COMBINED PARENT-CHILD COGNITIVE BEHAVIORAL THERAPY (CPC-CBT)
WHAT IS COMBINED PARENT-CHILD COGNITIVE BEHAVIORAL THERAPY?
CPC-CBT, an evidence-based treatment (EBT) designed to address the needs of children and families at-risk for child physical abuse, was developed by Melissa K. Runyon, PhD in collaboration with Esther Deblinger, PhD. CPC-CBT is a structured EBT for children ages 3-17 and their parents (or caregivers) in families where parents engage in a continuum of coercive parenting strategies. CPC-CBT is designed not only for families where physical abuse has been substantiated, but also as preventative with cases where families are considered at-risk of physical abuse occurring. At-risk may be defined as those families who have had multiple referrals to CPS with no substantiation, as well as those families who report using excessive physical punishment and coercive parenting strategies with their children. It may also include parents who experience high levels of stress, perceive their children’s behavior as extremely challenging, and fear they are going to lose their temper with their children.
CPC-CBT consists of parent interventions, child interventions, and family interventions CPC-CBT is grounded in cognitive behavioral theory and incorporates elements (e.g., trauma narrative and processing, positive reinforcement, timeout, behavioral contracting) from CBT models for families who have experienced sexual abuse, physical abuse, and/or domestic violence, as well as elements from motivational, family systems, trauma, and developmental theories. CPC-CBT can be offered in either individual (90-minute sessions) or group (2-hour sessions) in 16-20 sessions across four phases: Engagement, Coping Skill Building, Family Safety, and Abuse Clarification.
Every session begins with the parent and child meeting individually with the clinician and concludes with the parent, child and clinician together. The amount of time spent jointly with the parent, child and clinician increases as therapy progresses. By the end of the course of treatment, the majority of the session is spent jointly with parent, child, and clinician.
In the simplest terms, CPC-CBT clinicians are helping parents to create positive family environments, to enjoy their children, and to enjoy being parents. Goals of CPC-CBT include helping children heal from their abusive experiences, empowering parents to effectively parent their children in a non-coercive manner, strengthening parent-child relationships, and enhancing the safety of all family members. Some of the components and skills offered during structured therapy sessions across the four phases are described below.
Phase 1: Engagement & Psychoeducation
Engaging and motivating parents who are often not contemplating changing their parenting style or interactions with their children by using the following techniques:
- Engagement strategies
- Motivational Interviewing/consequence review
- Individualized goal setting
Providing violence psychoeducation including educating both parents and children on:
- Different types of violence
- The continuum of coercive behavior
- The impact of violent behavior on children
Providing psychoeducation for parents about:
- Child development
- Realistic expectations for children’s behavior.
Addressing parental history of trauma exposure including its impact on:
- Their relationships with their parents
- Their parenting approach with their own children.
Phase 2: Effective Coping Skill Building
Empowering parents to be effective by working collaboratively with them to:
- Develop adaptive coping skills
- Cognitive coping
- Anger management
- Problem solving
- Assist them in remaining calm while interacting with their children.
- Develop non-violent conflict resolution skills.
- Develop a variety of problem-solving skills related to child rearing.
- Develop a variety of non-coercive child behavior management skills.
- Learn the dynamics of their interactions with their children and what escalates anger and violence during these interactions and how to use skills to diffuse the situation.
Phase 3: Family Safety
Developing a family safety plan that involves:
- Learning how to identify when parent-child interactions are escalating.
- Taking a cool down period in order to enhance safety and communication in the family.
- Having parents and children rehearse the implementation of the family safety plan.
- Introducing other safety components across the therapy.
Phase 4: Abuse Clarification
Clarification involves the parent writing an abuse clarification letter and the child developing a trauma narrative about the abuse experienced.
Specifically, the clinician encourages the children to write about or share their abusive experiences while focusing on their thoughts and feelings associated with the abuse.
While the child is developing this trauma narrative, the clinician also assists parents in processing their own thoughts and feelings while writing and revising a “clarification” letter to their children to enhance their empathy for their children and to demonstrate that they take full responsibility for their abusive behavior.
The clarification letter also serves to:
- Alleviate the child of blame.
- Respond to the child’s questions and/or worries.
- Correct the child’s cognitive distortions concerning the abuse.
The parents and children share the clarification letter and trauma narrative in joint segments, unless this process is contraindicated. However, in most cases, this process enhances the parent’s empathy for the child and is a powerful therapeutic tool for strengthening the parent-child relationship. CPC-CBT is the only treatment involving at-risk parents that incorporates the trauma narrative into the clarification process.
Parenting Skills Training
Parenting skills training is provided across all phases:
- The therapists help families develop effective communication skills to increase family members’ feelings of validation and cooperation with one another.
- Over the course of treatment, joint parent-child sessions involve having parents practice implementation of active listening, communication skills, and positive parenting first with the therapist and then with children while the clinicians coach them by offering positive reinforcement and corrective feedback to enhance the skills.
DEVELOPMENTS IN COMBINED PARENT-CHILD COGNITIVE BEHAVIORAL THERAPY
- Center for the Study of Social Policy has selected Combined Parent-Child Cognitive Behavioral Therapy to be featured in their effective program and practice guide for Expectant and Parenting Youth in Foster Care
- Included on the federal government’s National Registry of Evidence-Based Programs and Practices (NREPP) website
- Included on the California Evidence-based Clearinghouse for Child Welfare (CEBC) website
- CPC-CBT manual published in Fall 2013 as a part of Oxford University Press Programs That Work series
- Swedish pilot study replicated findings of initial CPC-CBT pilot study Large scale dissemination project and controlled comparison underway in Sweden
- Dissemination of CPC-CBT for Army Family Advocacy Program therapists in US and abroad
- Dissemination of CPC-CBT in agencies across New South Wales region in Australia
HOW EFFECTIVE IS COMBINED PARENT-CHILD COGNITIVE BEHAVIORAL THERAPY
Research has supported CPC-CBT for reducing the use of physical punishment and parental distress, as well as improving positive parenting skills and children’s emotional and behavioral functioning. A small pilot study compared children’s and parents’ functioning prior to initiating treatment to their functioning after completing a 16-session course of group CPC-CBT. After their participation in CPC-CBT, parents and children reported significant reductions in the use of physical punishment, reductions in parental anger toward their children, as well as improvements in consistent parenting, children’s PTSD symptoms, and behavioral problems (Runyon, Deblinger & Schroeder, 2009; CARES group pilot study).
In a randomized controlled study, CPC-CBT (Runyon, Deblinger & Steer, 2010; CARES NIMH-funded trial) was compared to CBT for the parent alone. CPC-CBT involving both the child and parent was associated with greater improvements in positive parenting skills and children’s PTSD. There were also pre- to post-treatment changes within the groups.
To examine outcomes associated with individual CPC-CBT, a pilot study compared children’s and parents’ functioning prior to initiating treatment to their functioning after completing individual CPC-CBT. After their participation in CPC-CBT, children reported significant reductions in depressive symptoms while parents reported improvements in their levels of depression, consistent parenting, and children’s externalizing behavior problems (Runyon, Deblinger & Schroeder, in preparation; CARES individual pilot study). Both children and parents reported significant reductions in the use of corporal punishment.
To further enhance engagement, the developer of CPC-CBT has attempted to increase the cultural sensitivity of the treatment and associated materials. For instance, the culturally relevant materials currently used in CPC-CBT were integrated based on consumers who participated in the initial comparison study – 75% of participating families who provided feedback identified themselves as being a member of a group that would be defined as an ethic minority.
CPC-CBT has also been evaluated in mental health centers and social service units in the United States and Sweden. Four child protection and child and adolescent psychiatry social service units across Sweden (Kristianstad, Linkoping, Lund and Malmo) were trained by the developer in CPC-CBT. As part of this dissemination project, researchers conducted a pilot study with a majority of participants receiving individual CPC-CBT (Kjellgren, Svedin, & Nilsson, 2013; Swedish pilot study). After their participation in CPC-CBT, parents (n=26) reported a significant decrease in depression, violent parenting tactics, and inconsistent parenting, and children’s trauma symptoms, and children (n=25) reported significant improvements in trauma and depressive symptoms. Children also reported significant decreases in coercive parenting tactics and improvements in positive parenting for their parents. The authors concluded that CPC-CBT was applicable and effective for treating CPA in Sweden which is defined as a much lower threshold of coercion than in the United States. Mental health therapists from five additional agencies have been trained in CPC-CBT and researchers are currently conducting a clinical trial comparing CPC-CBT to treatment as usual in Sweden.
In another dissemination project, three agencies in Mississippi were trained in CPC-CBT using the National Child Traumatic Stress Network’s Learning Collaborative (LC) framework. While a small group of clinicians (12 clinicians) from these agencies were trained and actively providing CPC-CBT to families, pre and post training data revealed significant changes in organizational practices, practices, clinicians’ practices, and clinical outcomes for families. The families who received CPC-CBT over the course of the LC reported significant improvements in parenting, reductions in the use of corporal punishment, and improvements in severity of children’s PTSD symptoms from pre to post-treatment. Participating clinicians also reported significant increases in the use of a number of CPC-CBT components and skills during parent, child, and joint sessions after their participation in the LC.
One of the striking findings across all studies is the reduction in the use of corporal punishment reported by children and parents after their participation in CPC-CBT.
To learn more about CPC-CBT, visit the websites below:
The CPC-CBT treatment manual may be obtained from Oxford University Press: Runyon, M. K., & Deblinger, E. (2014). Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT): An Approach to Empower Families At-Risk for Child Physical Abuse. New York, NY: Oxford University Press.