Abstract
No increased effect has been associated with parent involvement in cognitive behavioral therapy (CBT) for youths with anxiety disorders. The purpose of this study was to explore parent and therapist experiences of CBT among non-responding youths with anxiety disorders, with a primary focus on parent involvement in therapy. Interpretative phenomenological analysis was applied to 24 sets of semi-structured interviews with families and therapists of anxiety-disordered youths who had not profited from CBT with parental inclusion. From the superordinate theme parents’ difficulties acting as co-therapists, which emerged from the analyses, two master themes represented the perspectives of parents (difficulty working together with the youth and feeling unqualified, with limited resources), and two represented the perspectives of therapists (family dynamics stood in the way of progress and difficulty transferring control to parents). Parent and therapist experiences complemented each other, offering two different perspectives on parent difficulties as co-therapists. However, the two groups’ views on their respective roles in therapy were in conflict. Parents wished to remain being “just the parents” and for the experts to take over, while therapists wished to act as facilitators transferring the control to parents. Clinical implications are drawn for parental involvement and enhancement of treatment outcomes for likely non-responders.
Anxiety disorders are among the most common psychiatric problems in children and adolescents (Pine & Klein, 2008), and unless treated, they may lead to future psychopathology (Pine, Cohen, Gurley, Brook, & Ma, 1998). Cognitive behavioral therapy (CBT) has been extensively evaluated for the treatment of children and adolescents (from now on referred to as youths) with anxiety disorders. James et al. (2013) found in a recent meta-analysis of 41 studies that the mean remission rate after the end of CBT was 59.4% for any anxiety disorder. CBT is often implemented through the use of treatment manuals, such as the Cool Kids Program (Rapee, Wignall, Hudson, & Schniering, 2000), which was recently evaluated in a Danish setting, with results supporting its efficacy (Arendt, Thastum, & Hougaard, 2015). In the Cool Kids Program, parents are actively involved in treatment. In other treatment manuals, such as the Coping Cat, parent involvement is minimal, and the therapy is characterized as child-only CBT (Kendall, 1990). In a meta-analysis of 16 studies, Thulin, Svirsky, Serlachius, Andersson, and Öst (2014) found a small, non-significant effect size in favor of the child-only treatments when compared to treatments with parental inclusion.
Parental involvement in CBT has been implemented in various ways, and parents have been assigned different roles in therapy in accordance with two main guiding assumptions. The first assumption is that parents may facilitate the generalization of the skills taught in therapy (Barmish & Kendall, 2005). Silverman and Kurtines (1996) had earlier described this generalization process as “transfer of control.” This transfer is achieved by therapists teaching parents how to use contingency management, for example, by encouraging and rewarding youths’ “brave” behavior when they face anxiety-provoking situations through exposures. Furthermore, it is expected that parents can continue to refer to the use of skills acquired after the end of treatment. When parents are included in treatment to assist youths and facilitate the transfer of knowledge, they are given the role of acting as co-therapists. Manassis et al. (2014) characterized the Cool Kids Program as being high on contingency management and transfer of control.
The second assumption behind parental involvement in CBT is that it may allow therapists to address family-related issues that contribute to the maintenance of anxiety in youths. There is a strong association between parental anxiety and anxiety in children (Craske & Waters, 2005), and an association has been found between anxiety in children and over-involved/over-controlling parental behavior (Wood, Piancentini, Southam-Gerow, Chu, & Sigman, 2006) or negative parental behavior (Ginsburg, Siqueland, Masia-Warner, & Hedtke, 2004). If therapists identify and change such dysfunctional parental behaviors, including parents in CBT would be expected to enhance the effect of treatment. Thus, parents have also been considered as co-clients because they are expected to work on their own feelings and behaviors during treatment. In the Cool Kids Program, parent modeling and reinforcement of anxious behaviors as well as their erroneous assumptions and beliefs concerning the child are targeted so that they may be altered and no longer maintain youths’ anxiety (Rapee et al., 2000).
To explore the lack of uniformity in what is considered parental involvement, Manassis et al. (2014) examined differences in treatment outcomes depending on the type of parental component. The authors found a more favorable outcome at the 1-year follow-up for studies that included parents as co-therapists and had a primary focus on teaching them contingency management and transfer of control. Wei and Kendall (2014) suggested creating individualized treatment plans to target problematic parental factors present in each family, implementing specific parental/familial treatment component(s), and proposed examining how parents should be involved in CBT to limit the occurrence of non-response. Taboas, McKay, Whiteside, and Storch (2015) recommended understanding the obstacles to improving therapy outcome through parental involvement to enhance existing treatments.
A source of information that could prove valuable in understanding possible obstacles to improving therapy outcome through parental involvement is the qualitative examination of the therapy experiences among families and therapists of non-responders. Palinkas (2014) pointed out that qualitative methods might offer a depth of understanding to complement the breadth afforded by quantitative methods, contributing to a richer interpretation of obtained results and the contextualization of phenomena of interest. Qualitative methods are ideal for eliciting the perspectives of those studied, and McLeod (2013) has suggested that descriptive accounts by therapists and clients may help establish a link between therapeutic processes and outcomes. Furthermore, McLeod (2011) proposed qualitative interviews as the most sensitive method for evaluating the harmful effects of therapy, inviting a more reflective stance from the participants of therapy than a brief end-of-therapy satisfaction questionnaire, which has been criticized for inviting particular answers (Schwartz, 1996). According to Hill, Chui, and Baumann (2013), interviews with both therapists and clients can be fruitful because as a result of their different roles and needs, they may also offer different perspectives on what takes place in psychotherapy.
We set out to examine the families’ and therapists’ experiences of therapy and their perspectives on possible obstacles that could have contributed to youths’ non-response to the Cool Kids Program. A common superordinate theme emerged in the reports from both parents and therapists related to parents’ difficulties acting as co-therapists. In light of the inconclusive quantitative findings regarding the effect of parent inclusion in CBT and the lack of qualitative research on this topic, we decided to examine this theme in this article.
The study aim was to explore how parents’ involvement in CBT as co-therapists may be associated with difficulties among anxious non-responding youths. We strived to obtain an understanding of the respective experiences of parents and therapists and their efforts to “make sense” of non-response in relationship to the parents’ assigned role as co-therapists. The hope was that the exploration of those experiences would contribute toward clinicians gaining a better understanding of how to include parents in treatment effectively, thereby enhancing treatment outcomes for likely non-responders. Thus, the study aimed at answering the following questions:
How do parents and therapists of non-responding anxious youths experience the parents’ role as co-therapists? How do parents and therapists make sense of the youths’ non-response when referring to parent involvement in therapy? How do the perspectives of parents and therapists complement or oppose each other?
Method
Participants
Participants were recruited from a university clinic in Aarhus, Denmark, from January 2011 to April 2012 in connection with a randomized controlled trial (Arendt et al., 2015) on a manualized CBT for youths with anxiety disorders and their parents (the Cool Kids Program; Rapee, Wignall, Hudson, & Schniering, 2000). Families were self-referred to the clinic, which offered CBT, free of charge, to youths with a primary anxiety disorder, diagnosed with the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (ADIS-DSM-IV; Silverman & Albano, 1996). Out of 106 youths, 24 (22.6%) were classified as non-responders to therapy, based on therapist evaluation at a 3-month follow-up assessment on the Clinical Global Impression–Improvement scale (CGI-I; Guy, 1976) after consulting changes on the ADIS-IV. A score of 1 or 2 on the CGI-I reflected a substantial, clinically meaningful decrease in anxiety, while non-responders to treatment were youths with a rating of 3 and above, indicating minimal improvement, no change, or worsening.
The families of non-responders were of Danish ethnic background, and their demographic as well as clinical characteristics are presented in Table 1. All families had completed treatment, and youths attended a minimum of seven sessions (M = 9.08, standard deviation (SD) = .93). Mothers attended an average of 8.50 sessions (SD = 1.82), and fathers attended an average of 7.29 (SD = 5.32). Of the 24 interviews of families of non-responders, in 12 cases, both parents attended the interview; in 9 cases, only the mother did, and in 1 case, only the father was present. One of the two anxiety clinic’s psychologists, who were trained in the Cool Kids Program, conducted the manualized treatment. The therapist with less clinical experience received weekly supervision from the other therapist, who was specialized in CBT. The therapist leading the groups of families with children (7–12 years) was interviewed regarding the eight families in that age group, while the other therapist leading the groups of adolescents (13–17 years) was interviewed about the remaining 16 families.
Demographic and clinical characteristics of families.
SD: standard deviation.
Treatment
Treatment consisted of 10 weekly 2-hour sessions of manualized CBT conducted in groups of five to seven youths with their parents. A 1-hour booster session was offered 3 months after the end of treatment. The “Cool Kids Program” for children (7–12 years) and “Chilled Adolescents” (13–17 years) were implemented through the use of workbooks for youths (Lyneham, Abbott, Wignall, & Rapee, 2003b; Lyneham, Schniering, Wignall, & Rapee, 2006b) and parents (Lyneham, Abbott, Wignall, & Rapee, 2003a; Lyneham, Schniering, Wignall, & Rapee, 2006a). The primary treatment components were psycho-education, cognitive restructuring, and graduated exposures through which youths were taught to recognize their emotions, restructure negative automatic thinking, and gradually confront feared situations. Parents were taught the same treatment principles as their children and were expected to assist youths with the implementation of treatment techniques between sessions in their homework assignments. Furthermore, they received psycho-education in parent management strategies (i.e. transfer of control, contingency management), while therapists addressed problematic parental behaviors in case they maintained youths’ anxiety. A psychologist led each group, and as part of an educational program at the clinic, graduate psychology students participated in the sessions.
Interview schedule
To obtain rich descriptive information about the participants’ experiences of treatment, we conducted semi-structured interviews. The themes guiding the interview questions are presented in Table 2. At the beginning of the interview, we tried to be as unobtrusive and broad as possible, asking very open questions to encourage participants to speak freely about their experiences. Next, specific questions were also posed and themes pursued as they appeared relevant for each case and that the participants chose to bring up.
Themes of interview guide for families’ and therapists’ experiences of treatment.
Data collection and analysis
After the identification of non-responders, their families were invited via e-mail to come to an interview to share their perspective on therapy. The first author, who had not been involved in the therapy, contacted the families and conducted the interviews. Both parents and youths were invited to the family interviews and were interviewed together, unless they preferred otherwise (in three cases). We chose to interview them together based on an expectation that doing so would help them remember issues that concerned them while in therapy and enable youths, who often had a social phobia diagnosis, to feel more comfortable opening up to the interviewer. The superordinate theme that will be considered in this study emerged from therapist and parent experiences only. Therefore, the youths’ reports from the family interviews are not presented here.
Therapists were interviewed at the clinic and informed that the purpose of the interviews was an examination of non-response among youths with anxiety disorders. All families signed a written consent form after they had received oral and written information about the study. The study was approved by the local county Ethical Committee and by the Danish Data Protection Agency. The interviews were recorded and lasted between 40 and 60 minutes. Two psychology students transcribed the interviews verbatim.
The material was coded with the qualitative analysis software NVivo 10 and analyzed using interpretative phenomenological analysis (IPA; Smith, 1995; Smith & Osborn, 2003). IPA is a qualitative research method that combines phenomenology with hermeneutics; the aim of the approach is an understanding of the subjective experience of participants (Smith, Flowers, & Larkin, 2009). In IPA, the researcher seeks to make sense of the participants’ meaning-making of a particular phenomenon (Smith, 2011). Any insights about the data experienced by the researcher are a product of interpretation, with the researcher’s reflexivity being emphasized during the process of analysis.
The first author analyzed the transcripts using a bottom-up procedure, where transcripts were read repeatedly to facilitate familiarity with the participants’ narratives, and recurrent themes were identified. Following Smith et al.’s (2009) recommendations, each transcript of the family interviews was initially analyzed by ascribing labels to the coding of the text of each transcript, capturing the meaning of that part of the text. Then, based on the researcher’s interpretation, clusters of sub-themes and eventually master themes were created. The labels for the themes were adjusted as more and more transcripts were analyzed. Finally, the master themes were grouped into superordinate themes, which reflected more broadly the shared experiences of participants. Subsequently, the same process was undertaken for the therapists’ interviews. The themes were repeatedly cross-referenced with the transcripts to ensure that they were indeed grounded in the data. The second author and an independent researcher knowledgeable in qualitative analysis also examined the identified themes and checked for consistency among themes as they had emerged from the transcripts. Differing interpretations were resolved through discussion.
Results
The superordinate theme parents’ difficulties acting as co-therapists emerged from the qualitative analysis of both parent and therapist experiences of therapy. It consisted of two master themes regarding parent experience and two regarding therapist experiences as they appear in Table 3, together with their respective sub-themes. The master themes will be presented consecutively with selected illustrative quotations.
Overview of themes.
Parent experiences
Difficulty working together with the youth
Almost all parents experienced difficulties when trying to assist their child in therapy work. In many cases, this difficulty seemed to be related to their having trouble understanding and targeting their child’s anxiety. The children appeared to be anxious about numerous situations and unable (or unwilling) to describe feelings and identify thoughts that were related to the anxiety. Consequently, parents felt that it was difficult to gain a concrete overview of the anxiety to do the homework assignments, where the implementation of treatment techniques required targeting specific thoughts and anxiety areas:
The problems were internal and on so many levels. You also need to identify: “What are you afraid of?” It wasn’t clarified. It was a bit diffuse . . . you don’t know what exactly is that, which makes it problematic. We had trouble communicating about it and then you cannot work on it.
Furthermore, parents often thought that the treatment techniques were difficult to implement because their child displayed a resistance to practice. Parents felt increasingly frustrated when they continuously tried to encourage their children to talk about their anxiety and do the assigned homework, but the youths were unwilling to open up and work with them. Instead of being able to show support and encouragement, parents felt frustration that, along with the youths’ resistance, contributed to conflicts:
It has been very difficult for us to help her, because she didn’t want us to interfere in this [therapy work] . . . When we tried pressuring her to sit and talk about it, she would get cross, impossible, and in no way willing to cooperate. Every time it evolved into a small quarrel, in which dad gets mad and mum gets disappointed.
Parents were the ones who took the initiative to refer a child to treatment. When youths were not as willing to work on their anxiety, a pattern emerged in some of the families in which the more parents tried to encourage their child to do therapy work, the more the child acted in a “stubborn” manner, refusing to work on the anxiety. Consequently, parents, who put a lot of effort into therapy, became frustrated when they did not succeed in practicing and progress did not occur. The frustration was often externalized by the fathers and internalized by the mothers. It was evident that family members held different roles and positions in the family, which were brought into therapy and guided the subsequent therapy work, when parents were expected to work together with their children.
Feeling unqualified, with limited resources
Parents had referred their child to treatment in the hope that experts would be able to help in a way that they had been unable to. They had already tried handling the problems on their own, and some described feeling “desperate for help” when coming to therapy. They hoped others would be able to take over so that they could just be the parents:
In order to practice, it gets to be invasive not only for the youth’s life, but also for the one that needs to practice with the youth . . . Now someone needs to talk to my child, so we can just be mum and dad. Having to be a therapist for your child—I think for some it is easy and for others very hard, depending on the child.
Many parents described feeling at times unable to meet the demands therapy placed on them. They felt that they lacked time and energy resources and referred to difficulties of their own (physical and psychological), full-time jobs, and other children who also needed attention. They thought the program was very intense, and they had trouble finding the time to practice between sessions. Parents’ difficulties with practicing were also often related to their feeling uncertain about how to support their child in therapy work. Parents were worried that they might push their child too much and did not feel properly trained by the therapist to assist in the implementation of the techniques:
We are not educated in this area, so we are not always able to help him move forward . . .
It takes time to get the techniques under your skin so they become part of you. I think the longer you have someone behind you that can say: “You are doing good, or try this . . .” the better it is.
Parents expected the therapist to be the expert, the person who knew what was best for their child, and it would give them a sense of security to follow the therapist’s advice. In this way, parents could give up some of the burdens of the responsibility:
Just coming to someone who knew what our son had . . . it gave a tremendous feeling of security . . . we are just the parents. We do not know about these things.
Parents wished to remain in their parenting role instead of taking up a co-therapist role during treatment. Their wish for the experts to take over and help seemed to be related to their fear of harming their child by pushing too much. They felt that they were expected too soon to manage on their own, and after therapy, they missed the therapist’s encouragement and guidance about whether they were doing the right thing. Parents seemed to feel insecure and would rather revert to their former practice of comforting and protecting, instead of challenging their child to face his or her fears, a practice that supported their child’s avoidance.
Therapist experiences
Family dynamics stood in the way of progress
Therapists had the impression that almost all parents experienced to some degree difficulties in acting as co-therapists. Some parents were described as lacking in resources because they often had difficulties of their own (e.g. feeling anxious or depressed) and would easily become overwhelmed by their child’s symptomatology. Therapists felt that this situation could contribute to a dynamic in which the parent experienced difficulties in setting demands and the youth challenged the permissive parent:
The mother has recurrent depressive episodes . . . An unfortunate dynamic appears where the mother is a bit afraid of Sarah [the child] and of challenging her. Sarah becomes violent towards the mother when angry . . . There are a lot of conflicts in the family and a lack of boundaries . . . It has been difficult to get something out of Sarah. However, it was easier when her mother was not present, because she evokes this very defiant side of her . . .
Therapists attributed some of the parents’ difficulties in practicing with the children to the youths’ lack of motivation to work on their anxiety. However, therapists also hypothesized that parents, who reacted with frustration or insecurity in response to youths’ anxiety, contributed to the youths’ acting in a stubborn manner toward them:
There appears this dynamic where the parents get really tired of her and then she needs to yell louder in order to be heard . . . The mother could not get her to do anything and would become irritated with her. They have all the skills, but they are a bit too insecure of themselves, and this contributes to a family dynamic that she [the child] can sense and it is not helpful . . . It was a subject that presented itself every time the parents needed to push her a bit further “not to break something.”
Therapists had the impression that parents would become overwhelmed by their own anxiety feelings when seeing their child in despair, which made it difficult for them to act in a supportive manner.
Therapists believed that in some families, one parent (most commonly the mother) was identifying “too much” with the youth’s difficulties and that this identification contributed to mothers becoming overinvolved and overprotective. Fathers, on the other hand, were seen as reacting to mothers’ overprotective behavior by behaving in an opposite manner, not acknowledging the youth’s anxiety and setting demands that were too high:
The father blames the mother for being too overprotective . . . he perceives the relation between the mother and Mie as the problem . . . I think he also felt a bit left outside. They have had their little symbiosis, and he was an appendix to it. So it has been difficult for him to become part of this.
Therapists hypothesized that youths’ anxiety was maintained due to problematic parental behaviors, which they believed were grounded in parental beliefs that needed to be challenged. The therapists experienced that parents’ inconsistent parenting and over-involvement prevented the parents from acting successfully as co-therapists. When therapists tried to assist the families in their planning of homework, they experienced that conflicts and cross-generational coalitions would not allow the family to work together as needed for homework completion.
Difficulty transferring control to parents
Therapists expected that parents would transfer the techniques taught to their child when working between sessions. However, therapists felt that some parents failed to understand this concept of therapy because they constantly depended on therapist guidance about what to do, instead of implementing the techniques. Furthermore, therapists noticed how the parents often did not relate to the others in the group to learn from their experiences:
It can be difficult to give them help for self-help. They seek advice from me that they then follow. They are unlikely to think by themselves: “What is best to do in this situation?” When they become anxious, they forget what they have learned. In a way, they misunderstood the concept because they think it is me that is supposed to help them and they haven’t really been engaged in the group treatment. They just didn’t understand the concept because they wanted me to tell them what specific things they needed to do.
Therapists felt frustrated when parents were unable to work more independently and when they took too much of the group’s time to discuss about their child. They felt pressured by the limited time, and it was their impression that this feeling contributed to their becoming more directive than explorative when talking with parents.
Therapists also experienced that it was difficult to change the parents’ problematic behaviors. Although therapists encouraged parents to reinforce their child’s brave behavior, they often had the impression that parents lacked an understanding of the treatment principles or needed additional help themselves before they could do so:
The mother needs to change her perspective. She needs help in order to handle her own feelings of anxiousness and helplessness, if she is to be able to be a secure base for Sally . . . The anxiety has a function in the family that you need to address therapeutically, and you cannot do that in a group format.
Overall, therapists were primarily concerned about teaching parents the treatment principles, offering parents help for self-help so that they could generalize the skills in other areas between sessions. Therapists experienced being limited by the group format of therapy because they felt unable to address each family’s needs to the degree they wished. When parents needed to deal with anxiety feelings of their own, or family conflicts stood in their way of acting as co-therapists, the therapists believed that additional therapy targeting those issues would have been more suitable.
Discussion
This study examined the experiences of parents and therapists who participated in the treatment of youths with anxiety disorders who had not responded to manualized group CBT, and the superordinate theme regarding parents’ difficulties acting as co-therapists was further explored. Parents experienced difficulties in working together with their child. They were unable to communicate and became frustrated because of their child’s unwillingness to do therapy work. Parents did not feel that they had gained a proper understanding of the techniques and were afraid that they might push their child too much. Therapists often attributed the maintenance of the youths’ symptomatology to the problematic family dynamics and the lack of homework completion. Therapists felt that the parents were very dependent on their advice and encountered difficulties in transferring the control to the parents. Furthermore, therapists tended to become frustrated because as a result of the therapy format, they were unable to address each individual family’s needs satisfactorily.
Parents wished to remain being “just the parents” instead of acting as coaches, and they wished for the therapists, the experts, to take over and help their child. Therapists, on the other hand, perceived themselves as facilitators who would offer “help for self-help” and expected parents to play an active role in transferring the techniques to their child, not being as dependent on their guidance, but using the group to exchange experiences. Parent and therapist experiences of therapy appeared to complement each other, providing us with a better understanding of the difficulties associated with parents acting as co-therapists. However, their respective views of their roles seemed to be in conflict: parents expected the therapist to help their child, while therapists expected the parents to implement the techniques and conduct exposures with their child. It appears that based on their distinct roles in therapy, therapists and parents had different needs and encountered different challenges. Therapists needed the parents to work more independently so that they would not feel as time-pressured, while parents needed a lot of reassurance that they were doing the right thing by pressuring their child because doing so was in conflict with their usual parental reaction to protect their child from “harm.”
According to the first assumption for involving parents in CBT, parents are expected to facilitate the generalization of the skills taught in therapy. CBT with parental involvement builds on collaboration between the therapist and the client as well as between parent and child to allow for the successful implementation of contingency management and transfer of control, which have been associated with better treatment outcomes in earlier studies (e.g. Khanna & Kendall, 2009; Silk et al., 2013). However, as revealed in our findings on families of non-responding youths, it might be difficult to establish collaboration within the family. More specifically, parents in our sample encountered difficulties with pushing their child and with the youths’ lack of motivation to do therapy work, problems also encountered among parents in CBT for youths with chronic fatigue syndrome (Dennison, Stanbrook, Moss-Morris, Yardley, & Chalder, 2010). In addition, the parents in our study felt unqualified and uncertain about how to help, while a lack of communication and conflicts stood in the way of their assisting their child in completing homework assignments. Our findings may contribute to our understanding of how some parents may experience difficulties acting as co-therapists. Breinholst, Esbjørn, Reinholdt-Dunne, and Stallard (2012) have already suggested that parent involvement may not always add to treatment effects because we rely on parent ability to act as co-therapists, and for some parents, this role may be very demanding.
The second assumption behind parent inclusion in CBT is that parents learn more suitable ways of behaving so that treatment outcome is enhanced. Although the therapists in our study observed problematic parental behaviors, they felt that there was a need for additional therapy to target parents’ dysfunctional beliefs and problematic family dynamics. The relevance of addressing those issues is supported by earlier studies, which have suggested that inappropriate parental beliefs about parents’ own self-efficacy and that of their child, as well as an inconsistent parenting style, may contribute to youths’ anxiety (Bögels & Brechman-Toussaint, 2006; Ginsburg & Schlossberg, 2002). When parents display a permissive parenting style (Baumrind, 1967), they accommodate the anxious or avoidant behavior of their child, and the child does not develop a sense of mastery and competence, which in turn reinforces the avoidance of certain situations and the lack of acquisition of age-appropriate coping strategies (Chorpita & Barlow, 1998). In this way, anxiety is maintained in the family. Studies have suggested that family variables such as high family conflict (Crawford & Manassis, 2001) and low family cohesion (Victor, Bernat, Bernstein, & Layne, 2007) can also have a negative impact on youths’ treatment outcome. Furthermore, parental psychopathology has been associated with a negative treatment outcome (Knight, Hudson, McLellan, & Jones, 2014; Lundkvist-Houndoumadi, Hougaard, & Thastum, 2014). Recent studies found that mothers with an anxiety disorder had significantly more negative expectations of child coping behaviors (Orchard, Cooper, & Creswell, 2015) and differed from mothers without an anxiety disorder in terms of intrusiveness, expressed anxiety, warmth, and quality of the relationship with the child (Creswell, Apetroaia, Murray, & Cooper, 2013).
Clinicians are expected to follow treatment protocols in a flexible manner, in accordance with the “flexibility within fidelity” principle (Kendall, Chu, Gifford, Hayes, & Nauta, 1998). However, the therapists in our study described feeling time-pressured. We would expect that if therapists need to address problems within families, doing so could distract their attention from directly addressing youths’ anxiety. As Breinholst et al. (2012) suggest, CBT with parental involvement may try to target too many things, resulting in no single thing being addressed satisfactorily in some families.
Our findings support Wei and Kendall’s (2014) suggestion to individualize the treatment plan of each youth to enhance treatment outcomes for likely non-responders by offering the most suitable form of parental component. As they have pointed out, this form could depend on the identification of three areas of problematic family issues: in case of parent–child conflicts, families could be trained in communication skills; in case maladaptive parental behaviors are present, it would be suitable to offer parenting training; and in case of parental psychopathology, additional therapy would need to be targeted to parents. On the other hand, we could suggest that in families where no problematic issues are present, parents can be involved as co-therapists from therapy initiation. Research attention should turn toward identifying treatment moderators regarding parental involvement in CBT. At the same time, we need to develop effective interventions to address problematic parenting behaviors and parental psychopathology. Hudson et al. (2014), who examined the effect of adding a component of parent anxiety management to the Cool Kids Program, found no improved outcomes for child or parent anxiety. Creswell et al. (2015) also found no evidence for a benefit in child outcome when adding to child-only CBT a component that either addressed maternal anxiety disorders or focused on maternal parenting cognitions and behaviors. Besides the fact that the additional components are of a short duration, parents may be reluctant to work on their own anxiety and may have difficulties focusing on working on their own fears when having to also assist their child in anxiety work.
Our study is not intended to generalize to CBT offered to all families of youths with anxiety disorders. It may offer an understanding of difficulties encountered during therapy among likely non-responders, suggesting clinical implications that would be relevant to examine further. We would expect that many factors were related to youths’ non-response, while the youths’ lack of progress may have presented parents with more difficult challenges (bi-directionality of influences). At the same time, it is possible that parents of youths who profited from treatment also experienced difficulties with their assigned co-therapist role, and it would be relevant to also examine their experiences. Furthermore, much could be gained from a study design that assesses parental psychopathology and combines real-time accounts of parents’ and therapists’ experiences with observations of family dynamics. An important study limitation is the fact that in most cases, families were interviewed together, which might have influenced the issues parents and youths chose to raise. However, it was not the interviewer’s impression that the participants felt uncomfortable when talking about the challenges they experienced during therapy.
In conclusion, these findings must be seen as preliminary. However, we believe that knowledge obtained from this study can contribute to our understanding of difficulties that may appear in manualized group CBT with a parental component among likely non-responding youths with anxiety disorders. The findings suggest that parents may encounter difficulties working together with the youth, while problematic family dynamics may stand in the way of therapy work. Not all parents may be comfortable with their assigned role to act as co-therapists, while therapists may feel restrained by the manualized group format of therapy in their efforts to transfer control to parents and meet the needs of each individual family.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors would like to acknowledge the financial support of this research by TrygFonden.