I. Description of Treatment
Parent management training (PMT) refers to programs that train parents to
manage their child's behavioral problems in the home and at school. PMT has
emanated from two lines of work. First, maladaptive parent-child interactions,
particularly in relation to discipline practices, have been shown to foster and to
sustain conduct problems among children. Second, social learning techniques,
relying heavily on principles of operant conditioning, have been extremely
useful in altering parent and child behavior. In PMT, parent-child interactions
are modified in ways that are designed to promote prosocial child behavior and
to decrease antisocial or oppositional behavior.
Treatment sessions include instruction in social learning principles and
techniques. The therapist provides a brief overview of underlying concepts,
models the techniques for the parents, and coaches parents in implementing
the procedures. Procedures and interaction patterns practiced in the sessions
are then used in the home. Parents usually are taught how to define, observe,
and record behavior at the beginning of treatment because once behaviors
(e.g. fighting, engaging in tantrums) are defined concretely, reinforcement and
punishment techniques can be applied. The PMT therapist details the concepts
and procedures derived from positive reinforcement (e.g., contingent delivery
of attention, praise, points) and punishment (e.g., time out from reinforcement,
loss of privileges, and reprimands). Reinforcement for prosocial and nondeviant
behavior is central to treatment. Parents are taught how to use reinforcement
and punishment techniques contingent on the child's behavior, to provide
consequences consistently, to attend to appropriate behaviors and to ignore
inappropriate behaviors, to apply skills in prompting, shaping, and fading, and
to use these techniques to manage future problems. There is an extensive
amount of practice and shaping of parent behavior within the sessions to
develop skills in carrying out the procedures.
Because the immediate goal of treatment is to develop parenting skills, the
therapist begins by having parents apply new skills to relatively simple
problems (e.g., compliance, completion of chores, oppositional behavior). As
parents become proficient using the initial techniques, the child's most serious
problem behaviors at home and in school are addressed (e.g., fighting, poor
school performance, truancy, stealing, firesetting). In most PMT programs, the
therapist maintains close telephone contact with the parents in-between
sessions. These contacts are used to encourage parents to ask questions about
the home programs, to provide an opportunity for the therapist to prompt
compliance with the behavior-change programs and reinforce parents' use of
the skills, to strengthen the therapeutic alliance, and to allow the therapist to
problem-solve when programs are not modifying child behavior effectively.
III. References
A. Background Research
Reviews of the outcome evidence, as well findings related to moderators of treatment,
generalization, and maintenance of changes, can be obtained from the following sources:
Dumas, J.E. (1989). Treating antisocial behavior in children: Child family approaches.
Clinical Psychology Review, 9, 197-222.
Forehand, R., & Long, N. (1988). Outpatient treatment of the acting out
child: Procedures, long-term follow-up data, and clinical problems.
Advances in Behaviour Research and Therapy 10, 129-177.
Kazdin, A. E. (1985). Treatment of antisocial behavior in children and
adolescents. Homewood, IL: Dorsey Press.
Long, P., Forhand, R., Wierson, M., & Morgan, A. (1994). Does parent
training with young noncompliant children have long-term effects?
Behaviour Research and Therapy, 32, 101-107.
Miller, G. E., & Prinz, R. J. (1990). Enhancement of social learning family
interventions for child conduct disorder. Psychological Bulletin, 108, 291-
307.
Moreland, J. R., Schwebel, A.I., Beck, S., & Wells, R. (1982). Parents as
therapists: A review of the behavior therapy parent training literature -
1975 to 1981. Behavior Modification, 6, 250-276.
B. Clinical References
Materials that describe the procedures and methods used in training for oppositional and antisocial
children can be found in the following sources:
Forehand, R., & McMahon, R.J. (1981). Helping the noncompliant child: A clinician's guide
to parent training. New York: Guilford.
Sanders, M.R., & Dadds, M.R. (1993). Behavioral family interventions.
Needham Heights, MA: Allyn & Bacon.
Webster-Stratton, C., & Herbert, M. (1994). Troubled families-problem
children: Working with parents: a collaborative process. Chichester,
England: John Wiley.
I. Description of Treatment
Stress Inoculation Training (SIT) emerged out of an attempt to integrate the
research on the role of cognitive and affective factors in coping processes with
the emerging technology of cognitive behavior modification (Meichenbaum,
1977). SIT has been employed on a treatment basis to help individuals cope
with the aftermath of exposure to stressful events and on a preventative basis
to "inoculate" individuals to future and ongoing stressors.
SIT is a flexible individually-tailored multifaceted form of cognitive-behavioral
therapy. In order to enhance individuals' coping repertoires and to empower
them to use already existing coping skills, an overlapping three phase
intervention is employed. In the initial conceptualization phase a collaborative
relationship is established between the clients and the therapist (trainer). A
Socratic-type exchange is used to educate clients about the nature and impact
of stress and the role of both appraisal processes and the transactional nature
of stress (i.e., how clients may inadvertently, unwittingly, and perhaps, even
unknowingly, exacerbate the level of stress they experience). Clients are
encouraged to view perceived threats and provocations as problems-to-be-
solved and to identify those aspects of their situations and reactions that are
potentially changeable and those aspects that are not changeable. They are
taught how to "fit" either problem-focus or emotion-focus to the perceived
demands of the stressful situation (e.g., see Folkman et al., 1991). The clients
are taught how to breakdown global stressors into specific short-term,
intermediate and long-term coping goals.
As a result of interviewing, psychological testing, client self-monitoring, and
reading materials, the clients' stress response is reconceptualized as being
made-up of different components that go through predictable phases of
preparing, building up, confronting, and reflecting upon their reactions to
stressors. The specific reconceptualization that is offered is individually-tailored
to the client's specific presenting problem (e.g. anxiety, anger, physical pain,
etc.). As a result of a collaborative process a more hopeful and helpful model is
formulated; a model that lends itself to specific intervention.
The second phase of SIT focuses on skills acquisition and rehearsal that follows
naturally from the initial conceptualization phase. The coping skills that are
taught and practiced primarily in the clinic or training setting and then
gradually rehearsed in vivo are tailored to the specific stressors clients may
have to deal with (e.g., chronic illness, traumatic stressors, job stress, surgery,
sports competition, military combat, etc.). The specific coping skills may
include emotional self-regulation, self-soothing and acceptance, relaxation
training, self-instructional training, cognitive restructuring, problem-solving,
interpersonal communication skills training, attention diversion procedures,
using social support systems and fostering meaning-related activities.
The final phase of application and follow through provides opportunities for the
clients to apply the variety of coping skills across increasing levels of stressors
(inoculation concept as used in medical immunization or in social psychology to
prepare individuals to resist the impact of persuasive messages). Such
techniques as imagery and behavioral rehearsal, modeling, role playing, and
graded in vivo exposure in the form of "personal experiments" are employed. In
order to further consolidate these skills individuals may even be asked to help
others with similar problems (Fremouw & Harinatz, 1975; Meichenbaum, 1994).
Relapse prevention procedures (i.e., identifying high risk situations, warning
signs, and ways to coping with lapses), attribution procedures (i.e., ensuring
clients take credit for and appropriate ownership by putting into their own
words the changes that have taken place), and follow-through (i.e., booster
sessions) are built into SIT.
SIT also recognizes that the stress an individual experiences is often endemic,
institutional and unavoidable. As a result, SIT has often helped clients to alter
environmental settings and or worked with significant others in altering
environmental stressors (e.g., hospital staff for medical patients, Kendall, 1983;
coaches for athletes, Smith, 1980; drill instructors for recruits, Novaco et al.,
1983; and so forth). SIT recognizes that stress is transitional in nature and that
there is a need to not only work with clients to bolster and nurture flexible
coping repertoires, but it is also necessary, on some occasions, to go beyond
individual and group interventions and to adopt a community based focus.
SIT has been conducted with individuals, couples, small and large groups. The
length of intervention has varied from being as short as 20 minutes for
preparing patients for surgery (Langer et al., 1975) to 40 one hour weekly and
biweekly sessions administered to psychiatric patients or to individuals with
chronic medical problems (Meichenbaum, 1994; Turk et al., 1983). In most
instances, SIT consists of some 8 to 15 sessions, plus booster and follow-up
sessions, conducted over a 3-to-12-month period.
V. References
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Deffenbacher, J., Story, D., Brandon, A., Hogg, J., & Hazeleus, S. (1988).
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Feindler, E. & Ecton, R. (1986). Adolescent anger control: Cognitive-behavioral
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Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. (1991). Treatment of
posttraumatic stress disorder in rape victims: A comparison between cognitive
behavioral procedures and counseling. Journal of Consulting and Clinical
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Folkman, S., Chesney, M., McKusik, L., Ironson, G., Johnson, D. S., & Coates, T. J.
(1991). Translating coping theory into an intervention. In J. Eckenrode (Ed.).
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Hains, A. A. & Szyakowski, M. (1990). A cognitive stress-reduction intervention
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84.
Holcomb, W. R. (1986). Stress inoculation therapy with anxiety and stress
disorders of acute psychiatric patients. Journal of Clinical Psychology, 42, 864-
872.
Holroyd, K., Andrasik, F., & Westbrook, T. (1977). Cognitive control of tension
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Jaremko, M. (1980). The use of stress inoculation training in reduction of public
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