practitioner review: when parent training doesn��t work: theory-driven clinical strategies

Practitioner Review: When parent trainingdoesn’t work: theory-driven clinical strategies

Stephen Scott1,2 and Mark R Dadds1,2,31King’s College London, Institute of Psychiatry, England; 2National Academy for Parenting Practitioners, England;

3University of New South Wales, Australia

Improving the parent–child relationship by using strategies based on social learning theory has becomethe cornerstone for the treatment of conduct problems in children. Over the past 40 years, interventionshave expanded greatly from small, experimental procedures to substantial, systematic programmesthat provide clear guidelines in detailed manuals on how practitioners should implement the stan-dardised treatments. They are now widely disseminated and there is a great deal of empirical supportthat they are very effective for the majority of cases. However, evaluations of even the best of theseevidence-based programmes show that a quarter to a third of families and their children do not benefit.What does the practitioner then do, when a standard social learning approach, diligently applied,doesn’t work? We argue that under these circumstances, some of the major theories of child develop-ment, family functioning and individual psychology can help the skilled practitioner think his or her waythrough complex clinical situations. This paper describes a set of practical strategies that can then beflexibly applied, based on a systematic theoretical analysis. We hold that social learning theory remainsthe core of effective parent training interventions, but that ideas from attachment theory, structuralfamily systems theory, cognitive-attribution theory, and shared empowerment/motivational interview-ing can each, according to the nature of the difficulty, greatly enrich the practitioner’s ability to helpbring about change in families who are stuck. We summarise each of these models and present practicalexamples of when and how they may help the clinician plan treatment. Keywords: Conduct disorder,antisocial behaviour, treatment, parent training, parent–child relationship.

Parent training programmes are very successful fortreating oppositional defiant and conduct disorders.There are a number of good general articles review-ing their content and effectiveness (e.g., Kazdin,2005; Reyno & McGrath, 2006); the one by Scott(2008) covers both attachment and social learningapproaches. This paper aims to complement thosereviews with a practical guide derived from ourclinical experience, including the programme ofDadds and Hawes (2006). Specifically, we presentuseful strategies derived from a range of theoreticalstandpoints. They are designed to stop things goingwrong in treatment, and to get them back on trackwhen they do. One of the joys of doing therapeuticwork, but also one of the complexities, is that thereare many useful theoretical approaches from whichto choose. The baseline from which we begin is sociallearning theory (SLT), which focuses on the impact ofexternal contingencies on the individual’s behaviour.This has been the dominant theory explaining anti-social behaviour in the past 30 or 40 years and hasled to extremely successful interventions set out indetailed manuals so that practitioners can deliverthem reliably. Controlled trials show that whenpractitioners are well trained and supervised, SLT-based programmes can be made to work for themajority of fairly severe cases under routine ‘real-life’clinical conditions (e.g., see Scott, Spender, Doolan,Jacobs, & Aspland, 2001).

However, even under optimal conditions, there arealways cases when the family doesn’t change. In thetrial cited above, a quarter of casesmade no progress.What does the clinician do then?Give up and label thefamily as ‘resistant’ or ‘not ready for therapy’ ? Webelieve that here a skilled practitioner deploys differ-ent strategies according to the demands of the situa-tion, drawing upon previous training and personalexperience of what has worked. This is sometimescalled ‘an eclectic approach’. However, as it is indi-vidual and unspecified, it may be good, bad or indif-ferent, and is hard to codify so it can be replicated byothers.We therefore wish to set out amore systematicapproach. It requires the practitioner to have a firmgrounding in four theoretical approaches as well asSLT, and to swing them in and out of action system-atically according to what is happening with thefamily. It gives the clinician a greater range of optionsthan found in any manual based on one theoreticalapproach.

Certainly, the best existing manuals do includesome procedures for maximising family engagement,minimising resistance, and problem-solving whenthings don’t go according to plan. But manuals canonly suggest so much, and beyond a certain pointthe practitioner needs to be able to think thingsthrough creatively and flexibly from first principles.We agree with Kurt Lewin’s axiom, that nothing isquite as practical as a good theory. The expert cli-nician, rather than having to rely on a limited num-ber of fixed, specific techniques, can think thingsConflict of interest statement: No conflicts declared.

Journal of Child Psychology and Psychiatry 50:12 (2009), pp 1441–1450 doi:10.1111/j.1469-7610.2009.02161.x

� 2009 The AuthorsJournal compilation � 2009 Association for Child and Adolescent Mental Health.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

through at the level of the underlying theory andthen come up with a wider range of skilful, creativesolutions. And practitioner skill is known to improvechild outcomes, over and above simple fidelity to themodel – more skilled practitioners get better results,and vice versa less skilled ones sometimes have noeffect and can even do harm (Scott, Carby, & Rendu,under review).

In this paper we present four theories that we havefound particularly useful for guiding interventionswith difficult and complex families when the stan-dard manualised SLT treatments don’t work. Weassume that a thorough assessment will have beencarried out, looking at the child’s problems, what isgoing on in the family, and whether there are par-ticular conditions or disorders that need attention(for an account of assessment see Scott, 2005). Theadditional theories we find useful are attachmenttheory, structural-systems theory, cognitive attri-bution theory, and shared empowerment/motiva-tional interviewing. We are not presenting these asalternatives to SLT, which provides a superb base forassessing and conceptualising problematic parent–child interactions that promote children’s antisocialbehaviour. However, any theory has its limitations,and a small set of complementary theoretical toolscan afford the practitioner greater scope to be flexibleand effective.

Social learning theory

Social learning theory evolved from general learningtheory and in particular operant behaviourism (Scott& Yule, 2008). The fundamental tenet is thatmoment-to-moment exchanges are crucial: if a childreceives an immediate reward for their behaviour,such as getting parental attention or approval, thenthey are more likely to do the behaviour again,whereas if they are ignored or punished then they areless likely to do it. This approach revolutionised workwith disruptive children in the late 1960s andremains the main evidence-based approach.

Patterson (1982) showed that two main processeswere operating in such families. First, parents modelantisocial and aggressive behaviour so the childlearns it too. Second, family process involves ‘rein-forcement traps’. For example, a parent makes anintrusive request of a child, the child protests withaversive behaviour, and the parent then backs off.Here the child is learning that if they get nasty, it iseffective in avoiding having to do somethingunpleasant. Consequently, the child is more likely todo it again. As the parent then gets more and moreaggressive and through this gets the child to obey,they too are learning that aggression works. Inanother reinforcement trap, the more a child engagesin undesirable behaviours, the less he or she will getreinforced for positive behaviours (Snyder &Stoolmiller, 2002). A range of efficacious behavioural

interventions has flowed from this model, such asParent–Child Interaction Therapy (Brinkmeyer &Eyberg, 2003), Parent Management Training fromOregon (Forgatch & DeGarmo, 1999), Triple P(Sanders, 2008), Helping the Noncompliant Child(McMahon & Forehand, 2003), and The IncredibleYears (Webster-Stratton & Reid, 2003). The appli-cation of operant principles to parent–child therapiesis one of the most potent innovations of the mentalhealth sciences; meta-analyses of scores of trials givelarge effect sizes (e.g., Lundahl, Risser, & Lovejoy,2006; National Institute for Clinical Excellence,2006; Reyno & McGrath, 2006).

For the practitioner, SLT offers clear principles fordirectly changing parenting behaviour that fostersand maintains child problems. It offers an explicitmethodology that parents can implement relativelyquickly – often they can be practising it within15 minutes of the first treatment session. The twoelements of increasing warmth and rewards forpositive behaviour, and setting clear limits and con-sequences for antisocial behaviour, can been given ineither order or simultaneously, according to clinicalneed. Usually, it is desirable to promote positivebehaviour first so the overall relationship improvesbefore punishments are given, but sometimes wherethe child is aggressive and disruptive, proceduressuch as time out need to be applied immediately togain control of the situation (Eisenstadt, Eyberg,McNeil, Newcomb, & Funderburk, 1993).

What is not covered by SLT, and when is thisimportant?

First, SLT defines rewards and punishers empiri-cally. That is, a parental behaviour is seen as a‘reward’ if it strengthens the child behaviour it fol-lows, and a ‘punisher’ if it weakens behaviour. Butexisting manuals seldom build in genuine assess-ments of which parent behaviours are rewarding andpunishing; rather, it is assumed that attention isrewarding, ‘time out’ is punishing and so on. SLT issilent on the issue of how and why attention, espe-cially from someone with whom the child is in a closerelationship, is rewarding. Attachment theory mayhelp here, especially when attention fails to berewarding.

Second, SLT developed by focusing on externallyobservable behaviour, ignoring the ‘black box’ of theinner world. But a common clinical scenario is whereparents cannot change because although they areclear how they should behave, they have strongbeliefs that prevent them doing so (‘he’s horrible andruins my life by winding me up, why should I be niceto him?’ ‘he’s so delicate and precious, it will harmhim if I upset him by being firm’). Most skilled cli-nicians know that addressing these thoughts andfeelings is crucial to treatment success and routinelywork with them, but existing manuals do notemphasise how. So what model can be used to think

1442 Stephen Scott and Mark R. Dadds

� 2009 The AuthorsJournal compilation � 2009 Association for Child and Adolescent Mental Health.

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about these cognitive-emotional processes in asystematic way? We argue that attribution theory,largely developed with social and health psychology(e.g., Abramson, Seligman, & Teasdale, 1978; Dix,Ruble, Grusec, & Nixon, 1986), provides a set oforganising principles for working with parentalbeliefs about their children and other family mem-bers in ways that can overcome blocks to change.

Third, its very strength in analysing moment-to-moment proximal interactions between parentsand children can come at the expense of attentionfocused on the larger system. SLT traditionallyfocuses on parent–child contingencies, but muchevidence is available to show that these are them-selves dependent on broader networks in which theyoccur, starting with the relationship between theparents themselves, and moving through the widerfamily, school and social network. It is helpful tohold in mind that healthy families show boundariesand hierarchies in how they are organised internallyand in relation to their social context, and to workwith these. Sometimes parent training doesn’t workbecause although one parent ‘gets it’ and puts theprinciples into practice, wider issues in the systemprevent progress, such as an undermining partner athome or bullying at school.

Fourth, SLT has had little to say about the familieswho simply don’t engage and won’t turn up. Yetantisocial children often have families who have nothad good experiences of authority and are suspiciousof outside agencies, have had many painful and dis-ruptive life events, lead rather chaotic lives, and arewary of attempts to help which anyway haven’tworked in the past. These families have high non-attendance and drop-out rates from treatment de-spite their children having the most severe problems(Kazdin, 2005), so that even well-run services oftenend up reaching only a small proportion of the overalltarget population. The skilled clinician thereforeneeds to have a systematic approach to fosteringengagement andminimising drop-out. We argue herethat two related ideas, shared empowerment andmotivational interviewing, can help by tapping intoandmaximising the aspirations andpassions of thesefamilies. We will now describe in greater detail howeach of these theoretical approaches can help thedelivery of parenting programmes.

Attachment theory

Bowlby (1982) and subsequent attachment theorists(Grossmann, Grossmann, &Waters, 2005) developeda model of parent–child relationships from a broadtheoretical base that included ethology. It focuses onthe nature, significance and function of a child’s tie tohis/her parent. Although based on observations ofchildren who experienced severely compromisedcaregiving, it has been widely applied as a model fornormal and abnormal development. However,‘parent–child attachment’ is not synonymous with

‘parent–child relationship’. Attachment focuses moreprecisely on how the parent protects the child againstharm and provides a sense of emotional security,providing a ‘secure base’ for exploration. Earlyattachment experiences do not shape subsequentdevelopment in a fixed, deterministic manner(Bowlby, 1988), so that insecure attachment is notsynonymous with disturbance, nor is secure attach-ment a guarantee against disturbance.

Attachment-based interventions have been devel-oped for a range of clinical problems (Cicchetti, Rog-osch, & Toth, 2006; Hoffman, Marvin, Cooper, &Powell, 2006; Dozier, Lindhiem, & Ackerman, 2005).For children, the theory differs from SLT in thatinteractions with parents are not just a matter ofrewards and punishments making certain behav-iours more or less likely. Rather it acknowledges theemotional importance of having a trustable, securefigure who can be relied upon to be responsive to his/her needs, especially around times of distress. If achild does not receive this, then various more-or-lessmaladaptive behaviour patterns towards the mother,father and others may ensue at times of stress,including avoidance, anxious-ambivalent preoccu-pation, and disorganised, disturbed behaviour.Adults who developed these patterns in childhoodmay in turn have corresponding difficulties in beingemotionally securely available as parents, insteadbeing dismissive, preoccupied, or unpredictablyalternating betweenwarm and frightening behaviour.

There have been several trials for attachment-based interventions, mostly with infants. Themeta-analysis by Bakermans-Kranenburg, vanIjzendoorn, and Juffer (2003) found 81 studies.Overall, the interventions modestly improved paren-tal sensitivity and attachment security. Importantly,they worked for the more severe cases with disor-ganised, disturbed attachment patterns. Thesestudies provide evidence of the theory’s utility,especially with infants, but we are not advocatingcommencing with attachment-based therapies forolder children with conduct problems. Rather weargue that there are aspects of attachment ideas thatcan add value to social-learning-based treatments(e.g., Shaw, Bell, & Gilliom, 2000; Lyons-Ruth,1996). Vice versa, largely forgotten animal learningexperiments helped elucidate the role that conflictingparental signals may play in generating attachmentdifficulties. Alternate pleasant (comfort and food) andnoxious stimuli (puffs of hot air) were delivered toinfant monkeys by their (mechanical) mother mon-keys. This produced ‘approach-avoidance’ conflictsin the infants, so that aversive stimuli from the mo-ther resulted in increased clinging rather thanavoidance, a pattern closely related to anxious/ambivalent attachment (Harlow & Harlow, 1962;Dadds, 2002).

This process happens with humans as well, andclinging behaviour by a young child can beexhausting for parents. While it may elicit comforting

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behaviours in mothers, it can also produce negativereactions that unfortunately often increase furtheraversive clinging behaviour from the child. Such avicious circle is very similar to that described byPatterson’s coercion theory. In extreme cases, theparent and child become trapped in a cycle of prox-imity seeking and rejection, with the child developingincreasingly aversive set of (mis)behaviours toattract the attention of the caregiver. Dadds (2002)describes this cycle as eliciting aversive disciplineinterchanges that become increasingly frequent andattachment ‘rich’. That is, they contain all sorts ofinterchanges relevant to basic attachment drives inthe child, and naturally, the child will continue toescalate. In this model, the child is misbehaving notfor any old attention per se, but for all the attach-ment-rich dynamics the discipline interchangesbring. Positive interchanges between the parent andchild become increasingly scarce, and any calminterchanges concern immediate practical issuesand are ‘attachment neutral’ – they rarely speak oflove and passion and nurturance.

An approach derived from attachment theory canhelp here. Many families trained in traditional SLTapproaches can correctly use rewarding strategiesfor positive child behaviour and a time-out proce-dure for misbehaviour. However, the treatmentsometimes does not work because the reward strat-egies (e.g., descriptive praise, behaviour charts) arestill ‘attachment neutral’ and the new disciplineprocedure is still ‘attachment rich’ (Dadds & Hawes,2006) because the parent gets trapped into beingnegative which then still triggers disturbed attach-ment-seeking behaviour. Parents who go down thispath often seek multiple referrals, complaining thatparent training programmes (by which they meanrewards and time out) don’t work for their child.

In these cases, careful interviewing or observationwill often reveal that the use of rewards is material-istic and boring and contains little in the way of allthe things that make people love and want to spendtime with each other. Time out, on the other hand,remains subtly infused with attachment-rich behav-iours (e.g., hostility, rejection, ambivalence) that arehighly salient and threatening to the child. Success-ful use of the SLT contingencies will only occur whenthe reward side of the ledger includes higher invest-ments of emotion, touching, time together, andexpressions of love and commitment (e.g., ‘where ismy special boy? Come and spend some time withme!’), than the discipline procedures. It can be verychallenging to parents to implement this type of‘balance sheet’. For example, a child that cooperateswith a request to pass a pen is not likely to receive thesame depth of highly emotional parenting engage-ment as the child who says ‘get f***ed’ in response tothe same request. The former is likely to motivateparents to use some modest praise and rewards atbest, whereas the child’s abusive response is likely toelicit the most extreme of parents’ feelings about the

child. Attachment ideas alert us that what we reallywant parents to do with a conduct problem child inresponse to the most menial act of cooperation isreact with love, appreciation, emotion, and even aneed for proximity, and not let any of the attachment-rich processes be affected by the abuse. Likewise,when responding to misbehaviour they shouldmaintain a firm positive attachment while calmlyremoving the child to time out.

Systems theory

By systems theory, we are referring to therapies thatdraw on systemic, cybernetic, narrative, or con-structivist/constructionist theories. In the childmental health context, the term is used in two sen-ses. Firstly, to refer to all the wider systems that canimpinge on a child, including for example the schooland neighbourhood. Secondly, to refer to the family,which has led to an array of interventions looselycalled Family Therapy. Gurman, Kniskern, andPinsof (1986) state that ‘Family therapy may bedefined as any psychotherapeutic endeavour thatexplicitly focuses on altering the interactionsbetween or among family members and seeks toimprove the functioning of the family as a unit, or itssubsystems, and/or the functioning of the individualmembers of the family’. There has been a host ofdifferent therapies developed under the generalbanner of systems/family therapy (Cottrell & Boston2002). Two particular manualised distillations ofsystems/family approaches have proven notablysuccessful for conduct problems and delinquency:Functional Family Therapy (Alexander, Pugh, Par-sons, & Sexton, 2000) and Multisystemic Therapy(Schoenwald & Henggeler, 2005). These are reviewedin more detail in Bailey and Scott (2008); here wewish to show how systemic thinking, especiallystructural family therapy, can help the parenttraining practitioner with difficult families.

In structural family therapy the underpinning the-ory is that problems result from inappropriate familystructure and organisation (Minuchin, 1974). Thetherapist is concerned with the boundaries betweenthe parental subsystem, the child subsystem and theextended family, and sees the family in terms of spa-tial relationships, extremes being enmeshed or dis-engaged. Allowing for variations across cultures, ahealthy family generally has a parental subsystemthat cooperates in caring for the children, but also hasits own time for love and friendship and so on. Thechild subsystem is clearly separated from the paren-tal subsystem, as are other relatives and friends. Theparents act as an executive system and can functioneffectively to solve family problems.

Families who present with conduct problem chil-dren often show distortions to this pattern. Manysuch parents are beset with their own relationshipproblems, cannot deal with problems as a team, and



find themselves split and estranged in their attemptsto manage the children. While there is little evidencethat problematic family structures are a direct causeof child problems, they can certainly maintain them.Green, Loeber, and Lahey (1992) showed that hier-archical structures tend to become disorganisedwhen a family has a problem child. Typically,boundaries between parent, child, and extendedfamily systems become unclear, the parents’ rela-tionship becomes conflicted, and the extended familymay get caught in the battles during the many failedattempts to manage the problem child.

Several studies have shown that targeting thisteamwork aspect of parental relationships canenhance outcomes for the children (e.g., Dadds,Schwartz, & Sanders, 1987). In practice, the processand content of therapy should be set up so that theparental subsystem is strengthened. This can bedone implicitly by making time to see both parentstogether without the children. Then the parentalrelationship can be targeted more explicitly in thestyle first advocated by Minuchin, whereby the cou-ple is asked, for example, to have a ‘date’ and refrainfrom talking about the children, or make structuralchanges in terms of who is responsible for varioushousehold and childcare tasks.

The child subsystem can be targeted the sameway. A common problem is that ‘better-behaved’siblings become increasingly close to and protectedby a parent, and the problem child therefore be-comes more and more resentful of this. There is asubsystem of the parent and the non-problem childfrom which the problem child feels excluded. Here,use of SLT parent training approaches whereby timeout and other contingencies are applied to theproblem child alone often fails. Thinking structurallyrequires strategies whereby the parent subsystem ishierarchically organised separately from the childsubsystem. Thus, the parent can be advised to notengage with telltale behaviour (who did what towhom – this is clearly dividing the child system andaligning with one or the other), to minimise punish-ing one child during fights, but rather to interpretfights as children jointly not getting along, and soapply contingencies to both children, and of course,reward both children when they are not fighting –thus reinforcing the child subsystem.

This type of structural thinking can be applied nomatter what structures and systems are encoun-tered, including single parents, parents with step-parent partners, extended families with relativesliving in the home, and so on. It is great for openlytargeting family processes as they impact on imple-mentation of SLT parent training.

Cognitive factors and attribution theory

Skilled clinicians know that careful consideration ofparents’ thoughts and feelings are crucial to treat-

ment success and routinely work with them in par-ent training programmes. But little attention hasbeen paid to explicitly presenting models to help usthink about these cognitive-emotional processes in asystematic way. Attributional theory, largely devel-oped with social and health psychology (e.g.,Abramson et al., 1978; Dix et al., 1986), provides aset of organising principles for working with parents’attributions in ways that overcome blocks to change.The fundamental principle is that we are all driven attimes to interpret each other’s behaviour alongdimensions of stable–transient, internal–external,and global–specific. A substantial literature hasshown that people who are in unhappy relationshipsare prone to attributing each other’s negativebehaviour to stable, internal, and global factors.Conversely, positive behaviour is assumed to betransient, externally caused, and specific.

A wealth of research has shown that parents ofconduct problem children develop problematicattributions about the meaning of the child’sbehaviour (e.g., Dadds, Mullins, McAllister, &Atkinson, 2003). Common examples include theparent feeling that the child’s problem behaviour isintentional and under the child’s control, is designedto deliberately upset the parent, is a sign of seriousmental problems, is inherited from other (disliked)family members (e.g., an abusive ex-spouse), or is insome way a punishment that the parent deserves.Conversely, when the child does show moments ofgood behaviour, or even good days, the parent isprone to dismissing these as transient, externallycaused, and specific. More generally, parents mayhave beliefs about models of discipline that areincompatible with the operant techniques typicallytaught in parent training programmes. All of thesecognitions can make it very difficult to calmly parenta child; they are a risk factor for failure to implementtraditional parent training programmes (e.g., Wahler& Dumas, 1989; Miller & Prinz, 1990).

There is some evidence that addressing attribu-tions helps. One study (Sanders et al., 2004) addedattributional retraining and anger management tobasic parent training. Parents in the enhanced con-dition showed a greater reduction in attitudes asso-ciated with child abuse, and fewer unrealisticexpectations. However, on measures of anger expe-rience or expression, parents in both interventionsshowed similar reductions. We think that the skilledtherapist will take time to ask about parent inter-pretations. Useful questions include things like:‘How did you feel last time he really tried to hurtyou?’ ‘What was the worst thought you had?’ ‘In yourdarkest moments, what do you think is happeningwith John?’

One approach is simply to get the negative attri-butions out in the open and keep them there. It canbe very useful to finish a discussion of these matterswith something like: ‘OK, so let’s keep an eye on howyou are going with these thoughts and feelings.



As we move through the programme, we can reviewthem and see how you are feeling.’ Here the hope isthat the changes in the parent–child interactionsthat occur as part of SLT parent training will providea chance for problematic attributions to be reviewedand hopefully replaced with more constructivealternatives as the parent begins to experience thechild as more helpful. However, if fixed attributionscontinue to block progress, they can be addressedusing classical cognitive approaches. For example,often one can get a parent who believes her child isintentionally ‘winding her up’ to see that this repre-sents his need to have close contact with her, even ifhe uses aggression to do so: by being close to him atother times, the aggression will often diminish. Orthe parent who feels his child is always randomlyaggressive can be taken through a detailed dailydiary, and episodes of good behaviour can be high-lighted, and often an understandable pattern for theaggression found; for example, it may occur whenDad is on the phone or a sister is being cuddled.During this it helps to try to reframe many of theparent’s own efforts as heroic and point out whenthey are successful: helping the parent regain asense of control often in turn reduces negativeattributions about the child.

Shared empowerment and motivationalinterviewing

It does not matter how effective a therapy is if parentswon’t engage in the first place, or if those who do startdon’t then implement the approach proposed. Infamilies with conduct problem children, initialengagement is often hard, and dropout rates of 25–50% are typical (Forehand, Middlebrook, Rogers, &Steffe, 1983; Kazdin, 2005) compared for example to10–20% in families with anxious children. Underthese circumstances, having a rationale on how tomanage the process of initial engagement and sub-sequent involvement of the family is necessary foreffectivechange.SLTcanprovideabasicstartingpointby emphasising that the practitioner should makeexpectations clear and praise the parent when theyimplement the programme. A collaborative approachwhereby oneworkswith parents to define and achievetheirgoals ishelpful fromtheoutset (Webster-Stratton& Herbert, 1994). However, sometimes this doesn’twork and indeed seems only to generate resistanceand make the parents feel bad. What should thepractitioner do next? There is little empirical parenttraining literature to guide the process; however,Patterson and Chamberlain (1994) showed that par-ent engagement and cooperation are best enhancedthroughuse of a stagedmodel, inwhichdidactic inputis suspended until client trust is built by giving par-ents adequate time to express their concerns.

We take the view that there are two interlinkedtheoretical positions worth deploying. First, and

right through the therapy process, a shared

empowerment model that emphasises teamwork,parent empowerment, and support will help engagefamilies and keep them on board (Dadds & Hawes,2006). This respects parents and maximises theirbuy-in. Secondly, if things grind to a halt, ratherthan persisting in trying to coerce the parents to dowhat we recommend (‘you really need to practise themethods at home’), we recommend taking a motiva-

tional interviewing approach.

Shared empowerment

Several shared empowerment techniques are useful.From the outset, the therapeutic team is seen ascomprising complementary ‘experts’, namely theparents who are experts on the family’s needs,aspirations, strengths and weaknesses, and thetherapist who is an expert at child mental health andtreatment. All information and decisions are madeopenly by the team, and the scientific and clinicalliterature on child mental health and treatment isnot ‘owned’ by the practitioner. Instead, the cliniciancan feed back the results, but say that his or herinterpretation is but one available: the findings areseen as an independent ‘contributor’ to the decisionprocess. ‘Resistance’ is discussed as a communica-tion by parents that something hasn’t been set upproperly, and the practitioner takes a ‘one-down’stance and apologises for moving ahead without fullyunderstanding what the parents need.

There are a number of risks when trying to engagethe family that can be addressed right from the firstsession. First, it can be hard to do useful therapyand also establish a good working relationship withthe parent (parental subsystem) independent of thechild or children, all in the first session. We believe itis crucial to interview the parent(s) alone, in order toallow them the space to vent on all relevant issuesand set up plans for treatment as an adult team.Observations of the broader system and interactionpatterns can follow in subsequent sessions. Second,failure to establish a trusting relationship with both

parents (if there are two). For example, a mother maydescribe her problems with her 6-year-old son. Whenthe father is asked for his views, he attacks themother’s handling of the boy, stating he has noproblems but that the mother is to blame for hernitpicking parenting style. Often inexperiencedtherapists instinctively move to protect the mother,subtly advocating for her in an attempt to bring somereason to the father. This often leads the father to feelthat the therapist (usually female too) is siding withthe mother. He drops out or pulls the family out, orstays but undermines the process. We thereforerecommend paying careful attention to making surethat all members of the family feel heard andrespected, no matter how outrageous their views,which should be integrated into the larger concep-tualisation. It is surprising how extreme views are



retracted and empathy increases all round once aperson has felt heard. Third, difficult issues, such asabuse and violence, family members’ feelings foreach other, parental attributions about the child’sbehaviour and problems, use of drugs and alcohol,the role of extended family, are either not raised orare done in a way that feels blaming. In a successfulfirst session, these issues will have been raisedsensitively but explicitly and incorporated into thejoint conceptualisation and treatment plan. Failureto do this risks the therapist marching valiantly intotreatment despite the parents not being at all con-vinced, so they later drop out.

Motivational interviewing

Motivational interviewing can be used alongside SLTparent training when engagement is proving difficult,or when parents actively resist proposed courses ofaction. Miller and Rollnick (2002) defined it as ‘aclient centred, directive method for enhancingintrinsic motivation to change by exploring andresolving ambivalence’. It was first developed withalcohol and substance misusing clients and comesin part from the theory of Carl Rogers insofar as itoperates from, and unconditionally accepts, the cli-ent’s view of the world and their problems. Any dis-crepancies that are explored concern incongruitiesamong the person’s own experiences and values.However, it differs from Rogers’ method as it direc-tively elicits and selectively reinforces change talk. Italso differs from the ‘traditional’ authoritative‘expert’ model of telling a client what the matter isand what to do about it. It is a method of commu-nication rather than a way to get people to do whatthey don’t want to do. Unlike SLT, it does not attemptto impose change through extrinsic means such aspraise and rewards, consequences or sanctions,especially when they are inconsistent with the per-son’s own beliefs. Unless a new course of action is insome way in the person’s inherent interest, changewill not happen: it arises through its relevance to theperson’s own values and concerns. Several trialsattest to the effectiveness of motivational interview-ing not only in helping clients engage with treatmentand accepting assessment results, but also inimproving outcomes during interventions (Miller &Rollnick, 2002). With conduct problem children,Prinz and Miller (1994) found that adding an initialsession with a related approach led to lower dropoutrates subsequently, as did Nock and Kazdin (2005)who took a more problem-solving approach to over-come barriers to participation.

Change talk is contrasted with resistance talk,which is seen not as a general attitude, but as onlypertaining to certain ideas. The practitioner can ofcourse elicit resistance, typically by arguing forchange, assuming the expert role (‘my knowledgehas the answers’), criticising, shaming or blaming,labelling (trying to shock the client out of the status

quo), being in a hurry, or claiming pre-eminence(‘praising your child will work if it is done properly’).Instead, the practitioner should ask open questions,including recognising both sides of a question orbehaviour (‘what do you find helpful about smack-ing?’), listen reflectively, affirm positive steps taken,and summarise what the person has said (in theirown words) before going on to elicit change talk.The latter, from the parent, includes recognisingthe disadvantages of the status quo, recognising theadvantage of change, expressing optimism aboutchange and then expressing intention to change.

When should such an approach be deployed?Typically, when one has little external control of thesituation. If the parent and child are engaged intreatment and complying, it may not be necessary.But it is particularly helpful when the practitionerhas less control: in initial engagement when theparent (or teacher or child) is doubtful about com-mencing treatment, or in accepting a view suggestedby test results; when a parent is dropping out oftreatment because the practitioner is gettingincreasingly coercive (trying increasingly desperatelyto get the parent to turn up on time or at all, todiscipline the child, and so on).

As an example, take the situation where parentscome in each saying they have had a hectic week andwere not able to implement the programme, andwhen they did it didn’t really work. At first, allpractitioners can try to problem-solve this and offerencouragement for a better outcome next session. Ifthis pattern is repeated, however, it is advisable to sitback and really listen. This discussion may culmi-nate with the practitioner saying ‘So it sounds likeyou have given it your best shot and it is not workingfor you’, or ‘I hear you. While this is often an effectivetreatment, it is not working for you. It is just toohard’. With the parent’s views then fully out, thepractitioner can prompt where they will go from here.Applied carefully, the use of motivational interview-ing techniques in these difficult situations can helpparents turn around of their own volition andundertaking, aware that the practitioner is warm,supportive and on their side, but unable to helpunless they help themselves.

Conclusion

In concluding, we suggest that the practitionershould hold in mind the same theories for their ownrelationship with the parents. Thus lots of rewardsshould be applied to parents’ behaviour (SLT); theprocess should follow attachment principles so thatthe therapist–parent relationship is predictable,reliable and able to be effectively tapered and thenterminated without distress; healthy family struc-

tures should be facilitated and reinforced byaddressing which family members attend sessionsand when. Family members should be given time



and enabled to talk about their darkest thoughts andfeelings (attributions) about the child, themselves asparents, and the family in general. The practitionershould offer shared empowerment to families andstrive to elicit their intrinsic motivation and passionto change.

Whether the approach set out above is actuallyeffective rather than another over-optimistic descrip-tion of the ‘this is how we do it’ kind by so-calledexperts will need careful evaluation. This will requireoutcomestudies (e.g., comparing ‘straight’ SLTparenttraining with this multi-model approach), processstudies (e.g., videotaping of therapy sessions withindependent assessment of when certain situationssuch as failure to progress, or parent resistance, arepresent, and whether the clinician adopts this model,and how skilfully, and whether it works) combinedwith qualitative interviews with parents and practi-tioners about what they thought was going on. Onlythis way will further progress be made.

To summarise, we have proposed some practicalapproaches derived from four different psychologicaltheories that practitioners can use when encoun-tering difficulty working with parents of childrenwith conduct problems. The bedrock of these treat-

ments is nonetheless social learning theory, whichprovides the theoretical and strategic tools to im-prove relationships through training parents in arange of techniques for correcting aggression, dis-obedience and the host of other antisocial behav-iours exhibited by uncontrolled and unhappychildren. Successfully helping parents to implementthese strategies can be a challenging undertaking asit involves parents changing their own behaviour andtheir family’s structure and processes. Experiencedpractitioners develop a coterie of techniques foraiding this process that they call on when things gowrong and the evidence-based manuals no longerhelp. We emphasise the theories underpinning anytechniques, because the former drive the latter andallow the practitioner to think creatively, from firstprinciples, about how to understand family difficul-ties and then generate practical solutions.

Correspondence to

Stephen Scott, Box P85, Institute of Psychiatry,King’s College London, De Crespigny Park, LondonSE5 8AF, UK; Email: [email protected]

Key points

• Parent training based on social learning theory is the treatment of choice for children with conductproblems; however, it doesn’t work in a quarter to a third of cases.

• Under these circumstances, flexibly but systematically applying a limited range of additional theories canhelp shift families who are difficult to change.

• When parents succeed in being more positive but still get very hostile in disciplinary exchanges, attach-ment theory can help make sense of why the child persists in being aggressive, and can lead to usefulintervention strategies.

• When parents know what they should do, but cannot put it into practice due to conflicting or negativebeliefs, cognitive attribution theory can inform a specific therapeutic approach.

• When one member of the family is interacting better with the child but other members or outside influ-ences are preventing progress, structural family systems theory approaches can help.

• When families are reluctant to engage or become increasingly resistant to suggested interventions, ashared empowerment/motivational interviewing approach can bring them back on board.

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Manuscript accepted 29 June 2009



practitioner review: when parent training doesn���t work: theory-driven clinical strategies

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practitioner review: when parent training doesn��t work: theory-driven clinical strategies