse, and past or present exposure to violence and trauma are all shown to impact on parenting and, therefore, on child development and wellbeing. Parenting and family interventions in Australia Parenting programs have become central to strategies to improve child outcomes nationally and internationally. These include home visiting programs, structured parenting courses, and targeted interventions with symptomatic families and children. Often based on adaptations of international models for which there is some evidence base, programs targeting Aboriginal families are increasingly delivered across Australia. For the most part, the adaptation of these approaches is unsystematic, unreported, and not evaluated. There has been little examination of the theoretical underpinnings or the process of cultural and pragmatic adaptations needed to support engagement and delivery for Aboriginal families, particularly in remote contexts.
Evidence suggests that parenting and family interventions tend to be more effective when children are younger, behaviour problems are less severe, there is less psychosocial disadvantage, and the family has supports. Scott and Dadds (2009) emphasise that standard parent training based on social learning theory and behavioural approaches may be insufficient for families or parents with multiple problems. Where there is a burden of significant adversity, as is true for many Aboriginal families, or where children have experienced maltreatment or attachment related trauma, targeted support in several domains may include addressing parental mental illness, substance misuse, and family violence. At the same time, there is a need for support to address the impact of cumulative disadvantage. Partnership with, or referral of the family to, Indigenous primary health services to address broader psychosocial and health issues may support delivery of a focused psychological intervention. It is essential that the needs and experience of children are not overlooked in situations of great family complexity and vulnerability. There is evidence for the effectiveness of a number of parenting interventions (Eyberg, Nelson, & Boggs, 2008; Reid, Webster-Stratton, & Baydar, 2004). In Australia, the Triple P Positive Parenting Program is the most widely adopted and rigorously evaluated parenting intervention (Sanders, Turner, & Markie-Dadds, 2002), although a recent meta-analysis raised questions about the strength of the evidence for the effectiveness of Triple P at a population level (Wilson et al., 2012). A trial of Triple P with urban Aboriginal families reported positive outcomes (Turner, Richards, & Sanders, 2007). However, this small study had high rates of attrition, casting doubt on its effectiveness and wider applicability without further attention to engagement and improving retention. This is a problem common to many interventions offered to Aboriginal families, where standards of evidence for the best credentialed parenting interventions have been difficult, if not impossible, to obtain. One parenting program that has been delivered and evaluated, albeit without a control group, for Aboriginal families and young children in a range of Northern Territory urban and remote communities is Let's Start. This parent-child group program was developed and trialled in a range of diverse urban, rural, and remote settings. Relying on multiple measures and informants, both quantitative and qualitative analyses of responses to the program were positive, and included statistically significant reductions in problems and risk behaviours among participating children, and strongly significant reductions in parental distress (Mares & Robinson, 2012; Robinson, Tyler, Jones, Silburn, & Zubrick, 2011). However, there were high rates of attrition among both urban and remote Indigenous participants, suggesting that issues of access, engagement, and acceptability are common to such interventions for Aboriginal parents.
Social and emotional wellbeing and mental health
Very high rates of psychological distress are identified within the Indigenous adult community (Australian Institute of Health and Welfare, 2009; Jorm, Bourchier, Cvetkovski, & Stewart, 2012) and many of these adults are parents. Aboriginal people are less likely to engage with mainstream
mental health services. When they do, they are likely to present at a more chronic level and to remain for a shorter time (Parker, 2010). It has been argued that this indicates a failure of mainstream services to embrace Indigenous concepts of health and wellbeing and to understand the historical context and pervasiveness of racial oppression and social disadvantage (Dudgeon, Picket, & Garvey, 2000; Westerman, 2010). Hunter and Milroy (2013) provide a summary of changes in the field of Indigenous mental health over the last 50 years. The empirical evidence that supports the delivery of a range of psychosocial interventions that have been implemented with Aboriginal and Torres Strait Islander adults and communities was recently reviewed by Day and Francisco (2013). Protocols for mental health service delivery in Indigenous communities have been outlined (Haswell et al., 2009) but less has been written about the social and emotional wellbeing of Aboriginal and Torres Strait Islander children (Bamblett et al., 2012).
The Longitudinal Study of Australian Children (Department of Families, Housing, Community Services and Indigenous Affairs, 2013) included a cohort of urban Indigenous children. This study found that, at 4-5 years and 10-11 years, Indigenous children had significantly poorer social-emotional wellbeing than non-Indigenous children. The Strengths and Difficulties Questionnaire, for children aged 3-16 years (Goodman, 1997), was used in the study. It has been reported to be culturally acceptable to clinicians working in Aboriginal health services in one region of Australia (Williamson et al., 2010a). On each of the subscales, even when socio-economic circumstances were controlled for, Indigenous children in the sample had poorer outcomes (Baxter, 2013). The Western Australian Child Health Survey (Zubrick et al., 2005) also reported data on Indigenous children and adolescents, using carer or teacher report, with a variant of the Strengths and Difficulties Questionnaire. In a review of the assessment tools and measures that have been used with Aboriginal children, Bamblett et al. (2012) stated that the use of standardised outcome measures has inherent risks "if implemented outside a cultural competence framework. The essential role of outcome measures ... is to benefit the children ... and to guide program planning, policy, and research to benefit all children" (p. 7). They suggested that mainstream approaches often ignore important aspects of Aboriginal children's social and emotional wellbeing, in particular their cultural and family connections. They proposed a "conceptual map" as a guide to exploring and developing children's cultural connections. This includes "who you are (personal identity), who you belong to (family, community), where you belong (country), what you do (participation, expression), where you come from (family history), and what you believe (values, beliefs, practices)"( p. 67). Service models and examples At the service level there are various ways in which organisations address the need to be accessible to Aboriginal and Torres Strait Islander families. Many states have established services specifically for Indigenous families and children; for example, the Aboriginal Family Support Services in South Australia, and Kummara Indigenous Family Care in
Queensland. Although they were established with the aim of improving access to, and utilisation of, family focussed services, there is no current evidence of the impact of these centres on child outcomes. There is preliminary evidence of the effectiveness of this model in findings from the Aboriginal Family Birthing Program in South Australia. This program enables women to be cared for during pregnancy and birth by an Aboriginal maternal infant care worker in partnership with mainstream service providers (Glover et al., 2013).
The increasing focus on approaches to healing for Aboriginal families and communities (Caruana, 2010) and the imperative to consider not only the needs of the whole person, but of the families and communities to which they belong, has led to the establishment of the Aboriginal and Torres Strait Islander Healing Foundation. Established in 2009, this aims to provide practical and innovative healing services to Aboriginal and Torres Strait Islander peoples as well as support to similar organisations. Employment of Aboriginal clinicians and cultural consultants within health and mental health services occurs in some mainstream urban services. A related approach to service delivery, particularly in regional and remote areas, utilises what can be called "therapeutic pairs", that is, a professional working with an Indigenous health or mental health worker. This is a key element of the approach of the Mobile Outreach Service Plus, a service in remote communities for Aboriginal and Torres Strait Islander children who have experienced trauma. There is a need to train and support Aboriginal workers in these positions as they carry significant professional, community, and family obligations. Often they do not have training in, and cannot invoke, protective frameworks and professional boundaries in the same way as clinicians from "outside" the community. Other services have developed specific programs in response to the needs of their client group. For example, Berry Street in Victoria has developed 'Yarning up on Trauma', training to assist workers in Aboriginal and Torres Strait Islander community organisations to recognise and deal with traumas of their own, as well as those of the children and families with whom they work. A qualitative evaluation of this program was strongly positive (Frederico, Jackson, & Black, 2010). Partnership with Aboriginal identified service providers and Aboriginal health or cultural workers, along with, at times, the use of interpreters, will be required, particularly when working with families in or from remote communities where English is a second or third language. There may also be a need to ensure a confidential and safe therapeutic space to shield families or individuals from the impacts of organisational politics, conflicts, and tensions within the community. At a theoretical level, narrative approaches to work with individuals, families, and children have been well defined by Epston and White (1992). Although there are few published outcome studies, it has been argued that such approaches are useful in work with Australian Indigenous families and communities (Agius & Hamer, 2003; Denborough et al., 2006).
This approach is described as 'holistic' in that spiritual meanings, physical symptoms, family and community expectations, and emotional reactions can all be included. Incorporation of narrative approaches into the Let's Start intervention with families and children in remote Aboriginal communities is outlined by Stock, Mares, and Robinson (2012). Aboriginal children are greatly overrepresented in child care and protection systems and this is due to a complex and cumulative range of factors (Australian Institute of Health and Welfare, 2012b; Delfabbro, Hirte, Rogers, & Wilson, 2010). The developing literature on trauma informed care includes care for children who have experienced maltreatment. Atkinson (2013) summarises the current literature on trauma informed services and care for Indigenous Australian children. The understanding that achieving positive outcomes for traumatised children, including Aboriginal children, requires a community and family orientation along with a cultural perspective, is not always put into practice (Frederico et al., 2010). Approaches to engagement and intervention It is necessary for practitioners to examine the assumptions and models underpinning their practice and the services in which they work. This is particularly true when many psychological interventions are based on models locating both psychopathology and the "locus of change" within the individual. This is an ongoing tension, particularly within psychiatric diagnostic and classification systems. Given the clear relational context of development, it is particularly problematic when working with children. It requires additional examination in the context of work with families in cultures based on collectivist notions of identity and obligation, where extensive kin relationships do not fit neatly with simplified nuclear notions of family composition and structure. There is an accumulating literature advocating culturally appropriate strategies and approaches to work with Aboriginal and Torres Strait Islander families (Arney, Bowering, Chong, Healy, & Volkmer, 2010; Caruana, 2010; Milroy, 2008; Walker & Shepherd, 2008), but little published evaluation of the impact of these strategies on program participation or child outcomes. In summary, these authors suggest that culturally safe and accessible programs will include a less formal approach to service delivery, encouraging talk and shared activities, and working in ways that demonstrate the importance of family and community, including the role of Elders. They will include some community control of services and choice about program priorities, and be informed by an integrative and holistic understanding of health and wellbeing (Williamson et al., 2010b). Practice suggestions Engagement • Keep in mind the history of Aboriginal people in Australia, including forced separations and family disruptions, negative experiences of "welfare", and local
customs and cultural practices, but do not assume you know anything about the individual family, and their particular history and concerns. • Take time to introduce yourself, as a person as well as a professional. Make sure the family and child know who you are and why you are visiting or offering an appointment. More than one contact may be required before you can assume engagement. • Be direct in explaining your obligations about safety of children and other family members, including risks related to family violence and/or substance use. Inform the family about mandatory reporting requirements at the outset. • Be reliable. Turn up when you say you will and do what you have said you will do. Clinical practice • Take enough time to consider what the family identify as their priorities and what they hope to get out of the contact. This process may take longer than anticipated but it is essential to listen carefully and to tolerate silences. • Be interested and patient; allow trust to develop before you expect intimate and personal issues to be discussed. • Always consider the needs and presentation of the individual child within their family and community context. A cultural and community orientation is essential. • Do not forget the children's experience, even though the adult and family stories can be overwhelming. • Support parents in a non-judgemental way; help them to be interested in, and to think about, their children's needs and experience. • Notice when parents and children seem to get things right and mention it. • Pay careful attention to ending, debriefing, feedback, and any needs for follow-up or additional support. Organisation • When possible and indicated, work with Aboriginal controlled services or Aboriginal health or mental health workers to ensure that often complex medical and social issues can be addressed in a coordinated way. • Recognise that when a lot of services are visiting a community or family and English is not a first language, it may take time for them to understand what your service offers and to give it priority. • Work with an interpreter or cultural worker/consultant when necessary. • Consider how your service or organisation might be made more accessible and 'safe" for Aboriginal and Torres Strait Islander families. • Undertake accredited or recommended training in cross cultural communication, cultural awareness, cultural competence, or cultural safety. Conclusion There is great diversity among Aboriginal families and communities. Although most Aboriginal people live in urban settings, both the proportion of Aboriginal people in the community and the proportion experiencing disadvantage increase greatly with remoteness. Work with vulnerable families must be based on practices of engagement that
acknowledge the local community, its values, its leadership, and its resources. In addition to showing respect for culture and community history, the key principles of practice must emphasise a high degree of responsiveness to the individual family, parent, and child. There is often far more variation between the needs and difficulties of individuals and their families than there is between community or cultural settings. Reference to, and respect for, community leadership and culture does not guarantee the capacity to recognise the specific needs of individuals and their families. The family and practitioner need to find a way together to explore and share important experiences and aspirations. The safety of the child and family must be ensured within culturally informed, accessible, and targeted interventions that address quality of parenting and family relationships in order to address the child's individual needs. Parent training programs are identified as first line interventions for uncomplicated presentations to address parents' needs to acquire skills to deal with behavioural challenges. However, careful attention must be given to developing models for therapeutic practice and preventive early intervention that deal with more complex needs and adversities. The greater the difficulties facing the family, the more likely that sensitive engagement over time, and collaboration with other services, will be needed to overcome barriers to participation and retention in treatment. Clinicians working with Aboriginal people should be mindful of the critical importance of family and identity issues, and the need to assess additional physical health or social factors that may complicate a diagnosis or presentation. Improvements in access to mental health and family services for Aboriginal people, and a more holistic approach to developmental, health, and mental health treatment is urgently required.
References Afifi, T. O., Enns, M. W., Cox B. J., Asmundson, G. J. G., Stein, M.
B., & Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946-52.
Agius, T., & Hamer, J. (2003). Thoughts on narrative therapy - Contributions to Indigenous mental health. Auseinetter, 18, August, 8-9. Retrieved from http://pandora.nla.gov.au/pan/10581/20040604-0000/auseinet.flinders.edu.au/resources/auseinet/netter18/auseinetter_18.pdf
Arney, F., Bowering, K., Chong, A., Healy, V., & Volkmer, B. (2010). Sustained nurse home visiting with families of Aboriginal children. In D. Scott, & F. Arney (Eds.), Working with vulnerable families: A partnership approach (pp. 109-134). Melbourne, Australia: Cambridge University Press.
Atkinson, J. (2013). Trauma-informed services and trauma-specific care for Indigenous Australian children. Resource sheet no. 21. Produced for the Closing the Gap Clearinghouse. Canberra, Australia: Australian Institute of Health and Welfare. Retrieved from http://www.aihw.gov.au/closingthegap/publications/
Australian Bureau of Statistics. (2012). Australian demographic statistics, March quarter 2012. Canberra, Australia: Author.
Australian Institute of Health and Welfare. (2009). Measuring the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. Canberra, Australia: Author. Retrieved from http://www.aihw.gov.au/publication-detail/?id=6442468208
Australian Institute of Health and Welfare. (2012a). A picture of Australia's children 2012. Canberra, Australia: Author. Retrieved from http://www.aihw.gov.au/publication-detail/?id=10737423343
Australian Institute of Health and Welfare. (2012b). The health and welfare of Australia's Aboriginal and Torres Strait Islander people. Canberra: Australia: Author.
Australian Medical Association. (2012). AMA Aboriginal and Torres Strait Islander Health Audit Report 2012: Progress to date and challenges that remain. Canberra, Australia: Author. Retrieved from https://ama.com.au/aboriginal-and-torres-strait-islander-health-report-cards
Bamblett, M., Frederico, M., Harrison, J., Jackson, A., & Lewis, P. (2012). 'Not One Size Fits All' - Understanding the social & emotional wellbeing of Aboriginal children. Bundoora, Australia: La Trobe University. Retrieved from http://www.childhoodinstitute.org.au/Assets/226/1/NotOneSizeFitsAllreportfinalNov2012.pdf
Baxter, J. (2013). The family circumstances and wellbeing of Indigenous and non-Indigenous children. The Longitudinal Study of Australian Children Annual statistical report 2012 (pp. 149-171). Melbourne, Australia: Australian Institute of Family Studies. Retrieved from http://www.growingupinaustralia.gov.au/pubs/asr/2012/asr2012j.html
Caruana, C. (2010) Healing services for Indigenous people. Family Relationships Quarterly, 13, 3-9.
Day, A., & Francisco, A. (2013). Social and emotional wellbeing in Indigenous Australians: Identifying promising interventions. Australian and New Zealand Journal of Public Health, 37(4), 350-355.
Delfabbro, P., Hirte, C., Rogers, N., & Wilson, R. (2010). The over-representation of young Aboriginal or Torres Strait Islander people in the South Australian child system: A longitudinal analysis. Children and Youth Services Review, 32(10), 1418-1425.
Denborough, D., Koolmatrie, C., Munuggirritj, D., Marika, D., Dhurrkay, W., & Yunupingu, M. (2006). Linking stories and initiatives: A narrative approach to working with the skills and knowledge of communities. The International Journal of Narrative Therapy and Community Work, No. 2. Retrieved from http://www.dulwichcentre.com.au/articles-about-narrative-therapy.html
Department of Families, Housing, Community Services and Indigenous Affairs. (2013). Footprints in time – The Longitudinal Study of Indigenous Children. Report from Wave 4. Retrieved from http://www.fahcsia.gov.au/about-fahcsia/publications-articles/research-publications/longitudinal-data-initiatives/footprints-in-time-the-longitudinal-study-of-indigenous-children-lsic
Downing, R., Kowal, E., & Paradies, Y. (2011). Indigenous cultural training for health workers in Australia. International Journal for Quality in Health Care, 23. Retrieved from http://intqhc.oxfordjournals.org/content/23/3/247.short
Dudgeon, P., Garvey, D., & Pickett, H. (2000). Working with Indigenous Australians: A handbook for psychologists. Perth, Australia: Gunada Press.
Epston, D., & White, M. (1992). Experience, contradiction, narrative & imagination: Selected papers of David Epston & Michael White 1989–1991. Adelaide, South Australia: Dulwich Centre Publications.
Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behaviour. Journal of Clinical Child and Adolescent Psychology, 37(1), 215-237.
Felitti, V. J., & Anda, R. F. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The hidden epidemic: The impact of early life trauma on health and disease (pp 77-87). Cambridge, England: Cambridge University Press.
Frederico, M., Jackson, A., & Black, C. (2010). More than words – the language of relationships. Take Two – third evaluation report. Bundoora, Australia: School of Social Work and Social Policy, La Trobe University.
Glover, K., Buckskin, M., Ah Kit, J., Miller, R., Weetra, D., Gartland, D., … Brown, S. (2013). Antenatal care: Experiences of Aboriginal women and families in South Australia. Preliminary findings of the Aboriginal families study. Melbourne, Australia: Murdoch Childrens [sic] Research Institute.
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581-586.
Haswell-Elkins, M., Hunter, E., Wargent, R., Hall, B., O'Higgins, C., & West, R. (2009). Protocols for the delivery of social and emotional wellbeing and mental health services in Indigenous communities: Guidelines for health workers, clinicians, consumers and carers. Cairns, Australia: Australian Integrated Mental Health Initiative, Queensland Health.
Higgins, D., Bromfield, L., & Richardson, N. (2005). Enhancing out-of-home care for Aboriginal and Torres Strait Islander young people. Canberra, Australia: Australian Institute of Family Studies. Retrieved from http://www.aifs.gov.au/nch/pubs/reports/empirical/empirical.html
Hoghughi, M., & Long N. (2004). Handbook of parenting theory and research for practice. London: Sage.
Human Rights and Equal Opportunities Commission. (1997). Bringing them home: Report of the national inquiry into the separation of Aboriginal and Torres Strait Islander children from their families. Canberra, Australia: Author. Retrieved from http://www.humanrights.gov.au/publications/bringing-them-home-stolen-children-report-1997
Jorm, A. F., Bourchier, S. J., Cvetkovski, S., & Stewart, G. (2012). Mental health of Indigenous Australians: A review of findings from community surveys. Medical Journal of Australia, 196, 118-121.
Mares, S., & Robinson, G. (2012). Culture, context and therapeutic processes: Delivering a parent-child intervention in a remote Aboriginal community. Australasian Psychiatry, 20(2), 102-107.
Milroy, H. (2008). Children are our future: Understanding the needs of Aboriginal children and their families. In A. S. Williams & V. Cowling (Eds.), Infants of parents with mental illness: Developmental, clinical, cultural and personal perspectives. Brisbane, Australia: Australian Academic Press.
Parker, R. (2010). Australia's Aboriginal population and mental health. The Journal of Nervous and Mental Disease, 198(1), 3-7.
Price-Robertson, R., McDonald, M., Lewis, P., & Bamblett, M. (2011). Working with Indigenous children, families, and communities: Lessons from practice. Melbourne, Australia: Australian Institute of Family Studies. Retrieved from http://www.aifs.gov.au/cafca/pubs/sheets/ps/ps6.html
Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004). Halting the development of conduct problems in Head Start children: The effects of parent training. Journal of Clinical Child and Adolescent Psychology, 33(2), 279-291.
Robinson, G., Tyler, W., Jones, Y., Silburn, S., & Zubrick, S. (2011). Context, diversity and engagement: Early intervention with Australian Aboriginal families in urban and remote contexts. Children and Society, 26(5), 343-355.
Sanders, M. R., Turner, K. M. T., & Markie-Dadds, C. (2002). The development and dissemination of the Triple P-Positive Parenting Program: A multilevel, evidence-based system of parenting and family support. Prevention Science, 3(3), 173-189.
Scott, S., & Dadds, M. R. (2009). Practitioner review: When parent training doesn't work: theory-driven clinical strategies. Journal of Child Psychology and Psychiatry, 50(12), 1441-1450.
Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S., … & Wood, D. L. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, e232-e246. Retrieved from http://pediatrics.aappublications.org/content/129/1/e232.full.pdf
Silburn, S., McGuinness, K., Dwyer, B., McDonald, T., Cocker, T., Poyner, E., … Munday, J. (2013). Findings from the first-stage focus groups for the development of a NT-wide campaign to prevent child abuse and neglect: Interim report to the Northern Territory Office of Children and Families. Darwin, Australia: Centre for Child Development and Education, Menzies School of Health Research.,
Silburn, S., Zubrick, S., Lawrence, D., Mitrou, F., De Maio, J., Blair, E., … Hayward, C. (2006). The intergenerational effects of forced separation on the social and emotional wellbeing of Aboriginal children and young people. Family Matters, 75, 4-9.
Stock, C., Mares, S., & Robinson, G. (2012). Telling and re-telling stories: The use of narrative and drawing in a group intervention with parents and children in a remote Aboriginal community. Australian and New Zealand Journal of Family Therapy, 33(2), 157-170.
Turner, K., Richards, M., & Sanders, M. (2007). Randomised clinical trial of a group parent education programme for Australian Indigenous families. Journal of Paediatrics and Child Health, 43, 429–437.
Walker, R., & Shepherd, C. (2008). Strengthening Aboriginal family functioning: What works and why? Kulunga Research Network, Telethon Institute for Child Health Research Australian Family Relationships Clearinghouse AFRC Briefing No. 7. Melbourne, Australia: Australian Institute of Family Studies. Retrieved from http://www.aifs.gov.au/afrc/pubs/briefing/briefing7.html
Westerman, T. (2010). Engaging Australian Aboriginal youth in mental health services. Australian Psychologist, 45(3), 212-222.
Williamson, A. B., Raphael, B., Redman, S., Daniels, J., Eades, S. J., & Mayers, N. (2010b). Emerging themes in Aboriginal child and adolescent mental health: Findings from a qualitative study in Sydney, New South Wales. Medical Journal of Australia, 192(10), 603.
Williamson, A., Redman, S., Dadds, M., Daniels, J., D'Este, C., Raphael, B., … Skinner, T. (2010a). Acceptability of an emotional and behavioural screening tool for children in Aboriginal Community Controlled Health Services in urban NSW. Australian and New Zealand Journal of Psychiatry, 44, 894-900.
Wilson, P., Rush, R., Hussey, S., Puckering, C., Sim, F., Allely, C. S., ... Gillberg, C. (2012). How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P. BMC Medicine, 10(1), 130.
Zubrick, S. R., Silburn, S. R., Lawrence, D. M., Mitrou, F. G., Dalby, R. B., Blair, E. M., … Li, J. (2005). The Western Australian Aboriginal child health survey: The social and emotional wellbeing of Aboriginal children and young people. Perth, Australia: Curtin University of Technology and Telethon Institute for Child Health Research.
Ethical Issues in Family Therapy Giles Burch, DCP PhD Associate Editor
hile the consideration of ethical issues in all types of therapy is of critical importance, as pointed out by Negash and Hecker (2010), when the unit of treatment comprises more than just one client, the
resultant dynamics present the therapist with a range of "unique ethical and legal issues" (p. 225). Over the past 40 years or so, numerous articles and book chapters have been published that have considered a range of ethical issues, in couple and family therapy, that have highlighted the complexity of such matters as confidentiality (or multiconfidentiality), keeping secrets, therapist's values, professional competency, dual relationships, informed consent, use of the DSM, and withholding services from families and non-attending members (e.g., Hines & Hare-Mustin, 1978; Margolin, 1982; Negash & Hecker, 2010; Shaw, 2011a; Walrond-Skinner & Watson, 1987; Zygmond & Boorhem, 1989). It is not possible to consider all the issues in this column, but I have decided to raise some of the main points in relation to: (1) informed consent; (2) confidentiality; and (3) use of the DSM, in order to illustrate some of the ethical complexities family therapists may face. Informed consent Informed consent is standard practice in therapy. However, such standard practice raises a number of ethical dilemmas in the case of family therapy when a number of people (i.e., all involved family members) are required to give that informed consent. As Ramisch (2012) notes, informed consent requires passing to the client of clear information that explains all risks and benefits associated with therapy, and provides the client with the option to withdraw from therapy at any time. In family therapy, such a process is a source of tension when such risks and benefits may be different for each person; that is, a particular outcome may be more desirable for one member of the family than for another (Margolin, 1982). The other main source of tension arises when one family member is keener than another member to participate in therapy. This has a particular bearing on the client's option to engage in and/or withdraw from therapy (Margolin, 1982), when the 'less willing' family member may feel coerced into therapy by other family members (or even by the therapist). Indeed, Shaw (2011a) pointed out how "social coercion" comes into play when asking the family member setting up the initial appointment to convene all family members for a meeting. These are complex issues and, as Ramisch points out, "informed consent is about a process and a dialogue. It is not simply a piece of paper that is signed" (p. 207). It is through this process and dialogue that these complexities can be addressed. Finally, Ramisch observes that children and
people with disabilities should be involved in this process as much as they possibly can. Confidentiality While confidentiality is paramount in any therapeutic relationship, within family therapy this can become a particularly complicated issue. Indeed, Ellis (2012) has suggested that "the privacy rights of patients and other family members in marital and family treatment cases is one of the most complex areas at the intersection of law and ethics" (p. 372). This is made even more complicated when there is a need to identify one member of the family as the 'patient' (see 'Use of the DSM' below). Margolin (1982) identified two approaches to confidentiality in family therapy: 1. To treat each person involved in therapy as though they
were an individual client, or 2. To not allow the hiding of secrets within therapy.
The source of tension here is whether individual family members have a right to confidentiality, or whether holding information back (keeping secrets from the rest of the family) is detrimental to the therapeutic process. This issue of confidentiality is of particular concern when one party may choose to keep confidential an issue that may have a critical impact on others in the family or on the family dynamics. However, as Shaw (2011a) points out, the issue of confidentiality is important when assessing for such factors as abuse. Ellis suggested that, in an ideal world, an agreement would be signed by all parties giving each of them "equal rights" in relation to the confidentiality of what they say. Meanwhile, Negash and Hecker (2010) have suggested that in order to avoid intruding on client's privacy and avoid ethical transgressions, keeping consent forms up-to-date, documenting information appropriately in case notes, and promoting an honest (no secrets) environment in therapy should generally help the therapist. Use of the DSM Negash and Hecker (2010) have highlighted the ethical dilemma for therapists using the DSM in family therapy. This is a particular issue when individual diagnosis is necessary for financial reimbursement of services provided – which is particularly the case in the USA. They suggested that the use of the DSM runs counter to systems theories underlying family therapy, and may even "perpetuate the dysfunctional system" (p. 228). However, Benson, Long, & Sporakowski (as cited in Negash & Hecker, 2010) have suggested that an individual DSM diagnosis does not rule out working systemically. Ellis (2012) also highlighted that by providing an individual diagnosis, the question is raised as to who is actually the 'patient'. Ellis went on to suggest that the therapist should discuss this issue openly as part of the informed consent process, and a mutual agreement should be achieved. The use of individual diagnosis within family therapy is a clear source of tension for the therapist. Negash and Hecker advise adhering closely to ethical codes of practice in order to avoid making violations of ethical practice.
Conclusion This brief column has highlighted some of the ethical issues that have been raised in the literature in relation to family therapy. However, this is only the starting point, and such ethical points should lay the foundation for decision-making in clinical practice. While this is beyond the scope of this brief column, readers are encouraged to delve further into the literature on ethical decision-making in family therapy and incorporate such processes into their modus operandi (see, for example, Hecker, 2010; Scher & Kozlowska; Shaw, 2011b; Zigmond & Boorhem, 1989).
References
Ellis, E. (2012). What are the confidentiality rights of collaterals in family therapy? The American Journal of Family Therapy, 40, 369-384.
Hecker, L. L (2010). Ethical decision making. In L. L. Hecker (Ed.), Ethics and professional issues in couple and family therapy (pp. 13-28). New York, NY: Routledge.
Hines, P., & Hare-Mustin, R. (1978). Ethical concerns in family therapy. Professional Psychology, 9, 165-171.
Margolin, G. (1982). Ethical and legal considerations in marital and family therapy. American Psychologist, 37, 788-801.
Negash, S. M., & Hecker, L. L. (2010). Ethical issues endemic to couple and family therapy. In L. Hecker (Ed.), Ethics and professional issues in couple and family therapy (pp. 225-240). New York, NY: Routledge.
Ramisch, J. (2012). Ethical issues in clinical practice. In L. Hecker (Ed.), Ethics and professional issues in couple and family therapy (pp. 203-224). New York, NY: Routledge.
Scher, S., & Kozlowska, K. (2012). Thinking, doing, and the ethics of family therapy. The American Journal of Family Therapy, 40, 97-114.
Shaw, E. (2011a). Ethics and the practice of couple and family therapy. In Psych, February. Melbourne, Australia: Australian Psychological Society.
Shaw, E. (2011b). Relational ethics and moral imagination in contemporary systemic practice. The Australian and New Zealand Journal of Family Therapy, 32, 1-14.
Walrond-Skinner, & Watson, D. H. (Eds.). (1987). Ethical issues in family therapy. London, England: Routledge.
Zygmond, M. J., & Boorhem, H. (1989). Ethical decision making in family therapy. Family Processes, 28, 269-280.
STUDENT AND TRAINING MATTERS The Experience of the First Practicum Dixie Statham, BA(Hons) MClinPsych DPsych School of Social Sciences University of the Sunshine Coast, Sippy Downs, QLD Julie Pellas, BSc(Hons) DipSc(Psych) BA School of Social Sciences University of the Sunshine Coast, Sippy Downs, QLD Dixie Statham is a senior lecturer in clinical psychology and Director of the USC Psychology Clinic. Julie Pellas is a full-time student undertaking her first year of postgraduate training in clinical psychology. Please address all correspondence to: Dixie Statham, PhD Email: [email protected] As part of their clinical portfolio, clinical psychology students at the University of the Sunshine Coast write reflections on their first practicum experience. The 2013 cohort of students was invited to provide excerpts from these for publication in The ACPARIAN.
ndertaking clinical training is an exciting yet daunting endeavour for most clinical postgraduate students as they begin the next step in their professional career. Striving to excel in a clinical program and developing
the competencies required of a clinical psychologist is a demanding process. Across Australian universities there is variation in the timing of the first practicum; in some clinical programs, students begin working with clients in their first semester, while in others this work may begin in the second or third semester. The number of practicums within different clinical programs also varies, with some dividing the 1000 required hours (1500 for doctoral students) across either three or four placements. In addition to the subtle differences across clinical training programs, students also vary in terms of the amount of prior experience they bring to the practicum. Clinical training programs may include general psychologists who have been working for many years, those who are changing careers to become psychologists, and those who are continuing on from their honours program. Despite these differences, the first practicum is often the most challenging. Learning curves are often steep and the work pressures are great as students manage not only their direct client work but also attend to all of the other demands of their program, including lectures, assignments, case presentations, and meetings. While their experiences are diverse, students bring their personal strengths to the work which assists them to
manage the often intense pressure of working in their new and challenging role. These are the words of the eight students who volunteered to share their reflections with the readers of The ACPARIAN. Student 1 “I found I enjoyed the client contact and, with my supervisor’s support, generally felt confident in identifying their needs and being able to apply a range of novel techniques, as well as more familiar practices. By contrast, I felt quite overwhelmed by the amount of paperwork required to appropriately document the client sessions, and develop written case formulations and treatment plans. Despite this, I have valued these tasks, as they forced me to pay careful attention to every aspect of treatment, and assisted me in improving my clinical assessment and report writing skills.” Student 2 “While still experiencing levels of uncertainty, self-doubt, and nervousness that originally challenged a 10 year long dream to become a psychologist, I very quickly began to feel like this was where I was meant to be. I remind myself constantly of how lucky I am that I have been given this amazing opportunity. My abilities and professional development over the past few months have been far beyond what I had expected. While I am proud of myself for my achievements, I am grateful for my fellow students, amazing supervisors, and inspiring lecturers for making this life changing process possible and enjoyable … .” Student 3 “I have had to develop exceptional coping and organisational skills and, although there have been occasions when the workload appeared limitless, I was able to break down the tasks into smaller, more manageable components which facilitated my progression through the practicum. Professionally, I initially had little knowledge of diagnostic classification systems, cognitive behaviour therapy, and evidence-based therapeutic interventions. … With each new client I am feeling more comfortable with developing and explaining formulations based on the cognitive behavioural model and developing treatment plans based on those formulations. Of importance, my confidence and knowledge have grown throughout this practicum, and I acknowledge that these will be areas of continual development … .” Student 4 “While the training provided strong preparation, the hurdle of a first client session was yet to be overcome. In my case, my client seemed just as eager to assess me as I was to assess her. She also seemed to have the upper-hand at first, arriving at the session armed with a psychiatrist’s diagnosis and a full treatment history. However, it was empowering to discover that my training had provided me with knowledge and skills that would be helpful to this client.”
Student 5 “I felt proud to be introduced to school staff as a psychologist on my first day at the school and it was at that moment that I realised that I had finally metamorphosed from “psychology student” to “psychologist”. Finally, after the many long years of study, assignments, and exams!! However, in addition to feelings of pride and excitement about working at the school on my own, deliberating my professional responsibility was also daunting. I was apprehensive about whether, at such an early stage of my career, I would have the ability to perform duties expected of me without having the immediate safeguard of Clinic personnel within close proximity. Despite this initial apprehension, working at the school and with the children and their families has been an extremely positive and rewarding experience.” Student 6 “The practicum has taught me the value of excellent supervision, not just receiving excellent professional advice but receiving supervision that encompasses the spirit of unconditional regard, and that values what a student brings to the table. “ Student 7 “… my basic interpersonal and counselling skills helped develop a growing confidence in my capacity to utilise a variety of cognitive and behavioural interventions acquired in lectures, in supervision, and through introspection. … my personal need to be organised has helped me to keep on top of all the documentation that has been required. I have enjoyed the collaboration and collegiality of working within a team again, including the capacity to laugh, debrief, support each other, share resources, and eat chocolate.” Student 8 “When presented with the psychology staff and clinic, I was very impressed with the set up and the genuinely friendly and caring staff members. … . After several weeks of lectures the client contact hours began with a cognitive assessment. … After much preparation, relaxation techniques, a big breakfast, and difficulty sleeping, my first ever client did not attend their session. I felt somewhat relieved, but for the most part disappointed. Consequently, my first session was with [this client]. After collaboratively deciding on the agenda, I took a deep breath, sat down, and have not looked back. With each client my confidence to successfully complete a session and utilise specific techniques grew.” Conclusion These reflections provide some insight into the tremendous personal and professional growth that postgraduate students in clinical psychology achieve through their first practicum experience. No less significant are the bonds of camaraderie and friendship that are forged through the experience.
Editorial Policy and Guidelines The ACPARIAN is the official e-Journal of the Australian Clinical Psychology Association and is published three times a year. Aim The ACPARIAN provides for the dissemination of knowledge on topics of interest informative to clinical psychologists. Its focus is on the latest clinical theory and research relevant to clinical practice including assessment and intervention, training and professional issues. Content Submissions to The ACPARIAN may include:
• letters to the Editor • general articles, viewpoints, opinions, and comments • articles of particular ethical and/or legal interest to
the profession • research reviews • theoretical perspectives • technology updates • students' news and viewpoints • book reviews • general information and announcements
From time to time, The ACPARIAN will focus on topics or issues of interest and call for submissions accordingly. The ACPA Editorial Board welcomes contributions and suggestions for topics from the membership. Contributions Submissions should be made electronically, in a Word document, to the Editor responsible for the relevant section:
Please observe the following word limits: • Letters to the Editor: 200 words • Feature articles, general, research reviews 2000 - 3000
words. A brief Abstract should accompany each paper: word limit 100 to 150 words Please use Australian-English spelling and ensure that in-text citations and Reference list are in APA (6th ed.) style. Please ensure that submissions are made by the stated deadline. Late submissions may not be accepted. Authors can expect the Editorial Board to review and change content for clarity and style. The Editorial Board will endeavour to make any significant revisions in consultation with the author. The Editor reserves the right to include or reject written works at any point in the publication process. All papers are submitted to peer review OR final acceptance of papers follows peer review. The views expressed by authors in The ACPARIAN do not necessarily reflect those of the ACPA Editorial Board. Editorial Board Editor Kaye Horley, PhD Associate Editors Giles Burch, DCP PhD Fiona Jamieson, MClinPsych Dixie Statham, PhD Copy Editor John Moulds, PhD Design Ben Callegari, MPsych(Clin)
February issue:
Relationships
Contributions are invited from those with clinical, psychotherapeutic, research, or other expertise in this area by 30 November, 2013. See Editorial Policy and Guidelines for submission requirements.
e-Journal of the Australian Clinical Psychology Association
2013 Advertising Rate Card Published February, June, October
Circulation Currently circulated to members on the Listserve and the ACPA Website (http://www.acpa.org.au/)
Advertising deadlines December 30 (February Issue), April 30 (June Issue), August 31(October Issue) ACPARIAN Rates1 Full page $400.00 (+ GST) Half page $200.00 (+ GST) Quarter page $100.00 (+ GST)
Multiple insertions Costs for multiple insertions shall be subject to negotiation with the Editorial Board
Advertising copy Advertisements are to be presented complete in Word, jpeg, and/or format that will allow layout without need for format conversion. No charges will be levied for colour
Notice to all advertisers 1. Events or activities that will be advertised in The ACPARIAN will be those deemed of relevance to the ACPA
membership 2. All applications and acceptance for advertising submitted to The ACPARIAN shall be subject to the consideration
and discretion of the ACPA Board and the ACPA Board of Directors 3. Acceptance and publication of an advertisement is not an endorsement by ACPA of the event, activity, or product 4. The topic of the event or activity shall not be similar to any upcoming official ACPA event 5. ACPA does not take responsibility for any copyright infringements related to the advertisement which is solely the
responsibility of the person placing the advertisement
Australian Clinical Psychology Association http://www.acpa.org.au
