PCIT Plus Motivational interviewing-Nzi,+Lucash,+Clionsky,+Eyberg-2016
PCIT Plus Motivational interviewing-Nzi,+Lucash,+Clionsky,+Eyberg-2016
PCIT Plus Motivational interviewing-Nzi,+Lucash,+Clionsky,+Eyberg-2016
ScienceDirect
Cognitive and Behavioral Practice xx (2016) xxx-xxx
www.elsevier.com/locate/cabp
Parent–child interaction therapy (PCIT) is an evidence-based family intervention for young children with disruptive behavior. Parents
and children who complete PCIT show greater immediate and long-term treatment gains than those who discontinue treatment
prematurely. PCIT is a time- and effort-intensive treatment, and parents ambivalent about its value for their child or their ability to
master the treatment skills may discontinue treatment before engaging sufficiently to experience change. Motivational interviewing (MI)
is a client-centered therapeutic method of increasing motivation for change through the resolution of ambivalence. This paper describes
how clinicians may incorporate MI strategies into PCIT to enhance parental motivation when signs of ambivalence arise. Vignettes and
scripted therapy exchanges illustrate use of the strategies to decrease ambivalence in PCIT, improve homework adherence, increase
parenting self-efficacy, and reduce attrition, thereby improving outcomes for young children with disruptive behaviors and their families.
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
2 N’zi et al.
the parent), children learn a new approach to “attention beliefs in the credibility of the treatment and their ex-
seeking”—most children learn quickly that now it is pectation that it will be successful with their child (Nock,
positive, cooperative behaviors that work to get parental Ferriter, & Holmberg, 2007).
attention (e.g., “It’s fun building block towers with you Parent expectancies predict adherence to treatment
because you are sharing the blocks with me”). procedures as well as parent retention (Nock et al.,
In the second phase of PCIT, parents learn to direct 2007). PCIT is a time- and effort-intensive treatment
the parent–child interaction when necessary. They learn that requires a considerable commitment from parents.
to give clear, direct commands to the child, to praise If parents are uncertain about whether treatment will
enthusiastically when the child obeys, and to alert the help their child or about whether they have the ability
child that time-out will follow if the child does not obey. In to learn the treatment skills, they may be apprehensive
this parent-directed interaction (PDI), time-out becomes about treatment procedures, not put their best effort into
effective as a discipline procedure because (a) during the mastering the skills, or discontinue treatment altogether.
CDI phase of treatment parental attention has become When parents present uncertainty, motivational inter-
a powerful positive reinforcer for the child, and (b) the viewing (MI) strategies can help refocus them toward
parents and child learn, through repeated practice in expectations for treatment success.
sessions and at home, that once the parent gives a direct
command, the parent will always follow-through. With Motivational Interviewing
such consistency, many children learn to obey and obtain
positive parental attention in just a few weeks’ time (Eyberg MI is an evidenced-based, client-centered therapeutic
et al., 2014). method of enhancing motivation for change through
Parents first learn the PCIT skills in a didactic “teach” the resolution of ambivalence (Miller & Rollnick, 2013).
session (one for CDI and one for PDI) in which the Ambivalence refers to an uncertainty or inability to make
therapist models and role-plays the skills with the parents a choice because of the simultaneous or fluctuating
alone. This session allows parents to discuss any concerns desires to engage in two opposite or conflicting activities.
they may have, anticipate how their child may react, and In PCIT, it is the parents’ conflict between making
practice relevant situations with the therapist. The teach changes in their parenting behaviors that will likely be
session is followed by “coach” sessions during which beneficial versus not making parenting changes that seem
parents spend most of the session practicing the skills difficult and possibly ineffective for their child. When
with their child while the therapist coaches them. In parents experience ambivalence about PCIT, MI can
coaching, therapists provide immediate positive feed- help move them toward “change talk,” statements that
back for parental skill use, in a DSA process parallel to indicate the parent is considering, motivated, or commit-
what the parent is learning to provide for their child. ted to change (Miller & Rollnick, 2013). MI uses four
In the coaching sessions, therapists code parent skills to key principles designed to facilitate the resolution of
guide their coaching and plan daily homework practice ambivalence and encourage positive change: (a) express
of the skills for the upcoming week. empathy, (b) develop discrepancy, (c) roll with resistance,
and (d) support self-efficacy (Miller & Rollnick, 2013).
The Importance of Parent Engagement in The first principle, express empathy, focuses on express-
Child Treatment ing an attitude of acceptance of the parent’s ambivalence
Psychosocial treatments for children that entail high in order to facilitate change through reflective listening.
levels of parent involvement show maximum effectiveness An environment in which a person feels accepted and
(Bratton, Ray, Rhines, & Jones, 2005; Kaminski, Valle, understood encourages change, whereas an environment
Filene, & Boyle, 2008), and literature reviews indicate that in which a person feel judged, patronized, or "told" to
parenting styles strongly influence child behavior (Luyckx change can hinder the change process (Miller & Rollnick,
et al., 2011). When the effectiveness of a child’s treat- 2013). A nonempathic exchange between parent and
ment is dependent on the parent’s active participation, therapist in PCIT is exemplified by the following response
parent motivation to engage in treatment is a significant to a parent who stated: “I had to work overtime this week
concern. and was just too tired most nights to practice with Charles
Families that complete evidence-based treatments when I got home.” The therapist responded, “Homework
typically demonstrate substantial and lasting improve- is essential for progress in treatment. Please find some way
ments in child behavior. Long-term follow-up studies have to get in that 5 minutes, perhaps in the morning before
shown significantly better child outcomes for treatment you get ready for work.” A therapist response consistent
completers than noncompleters years later (Boggs et al., with MI principles would instead be, “It’s hard to practice
2005; Kazdin, Mazurick, & Siegel, 1994). Parent factors when we feel exhausted. How did you feel the nights you
that influence treatment completion include parents’ were able to practice?”
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
Enhancing PCIT With MI 3
The second principle, develop discrepancy, highlights the change and can build on their own intrinsic motivation.
incongruity between a person’s present behavior and his The MI therapist uses specific communication strategies
or her desired goals. Therapists reflect a person’s to help achieve the goals these principles set forth. These
conflicting desires or goals in order to develop the strategies are called “OARS” strategies, and include open-
person’s awareness of the discrepancy. Therapists guide ended questions, affirmations, reflections, and summaries
individuals to present the arguments for change rather (Miller & Rollnick, 2013). Originally developed for
than presenting the reasons themselves (Miller & Rollnick, people with substance abuse disorders, the MI principles
2013). For example, a therapist might say, “Our weather and strategies have been found effective for enhancing
this winter makes the trip here pretty stressful—we haven’t motivation for change in a number of difficult popula-
been able to coach you regularly in the skills, and I tions (Miller & Rollnick, 2013).
know how much you want Jennifer to learn to be polite Studies of PCIT with maltreating parents mandated
and cooperative. How could we schedule the sessions more into treatment have shown that adding a motivation
effectively to help you meet your goals for Jennifer?” enhancement module before standard PCIT can improve
The third principle, roll with resistance, means that attendance and adherence in treatment for certain
therapists do not directly oppose or argue for change but families (Chaffin, Funderburk, Bard, Valle, & Gurwitch,
rather invite new perspectives while encouraging a person 2011; Chaffin et al., 2009). For these studies, a 6-week
to be the primary agent for discovering new solutions protocol based on MI was created. This protocol included
(Miller & Rollnick, 2013). A permissive parent hesitant the decisional techniques of weighing the pros and
to face an angry outburst from his or her child when cons of changing harsh discipline patterns, listening to
the child is told what to do might say, “I know we decided testimonials from families that completed PCIT, and
last week to have Sammy put his toys away before bedtime, encouraging parents to set goals and plan for change
but it’s really not that big a problem for me. I realized in their parenting. The investigators found that this
this week that it is just easier for me to do it myself.” motivational module was effective for parents in the child
A defensive response, such as “But we need to teach him welfare population with initially low to moderate motiva-
to clean up at home to help him learn to clean up at day tion for change (Chaffin et al., 2009). Unfortunately,
care,” strengthens parents’ efforts to validate their own parents with initially high motivation had a higher rate
perspective, thus further committing themselves to their of attrition after the motivational enhancement module
preexisting beliefs. When resistance occurs, therapists (Chaffin et al., 2009). The investigators speculated that
engage in reflective listening while inviting, not imposing, lower levels of PCIT completion in the latter group may
new perspectives (Miller & Rollnick, 2013). A therapist’s have been due to their initial eagerness to begin and
response such as “It is a lot quicker to clean up his toys waning motivation during the 6-week motivational compo-
on your own. I know you mentioned before that Sammy nent or, alternatively, the reexamination of their parenting
gets in trouble at day care for not cleaning up. How might beliefs during the 6-week period may have decreased their
you be able to help him learn more about this skill?” motivation to change their parenting behaviors (Chaffin
encourages the parents to consider a new perspective et al., 2009). Incorporating motivational principles and
about cleaning up. strategies throughout treatment may maintain motivation
The final principle, support self-efficacy, urges therapists and facilitate adherence and retention not only for parents
to elicit independent problem-solving strategies, and it initially resistant to treatment but also for parents excited
fosters autonomous thinking. The therapist encourages to begin PCIT.
parents to carry out their own change by highlighting
their past successes and expressing their belief in the Integrating MI Into PCIT
parents’ ability to maintain changes resulting from treat- Attrition from PCIT can have negative, long-term
ment (Miller & Rollnick, 2013). A PCIT therapist might consequences on the maintenance of child treatment
encourage a parent who is nervous about his or her ability gains (Boggs et al., 2005). Studies investigating attrition
to maintain treatment gains after treatment ends by from PCIT have identified several predictors, including
saying, “I remember when you first started PCIT you felt low socioeconomic status, low maternal praise and high
overwhelmed by ShaDay’s behavior. Now her attitude maternal criticism during parent–child interactions at
has improved at home and school, and she is listening to pretreatment assessment, high levels of parent-reported
you much more quickly. You have worked hard to make barriers to treatment, and a less engaging therapist verbal
these changes. What do you think you can continue to style (Fernandez & Eyberg, 2009; Harwood & Eyberg,
do when treatment ends so that she can continue making 2004). Among the most frequent reasons for dropout
progress?” reported by parents of children with DBDs are disagree-
These four guiding principles provide an empathic ment with the treatment approach, logistical concerns
atmosphere in which parents can explore their desire for such as transportation and child care for siblings, and
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
4 N’zi et al.
maternal stress (Boggs et al., 2005; Capage, Bennett, & to the treatment approach, MI can be used to enhance
McNeil, 2001; Fernandez & Eyberg, 2009). Understanding motivation for PCIT.
parents’ specific concerns can help therapists be alert to Maria and her 5-year-old son, Anthony, were referred
situations in which timely application of MI techniques may by Anthony’s pediatric oncologist following complaints
benefit treatment continuation. of disruptive behavior. Anthony has a history of leukemia
The use of MI strategies can help the therapist work as a toddler and has been in remission for 1 year. Maria is
in partnership with the parent to resolve resistance arising most concerned with his noncompliance, aggression, and
at any point in treatment. Even with the skilled use of running away in public. She has struggled unsuccessfully
MI strategies, some parents may remain unwilling to for 3 years to manage his behavior, having tried multiple
change their parenting. The role of MI is to help resolve disciplinary techniques that her friends suggested or that
ambivalence, not to force a behavioral change. Even if she read about in parenting books. Maria is convinced
the therapist uses MI, a family might come to the con- that behavioral techniques are ineffective with her son
clusion that they cannot follow-through with the disci- because he is “unique” and “unpredictable,” and there is
pline procedures outlined in the PCIT protocol. If that little she can do to help his behavior. At this point, she is
happens, it would be important to explain to the parents considering placing Anthony in a group home.
that it is not possible to complete PCIT without such a Maria and Anthony were seen initially for a consult in
core component and the therapist should help the family the pediatrician’s office, and Maria agreed to try PCIT
find an alternative approach, inviting them to return to because the pediatrician was so enthusiastic about the
PCIT in the future if they change their mind. intervention. She and Anthony traveled nearly an hour
Most frequently, it is through MI that the parent and from their home to attend the first session, the clinical
therapist identify a common goal they could achieve interview, and observational assessment. As the therapist
together, such as increasing the warmth in the parent– was providing feedback and an overview of PCIT, Maria
child interaction. It is through this goal that the parent stated her reluctance to commit to a treatment in which she
and child create a powerful working alliance. Parents are would be primarily responsible for facilitating Anthony’s
the experts on their child. A PCIT therapist is an expert behavior change.
on behavior change. A solid partnership between the To improve motivation for PCIT in this case, the
parent and PCIT therapist is crucial to success. therapist must create a supportive environment in which
Ideally, strong rapport is established with families and to help Maria explore her ambivalence about beginning a
treatment ambivalence is addressed in the first meeting. treatment program that involves changing her parenting
Even with successful engagement strategies, though, am- approach to improve her son’s behaviors. Maria’s am-
bivalence can arise during treatment, and dealing with bivalence is rooted in her lack of self-efficacy about her
this when it first appears can increase treatment reten- ability to change Anthony’s behavior. To improve her
tion. Clinical experience tells us where in PCIT ambiva- self-efficacy, the therapist uses several MI strategies:
lence is most likely to occur, such as around completing (a) open-ended questions to help Maria consider
homework consistently, attending treatment sessions treatment options that could meet the behavioral needs
regularly, believing that CDI has therapeutic value, or of her son, (b) affirmations to help her feel supported by
using the time-out procedure in PDI. the therapist, and (c) summary statements to guide her
In this section we present three hypothetical PCIT case toward arguments supporting self-efficacy for changing
vignettes with transcripts that exemplify ways in which Anthony’s behaviors.
the MI principles may be used to resolve ambivalence
and enhance parent motivation to change. The first case
addresses initial engagement in PCIT. The second case Statement Commentary
illustrates how common barriers that arise in CDI can be
MARIA: I appreciate what you Maria begins to express
dealt with using MI strategies. The final case demonstrates
are trying to do for us, her concerns about this
how the MI principles and strategies can improve the
but I have tried things treatment approach.
parents’ confidence in treatment procedures that have
like this before, and they
been difficult for them to implement successfully in the just don’t work.
past. Anthony’s behavior is
Case Examples different than other kids.
He is erratic. The doctor
Case 1: Addressing Treatment Engagement in PCIT told me your program
Disagreement with the treatment approach is a com- has helped other families
mon reason for dropout in PCIT (Fernandez & Eyberg, a lot, but honestly I just
2009). When a family presents initially with resistance
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
Enhancing PCIT With MI 5
(continued) (continued)
Statement Commentary Statement Commentary
don’t feel it is worth an THERAPIST: You have tried very hard Therapist builds Maria’s
hour-long drive every to help Anthony. You self-efficacy by
week. drove an hour to come highlighting all the
THERAPIST: It is frustrating to hear Therapist resists the urge here today. You are positive steps she has
people tell you what to lecture or convince reading books. And, you taken to try to help her
might work for you and Maria about how PCIT are considering other son. The therapist
your son. You have read could help her and her options to get more validates Maria’s need
a lot about different son. Instead, the support for him. You for behavioral support
ways to manage his therapist communicates need support. You really for her son and social
behavior. What are your empathic understanding feel Anthony needs a support for herself.
thoughts on what is best of Maria’s frustration and behavior coach with him
for Anthony? creates an opportunity all the time.
for her to share her MARIA: I really do. If I tried this, Maria’s resistance
opinion on the solution. I’d be worried that if begins to decrease. She
MARIA: I don’t know what is Maria becomes less something goes wrong, expresses her initial
best. I’ve been thinking defensive and begins to we would be an hour goals and expectations
about placing him in a share her concerns about away with no support for what a successful
group home because I her son, her feelings of nearby. I need someone treatment approach
feel out of options. I hopelessness, and her to help me do the things might look like for her
would love to keep him reasons for considering a that will change his and her son.
at home, but I can’t cope group home placement. behavior. That’s been
with his behaviors. He’s my problem with reading
always playing tricks, like books and people telling
hiding my purse and me what I need to do
laughing when I can’t find differently. They don’t
it. At church he yells out, know Anthony, and they
just to see what people don’t know how different
will do. Or, when we’re he is. They’ve never
out, he just runs off and really helped me parent
hides from me. him. When Anthony finds
THERAPIST: His behavior has really Therapist begins to a loophole then whatever
been difficult to manage develop discrepancy others suggested no
on your own, so you between Maria’s longer works and I’m
have considered a conflicting desires. The back at square one, on
group home and, at the therapist asks an my own.
same time, you also open-ended question to THERAPIST: I want to make sure Therapist summarizes
really want to keep him help Maria consider I’ve heard all of your Maria’s concerns,
at home with you. What alternative solutions. concerns. Anthony has making sure to end the
do you need help with to had more tough times summary with Maria’s
feel like you could keep than other kids his age self-identified goals for
Anthony at home? because of all his chemo change in order to build
MARIA: Ha—what I need is a Maria has a difficult time treatments and doctors’ motivation for treatment.
person to just follow him arguing for change appointments. You know
around and guard him! because her feelings of his past better than
(laughs) I know that’s self-efficacy are low. anyone, and you know
unreasonable. But I what it’s like to try to
really do think Anthony manage him every day.
needs a professional To change his behaviors
with him all the time to now, it will be very
manage his behavior. I important that you have
tried to learn how to help someone to collaborate
him by reading parenting with you and see how he
books, but what I learned reacts when you try new
doesn’t seem to be skills.
enough.
(continued on next page)
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
6 N’zi et al.
(continued) (continued)
Statement Commentary Statement Commentary
MARIA: Yes, I really do know Maria begins to consider open-ended question to
Anthony and I want to PCIT as a treatment create a nonjudgmental
keep him at home. We option for her and her son. environment.
definitely need coaching AMBER: I know he will love CDI. Amber expresses
to make new skills work. But, I am not sure this concerns that treatment
Can you tell me how will change his behavior will not progress quickly
PCIT works again? fast enough. I am afraid enough to prevent
Benjamin might get serious consequences
kicked out of day care if to her family.
Case 2: Addressing Barriers in the CDI his behavior doesn’t
Scenario 1: Engagement in CDI improve, and I don’t
Research has shown that children’s hyperactive and know what I would do if I
lost my job.
disruptive behavior problems improve in the classroom as
THERAPIST: It is really scary to think Therapist resists the
well as at home after PCIT (Bagner, Boggs, & Eyberg,
about losing your job if urge to convince her
2010; Eyberg, 2015; Funderburk et al., 1998); however, he is not able to stay in that sticking to the
children’s behavioral changes in both settings typically day care. course of treatment is
occur gradually over weeks. In the following vignette, the what she and her son
parent of a child who is hyperactive and oppositional is need. Amber expresses
receiving pressure from teachers and other caregivers to empathy by reflecting
change the child’s behavior quickly. her affective experience
Amber, a single, working mother, has come to to allow her to explore
treatment with her 3-year-old son, Benjamin. Benjamin her conflicting feelings.
AMBER: Yes. I know this will help Amber expresses tension
displays many hyperactive and disruptive behaviors at
his behavior in the long between her long-term
home and in his day care class. He defiantly refuses to
run, but I am not sure goals, changing
obey Amber’s requests. He also ignores the directions of
that it will change his Benjamin’s behavior, and
his day care teacher if asked to change activities. His behavior fast enough for her short-term needs,
refusals escalate to temper tantrums if the requests are his day care to keep him keeping her son in day
repeated, and persist until the requests are withdrawn. enrolled. care so she does not lose
His teacher has told Amber that if his behavior does not her job.
improve, he will be removed from the day care. Amber THERAPIST: You are feeling pressure Therapist asks an
is fearful that she may not be able to find day care for from day care to make exaggerated,
Benjamin if he is removed from this day care, threatening quick changes in open-ended question to
her employment. She has tried many discipline strategies Benjamin’s behavior. help Amber argue for a
unsuccessfully and is feeling anxious and angry with What do you think might realistic solution to this
be able to change his predicament.
Benjamin.
behavior overnight?
This case illustrates how a therapist can express
AMBER: Well, I don’t think Amber begins to express
empathy for the mother’s concern about her employment anything can change his change talk as she
while building her motivation to continue in treatment. behavior that fast. I really identifies what would
The therapist combines reflections and open-ended ques- need the school to be need to happen to
tions to help Amber commit to a plan of action that patient with me while we proceed with PCIT and
can address her concerns about Benjamin’s school. The are in therapy. prevent the loss of her
therapist helps Amber elucidate her own solutions rather job.
than assuming the expert role and attempting to convince THERAPIST: You know what you are Therapist summarizes
her with facts and figures about the effectiveness of PCIT doing here will work and Amber’s argument to
changing her son’s school behaviors. you need the school to help her move toward
give you the time to do creating a concrete goal.
that work.
Statement Commentary AMBER: Right. Maybe I should Amber identifies a goal,
THERAPIST: I’m wondering what you Noticing Amber’s talk with the school and talking to his teacher
are thinking about these hesitancy, the therapist let his teacher know I am about therapy, which
skills so far. asks for Amber’s getting him help. Is there demonstrates
opinions using an anything I could give the commitment to
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
Enhancing PCIT With MI 7
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
8 N’zi et al.
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
Enhancing PCIT With MI 9
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
10 N’zi et al.
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002
Enhancing PCIT With MI 11
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decade of the Developmental Trends Study. Clinical Child and authors and does not necessarily represent the official views of the
Family Psychology Review, 3, 37–60. http://dx.doi.org/10.1023/A: National Institutes of Health.
1009567419190 Address correspondence to Amanda M. N’zi, Children's Hospital
Luyckx, K., Tildesley, E. A., Soenens, B., Andrews, J. A., Hampson, S. E., Colorado, 13123 East 16th Avenue, B285, Aurora, CO 80045; e-mail:
Peterson, M., & Duriez, B. (2011). Parenting and trajectories of
[email protected].
children’s maladaptive behaviors: A 12-year prospective commu-
nity study. Journal of Clinical Child and Adolescent Psychology, 40,
468–478. http://dx.doi.org/10.1080/15374416.2011.563470 Received: February 16, 2015
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping Accepted: March 14, 2016
people change. New York, NY: Guilford Press. Available online xxxx
Please cite this article as: N’zi et al., Enhancing Parent–Child Interaction Therapy With Motivational Interviewing Techniques, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.03.002