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CAT and the “Incredible Years” programme: Towards a CAT parenting guidance framework

Marie-Anne Bernardy-Arbuz, 2017. CAT and the “Incredible Years” programme: Towards a CAT parenting guidance framework. Reformulation, Summer, pp.22-31.

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Introduction

We have been offering a parental guidance program called ‘Incredible Years’ (IY), developed by Caroline Webster-Stratton (1989) since 2009 at our CAMHS in Paris. Most of the parents we see are searching for help for their children, who show oppositional, provocative, defiant and/or aggressive behaviour. The parenting group meets once a week for twenty sessions of 2 hours’ duration.

IY is a cognitive behavioural model, introduced more than 30 years ago in the USA (1984, 1985a, 1989). It is continuously researched and a great deal of evidence can be found showing its effectiveness (1992a, 1997, 2004, 2006, see references below). IY helps parents change their parenting styles. It allows them to improve the parent/child relationship through play and positive attention, helps them to feel reassured in their parenting role and to set clear limits. These limits are followed through with commands, an ability to ignore certain behaviour and implement consequences like time-out and loss of privileges for behaviour that cannot be ignored. Incredible Years is a structured, manualised program, where each session provides a specific learning goal. However, this leaves little space to address any personal issues the parents might have.

Furthermore, many parents tell physicians that they are interested in joining a group, but do not come to the first meeting. They find a lot of excuses when we invite them to participate. Some come for 2-3 sessions and then drop out without giving any explanation; some argue that they have nobody to look after the children when they come to the sessions; some explain that they have started working and can no longer attend.

As professionals with a former psychoanalytic and psychodynamic individual and group training, it seemed important to our team that parents’ personal difficulties should be addressed, since we noticed the trouble they had in implementing the teachings of the program at home. We felt that if a child has a problem, we had to examine if and how this difficulty may be related to a possible parental unresolved problem or conflict. A major hypothesis in our work is that: ”If we are to help a child, we need to examine the parent-child relationship and understand how we can help the parent “.

Over the years, we have been trying to find answers to some of the questions that have emerged, for example:

1. Why is it so difficult for parents to join the group and participate in all the sessions?

2. Why is it so difficult for parents to change their behaviour and implement the program at home?

Could CAT help?

During the group sessions, parents can bring in any personal difficulties; for example, playing with a child, facing the child’s reactions to limit setting, frustration and tantrums, feelings of being judged and criticized, being stigmatized a “bad parent”, feeling overwhelmed by certain situations and not being able to cope. Having worked for many years with parents, we are convinced that if we do not address parents’ personal needs, they cannot listen to the needs of their children and to the solutions we are offering them. This means mirroring a healthy reciprocal role of listening/heard as opposed to criticizing, judging, blaming/criticized, judged and blamed.

We are aware that some parents’ personal and childhood problems are actualized when they have children of their own. It might be that these difficulties make it impossible for them to fully use the tools offered by the program which does not address these personal and relational difficulties. However, IY helps the parent to “learn how to be a parent”, by giving them clear indications, rules and tools on how to behave with their child: learning to change their behaviour in relation with their children can change their children’s behaviour. Without being conscious of it, parents can adopt a behaviour that will provoke a repetition of former schemas. Thus we hear comments like “it did me no harm, it did not prevent me from growing up, our parents acted in this way, so why should we behave differently?”

The notion of teaching the parents to behave differently with their children and thus bring about change in the children’s behaviour can be directly linked to CAT as a relational model, where Reciprocal Roles are a fundamental part of CAT theory and practice. There is also the idea of modeling/imitating in IY, also found in CAT, together with attachment and mimetic behaviour theories. Rachel Pollard (2008, p92) draws our attention to mimetic behaviour, quoting René Girard: “Fundamental to human psychology is the propensity to imitate others, particularly the desires of others”.

However, solely implementing a cognitive-behaviour program, can make parents feel guilty since they may feel “this is what you have to do – here is the answer, the solution” and in order to escape this feeling they subsequently reject the teachings of the program and leave. Sometimes parents say “we have come in order to learn … get recipes that enable us to deal with our children, make them listen, make them behave and stop throwing up tantrums and being tyrannical”. They do not want to learn how to play with their child; rather, they are interested in methods to make the child comply, obey. They say “it is our child that has a problem”… or “it is not us who have to change, if our children change, everything will be alright”.

Hearing all these comments made us think that the methods we offer in order to change and deal differently with the children might be insufficient for some parents.

Development of IY Model and CAT

Raising children is about relationships. If parents want children to comply and behave, we need to think about the quality of the parent-child Reciprocal Roles such as listening/heard, shouting/terrified, misbehaving, provoking, opposing or defying/powerless, inadequate.

But raising children is also about “trying to write a new page”, when this supposedly “new page” is already full of invisible patterns of former experiences, relations, events, and family secrets which make up a parent’s personality. Notably, in his article “On Narcissism : An Introduction (1914)“, Freud writes “the child shall have a better time than his parents….he shall once more really be the centre and core of creation – ‘His Majesty the Baby’ as we once fancied ourselves. The child shall fulfill those wishful dreams of the parents which they never carried out.”

We then have to help parents find an answer to the question “how can they operationalise change, when this very change comes to shake their beliefs and the models they have learned as children – be they repeated or rejected?” And, more generally, how do we change? We do not “learn” how to be a parent. Most of the time, we are caught in our personal and cultural representations and beliefs from childhood, sometimes consciously trying to oppose learned patterns.

In our out-patient clinic, parents come and ask for help acknowledging that they are lost, especially as they try to listen to the contradictory messages of society which are perhaps in conflict with the criticising, shaming and controlling inner voices.

Over the years, we have noticed that parents can benefit from individual sessions along with IY group sessions. In individual sessions, they can discuss their difficulties with their children and understand links of past experiences and present behaviour that they cannot address in the group sessions. As mentioned earlier, some parents carry a lot of shame and guilt, which they might not be ready to share with the group members.

Using CAT in order to address parents’ problems: is there another word instead of ‘problems’?

For the last three years, we have been offering 5-6 individual sessions of CAT in order to respond to parents’ needs. We wanted them to feel listened to, without judgment or criticism; to feel heard and thus encouraged to change their way of relating to their children. We thought CAT would allow them to understand how their relationship with their own parents, their siblings and other family members - caught as they are between problems of family loyalty and difficulties in their own childhood - can affect their children.

Hypotheses for using individual CAT sessions with parents attending IY group:

1. Individual CAT sessions would help parents express their personal difficulties, explore their parental models and reflect on their family history.

2. Individual CAT sessions would allow parents to understand the blockages that make it difficult and sometimes impossible for them to change, to feel secure enough and to learn how to change in order to help their children.

Framework for 5 sessions of individual CAT together with 20 sessions of Incredible Years

We built a CAT 5-session framework with the following aims:

1. How parents behave with their children and how children act and respond;

2. The basis/genesis of parental beliefs and reactions;

3. How parents might be affected by the misbehaviour of their children and why.

Session 1 (after IY Session 1): Draw an account of parents’ difficulties and create a “quick mapping” reformulation;

Session 2 (after IY Session 5): Create a Sequential Diagrammatic Reformulation (SDR) with reciprocal roles and any issues arising;

Session 3 (after IY session 10): SDR of possibility of recognizing difficulties and/or stopping unproductive parental behaviour and reactions;

Session 4 (after IY session 15): SDR of possibilities of change and finding exits;

Session 5 (after final IY session 20): “Goodbye letters” from both therapist and parent, with parents stating where they are and what they have learned.

Results: Use of CAT and IY together for 3 consecutive parent groups

In the following chart, we present the number of parents who attended parenting groups for the last 3 years as well as individual CAT sessions :

Of 22 parents accepting to join IY, 11 parents who followed 5 sessions of CAT were enabled to use the tools of the 20 session IY programme to the full, without getting mixed up in their personal difficulties.

4/11 parents were offered a full CAT therapy after they had finished the IY program in order to address further the personal problems brought up in 5 sessions of CAT.

Of 22 parents accepting to join IY, half (11) of the parents dropped out at different times.

Discussion

The framework of 5 sessions of CAT used together with IY sessions proved to be difficult to adapt for individual parents as most of them needed more than one session to explain personal matters.

CAT sessions after 1, 5, 10, 15 and 20 sessions of IY proved “unrealistic” and ineffective and did not prevent drop-outs. When we noticed that parents could not “adapt” to this framework, we tried to change the framework to accommodate their needs; specifically we felt that we had to respect parents’ Zone of Proximal Development (ZPD) according to their relational problems with their children and to their personal difficulties.

As to the question we were asking at the beginning, related to parents’ difficulties to join the group and attend all the sessions, we have been reflecting on the difference between the French health system, the British NHS and the health system in the USA. In France, parents can seek help according to their own choice in various places in the private or public sector (general practitioner, psychiatrist or psychologist). Our out-patient clinic is attached to a teaching hospital for children and adolescents, but parents can also seek help from practitioners in the private sector and social security will pay for most of the treatments, private or public. This could be an explanation for drop-outs as they can choose to change practitioners whenever they want.

We also wondered whether parents might feel ashamed, guilty, criticized and designated as being “bad parents” when referred by teachers, school psychologists and doctors. This might make it difficult for them to engage in group and individual sessions, however helpful they could be.

It has been impossible for us to examine cultural issues that might prevent parents from following the program and using it at home. Further research is needed.

We are sure that CAT can help parents address their personal difficulties, examine their parental models and reflect on their family history, but we will need to find a different framework in order to increase attendance. We believe that using a CAT parenting model will allow us to work on changing parental behaviour and thus enhance implementation of IY at home.

Adaptations of our framework to be made in relation to these results:

1. Discussion of the above results at Debbra Mortlock’s workshop at the national CAT conference in Exeter this year made us reflect on the framework we have been implementing for IY and CAT over the last 3 years. We have started to consider the possibility of developing a parental guidance framework for CAT with Debbra and Nick Barnes. It would be interesting to have experiences from various professionals in this field.

2. Looking at the 50% of drop-outs (n=11), we now aim to test a different framework and offer 5-6 sessions of CAT before we start the IY program. We wonder whether this might allow parents to focus on their personal issues before they start parental guidance programs and “deposit a weight of their past“ so that they feel freer to attend all the sessions. We will contact the parents who dropped out and invite them for a semi-structured interview in order to understand the reasons that made them stop coming to the group sessions.

3. In our CAMHS, we hope to offer a follow-up group 3 months after finishing the IY group; here, parents can bring their CAT diagrams and reflect on “where they are now – what is still blocking, difficult and what is improving“ in their relationships with their children.

4. In the longer run, we plan to set up a permanent CAT group for parents, meeting on a monthly basis after 20 IY sessions and the 5 CAT individual sessions. This would allow parents to continue working on the relationships with their growing children, exchange ideas with other parents and compare and learn from one another.

Putting Incredible Years parenting program and CAT into dialogue

Looking at the parenting pyramid in C. Webster-Stratton’s parental guidance program [www.incredibleyears.com/programs/implementation/] made us think about the parent / child relationship and their reciprocal roles. We have listed Reciprocal Roles operating on the different levels of this pyramid and developed a relational pyramid of parent-child reciprocal roles as follows:

Relational Pyramid with Reciprocal Roles – parent and child roles developed by M.Bernardy-Arbuz

The following 3 diagrams during 3 parents’ CAT sessions show how we were working with parents’ childhood patterns. We constructed the diagrams collaboratively. Parents were also attending the IY 20-session parental guidance program:

Diagram 1 : ‘Emily’

Emily had already been trying to come to two former parental guidance groups, but her attendance was very irregular and she never finished a group. The third time she enlisted, we offered to see her for 5 individual CAT sessions. She was very impulsive, could not focus, showing at the same time attention deficit, but also borderline personality disorder. One of her children had already been placed into foster care and social services were threatening to place the 2 younger children as well.

In the first and only individual CAT session, we drew the following diagram. It allowed us to see how much she was damaged and imprisoned in her childhood suffering, repeating old procedures. She was so disorganized, that for the third parental group, her attendance remained very irregular and we could not go further in CAT work either. Her 2 younger children were placed in the care of social services a few months ago (at the time of writing).

It might have helped if social services and health services could have worked systemically and relationally together.

Diagram 2 : ‘Sarah‘

As we work on her relationship with her eldest son, Sara says “I see myself “, with reciprocal roles of: attacking/attacked, criticising/criticised, agressing/agressed, abusing/abused, shaming/shamed, guilty, rejecting/rejected, abandoning/abandoned, crushing/crushed.

During Sarah’s 1st individual CAT session during the Incredible Years group, she realised how much her childhood experience was present in her relationship with her child today. This, in turn, made it impossible for her to follow through with her limits and commands; it also made it impossible for her to implement what she had learned from the IY group at home with her children.

Diagram 3 : ‘Gina’

Gina has been referred by colleagues for Incredible Years parenting sessions. She shows borderline personality disorder which makes it difficult for her to respect group rules and boundaries. She has a terrible story of abandonment and abuse during her childhood which she starts unpacking during the individual CAT sessions. She recognizes how much her feelings and reactions coming from the past are enmeshed with her reactions to her son’s behaviour today.

Conclusion

In the last 2 diagrams, we have tried to work on a framework for CAT, showing in Framework 1 how the parents we see at CAMHS are carrying into their adulthood unhealthy images, certainties, schemas, beliefs and repeating ways of acting learned from their own childhood.

Even if consciously, they want to change these early learnings, they might keep repeating unhelpful, unconscious patterns which will affect their relationships with their children. Parents would like to REPAIR. But if they go unheard in their difficulties, they are compelled to repeat. In therapy we can work on their personal difficulties; otherwise they will not be able to implement the teachings of parenting programs and use the tools IY offers efficiently.

References

Freud S. (1914 in The Standard Edition. Volume 14. 1957). On Narcissism : An Introduction. The Hogarth Press, London.

Pollard R.(2008) Dialogue and Desire. Mikhail Bakhtin and the Linguistic Turn in Psychotherapy. UKCP Karnac Series.

Webster-Stratton C. (1984).Randomized trial of two parent-training programs for families with conduct-disordered children. Journal of Consulting and Clinical Psychology, 52, 666-678.

Webster-Stratton C. (1985a). Predictors of treatment outcome in parent training for conduct disordered children. Behaviour Therapy, 16, 223-243.

Webster-Stratton, C., Kolpacoff, M., & Hollinsworth, T. (1988). Self-administered videotape therapy for families with conduct-problem children: Comparison with two cost-effective treatments and a control group. Journal of Consulting and Clinical Psychology, 56(4), 558-566.

Webster-Stratton C. (1989). Incredible Years : The Parents and Children Series, A comprehensive course divided into four programs – play, praise and rewards, effective limit setting, handling misbehaviour. Incredible Years Publisher.

Webster-Stratton, C., Hollinsworth, T., & Kolpacoff, M. (1989). The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. Journal of Consulting and Clinical Psychology, 57(4), 550-553.

Webster-Stratton C.(1992a).The Incredible Years : A trouble-shooting guide for parents. Toronto: Umbrella Press.

Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65(1), 93-109.

Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating Children With Early-Onset Conduct Problems: Intervention outcomes for Parent, Child, and Teacher Training. Journal of Clinical Child and Adolescent Psychology, vol. 33, no. 1, 105-124.

Webster-Stratton, C., & Reid, M. J. (2006). Treatment and Prevention of Conduct Problems: Parent Training Interventions for Young Children (2-7 Years Old). Dans K. McCartney, & D. A. Phillips, Handbook on Early Childhood Development (pp. 616-641). Malden, MA: Blackwell.

 

Details of “The Incredible Years” project can be found here: www.incredibleyears.com

Full Reference

Marie-Anne Bernardy-Arbuz, 2017. CAT and the “Incredible Years” programme: Towards a CAT parenting guidance framework. Reformulation, Summer, pp.22-31.

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