connect parent group therapy

Connect: An Attachment Focused Treatment Group for Parents and Caregivers

Synopsis of the Program & Manual

NOTE: This is not a treatment manual but a synopsis that provides an overview and description of key features of the program. Manuals are provided to trainees upon enrolment in the Connect training workshop. Provision of services without training and certification is not recommended, should not and will not be recognized as the Connect program.

For information on Connect training go to: http://adolescenthealth.ca/connect/

The Connect Program is a Community-University Partnership between researchers at Simon Fraser University, the Maples Adolescent Treatment Centre and the BC Ministry for Children and Family

Development.

CONNECT PARENT GROUP – MANUAL SYNOPSIS

2

Preface Connect was originally developed as a collaborative work between the Maples Adolescent Treatment Centre and Simon Fraser University in response to a need to provide a clinically and developmentally informed treatment for parents or alternative caregivers of pre-adolescent and adolescent youth struggling with significant behavioural and mental health issues, most notably aggression and delinquency, concurrent anxiety, depression, PTSD and substance use problems. The following manualized versions and supplements are available:

• Connect Parent Group – Adolescent Edition (for parents of 13-18 year-old youth) • Connect Parent Group – Pre-Adolescent Edition (for parents of 8-12 year-old children) • Connect Parent Group – Supplement for Supporting Parents of Youth with Major Mental Health

Disorder The Adolescent and Pre-Adolescent Editions of the Connect manual are tailored to each of the age groups. The supplement is intended to be used alongside either the Connect Adolescent or Pre-Adolescent version and addresses issues related to parenting of children and teens challenged by disorders such as schizophrenia, schizoaffective disorders, and/or bipolar disorder. For more information about the different Connect manuals and the supplement, please consult our webpage http://www.sfu.ca/connectparentgroup Research and Program Evaluation Research and ongoing program evaluation are integral parts of the Connect Parent Program. Ongoing program evaluation procedures are crucial to maintaining program integrity and ensuring continued assessment of program effectiveness. Program evaluation must be completed for every Connect group. Up to date information and downloadable measures can be found online at: http://www.sfu.ca/connectparentgroup (access through a password for all certified Connect leaders) or through the Connect SharePoint page at https://cio.mcfd.gov.bc.ca/maples/connect/default.aspx (access for certified Connect leaders affiliated with the BC Ministry of Children and Family Development). The evaluation materials are updated from time to time so visit the website and download the measures each time you run the Connect group. Along with various support documents (e.g., Attendance Record), measures will include the following:

• Connect Caregiver Admission Questionnaire Package (includes the Connect Pre-Inclusion Interview – sample illustrated in the Connect Manual, and Caregiver Questionnaires)

• Connect Caregiver Discharge Questionnaire Package (includes the Connect Feedback Form, and Caregiver Questionnaires)

• Connect Integration and Feedback Interview (sample illustrated in the Connect manual) Leaders complete the Pre-Inclusion Interview with parents preferably in their home or other setting that puts parents and families at ease. At the Pre-Inclusion Interview, leaders assist parents in completing the first few pages of the Admission Questionnaire Package on demographic and other information, and then explain the remaining questionnaires. Parents are asked to complete the package and bring it with them no later than Session 1. Leaders should phone in advance of Session 1 and remind parents to return the package. They should also offer their assistance if parents seem confused or concerned about questions.


3

The Discharge Questionnaire Package is distributed to parents in Session 9 and returned in Session 10. If Session 9 and 10 are merged, which sometimes occurs due to scheduling issues, the Discharge Questionnaire Package is provided during Session 8 and collected at Session 9/10. Alternatively, the package can be distributed at the end of Session 10 and completed on site in which case an extra 30-45 minutes should be booked. Liability Disclaimer No liability shall be incurred by M. Moretti, K. Braber, I. Obsuth, Simon Fraser University, the Maples Adolescent Treatment Centre or the Government of British Columbia for any damages or losses of any kind by any leader, client, or third party sustained while participating in Connect or as a result of delays in or termination of services.


4

Introduction and Overview CONNECT: AN ATTACHMENT FOCUSED APPROACH TO SUPPORTING CAREGIVERS AND FAMILIES

Connect (Moretti, Holland, Braber, Cross, & Obsuth, 2006; Moretti & Obsuth, 2009) is a 10-week manualized program for parents (or alternate caregivers) of pre-teens and teens who struggle with significant behaviour problems and other mental health issues. The program focuses on the enhancement of the core components of secure attachment: parental sensitivity and cooperation; reflective capacity; and dyadic affect regulation. These components of parenting are the ‘building blocks’ of secure attachment and have been demonstrated to exert sizeable influence on children’s social, emotional, and behavioural adjustment. Rather than simply teach parents1

a set of parenting techniques, Connect encourages and guides parents to reflect on the relational context and attachment needs of their child. In particular, Connect works to increase parenting competence by teaching skills that help parents ‘reframe’ their child’s behaviour; modulate their own emotional response to problem behaviour; and practice and communicate empathy for their child’s experience. With an understanding of their child’s attachment and developmental needs in hand, parents can then utilize a variety of basic parenting techniques in ways that promote positive parent-child relationships and provide structure, safety, and a healthy context for the emergence of autonomy.

Connect is delivered in a 10-session manualized format by two leaders. Each session begins with the presentation of an attachment principle that helps parents acquire new knowledge about attachment and developmental issues (see Table – Connect Parent Group Principles and Illustrative Goals). Parents are encouraged to consider new ways of understanding their child and their behaviour, new ways of understanding themselves and their parenting responses, and new options in parenting. Connect is a ‘developmentally-informed’ intervention. Parents acquire knowledge about the ways in which attachment is important to child development from infancy through adolescence. They also learn about the ways in which transitions in development, such as the transition from pre-adolescence to 1 The term ‘parent’ is used throughout this manual as an inclusive term to refer to all adults who take on a parenting role in relation to a particular child, including biological, adoptive, and foster parents; extended family such as grandparents, aunts, uncles, and adult siblings; and other professional caregivers such as staff from group homes, and temporary or permanent care facilities.

Connect is:

Manualized and delivered over 10 sessions by two leaders. Developmentally informed. Relational and systemic. Principle-based. Strength-focused and future-oriented. Inclusive and integrates diverse intervention strategies and

techniques. Structured and psycho-educational yet experiential and supportive.


5

adolescence and later to young adulthood, relate to attachment challenges. Connect adopts a relational and systemic perspective. Connect recognizes that parenting is something that emerges as a function of both parent and child characteristics; it is bidirectional in influence and transactional over time. Past events shape how parents and children understand and respond to new experiences, but new experiences also reshape their understanding of past events. Parents and children are also influenced by the larger systems in which they are embedded, including their family and community context, and broader cultural and social milieu. Connect is a ‘principle-based’ program. Connect does not attempt to teach parents the A-B-C’s of parenting, but instead helps them learn basic principles of attachment, relationships, and child development, which can then be applied across a broad range of contexts. Connect does not tell parents the ‘right’ versus ‘wrong’ way of parenting; instead the program strives to stimulate curiosity, reflection, and informed choices in the use of parenting strategies. At all costs, Connect avoids blaming parents or their children for problems that may have arisen. The focus is on developing understanding, skills, and mindful parenting rather than assigning blame. Connect is strength-focused and future-oriented. Many parents come to the program with a history of difficulties in parenting and failed attempts to make productive changes. Rather than find weaknesses and reasons for past failures, Connect leaders are trained to meet parents where they are, to recognize the skills that they possess, and to move forward from there. Connect is inclusive and integrates therapeutic techniques to achieve set goals. Intervention techniques derived from cognitive-behaviour therapy, emotion-focused therapy, relational approaches, and mindfulness training are strategically used to reach goals that are specified for each session. Connect utilizes these techniques and experiential exercises to help parents understand the principles of secure attachment across the lifespan. Connect adopts a structured, psycho-educational approach with opportunities for hands-on learning and self-reflection in a supportive context. It is a structured program that is supportive to parents but is not a ‘support group’ in the traditional sense. Parents share some information about their challenges in parenting; however, the focus is on learning, moving forward, and trying new approaches, rather than on in-depth exploration of personal problems.

CLIENT CONSIDERATIONS

We recommend Connect for caregivers of pre-teens between the ages of 8-12 or teens between the ages of 13-17 who struggle with moderate to clinically significant challenges of behaviour and concurrent mental health issues such as anxiety, depression, PTSD and delinquency. Because these two age groups and their parents face different challenges, we do not recommend that they be mixed in the delivery of the program. Connect may be useful with caregivers of pre-teens in preventing escalation of problems as they move into adolescence; the application of Connect with teens can reduce the severity of risk taking and other mental health problems. The use of Connect with other populations is not advised without consultation with the Connect team.

CONNECT AS A COMPONENT OF WRAP AROUND CARE: THE IMPORTANCE OF A SYSTEMIC PERSPECTIVE

It is imperative that the severity and range of clinical needs be fully assessed in advance of providing the


6

Connect program. In situations where parents and youth present with moderate problems that are limited in scope and across contexts, Connect may be used as a stand-alone intervention. Connect should be used as part of a systemic wrap-around program of care in situations where parents and youth present with severe and chronic problems across multiple domains of functioning. In such cases, using Connect alone is not advised. The relation between the complexity of clinical needs and the provision of systemic care is summarized in Figure 1 – Matching Systemic Intervention to Clinical Needs. The assessment of clinical needs should be guided by a systemic perspective on child development, health, and service delivery. This perspective begins with the acknowledgement that children are nested within their families, who are in turn nested within their social and cultural contexts and broader social systems (see Figure 2 – A Multi-level Ecological Model). Assessing clinical needs requires consideration of key domains in which children function, such as their families, schools, and other community contexts, to best understand the strengths and areas of need within these systems. Where multiple domains of functioning require support, we recommend an integrated program of care that utilizes Connect as a central organizing component (see Figure 3 – Connect as an Integrating Component of Systemic Programming). Application of the Connect principles2

across multiple domains can support a shared understanding, a clear focus, and an integrated intervention strategy. This multi-systemic approach has been adopted by the Maples Bifrost Program. For further information on the Bifrost Program, contact the Maples Adolescent Treatment Centre.

EFFECTIVENESS

Connect has been shaped through ongoing evaluation and parent feedback. The effectiveness of this program has been evaluated in several community-based trials. Detailed results of these trials are available in publications listed below. Briefly, initial results from two small uncontrolled trials showed significant pre- to post-treatment reductions in parent reports of externalizing and internalizing problems in pre-adolescent and adolescent youth (Moretti, Holland, Moore & McKay, 2004; Obsuth, Moretti, Holland, Braber & Cross, 2006). A subsequent waitlist control study (Moretti & Obsuth, 2009) revealed that while no significant improvements occurred over the waitlist period, significant reductions in parent reports of youths’ externalizing and internalizing problems were observed from pre- to post-treatment. Parents also reported significant improvements in their perceived parenting efficacy. All improvements were maintained at 12-months post-treatment and further significant decreases were observed on several scales of internalizing and externalizing problems. In our fourth study (Moretti & Obsuth, 2009) the program was evaluated across 15 community sites serving 217 caregivers. Standardized training and supervision were delivered to ensure treatment adherence. Results confirmed significant reductions in problem behaviour and enhanced satisfaction and efficacy in parenting. Connect was found to be equally effective for pre-teens (9-12 years) and teens (13-17 years); girls and boys; youth from urban and rural settings. Further, the effectiveness of the program was similar for youth with moderate versus high levels of challenging behaviour. In addition to evaluating the effectiveness of Connect with respect to parental reports of youth

2 Principles and goals have been expanded and updated from those reported in our earlier paper - Moretti, Holland, Moore, and McKay, 2004.


7

functioning and parenting behaviour, in all studies we have evaluated the attendance, as well as perceived applicability and acceptance of the program by caregivers. Attendance in the program is good to excellent, reflecting the utility of those components of the program (e.g., pre-inclusion interviews, continuing support) that focus on removing treatment barriers and enhancing treatment motivation. Parents almost invariably report that they believe the program helps them to better understand and parent their child; they frequently apply what they learn in the program; and they believe it results in positive changes in their relationship with their child. Connect places a strong emphasis on continuing evaluation of client satisfaction and treatment effectiveness. Evaluation procedures are integrated into the manual and standardized measures are made available to group leaders. Parents are invited to participate as partners in continuing to refine the program by completing baseline and post-treatment measures that assess parent and child functioning. They also participate in the Connect Integration and Feedback Session which closes the program. A client satisfaction questionnaire (Connect Feedback Form) and semi-structured group interview (Connect Integration and Feedback Interview) are completed in the feedback session. Evaluation data is returned to the Connect evaluation team who in turn generate standardized reports which leaders and communities can use to assess the degree to which Connect meets the needs of clients and mental health service mandates in their communities. Further information regarding program evaluation is provided during training, at which point leaders will acquire online access to the full suite of materials.

Connect References Moretti, M. M., Holland, R., Moore, K., & McKay, S. (2004). An attachment-based parenting program for

caregivers of severely conduct disordered adolescents: Preliminary findings. Journal of Child and Youth Care Work, 19, 170-179.

Moretti, M. M., & Obsuth, I. (2009). Effectiveness of an attachment-focused manualized intervention for parents of teens at risk for aggressive behaviour: The Connect program. Journal of Adolescence.

Obsuth, I., Moretti, M. M., Holland, R., Braber, K., & Cross, S. (2006). Conduct Disorder: New directions in promoting effective parenting and strengthening parent-adolescent relationships. Canadian Child and Adolescent Psychiatry Review, 15, 6-15.

Additional References Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2003). Less is more: Meta-analyses of

sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195-215.

Diamond, G. S., Reiss, B., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-based family therapy for depressed adolescents: A treatment development study. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1190-1196.

Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers’ and preschoolers’ attachment classifications: The Circle of Security intervention. Journal of Consulting and Clinical Psychology. 74, 1017-1026.

Keiley, M. K. (2002). The development and implementation of an affect regulation and attachment intervention for incarcerated adolescents and their parents. The Family Journal: Counseling and Therapy for Couples and Families, 10, 177-189.


8

Before You Begin: Training, Preparing, and Using this Manual

TRAINING

Training and certification are required to become a Connect group leader. For further information about training refer to our website (http://adolescenthealth.ca/connect/) or contact Dr. Moretti at [email protected]. USING EVIDENCE BASED STRATEGIES TO ENGAGE FAMILIES

An overview of the program is provided in the Table. Setting the stage for treatment is essential. To achieve this goal, Connect incorporates evidence based strategies for engaging families. Many of the families served by Connect have experienced limited success with previous treatment regimes. Understandably, they are not optimistic about the potential benefits of entering yet another parenting program and they may harbour feelings of anxiety and frustration about treatment in general. Many families are challenged by a myriad of barriers that prevent them from fully benefiting from treatment. Identifying these barriers and finding viable solutions wherever possible is essential to the success of any social or mental health service, including Connect.

CONDUCTING THE PRE-INCLUSION INTERVIEW

To help leaders identify and find solutions to treatment barriers, Connect relies on the standardized Pre-Inclusion Interview. This interview (available online after leader training) provides a context for leaders to identify the barriers that get in the way of parents attending and benefiting from the program and to collaborate with parents to overcome these obstacles. The Pre-Inclusion Interview also focuses on decreasing anxiety about treatment, inspiring hope that it will be helpful and enhancing motivation to attend and complete the program. Finally, information on client characteristics is collected in the Pre-Inclusion Interview, which is essential for determining the effectiveness of Connect across different subgroups of parents and families. We advise that leaders establish a relationship with a clinical consultant or clinical service team within their community prior to beginning Connect. This contact should be capable of facilitating or providing additional clinical services and/or responding to acute clinical needs should they arise. Supervision provided by the Connect team focuses on the development of leader skills and is neither designed nor sufficient to address individual client issues. You will be provided with additional guidance in using the Pre-Inclusion Interview during training and in supervision.

CONNECT: GROUP AND SESSION STRUCTURE

Following the completion of Pre-Inclusion Interviews, leaders must form the group. We advise that groups be initially formed with 12-14 caregivers to ensure that group size does not fall to less than 8 caregivers. Smaller groups may present challenges in maintaining a psycho-educational focus. In addition, it is critical to maximize economic viability and good access to treatment in your community: small groups are more expensive. Once group members are selected, the Connect program begins with an introduction night where parents are provided with information on the focus and format of the program....


9

This is followed by nine sessions, each focused around an attachment principle and a set of learning objectives. Sessions include a didactic component and hands-on learning exercises such as role-plays and reflection exercises. Following each session, parents are provided with a handout that summarizes the major points and the take home message for that week. Leaders occasionally suggest homework exercises or topics to think about in the interim between sessions. The final session of the Connect program provides parents with an opportunity to debrief, ask questions, and provide feedback. This session is as important as the rest of the sessions, as it provides parents with an opportunity for consolidation and active ownership of treatment gains made during the program.

THE MANUAL…

The first several sessions of the manual provide detailed descriptions, concretely illustrating how to introduce learning material, how to use role-plays and reflection exercises, and how to emphasize key take home messages. The manual provides tips on ensuring coverage of key points, managing group dynamics, and maintaining a balance between structure and support. This material is illustrative rather than prescriptive. With experience, group leaders are encouraged to tailor their presentation to their own personal therapeutic style and the unique needs of each group, however, key principles and goals remain set and clear for each session.

Failure to adhere to these aspects of the intervention will compromise the impact of the intervention.


ILLUSTRATIVE SESSION

Session ONE

Understanding the Influence of Attachment on Behaviour

PRINCIPLE: All behaviour has meaning.

Attachment is a basic human need that shapes behaviour.

LEADER GOALS FOR THIS SESSION:

To create a sense of safety within the group. To provide an orientation to the structure and format of the group sessions. To recognize that all behaviour is a form of communication about attachment. To recognize that all behaviour has an impact on our relationships with others. To recognize that the same behaviour may have different meanings.

PARENT EDUCATION GOALS:

Parents begin to see that they have options in how they respond to their child’s behaviour rather than simply react to it. The options they have depend on how they understand the intent and meaning of their child’s behaviour.

Parents begin to understand that they can provide structure and guidance even in the face of ‘difficult behaviour’ and they begin to consider options that work to maintain a healthy connection with their child.

PARENTING SKILL GOALS:

Parents begin to think about their child’s behaviour through an attachment lens; that is, they think about the attachment issues behind behaviour.

Parents attempt to step back and consider the possible meanings and function of their child’s behaviour in terms of the parent-child relationship.

SYNOPSIS OF THE BACKGROUND AND RATIONALE FOR GROUP LEADERS:

Attachment is a biologically-based system that is essential for survival. Infants and children experience distress when separated from their parents or caregivers, particularly when overwhelmed by fear or other needs such as hunger or pain. They communicate their distress through crying and they search out their parents for comfort and safety. The simplest example of the attachment system in operation is when a baby cries and the mother goes to the baby and provides soothing ....


Through repeated experience in their relationships with caregivers, children begin to develop a ‘pattern’ in their expression of attachment needs .... Although early work on attachment focused on infants and young children it is now widely recognized that attachment continues to be critical for healthy adjustment in later childhood, adolescence, and throughout adulthood .... . .... Even though teens do not require the same degree of physical proximity as infants and younger children, it is important to note that the need for connection, safety, and security remains constant. Secure attachment – or what most people call a ‘healthy relationship’ – requires a balance of connectedness and separateness .... we constantly balance the need for safety and protection (being close and connected to others) with the need to explore and take on new challenges (being independent, separate, and distinct from others). Attachment patterns develop from our experiences with others, particularly people who have been responsible for our care early on. However, even though early experiences in relationships have a powerful impact on attachment, attachment patterns are not set in stone at a certain age – they develop over the course of our lifetime and change as our relationships and life contexts change ... Understanding an individual’s ‘life story’ helps us to understand the way they express their attachment needs. Each individual has unique experiences and has learned ways of connecting with others. An attachment perspective encourages us to be mindful, curious, and sensitive to others and the meaning behind their behaviour. It helps us to step back and wonder about the message behind the behaviour. When we do this, we are in a better position to respond supportively and effectively rather than to react. When we allow for different meanings of behaviour we also discover that we have choices in how we respond.

Recognizing the underlying attachment needs expressed through behaviour can be challenging in our relationships with our children and our relationships with our adult partners. However, it is often more challenging in our relationships with our teens because their behaviour seems contradictory – it can feel as if they are asking for closeness and independence in the same second.

At other times it seems as if our teens do things just for the sake of doing them, or even to ‘push our buttons’. Adolescents often seem confused themselves by their behaviour – if you ask them why or “what’s going on?” they may say “I don’t know” or they simply do not answer at all. When we do not understand someone’s behaviour and we are frustrated by it, we end up making assumptions that fit with how we feel – we may incorrectly assume that the person intends to hurt us or does not care about us. We react to their behaviour based on these assumptions and our responses sometimes escalate their behaviour. When this happens our relationship can be damaged. Therefore, as much as it is difficult, it becomes important to step back and take the extra time to think about the meaning behind the behaviour in order to respond in a constructive way that will support and sustain our relationships.


SUGGESTED BACKGROUND READINGS:

Bowlby, J. (1977). The making and breaking of affectional bonds: I. Aetiology and psychopathology in the light of attachment theory. British Journal of Psychiatry, 130, 201-210.

Bowlby, J. (1982). Attachment and loss. Vol. 1: Attachment (2nd ed.). New York: Basic Books. (Original work published 1969).

Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Davila, J., Karney, B. R., & Bradbury, T. N. (1999). Attachment change processes in the early years of marriage. Journal of Personality and Social Psychology, 76, 783-802.

Egeland, B., & Farber, E. (1984). Infant-mother attachment: Factors related to its development and changes over time. Child Development, 55, 753-771.

Moretti, M. M., & Peled, M. (2004). Adolescent-parent attachment: Bonds that support healthy development. Paediatrics & Child Health, 9, 551-555.

Rauh, H., Ziegenhain, U., Muller, B., & Wijnroks, L. (2000). Stability and change in infant-mother attachment in the second year of life: Relations to parenting quality and varying degrees of day care experience. In P. M. Crittenden & A. H. Claussen (Eds.), The organization of attachment relationships: Maturation, culture, and context (pp. 251-276). New York: Cambridge University Press.


SESSION FORMAT USING THIS MANUAL – IMPORTANT NOTE: ....

1. Welcome to participants and brief introduction of group leaders.....

2. Set the stage for the current session – outline the structure and goals for this session.

3. Introduce structure and general guidelines of the program 9 sessions and 1 feedback session (10 sessions in total; note any changes due to holidays or school

breaks). Sessions will begin at ______ p.m., 60 minute length.

Leader (il lustrative introduction):

We are aware that you are busy and appreciate your effort to attend each week. As leaders we will try to use the time as effectively as we can. We will begin and end each session on time. Come early to have coffee and food and chat with others if you wish.

Each session will introduce a specific attachment principle and information about this principle. We will have learning activities as a way of thinking through and discussing each principle while also

sharing our experiences. We will often use role-plays to illustrate the issues we talk about .... As we have ___ people in this group, I ask that you be considerate with your time when talking so

that everyone has an opportunity to speak ... .... If you find yourself drawn into personally distressing issues during the group, I might suggest that this would be good to discuss with a therapist outside of the group. This will help to keep you feeling safe and it will help the group to move through all the material we need to cover.

.... While in this group we will provide a supportive environment, we don’t consider this to be primarily a support group. This group is primarily educational and skill development focused; it is about helping you establish foundations and develop sk ills that w il l be helpful in parenting and supporting your relationship w ith your child.

This will take hard work ... . Our goal is to help you and your family to get back on track and to provide you with useful skills to further your development ....

4. Group confidentiality

Participants will have already consented to participate in the group and will have had confidentiality explained and signed a waiver regarding recording.

Leader:

People within this group undoubtedly have different backgrounds and experiences and therefore have different perspectives. It is important that we respect this and allow people to share their perspectives in a way that feels safe to everyone ...

What you hear in the group needs to stay in the group ...

5. (If there are supervisors, observers and/or if the sessions are video/audio-taped.)


Leader: We want you to be aware that our work in this group is currently supervised by _______________________. This involves having our supervisor(s) review the videotapes from each group and discuss our progress. Our supervisor(s) focus primarily on how we do as leaders ...From time to time we may use feedback from our supervisor to revisit issues that we covered in our sessions ...We may also have observers join us for the purpose of training. In all cases, you will be informed in advance of who the observer is and the purpose of their involvement ...

6. Introductions of leaders and participants Group leaders give a brief description of your experience; express your commitment to helping families, and eagerness in working with the members of the group ... Ask for each participant’s name, their child’s name, and any information that they wish to share about themselves, their family situation, their relationship with their child, and possibly what it feels like to come to this group; what are their hopes or concerns about coming to the group? Tip 1: It is important to offer each group member an opportunity to share their story. This is an optimal time to demonstrate active listening, positive regard, and empathy; and thereby foster a safe environment for participants to share. However, if the group is large, leaders may wish to frame the question as: “In one or two sentences, tell us something about your family situation and your relationship with your child.” Tip 2: The group composition will become apparent to the group members during this session. That is, there may be biological parents, adoptive parents, extended family members, step-parents, group home parents, and/or foster parents. ... It is important to recognize the variety of caregiver roles, but stress that the sessions will have something of value for everyone – reiterate that all group members have a common goal, and despite their different roles with their child, attachment is important in every relationship.

7. Introduction Summary

At the conclusion of the participants’ introduction...Acknowledge the common themes presented such as feeling frustrated, hopeless, and hurt/pain as well as the participants’ perseverance and obvious caring about their relationship with their child, as well as their child’s welfare. Leader: These sessions will not be about ‘teaching’ you ‘behaviour management’. ... Our goal is to help you develop a different way of understanding your child’s behaviour – one that focuses on your relationship with them and their attachment needs. ...To achieve this we will encourage you to think about what is happening in your child’s life and about your relationship with your child so that you recognize the choices you have as a parent. In turn, we believe this will make a difference in your relationship with your child, how you feel as a parent, and in how your child feels.

8. Learning Content (5 minutes): Overview of first principle.

The guiding principle tonight is:


Direct attention to Connect Principle Poster I for review and keep it (and gradually the following principles) displayed for the duration of the parent group. Leader: This is the principle we are going to focus on today. We will discuss this principle through questions, discussions, and a role-play. What we mean by this principle is that all behaviour is a form of communication. It tells us something about:

the person who engages in the behaviour; what he or she may have experienced in past relationships; what he or she expects about how others will respond in the current situation.

Attachment – or what we often call ‘relationship’ – with caregivers is a biologically-based need. It is essential for survival. When a baby cries, the mother goes to the baby and looks after the baby’s needs .... this is the process of attachment, or relating to each other.. Attachment needs are expressed differently as children grow and develop ...Nonetheless, the need for attachment remains constant. We need to feel safe and secure in our connection with others and we need to feel that we can be independent and effective in the world ... In today’s session, we are going to ask you to take a ‘step back’. We’re going to ask you to try to think about your child’s behaviour from a different perspective in order to discover new ways of responding and connecting with your child. This does not mean that we will encourage you to let anything go, instead we will support you in making choices about how you are going to respond. This also does not mean that you should agree with or condone your child’s behaviour – we are merely asking you to step back and think about what’s going on behind your child’s behaviour before you respond to it.

9. Active Learning Exercises (20 minutes):

Prioritize the reflection exercises and discussion questions. Know and keep in mind throughout the session what the principle is and where you want to get to by the end of the session. Whenever you feel that the group is getting off track, pose the following question to the group: “Now let’s go back to the principle and make sure we’re on track... How is our discussion right now related to the principle?” a. Reflection exercise: Communicating Needs

On flip-chart, post: Children have ways of letting us know what they need from the moment that they are born.

AAllll bbeehhaavviioouurr hhaass mmeeaanniinngg .. Attachment is a basic human need that shapes behaviour.


Post the following questions on flip-chart with enough space to write down examples offered by parents. How did your baby let you know what they needed?

Typical responses:

Crying, smiling So babies use a variety of behaviours to communicate their needs – and babies can be quite different in how they communicate. b. Reflection exercise: Understanding Needs

On flip-chart, post: We try to do our best to meet our child’s needs. How did it feel when you understood what your baby needed and you could soothe them?

Typical Responses:

Fulfilling, effective How did it feel when you struggled to understand what your baby needed?

Typical Responses:

I felt scared, helpless What did you do when you didn’t understand your baby’s needs? Leader: As parents, trying to understand the needs of our kids can be like trying to ‘crack the code’. Sometimes finding the underlying message can be confusing and frustrating; we can feel inadequate and helpless or irritated and angry ...

Tip: Be selective in choosing the above questions so as to prompt caregivers to think ... how the child’s behaviour communicates needs to the caregiver; how the caregiver attempts to understand (decode) what the behaviour means; and what the caregiver does behaviourally and emotionally to respond to the child’s behavioural communication. Leader: ... sometimes it is hard work to figure out what your child’s needs are or what your child is trying to communicate. We all vary in how we communicate our needs. ... like babies our older children and adolescents also communicate through their behaviour despite their ability to talk and express some of their needs verbally. It can be even more challenging and frustrating to try to understand older children’s behaviour (i.e., ‘crack the code’) and the meaning behind it (even though they can talk!), particularly when your child is an adolescent. We may wish they would ‘just tell us’ exactly what they need, however often they may not understand what they need nor can they express in their needs in words. c. Role-play

Included are two suggested role-plays. It is best to do only one and ‘unpack’ it slowly and fully. ... The role-play should be short and ambiguous to facilitate multiple views/interpretations of the behaviour ... Leader: Now we are going to do a role-play to illustrate and reflect on what we’ve talked about.


All we want you to do is just watch closely...(Group leaders should identify who is role-playing the parent and who is the teen.) Have discussion questions written out on the flip-chart in advance ...

Discussion questions – point out that there are no right or wrong answers; ask parents about what first comes to mind. Go through the questions sequentially – it is a good idea to tape up the bottom of the page so you only see the question under discussion as it arises. What behaviour did you see in Steve? How about in the parent?

What was Steve thinking and feeling?

What was the parent thinking and feeling?

Note: It can be very tempting for the group leader to ask the other leader playing the youth what was ‘really’ going on for them in the role-play. ...The purpose of the exercise is to appreciate that there are many ways to view a set of behaviours and the task is to ‘not assume’, but to peel away the layers beneath the behaviours and look at the possible reasons for the behaviours ... What do you think Steve’s behaviour means?

Typical Responses: He obviously doesn’t want to talk to his parent, but he phones a friend to talk about it. Even though he doesn’t talk to his mom about it, he obviously wants his mom to know that he’s

upset by slamming his books down, etc.

Tip: If parents give very similar responses, suggest a few alternatives yourself and help them appreciate that the behaviour could have more than one meaning. Leader: First Point: Isn’t it interesting that we all watched the same role-play, and we had 10 different takes on what was going on for Steve? It’s like watching a movie. Sometimes we can watch the exact same movie and notice different things or have completely different interpretations of someone’s behaviour than the person sitting next to us.

Note: Use parents’ responses to illustrate the principle. For example: “John, you thought this child was disrespectful and thought he could get away with anything, but Sally you thought that he was sad about

Parent is sitting, watching TV when youth enters, slamming the door behind him. Parent: Hi Steve... Youth walks past parent without saying anything and glares directly at his parent – he slams his books or bag down on the table. Youth looks and behaves in an angry, sullen manner. He then takes out a cell phone from his pocket and dials, turning his back away from the parent and the group members. Parent and group members cannot hear who he is talking to/what is being said. The parent looks dumbfounded.


something”. The meaning that we make of the behaviour may depend on our prior experience and our expectations. Leader: Second Point: Now let’s go back to the first question. What did it say – it asked us “what behaviour did you see”. Many of us jumped right away to what the child or parent was thinking or feeling, and to judgments about the behaviour. This one set of behaviours sets off many of our own thoughts and feelings. We make assumptions about our child’s behaviour based on our own experiences and the history of similar behaviours from the past. We then react according to these assumptions. Our assumptions may be correct but we could be off-base... Key Question: Do you think you would respond differently to the child’s behaviour depending on the meaning you ascribed to the behaviour– that is, what you thought the child was thinking/feeling; your awareness of what you were thinking/feeling; and what you thought the behaviour meant?

OPTION: ALTERNATE ROLE-PLAY

We’re going to do a role-play. All we want you to do is just watch closely...

Follow up discussion questions (same as for previous role-play): What behaviour did you see in Marcy? In the parent?

What was Marcy thinking and feeling?

What was the parent thinking and feeling?

What do you think Marcy’s behaviour means?

Parent and youth are driving in a vehicle. Youth looks anxious, sullen, and/or downcast. Youth looks out the window and avoids looking at parent. Parent pulls the vehicle over to park. Parent (pleasantly): Ok Marcy...we’re here. Youth does not respond and continues to look down. Parent (still pleasantly, but slightly impatiently): C’mon Marcy. You need to get going or you’ll be late. Youth remains unmoving. Parent glares at youth. Youth (continues to look out the window and emphatically states): I am NOT going!


10. Take Home Message

Note: I t is essential that each session end w ith a simple and very clear take-home message. Group leaders should have this message in mind from the beginning of each session and ensure that it is woven throughout the session. Summarize the principle of this session, recapping the rationale. Leader: Let’s take a few minutes to review what we’ve done today. The goal of this session was to start us thinking about what behaviour means and to show that there are many ways to view a set of behaviours. Sometimes it is hard to ‘not assume’ what it means; it is hard to stop and think about the possible meaning behind the behaviour, and to look at the possible reasons for behaviours, particularly with our children and family members we have known for years. But doing so can provide the opportunity for seeing things in a different light and for responding in a different way. We can consider the behaviour of our youth in the context of what is going on in their lives and what is going on in our relationship with them. If we look at things from a different perspective we have alternatives in how to respond and we can choose to respond in a way that supports and maintains our relationship/attachment with our children AND also communicates clear expectations and structure. When we communicate our understanding of another person’s experience – even if we do not condone their behaviour – we open the door to more open communication and greater mutual respect.

11. REFLECTION QUESTIONS: Depending on the emotional tone and openness of caregivers, ask one of the following two questions for reflection. If caregivers have provided emotionally strong descriptions of their struggles with their children, it is best to ask them to reflect on the first rather than the second question. REFLECTION QUESTION #1: Have you ever had someone assume your behaviour meant something that you felt it did not? ... What did you think? And how did it influence your relationship? What could they have done differently to better understand the meaning of your behaviour? Perhaps you can think about this over the next week. REFLECTION QUESTION #2: When you introduced yourself tonight, you provided a brief description of your teen. Reflecting on what we have talked about tonight, do you think you might describe your teen any differently? Perhaps you might – or perhaps not. It is something to think about over the next week.

12. Wrap Up and Handout:

Provide handout. Add a teaser about next week’s session – for example, “Next week we are going to talk about how attachment extends from birth throughout life and w hat this means about understanding our children.” Thank participants for coming, sharing w ith the group, and being respectful to each other as they share.

CONNECT PARENT GROUP

Figure 1. Matching Systemic Intervention with Clinical Needs

Figure 2. A Multi-level Ecological Model

INTRODUCTION AND OVERVIEW

Figure 3. Connect as an Integrating Component of Systemic Programming

Table. Connect Parent Group Principles and Illustrative Goals

Session Title Principle Illustrative Goals & Skill Development Focus

Pre-Inclusion Interview Identify and find solutions for treatment barriers.

Enhance treatment motivation.

Decrease treatment anxiety.

Introduction Session Attachment and your child.

Provide information on the role of attachment in development and adolescence.

Provide overview of program and enhance motivation.

1 Understanding Behaviour Through

Attachment

All behaviour has meaning.

Enhance recognition of behaviour as a form of communication about attachment.

Develop skills in stepping back and considering alternate meanings of behaviour.

2 Attachment over the Lifespan

Attachment is for life.

Enhance recognition that attachment needs continue throughout life but are expressed differently as children develop.

Develop skills in reframing children’s behaviour in terms of their developmental level and attachment needs.

3 Conflict – An Opportunity for

Understanding and Connection

Conflict is part of attachment.

Enhance recognition and acceptance of conflict as a normative part of relationships, particularly during adolescence, which often communicates attachment needs.

Develop skills in regulating affect, maintaining connection and negotiating in the face of conflict.

4 Autonomy Includes Connection

Secure attachment contains a balance

between connection and independence.

Enhance recognition and acceptance of adolescent strivings for autonomy but continued need for parental availability in support.

Develop skills in providing continued emotional support coupled with clear structure and expectations in response to adolescent behaviour.

5 Empathy – The Heartbeat of Attachment

Understanding, growth, and

change begin with empathy.

Enhance understanding of the role of empathy for children’s and parents’ experiences as essential to secure attachment.

Develop skills in empathic listening with others in conflict situations

23

Session Title Principle Illustrative Goals & Skill Development Focus

6 Balancing Our Needs with the Needs of

Others

Relationships thrive when we recognize

and balance our needs with the

needs of others.

Enhance parents’ understanding that working toward balance in recognizing their own and their children’s needs is an ongoing process in healthy relationships.

Develop skills in recognizing and responding to their child’s needs while simultaneously being aware of their own needs.

7 Change – Understanding It and

What It Takes

Growth involves moving forward

while understanding the

past.

Enhance understanding of the impact of one’s own personal narratives on one’s experiences in attachment relationships and capacity to be open to new experiences.

Develop skills in identifying the expectations and barriers parents carry regarding change in relationships with their children and enhance motivation to overcome these obstacles.

8 Celebrating Attachment Attachment brings joy and pain.

Enhance understanding that attachment brings joy through celebration of connection with adolescents and pain through negotiation of conflict and change in the relationship. A focus on conflict and change can obscure opportunities for continued celebration of connection.

Develop skills in continuing to embrace opportunities for celebration of connection despite conflict and the importance of clarity and consistency in expectations for adolescent behaviour.

9 Two Steps Forward, One Step Back: Staying

the Course

Attachment allows trusting the

relationship even during turbulent

times. Adversity is an opportunity for

learning.

Enhance understanding that change is not a straightforward process; setbacks occur and can undermine motivation (i.e., relapse recognition and prevention).

Develop skills in reframing ‘setbacks’ as opportunities for learning and growth rather than failures.

10 Integration and Feedback Session

The parent group is a tool-kit for

continued work in relationships.

Encourage understanding of parenting group as a tool-kit for continued work in their relationships.

Gather participant feedback to improve delivery of service.

connect parent group therapy

Documents