parent-child interaction therapy: the rewards and challenges of a group format

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Parent-Child Interaction Therapy: The Rewards and Chal lenges of a Group Format

Larissa N. Niec, J anne l M. H e m m e , and Just in M. Yopp, Central M i c h i g a n Universi ty Elizabeth V. Brestan, A u b u r n Universi ty

Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment for young children with severe behavior problems. Typically, it is individually administered to families by a therapist and a cotherapist. Howev~ converting PCIT to a group fo~vnat can be a cost-effective way to reach a largo number of families in need of treatment. In addition, PCIT offers techniques to facilitate parents' skill development and generalization of skills that are not commonly used in group parent training programs. This article has multiple goals: (a) to review the structure of a group PCIT program, (b) to discuss the empirical rationale for use of the program, and (c) to provide a case example that illustrates the rewards and challenges of group PCIZ

D ISRUPTIVE BEHAVIOR PROBLEMS in young children can lead to serious difficulties in broad areas of func-

tioning, including difficulties in family, peer, school, and community interactions. Children with disruptive behavior disorders (e.g., opposifional-defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder) have been found to be at risk for school adjustment problems (Campbell & Ewing, 1990; McGee, Partridge, Williams, & Silva, 1991), antisocial activity (Kratzer & Hodgins, 1997; Loeber, 1990), and have higher than normal rates of substance abuse and interpersonal problems (e.g., Lynskey & Fergusson, 1995; Weiss & Hectman, 1993). Although effective treatments are available for these children (Brestan & Eyberg, 1998; Chambless & Ollendick, 2001), there is a current need for programs that are cost-effective and eas- ily disseminated. Providing group parent training is one way to meet that need, as it is substantially more cost- effective than individual treatment (Barldey, 1987; Webster- Stratton, Kolpacoff, & Hollinsworth, 1988). One empirically based treatment for individual families, Parent-Child Interaction Therapy (PCIT; Hembree-Kigin & McNeil, 1995), is particularly promising as a group treatment.

PCIT is an empirically based behavioral family treatment program designed to address the behavior problems of children 2 to 7 years of age. It is typically administered individually to each family by a therapist and a cotherapist. PCIT differs from many parent training programs in its dual focus on the development of the parent- child relationship and parents' behavior management skills (Foote, Eyberg, & Schuhmann, 1998; Nixon, 2002). Components of PCIT that are not commonly provided in

Cognitive and Behavioral Practice 12, 113-125, 2005 1077-7229/05/113-12551.00/0 Copyright © 2005 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

group programs (e.g., live coaching of parent-child interactions and immediate feedback) make it a valuable and innovative protocol for group parent training. Despite tile potential benefits of using PCIT in groups, very few clinics have done so (e.g., Auerbach, Nixon, Forrest, Gooley, & Gemke, 1999; Brestan, Valle, & Funderburk, 1999; Niec & Yopp, 2001), and to date, no published paper has discussed the modifications necessary to adapt PCIT from an individual to a group format. The goals of this paper are to review the structure of a group PCIT program, discuss the empirical rationale for use of the program, and provide a case example that illustrates the rewards and challenges of group PCIT.

Structure a n d Goals o f PCIT

Based on Hanf's (1969) two-stage parent training model, the theoretical foundation of PCIT integrates concepts from social learning theory, traditional play therapy, and attachment theory to enhance the parent- child relationship, increase children's prosocial behaviors, and increase parents' behavior management skills (Eyberg, 1988; Hembree-Kigin & McNeil, 1995; Herschell, Calzada, Eyberg, & McNeil, 2002a; Herschell, Calzada, Eyberg, & McNeil, 2002b). PCIT differs from many parent training programs in its use of live coaching to provide parents with immediate feedback regarding their interactions with their children. Typically, therapists coach the parent from an observation room, while the parent, wearing a bug-in-the-ear device, interacts with his or her child in the therapy room. This equipment is optimal, but not required, as coaching can also be conducted in the same room with the parent and child (Herschell et al., 2002b). Whether coaching is in-room or out, the use of these immediate feedback techniques may be one component of PCIT that facilitates skill development (Eyberg & Matarazzo, 1980).

114 Niec et al.

Assessment is fundamental to the PCIT program and is used throughout treatment. Ongoing assessment en- ables therapists to target specific problem behaviors, guide treatment, and provide a means of evaluating treatment efficacy and treatment satisfaction. The PCIT assessment process is a multisource, multimethod approach that includes behavior ratings from caregivers and teachers, standardized behavioral observations during weekly treatment sessions, and parent monitoring during daily homework practices (Bahl, Spaulding, & McNeil, 1999). Assess- ment can also be a tool to initiate and maintain parents' engagement in the treatment process. For example, conducting weekly behavioral observations allows parents to see areas of behavioral improvement, which can be reinforcing.

The PCIT protocol has been described in detail elsewhere (Hembree-Kigin & McNeil, 1995; Herschell et al., 2002b). To summarize the procedures, the two phases of PCIT are Child-Directed Interaction (CDI) and Parent- Directed Interaction (PDI). CDI, the first phase, focuses on building parents' skills to elicit children's positive behaviors and to enhance the parent-child relationship. During CDI parents are taught child-centered play skills similar to those used by nondirective play therapists. Because parent- child interactions in families with behavior-disordered children are frequently negative and coercive in nature (e.g., Campbell, 1995; Stormont, 2002, for reviews), a critical goal of CDI is to increase positive, nurturing interactions. Specific relationship-enhancing skills include the PRIDE skills (Praising, Reflecting, Imitating, Describing, and Enthusiasm; Herschell et al., 2002b). Parents are also taught to avoid using criticisms, commands, and questions during CDI practice sessions. In each session, the therapist conducts a brief behavioral observation, as- sesses parents' skill development, and provides feedback regarding parents' observed strengths and weaknesses. Once parents are able to use the PRIDE skills consistently to interact in a positive manner with their children, the second phase of treatment is introduced.

Skills taught during the PDI are primarily based on social learning theory and include such concepts as differ- ential attention, social reinforcement, punishment, and problem-solving skills training. The primary goal of PDI is to teach parents how to discipline their children effectively. Appropriate discipline techniques and problem- solving skills are taught and practiced during the PDI phase, and child compliance is emphasized (Hembree- Kigin & McNeil, 1995). Specifically, parents are coached during each PDI session to ignore inappropriate, attention- seeking behaviors and to provide consequences for noncompliance (Eyberg & Boggs, 1989). Parents direct child behavior using age-appropriate instructions, giving effectively stated commands, praising appropriate behaviors, and providing consistent consequences for noncompliance.

Efficacy of Individually Formatted PCIT

Multiple studies have demonstrated the statistical and clinical efficacy of PCIT when administered in an individual format (e.g., Eyberg & Boggs, 1989; Gallagher, 2003; McNeil, Capage, Bahl, & Blanc, 1999; Nixon, Sweeney, Erickson, & Touyz, 2003; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Schuhmann and colleagues demonstrated that clinic-referred families who completed PCIT reported fewer child externalizing behavior problems, criticized their children less frequentl}; and praised their children more frequently" than wait-list controls. Mc- Neil and colleagues (1991) found that preschool-aged children referred for treatment secondary to problematic behaviors in the home setting were reported by teachers to have notable improvements in their school behavior following completion of PCIT. Positive effects have been demonstrated on untreated siblings in addition to the targeted child. Specifically, parents reported an improvement in the untreated siblings' behaviors following treatment (Brestan, Eyberg, Boggs, & Algina 1997; Eyberg & Robinson, 1982).

PCIT has been used effectively with a variety of populations, including low-income families (Querido & Eyberg, 2001) and culturally diverse populations (Capage, Ben- nett, & McNeil, 2001; Querido & Eyberg, 2002). Case studies have provided preliminary support for the effectiveness of PCIT with families at high risk for physical abuse (Borrego, Urquiza, Rasmussen, & Zebell, 1999; Herschell et al., 2002b).

PCIT has also demonstrated long-term maintenance of treatment gains. Follow-up assessments of families treated with PCIT demonstrate maintenance of gains in children's compliance and positive parent-child interactions at 4 months (Schuhmann et al., 1998), 1 year (Eyberg & Robinson, 1982; Funderburk et al., 1998), 2 years (Eyberg et al., 2001), and 3 to 6 years (Hood & Eyberg, 2003).

Efficacy of Group-Formatted Parent Trainin~

To date, no published studies have investigated tee efficacy of group PCIT using a well-controlled experimental design. However, Auerbach et al. (1999) reported on a multimodal program for oppositional children that included group PCIT as a treatment component. Their program included group PCIT, supportive group therapy for parents, and group social skills training for children. Preliminary data reflected no reductions in children's behavior problems as assessed by standardized measures, and parents repor ted high levels of stress at both the pretreatment and posttreatment assessments. Qualitative reports by parents and staff impressions of the families suggested that children's problem behaviors decreased

Group Parent-Child Interaction Therapy 115

following the multimodal program (Auerbach et al., 1999). Although this program converted PCIT to a group format and included innovative techniques (e.g., therapist- led excursions to public areas to promote generalization of parenting skills), it is difficult to determine whether group PCIT was the change agent, as these families received several services simultaneously. In addition, 50% of the families continued to receive individual family treatment following the PCIT group, and the posttreatment outcome measure results were equivocal. In another study of modified PCIT, McNeil, Herschell, Gurwitch, and Clemens-Mowrer (in press) reported on a program in which foster parents were taught PCIT skills during a 2-day group workshop. Preliminary data demonstrated significant reductions in foster children's levels of behavior problems 1 month posttraining. Mean behavior problems moved from the clinically significant range to the normal range on the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), and these changes remained at 5 months posttraining. This investigation of a promising PCIT workshop format suggests that behavioral change can occur following a brief 2-day group intervention. The au- thors caution, however, that such a brief treatment may not be appropriate for highly stressed families presenting with multiple problems, as families receive fewer coached sessions and have fewer opportunities to problem solve with therapists and group members.

Although no controlled studies with group PCIT have been published, parent training is frequently provided in a group format and a variety of group parent training models have demonstrated effectiveness in preventing and reducing children's externalizing behaviors (e.g., Pisterman et al., 1989; Ruma, Burke, & Thompson, 1996; Sheeber &Johnson, 1994; Webster-Stratton & Hammond, 1997; Webster-Stratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Reid, & Hammond, 2001). Parent training groups have addressed a range of externalizing behavioral problems such as aggression, hyperactivity, and noncompliance in children diagnosed with attention- deficit/hyperactivity disorder (Barkley, 1987; Pisterman et al., 1989), children diagnosed with oppositional defiant and conduct disorders (Webster-Stratton, 1981; Webster-Stratton & Hammond, 1997), children with difficult temperaments (Sheeber &Johnson, 1994), and children with learning disabilities (Chadwick, Momcilovic, Rossiter, Stumbles, & Taylor, 2001). Parent training groups typically range from 5 to 13 sessions, with weekly sessions lasting from 1½ to 2 hours. Group parent training programs utilize a variety of techniques to assist parents in improving their children's behaviors. These methods include using videotape vignettes, didactic training, role-playing, modeling, group discussion, and homework (Sampers, Anderson, Hartung, & Scambler, 2001). Group parent training techniques do not commonly in-

clude live coaching of parents' interactions with their children. In fact, other group formats of parent training typically included only parents, not children, in the session. The inclusion of children in the session and live coaching are two advantages of group PCIT that may help parents to gain mastery of behavior management skills and facilitate skill generalization. Live coaching of parent-child interactions has not been empirically examined in group parent training protocols. However, pro- riding continuous feedback to parents during the session is fundamental to PCIT, and this technique has been shown to be effective in producing behavior change within the context of individual family treatment relative to didactic-focused group parent training (Eyberg & Mat- arazzo, 1980).

One widely researched group parent training protocol is the videotape modeling program developed by Webster-Stratton (1981). Similar to PCIT, this program addresses externalizing behavior problems of preschool to early elementary-age children. Both the Webster-Stratton program and PCIT teach parents to interact with their children in a manner aimed at eliciting prosocial behavior, and both programs provide parents with discipline strategies based on behavioral principles. The Webster- Stratton program, however, is regularly administered in a group format and typically entails 10 to 14 two-hour sessions involving between 8 and 15 parents. The program uses modeling to teach parents effective strategies for interacting with their children; videotaped vignettes of parent-child interactions serve as a springboard for therapist-led group discussion among parents. The program does not include live coaching of parent-child interactions; thus, therapists do not have the opportunity to observe parents' actual behaviors with their children in session and must rely on parent report. Numerous studies have demonstrated the efficacy of the Webster- Stratton group parent training model in reducing children's conduct problems and improving the quality of the parent-child interaction (Webster-Stratton, 1981, 1982, 1984, 1990). One controlled study also supported the program's effectiveness in a community mental health center (Taylor, Schmidt, Pepler, & Hodgins, 1998).

Few studies have directly examined the relative efficacy of group and individual parent training (Brightman, Baker, Clark, & Ambrose, 1982; Pevsner, 1982; Webster- Stratton, 1984). Overall, these studies have yielded in- consistent results in regards to which format is more effective. Some have found individual and group parent training formats to be equally effective in treating children's behavior problems (Brightman et al., 1982; Pev- sner, 1982; Webster-Stratton, 1984). Webster-Stratton (1984) compared three conditions (group parent training, individual therapy, and wait-list controls) for treatment efficacy in reducing child noncompliance. Results at post-

116 Niec et al.

t rea tment and at 1-year follow-up revealed that chi ldren of parents receiving either group or individual t rea tment exhibited a similar reduct ion of behavior problems relative to the wait-list control group. Other studies have noted superior results for individual parent t raining (Chadwick et al., 2001; Eyberg & Matarazzo, 1980; Hampson , Schulte, & Ricks, 1983; T i edemann &Johnston, 1992). In these studies, however, the t rea tment condit ions varied along mult iple variables other than format. For example, both Chadwick and colleagues (2001) and Hampson and colleagues (1983) compared home-based individual paren t t raining to clinic-based group parent training. In the Eyberg and Matarazzo (1980) and T iedemann and John- ston (1992) studies, individual therapy included coaching of parent-child interactions with immediate feedback, whereas group therapy included no coaching. Though conclusions cannot yet be drawn regarding the relative efficacy of individual and group parent training, overall, group paren t t raining programs have demonstra ted efficacy relative to wait-list controls for a variety of behavior problems in young children.

Converting PCIT to a Group Format When convert ing PCIT to a group format, the overall

structure remains similar to the original protocol: families complete an intake assessment, CDI teaching and coaching sessions, PDI teaching and coaching sessions, a post- t reatment assessment, and a booster session (see Table 1). PCIT with mult iple families, however, requires several modifications that distinguish it from the original PCIT protocol and from other group models. For instance, as described previously, group parent t raining programs have no t typically employed live coaching of parent-child interactions, which is an essential componen t of PCIT. Coaching requires individual time and sufficient space for each parent-child dyad. Thus, while other groups may involve anywhere from 5 to 15 families, PCIT groups are most manageable with 3 to 6 families. PCIT group sessions typically last between 90 minutes and 2 hours to ensure that each family has adequate coaching time (see Table 2).

The m a n a g e m e n t of time for group PCIT depends largely on the availability of space in the clinic and the n u m b e r of parent-chi ld dyads in the group. U n d e r op- t imal circumstances, the group would have access to two sets of rooms properly equipped for observation of parent-child interactions (e.g., one-way mirror, bug-in- the-ear device, playroom, and observation room). The availability of two sets of rooms and two therapists allows for mult iple parent-child interactions to occur simultaneously, thus increasing the amoun t of time parents receive live coaching. In groups with at least four parents, using two rooms still allows each paren t to be observed by, and receive feedback from, another parent. However, group PCIT may be conducted with the use of just one set

Table 1 Structure for Group PCIT

Session Session Format and Basic Content

Intake a s s e s s m e n t

Session 1

Session 2

Session 3- 7 Session 8

Session 9 Session 10-12 Session 13

Session 14

Session 15

Session 16

Booster session

Individual session. Completion of all assessment materials.

Group session. Pretreatment assessment. Introduction to PCIT.

Group session. CDI teaching session to learn special time skills.

Group session. CDI coaching. Group session. PDI teaching session to learn

new discipline program. Individual session. First PDI coaching. Group session. PDI coaching. Group session. Fifth PDI coaching. Discuss how

to establish house rules. Coach realistic commands outside clinic room.

Group session. Sixth PDI coaching. Discuss how to take PCIT "on the road." Coach realistic commands outside the clinic room.

Group session. Seventh PDI coaching. Discuss how to manage future behavior problems.

Group session. Termination: review progress, complete posttreatment assessment, and have a celebration.

Individual session. Six months posttreatment. Provide skill booster as needed and complete follow-up measures.

of rooms. A benefi t of using one set of rooms is that each parent -chi ld in te rac t ion is observed by all parents in the group, allowing for opt imal feedback du r ing group discussion.

We have found that PCIT groups run well with three to six families (e.g., three to eight parent-child dyads). How- ever, we have run groups with as few as two families when necessary to prevent parents from suffering excessive waits for larger groups to form. With a m i n i m u m of two families, parents can still benefi t from the support of

Table 2 Breakdown of the Z-Hour PCIT Group During a Coaching Session

Time: minutes Activity

0-30

30-50 50-70 70-90 90-120

Review homework and select goals for the present coaching session

Two dyads coached Two dyads coached Two dyads coached Provide summary feedback for each family and

select goals for the coming week's homework

Note. This breakdown assumes a typical-size group--four families with six parent-child dyads--and two sets of therapy rooms.


others who share similar problems. Coaching greater than e ight parent-chi ld dyads dur ing a g roup session signifi- cantly decreases the a m o u n t of t ime each pa ren t receives direct coaching and feedback.

To provide group PCIT, modif icat ions are also n e e d e d for the initial session, the CDI phase, and the PDI phase of t rea tment (see Table 3 for an overall compar i son of g roup and individual PCIT). The purpose of the initial session is to provide parents with an overview of PCIT, explain the structure of group sessions, bui ld r appor t among the therapis t and parents, establish group guidelines, and set a tone conducive to therapeut ic gain. One o f the fundamen ta l differences between individual and group PCIT is that g roup PCIT member s spend much o f the session observing o the r parent -chi ld interactions. In the first session, therapists p repa re parents to be observed. Prepara t ion includes discussion of the ra t ionale and benefi ts of watching o the r families ' interactions. Par- ents ' anxiety is normal ized and families are encouraged to view challenges in thei r parent-chi ld interact ions as l ea rn ing opportuni t ies . In our exper ience , the majori ty of parents demons t ra te mild anxiety in the first coaching session. No parents have r e p o r t e d refusing group treat- m e n t or d iscont inuing t r ea tmen t because of the observa- t ion componen t . However, we have no t formally assessed parents ' feelings about be ing observed. The r ema in ing t ime dur ing the first session is focused on developing cohes ion within the group. Parents are encouraged to iden- tify constructive similarities with o the r parents (e.g., that they are all a t t end ing t r ea tment to learn new ways o f manag ing their chi ldren 's behavior and to enhance their relat ionships with their ch i ldren) . Finally, g roup guidelines are establ ished to set a tone of respect, support , and col laborat ion among group members .

Table 3 Comparison of Individual and Group PCIT Formats

Individual Group

Individual intake assessment Yes Yes CDI didactic Yes Yes PDI didactic Yes Yes Weekly behavioral assessment Yes Yes Posttreatment assessment Yes Yes Individual booster session Yes Yes

Number of sessions Untilbehavior 16 WNL

Number of therapists 2 2 Number of families 1 3-6

Family members involved Caregivers & Caregivers & child child

Live coaching & immediate feedback Yes Yes

Feedback from other parents No Yes In-room coaching feasible Yes Yes

The CDI teaching session is p resen ted dur ing the second session. The format of the g roup teaching session is similar to the or iginal PCIT pro tocol (e.g., H e m b r e e - Kigin & McNeil, 1995; Herschel l et al., 2002b), bu t with an a d d e d focus on engaging all families so that each paren t begins to cons ider how to apply the CDI skills to his or he r own child. After the teaching session, CDI coaching begins. Typical coaching sessions start with a review of the previous week's homework and each paren t ' s selec- t ion of one or two goals for his or he r skill d e v e l o p m e n t dur ing the session. After this review, parent -chi ld dyads are observed and coached. While one family is coached by a therapist , o the r parents observe and record the coached paren t ' s skill usage using a simplif ied version o f the Dyadic Parent-Chi ld In terac t ion Coding Sys tem- I I (DPICS-II) coding sheet (Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994). Therapists note that coding o thers ' pa ren t -ch i ld in te rac t ions helps pa ren t s to solid- ify their unde r s t and ing of the PRIDE skills. Parents are coached somewhat less t ime per session than in individual PCIT (15 to 20 minutes ra ther than 20 to 30 minutes); however, they also observe o the r families prac t ic ing the skills and receiving coaching. After all families have been coached, parents receive feedback f rom the therapists and f rom o the r g roup member s dur ing a g roup discussion.

In individual PCIT, t ransi t ion f rom CDI to PDI occurs after parents reach a p r e d e t e r m i n e d cri teria in the i r use of the CDI skills (e.g., using 15 p ra i se s - -wi th no less than 9 labe led praises, a c o m b i n e d total of 25 descr ipt ions and reflections, and a c o m b i n e d total of no more than 3 criticisms, commands , or quest ions in a 5-minute play period; Hembree-Kigin & McNeil, 1995). In g roup PCIT, the CDI to PDI transit ion is not based on parents ' achieve- men t of set criteria. PDI begins in the e ighth session (after five CDI coaching sessions) for all parents. However, parents ' PRIDE skills are assessed weekly, as in individual PCIT, and families are given the cri ter ia as a goal for which to strive dur ing special play time. Whe the r pre-PDI mastery o f CDI skills affects long-term t rea tment ou tcome is an empir ica l quest ion that has yet to be addressed.

Modif icat ions to the PDI phase of g roup PCIT ensure that t r ea tmen t is individual ized for each family. Follow- ing the group PDI teaching session, the first PDI coaching session is scheduled individually. This is the only o the r session conduc ted individually, in add i t ion to the intake assessment and the boos te r session. The first PDI coaching session is f requent ly an e x t e n d e d session because chi ldren are learn ing and testing their parents ' new responses to noncompl iance . An individual session provides bo th parents and ch i ldren the t ime and a t ten t ion they need to successfully negot ia te the ini t iat ion of the discipl ine phase. This individual PDI coaching session also allows the therapis t ext ra t ime to evaluate the proce- du re each family will use as a backup to the PCIT time-

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out protocol . For some parents, a ho ld ing chair may be the most effective backup (see Hembree-Kigin & McNeil, 1995). For o the r families (e.g., families at risk for child physical abuse) , using a ho ld ing chair may no t be appro- pr ia te and a tangible r e in fo rcement p rocedure , t ime-out room, or o the r p rocedure will need to be implemented .

The final g roup session is a wrap-up ce lebra t ion that allows parents to review their progress, discuss strategies to mainta in gains, and consider areas where they would like to cont inue to improve. Parents comple te a posttreat- m e n t bat tery similar to the p re t r ea tmen t battery, with the addi t ion of a cl ient satisfaction survey (for a deta i led descr ipt ion o f pos t t r ea tment measures, see Hembree-Kigin & McNeil, 1995). Chi ldren and parents share pizza and receive certificates of complet ion . Therapists encourage families to cont inue to suppor t each o the r and to contact the clinic if addi t ional suppor t is needed . An individual boos te r session is offered to each family at 6 months after t r ea tment complet ion . In cases where families are in need of addi t ional suppor t to mainta in t r ea tment gains, it may be preferable to offer the boos te r session earlier. Individual PCIT typically provides a boos ter session at 1- m o n t h pos t t rea tment . We selected a 6-month boos te r to obta in follow-up informat ion fur ther f rom the comple- t ion of t rea tment .

In addi t ion to the modif icat ions necessary in the paren t group, conduc t ing PCIT in a g roup format presents the chal lenge o f supervising the chi ldren. Dur ing individual PCIT, ch i ld ren are directly involved in therapy for the majori ty of the session. However, for the 2-hour PCIT group session, each child interacts with his or he r pa ren t for only 15 to 20 minutes, and ch i ldren a l ternate so that, at any t ime dur ing the group, approximate ly half the chil- d ren are no t in terac t ing with their parents. In addi t ion, when families are unable to afford or obta in a babysit ter for siblings of the child in t rea tment , they are encouraged to b r ing the siblings. It is necessary, therefore, to have child-care assistants. The assistants are typically vol- unteers who provide care that is consis tent with PCIT principles. They provide constructive toys similar to those used dur ing parent -chi ld interact ions (e.g., blocks, cray- ons, and paper ) . Destructive toys and toys that encourage high levels of activity (e.g., guns, punch ing bags, balls) are no t inc luded in the playroom. Child-care assistants employ CDI skills dur ing thei r interact ions with the children. Ignor ing and red i rec t ion are used to address non- destructive negative behaviors. Destructive or aggressive behaviors occur rarely in this con t ro l led setting. How- ever, when such behaviors do occur, child-care assistants provide a warning to ch i ld ren that they can e i ther choose a positive incompat ib le behavior or their parents will come to adminis te r a consequence . If parents have no t yet r eached the discipl ine c o m p o n e n t of t rea tment , parents may use one of thei r cur ren t consequences (e.g., re-

moval of privileges), or, in ex t reme cases, the session may be ended. If parents have reached the discipl ine component , therapists coacla the pa ren t th rough the use of the t ime-out p rocedure . Because the child-care g roup has a nondirect ive, chi ld-centered focus, pa ren t in tervent ion is n e e d e d infrequently. However, if there is such a need , much of the t ime a therapis t will be available to assist, as coaching occurs dur ing only one half of the g roup time. Alternatively, in some si tuations, chi ld-care coord ina to r s may be t ra ined to coach paren ts t h rough the t ime-out p rocedure .

While the child-care g roup itself is no t cons idered an active por t ion of t rea tment , it is possible that the ch i ld ren who exper ience the addi t ional t ime in a ch i ld-centered env i ronment may exper ience some benefits. Certainly, child-care may be an incentive to stressed parents to attend t reatment .

Rewards o f Group PCIT Group PCIT provides mul t ip le families s imul taneous

access to an evidence-based t reatment . This is part icular ly advantageous in settings where referrals are a b u n d a n t and therapis t availability is l imited (Barkley, 1987). Use of PCIT groups may decrease the l ike l ihood that families are p laced on a wait-list for t rea tment . Group PCIT also offers families a cost-efficient al ternative for therapeut ic services. Tradi t ional g roup therapy requires approxi- mately half the professional t ime pe r family as individual services (Brightman et al., 1982). A typical PCIT group consists of approximate ly four families with two therapists, whereas individual PCIT typically consists of two therapists pe r family. Thus, g roup PCIT is bo th efficient and cost-effective. In addi t ion, g roup PCIT includes chil- d ren actively in t r ea tment sessions and provides live coaching to parents as they pract ice skills. These aspects of PCIT set it apar t f rom o ther g roup pa ren t t ra ining models and may provide significant benefits to families.

High rates of at tr i t ion and poo r adhe rence to treat- men t are serious p rob lems a m o n g pa ren t t ra ining programs. Assemany and Mclntosh (2002) r epor ted that rates of attri t ion for pa ren t training programs have ranged from 8% to 48%. Attrit ion for individual PCIT has been repor ted to range from 23% to 35% (e.g., Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk , 1993; Herschel l et al., 2002a; Nixon et at., 2003). Both at tr i t ion and adhe rence are critical issues in a p rog ram such as PCIT, which relies on active par t ic ipat ion and comple t ion of homework to facilitate parents ' genera l iza t ion of skills. In g roup PCIT, cohesion a m o n g member s may he lp to amel iora te these problems. Positive pee r suppor t among group member s can increase families ' e nga ge me n t with the p rog ram (Webster-Stratton, 1997) and positive pee r pressure may increase adhe rence in session and at home (e.g., families keep up because they do no t want to be left beh ind) . In


addition, families who consistently attend treatment provide models for less-well-attending families, and therapists can shape behavior with strategically applied reinforcement. For example, in a group format, therapists frequently reinforce parents who have completed and re- turned homework forms. Although the effect of group format on adherence and attrition has not yet been sys- tematically evaluated, some of the lowest attrition rates among parent training programs have been found in studies of Webster-Stratton's treatment model, which is a group program (Assemany & McIntosh, 2002).

Group treatment can also provide a valuable source of social support for parents (Webster-Stratton, 1997). Low levels of, and dissatisfaction with, perceived support has been associated with parenting problems including increased risk for child maltreatment (Bishop & Leadbeater, 1999; Budd, Heilman, & Kane, 2000; Kotch, Browne, Du- fort, & Winsor, 1999). PCIT group therapists can nurture parents' support of each other by highlighting similarities in parenting goals, creating an environment where parents provide each other frequent reinforcement for positive behaviors, and encouraging parents' collabora- tion in problem solving. AS a result, we have found that parents frequently contact each other outside of therapy. In group, they share personal experiences and often share educational and professional information such as books, programs, names of teachers and physicians, and other community resources that they find helpful.

Group PCIT provides parents with the opportunity not only to share experiences that occur outside the group but, because of the live coaching sessions, to share in- tense parent-child experiences as they occur. This sharing can decrease feelings of isolation. Parents develop relationships with families who have similar problems, which may reduce the stigma of having a "problem child" (Webster-Stratton & Herbert, 1993). Group PCIT also provides powerful opportunities for social reinforcement by a peer group. Social reinforcement plays a role in engaging families in treatment, maintaining attendance, and shaping parenting behaviors (Borrego & Urquiza, 1998). Although Borrego and Urquiza focused on the social reinforcement of parents by the therapist, expanding their conceptualization to include group members makes sense in the context of group-formatted PCIT. The social reinforcement that families provide each other in group PCIT can reduce parental feelings of isolation and may decrease premature dropout.

Challenges of Group PCIT As a treatment modality, group psychotherapy pre-

sents challenges to the therapist that individual psychotherapy does not. For example, group discussion must be managed so that every parent has time to talk about individual progress and concerns, a therapeutic alliance must

be developed and maintained with multiple families simultaneously, and feedback from parents to each other must be shaped so that it is relevant and constructive. Group PCIT presents a number of additional challenges, as well Some of these have already been discussed (e.g., caring for children during group). Each challenge must be considered and addressed when deciding whether to implement the modified format of PCIT.

Because of the many complex issues involved in the effective administration of group psychotherapy, we recom- mend that therapists consider using group PCIT when they have had previous training and supervision in the use of parent groups. Therapists seeking to expand their understanding of common group therapy challenges are referred to the recent literature (e.g., Conyne, 1999; Fehr, 1999; MacKenzie, 1995; Spitz & Spitz, 1999; Stern, 2000). After the decision has been made to implement group PCIT, therapists must still consider the appropri- ateness of the modality for each referred family before beginning treatment. A number of factors may reduce the efficacy of PCIT, including severe psychopathology in the parents (e.g., personality disorders), marital distress, and substance abuse (Hembree-Kigin & McNeil, 1995). In some cases, it may be necessary to implement individual treatment for parents prior to beginning parent training. Severe psychopathology in one or two parents in a group may be disruptive to the development of group cohesion and may also require a disproportionate amount of the therapist's attention. Screening for parent psychopathology at the intake assessment is recommended to help facilitate the decision as to whether group is an appropriate form of treatment for a particular famil~

Managing parents' feedback to each other is another challenge of group PCIT. Feedback is an important component of the collaborative relationships between the therapist and the group members and among the group members themselves (White & Freeman, 2000). As previously described, group PCIT uses parents' feedback to each other as a way to enhance skill development. The challenge is to ensure that comments are on topic and constructive. Group therapists shape parents' feedback through a three-step process of education, modeling, and reinforcement. At the beginning of the PCIT group, parents are educated as to the purpose of constructive feedback and are given examples of the type of comments they will be asked to provide. Comments about other parents' interactions with their children should be specific to the PCIT skills and not personally based (White & Freeman, 2000). Next, therapists model effective feedback by providing labeled praises to parents for their areas of strength and providing encouragement regarding areas in need of development. Finally, therapists ver- bally reinforce parents for providing specific, constructive comments to others. In our experience, parents are

120 Niec et al.

receptive to feedback f rom o the r parents, and in giving feedback are more likely to be overly positive than overly critical. This k ind of feedback can be useful to p romo te cohesion a m o n g g roup members and can be modi f ied in a n u m b e r of ways, if necessary. For example , after the feedback, therapists can ask parents to descr ibe thei r own ongo ing goals for improving their interact ions with their chi ldren.

T ime is a chal lenge to manage in g roup PCIT because the needs of mul t ip le families must be ba lanced so that each family receives adequa te coaching and therapis t at- tent ion. Overall, parents in groups receive less individual coaching t ime bu t more t ime observing the skills and coaching of o the r families than parents in individual PCIT. Some specific situations that can make t ime man- agemen t more difficult inc lude having parents who mo- nopol ize g roup discussion, having families with mul t ip le siblings in a group, and having a chi ld or ch i ld ren who require unusual ly long t ime-out procedures .

The re are a n u m b e r of books on group psychotherapy • that can provide techniques for working with members

who repea ted ly monopo l i ze the discussion or therapist 's t ime (e.g., Fehr, 1999; Free, 1999; Spitz & Spitz, 1999; White & Freeman, 2000). We will no t review them here. However, strategies that have been effective in g roup PCIT include, for example , creat ing a g roup environ- m e n t in which every pa ren t is expec ted to cont r ibute and to listen, using redi rec t ion to keep parents goat-focused, and providing oppor tun i t ies for parents to write down quest ions for therapists that can be addressed dur ing sub- sequent sessions. For some families, always having more pressing issues than can be addressed dur ing group t ime may be an indicat ion that addi t ional t rea tment (e.g., marital therapy, individual adul t psychotherapy) is warranted.

Time constraints can occur when parents have multiple ch i ld ren involved in t rea tment . This may mean that fewer families can fit in a group. An al ternate solution, however, is to coach the parents of the siblings for a shor te r a m o u n t o f t ime with each child. Since the pa ren t will be coached at least twice, the amoun t of t ime spent with each child can be r educed without reduc ing overall coaching time. In the case of two parents and two chil- d ren in a family, parents can rotate across sessions so that each pa ren t is coached with one child each week.

Dur ing the PDI phase of t rea tment , coaching is no t e n d e d until any ongo ing t ime-out p rocedu re is completed. This means that sessions can take longer than scheduled. Long sessions are part icular ly likely dur ing the first PDI session when ch i ldren are learn ing the new consequences for noncompl iance , which is why the first session is conduc ted individually. How should therapists respond, however, when a family goes over thei r sched- u led t ime dur ing a group coaching session? If the ex- t ended session occurs once, o the r families are encour-

aged to stay to learn th rough observat ion and to provide addi t ional suppor t for the s t ruggling parent . Dur ing this time, o the r parents should still be provided with coaching by the cotherapist . I f it becomes clear that a par t icular family will require more t ime over mul t ip le sessions, it is r e c o m m e n d e d that an addi t ional individual session be provided. Al though we have no t yet encoun te r ed this sit- uation, it is possible that, even with one or two supple- menta l sessions, a family will need more t ime to comple te the discipline p rocedures than available in the group. This p rob lem raises a re la ted issue, that is, how to determine when a family needs to shift f rom group to individual t reatment .

Careful intake assessments should reduce inappropr i - ate p lacements to g roup PCIT; however, some problems may no t appear to be unmanageab le in group unti l treat- m e n t has started. Because the most likely t ime for addi- t ional difficulties to surface is halfway th rough the group dur ing the PDI phase, member s will a l ready have developed a t tachments to each o the r and to the group as a whole. Therapists should balance the costs of d is rupt ing group cohesion by removing a family with the need for each family to receive sufficient therapis t a t tent ion. Pr ior to shifting a family out of the group, o ther opt ions should be considered, for instance, providing an addi t ional individual session or offering adjunct therapy (e.g., mari ta l therapy) as descr ibed above. Further, it may be possible to mainta in a family in the group, bu t to provide addi- t ional individual t r ea tment after the group 's complet ion .

The final chal lenge of group PCIT that we will discuss is the need for specialized equipment . When no bug-in- the-ear device is available for the therapist to coach parent- child dyads from outside the therapy room, it is possible to conduc t in-room coaching, as descr ibed elsewhere (e.g., Herschel l et al., 2002b). However, it is no t feasible to have an ent ire group of parents in the therapy room observing a parent -chi ld interact ion. This would be too distract ing and could pose possible dangers for others if a child is physically aggressive. In o r d e r to mainta in the oppor tuni ty for parents to observe o ther families dur ing coaching, it is necessary for the group member s to observe from another room. Therefore, an observation room and one-way mi r ro r are required. Fortunately, having at least one therapy space e q u i p p e d with an observation room is no t u n c o m m o n among menta l heal th clinics, and this c o m p o n e n t is less expensive than the bug-in-the- ear receiver system.

In summary, imp le me n t ing PCIT in a g roup format ra ther than an individual one presents a n u m b e r of challenges. These chal lenges must be taken into account when a clinician is making the decision regard ing how to adminis te r PCIT. However, g roup PCIT 1Tlay be advantageous for a n u m b e r of reasons: more families can be treated with fewer therapist hours, live coaching of parent-


child interactions permits ongoing behavioral assessment of families' progress, group cohesion may reduce attrition and enhance adherence, parents have the opportunity to observe other parent-child dyads, and group members provide and receive social re inforcement regarding skill development.

Rewards and Chal lenges: A Case Example o f a PCIT Group

Case Backgrotmd Information Group PCIT was conducted at the psychological train-

ing center of a university psychology depar tment as part of an ongoing project to assess the efficacy of group versus individual PCIT. The members of this group included three families with a total of four chi ldren (ages 26 to 56 months) . Families were referred by communi ty mental health agencies or were self-referred for a range of disruptive behavior problems including pervasive noncompliance, severe tantrums, hyperactivity, verbal aggression, physical aggression toward siblings and peers, and fire setting. Two families were single-parent homes. Mothers were the primary participants for all families, and no families had involvement with child protective services. Fami- lies ranged in socioeconomic status from 20 to 48 on the Holl ingshead Four Factor Index of Social Status (Holl- ingshead, 1975).

Assessment Intake therapists evaluated each family individually 1

day to 6 weeks prior to the start of the group. Families participated in a clinical interview and completed the following standardized measures as part of the assessment battery: Behavior Assessment System for Chi ld ren-Paren t Rating Scales (BASC; Reynolds & ICamphaus, 1992), Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), Parent ing Stress I n d e x - S h o r t Form (PSI-SF; Abidin, 1990), and Peabody Picture Vocabulary Tes t -Thi rd Edi- tion (PPVT-III; D u n n & Dunn , 1997; see Table 4 for scores at intake). All chi ldren were within the clinical range by paren t report on either the BASC externalizing composite or the ECBI intensity score at intake. All parents reported high levels of stress related to parenting. Recep- tive vocabulary ranged from 112 to 115 for the three children old enough to complete the PPVT-III. After intake and prior to treatment, a therapist contacted families by phone weekly to administer the ECBI and moni tor children's ongoing behavior problems. The weekly contact was also used to mainta in families' engagement while they waited for the group to begin,

CDI Phase Two graduate students in a doctoral clinical psychol-

ogy program administered the group PCIT protocol under

Table 4 Pre- and Posttreatment Measures for Group Members

ECBI BASC PSI %ile

Externalizing Intensity Problem Total Stress

Child 1 Intake 73 171 23 99 Pre-tx 69 173 23 99 Posvtx 53 91 5 70

Child 2 Intake 61 170 20 99 Pre-tx 75 200 27 - - Pos~tx 52 88 2 85

Child3 Intake 86 175 17 75 Pre-tx 91 169 20 75 Posvtx 76 124 12 70

Chfld4-Parentl Pr~tx 59 140 4 70 Post-tx 61 162 10 85

Child ~Parent 2 Pre-tx 68 154 13 75 Pos~tx 68 175 14 95

Note. BASC = Behavior Assessment Systems for Children-Parent Rating Scales, Externalizing = Externalizing Composite Score; ECBI = Eyberg Child Behavior Inventory; PSI = Parenting Stress Index-Short Form; Scores on the BASC are presented as T-scores. ECBI Intensity and Problem scales are raw scores. Child 4 received an intake 1 day prior to treatment, thus only pretreatment data were collected.

the supervision of a doctoral-level psychologist. Over the course of 16 sessions, Family 1 a t tended 13 sessions, Fam- ily 2 attended 14 sessions, and Family 3 attended 15 sessions. Families that miss more than 2 sessions receive a makeup session to prevent them from falling too far beh ind the group and to assess their commi tmen t to the t rea tment process. Family 1, therefore, received one makeup session.

Each family demonst ra ted different patterns of relative s trengths and deficits in their parent -chi ld interactions, and therapists individualized the CDI coaching to meet their needs. For example, dur ing the first two CDI sessions, Family 3 struggled with the use of selective at tent ion with a very active child who was frequently out of his chair, while Family 2 focused on reducing an excep- tionally high level of paren t questions. Family 1 began with a relatively high level of CDI skills and provided a model for the other families. Although therapists individualized coaching and feedback, dur ing discussion peri- ods they encouraged group members to work together to manage challenges encoun te red in their parent-child interactions. Group members responded readily. For example, Family 2 exper ienced particular difficulty shaping their child to remain at the table because of his young age. Group members offered creative solutions, and the

122 Niec et al.

family chose to work with the child using a b lanket on the floor. Therapis ts avoided unproduct ive discussion a m o n g group member s (e.g., parents ' focus on chi ldren 's negative behaviors) by val idat ing paren ts ' frustrations and re- direct ing the discussion toward CDI skill deve lopment as a means to increase their positive parent-chi ld interactions.

As group cohesiveness con t inued to develop, positive pee r pressure a p p e a r e d to motivate parents to keep up with the homework and a t tendance . For example , one group m e m b e r expressed concern that missing a session had pu t he r beh ind the group, and she worked to a t tend all future sessions. In fact, when she la ter faced transpor- tat ion problems, she sought he lp f rom ano the r family and they provided her with a r ide to t reatment .

Chi ldren ' s behavior changes were assessed dur ing CDI using the ECBI. From pre t r ea tmen t to comple t ion of CDI, the ECBI scores of three out of four chi ldren d r o p p e d (decreases r anged from 6 to 42 points) . Surprisingly, one child showed an increase of 31 points; however, this child no longer demons t r a t ed any self-destructive behaviors, which the parents r epo r t ed as the most distressing behavior at intake. Additionally, by the end of this t r ea tment phase, no fire-setting was exhib i ted by any child.

Parents ' behaviors were assessed at the last CDI coaching session th rough observat ion o f each parent -chi ld dyad in 5-minute, uncoached play interact ions. All three families met the CDI skills mastery cri teria as descr ibed previously (Hembree-Kigin & McNeil, 1995). That is, they used at least 15 praises (no less than 9 labe led praises), at least 25 descr ipt ions and reflections, and had no more than 3 questions, criticisms, and commands during the 5-minute observation.

PDI Phase By the PDI phase of t rea tment , g roup cohesiveness

was firmly es tabl ished and group member s rout inely pro- v ided each o the r with suppor t bo th in and out of session. Because the PDI c o m p o n e n t can be stressful to parents as they init iate a new discipline p rog ram with their children , g roup suppor t was part icular ly valuable. Within session, for example , one pa ren t faced a part icular ly difficult t ime-out and ho ld ing p rocedure , and the observing families told the coach to let the pa r en t know, "We're all here. Hang in there!"

Group member s also he lped each o ther to solve challenges with the new discipl ine p rog ram that occur red outside the clinic. For example , the g roup provided a pa r en t with creative ideas on manag ing her child who re- peatedly wanted to "rescue" his sibling f rom time-out. With therapis t and group support , the pa r en t dec ided that when one child was sent to t ime-out she would (1) praise incompat ib le behaviors exhib i ted by the sibling no t in t ime-out to prevent him f rom intervening, (2) provide positive red i rec t ion if he a t t empted to intervene,

and (3) refrain f rom giving h im direct commands to avoid the potent ia l for s imultaneous t ime-out procedures . Dur ing this phase of t rea tment , g roup member s began to a r range to go to events toge ther outside of session, and they all par t ic ipa ted in a trip to the park.

Treatment Completion During the last session, therapists reviewed group

members ' progress and discussed me thods to mainta in t rea tment gains. The group members p l a nned a PCIT barbecue to be he ld within the nex t 2 weeks as thei r own "booster" session.

See Table 4 for pos t t rea tment data. Overall, chi ldren 's levels of disruptive behaviors decreased. On the ECBI, three of the four ch i ld ren moved from the clinically sig- nif icant range to the normal range. On the BASC Exter- nalizing composi te , two ch i ldren moved f rom the clinically significant range to the no rma l range. Regard ing levels of pa ren t ing stress, one family moved f rom the clinically significant to normal range on the PSI (from 99th percent i le to the 70th percent i le ) . Two parents r e m a i n e d in the no rma l range t h roughou t t rea tment . The stress of one family out of the four increased. This same family re- po r t ed no decrease in their child 's behavior problems. U p o n discussion, the parents r e p o r t e d a recen t change in thei r living si tuation (a distant family m e m b e r had un- expectedly come to live with them) that caused stress in the home, which was ref lected by an increase in parenting stress and child behavior problems. All clients repor ted high levels of satisfaction with the t rea tment (mean overall rat ing 4.92 out of 5), though this n u m b e r should be in te rp re ted with some caut ion because the group therapists admin i s te red the surveys; thus, social desirabil- ity may have played a role in parents ' responses.

Al though the majori ty of the chi ldren demons t r a t ed increases in positive behavior, no t all ch i ld ren were in the no rma l range at the pos t t rea tment assessment. This is a p rob lem inhe ren t in t radi t ional g roup formats and raises the quest ion of how to best work with families who are still in need of services when group t r ea tment is complete. In individual PCIT, families do no t progress f rom CDI to PDI unti l specific cri teria are met (Hembree-Kigin & McNeil, 1995), and te rmina t ion is not p l a n n e d unti l the child no longer exhibits behavior p rob lems in the clinical range. Clinicians must hand le the chal lenges of group PCIT in new and creative ways. For example , in this p rogram, therapists mee t with families individually dur ing the first PDI coaching session and provide an individual makeup session if a family misses more than two group meetings. If a family has no t met the cri teria for CDI skill mastery at the t ime PDI begins, one alternative is to provide an individual "catch-up" session. A second opt ion is to refer families who do no t mee t cr i ter ia for ter- mina t ion to con t inued t r ea tment after comple t ion of the

Group Parent-Child Interaction Therapy i23

group . In the case o f this g roup , only o n e ch i ld r e m a i n e d

in the cl inical r a n g e o n the ECBI In tens i ty Scale at post-

t r ea tmen t , a n d tha t family i n t e r p r e t e d the r e m a i n i n g be-

hav io r p r o b l e m s as a r eac t ion to r e c e n t family stressors.

T h e family d id n o t feel c o n t i n u e d services were neces-

sary, b u t a g r e e d to con tac t t he cl inic shou ld b e h a v i o r

p r o b l e m s con t inue .

S u n l m a r y

O n e o f the benef i t s o f g r o u p P C I T is tha t pa ren t s re-

ceive suppor t , accep tance , a n d social r e i n f o r c e m e n t

f r o m o t h e r g r o u p m e m b e r s . In adu l t g r o u p psychother -

apy, such g r o u p cohes iveness has re la ted to posi t ive ther-

apeu t i c o u t c o m e s (Bal l inger & Yalom, 1995). In the

p r e s e n t g roup , therapis ts n o t e d that m e m b e r s e x h i b i t e d

h i g h levels o f cohesiveness . A l t h o u g h each family h a d

mul t ip l e ch ron i c stressors (e.g., s ingle p a r e n t h o o d , f inan- cial stress, ch i l d r en with severe b e h a v i o r p r o b l e m s ) , they

still p r o v i d e d s u p p o r t for each o t h e r in a n d o u t o f ses-

sion. This suppo r t may have p layed a pa r t in faci l i ta t ing

t r e a t m e n t gains o f ind iv idua l pa ren t -ch i ld dyads, increas-

ing t r e a t m e n t a d h e r e n c e , and gene ra l i z ing p a r e n t i n g

skills f r o m clinic to h o m e . Several factors wi th in this

g r o u p may have e n c o u r a g e d t he i r cohes ion : first, all the

c h i l d r e n in the g r o u p were relat ively close in age (2 years,

2 m o n t h s - 4 years, 8 m o n t h s ) , so famil ies c o u l d re la te to

each o t h e r as they discussed the i r ch i l d r en ' s c h a l l e n g i n g behav iors and cha l l enges a r o u n d i m p l e m e n t a t i o n o f the

P C I T skills; second , n o famil ies h a d ch i ld p ro tec t ive ser-

vices referrals , thus no pa ren t -ch i ld r e l a t ionsh ip h a d be-

c o m e so p r o b l e m a t i c as to l ead to m a l t r e a t m e n t ; finally,

n o m a j o r p sychopa tho logy exis ted a m o n g any g r o u p

m e m b e r s . T h e i m p a c t o f such factors o n g r o u p cohesive-

ness a n d how cohes iveness re la tes to t h e r a p e u t i c out-

c o m e in p a r e n t t r a in ing g roups has yet to be invest igated.

C o n c l u s i o n s

In the i r discussion o f new d i rec t ions for PCIT, Her-

schel l a n d co l l eagues (2002a) ca l led for a l t e rna te me th -

ods o f t r e a t m e n t del ivery to r e m o v e bar r ie rs to famil ies '

t r e a t m e n t a d h e r e n c e a n d c o m p l e t i o n . G r o u p PCIT has

the po ten t i a l to address several s igni f icant barr iers: it may

a m e l i o r a t e f inancia l stressors by r e d u c i n g t r e a t m e n t costs

a n d p r o v i d i n g g r o u p ch i ld ca re fo r siblings o f the ta rge t

child, it may r e d u c e mot iva t iona l bar r ie rs tha t i n f luence

a d h e r e n c e a n d a t t r i t ion t h r o u g h p e e r s u p p o r t a n d g r o u p

cohes ion , a n d because it d e m a n d s fewer resources in

t e rms o f the rap i s t hours , g r o u p P C I T may r e d u c e accessi-

bili ty bar r ie rs a n d al low m o r e famil ies to ob ta in services

in a t imely m a n n e r .

G r o u p P C I T is a p r o m i s i n g t r e a t m e n t moda l i ty

a d a p t e d f r o m an ev idence-based t r e a t m e n t tha t has dem-

ons t r a t ed efficacy a n d utility in the r e d u c t i o n o f chil-

d ren ' s d isrupt ive behav iors a n d the e n h a n c e m e n t o f

parent-chi ld relationships. However, several empi r ica l ques-

tions n e e d to be addressed t h rough con t ro l l ed studies o f

ind iv idual versus g r o u p PCIT: Is g r o u p PCIT c o m p a r a b l e

to ind iv idua l P C I T in efficacy and m a i n t e n a n c e o f treat-

m e n t gains? Does c o h e s i o n wi th in P C I T g roups l ead to

i m p r o v e d t r e a t m e n t o u t c o m e ? Can g r o u p P C I T increase

pa ren t s ' p e r c e i v e d social suppor t? W h a t factors m a k e a

family m o r e likely to bene f i t f r o m a g r o u p m o d e l ? G r o u p

P C I T is an innova t ive t r e a t m e n t moda l i ty wi th t he p o t e n -

tial to e n h a n c e service p rov is ion fo r m a n y c h i l d r e n a n d

families. To address these u n a n s w e r e d ques t ions a n d bet-

te r serve famil ies in n e e d o f t r ea tmen t , a large, mul t i s i te

inves t iga t ion o f g r o u p PCIT m u s t b e c o m e a pr ior i ty fo r

P C I T researchers .

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Address correspondence to Larissa N. Niec, Ph.D., Central Michigan University, Department of Psychology, Mr. Pleasant, MI 48859; e-mail: [email protected].

This article was accepted under the editorship of Anne Marie Mbano.

parent-child interaction therapy: the rewards and challenges of a group format

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