Staff Perspective: A Look at Parent-Child Interaction Therapy
Parent-Child Interaction Therapy (PCIT), developed by Dr. Sheila Eyberg, CEO of the newly established PCIT-International, is an evidence-based intervention for preschool children (2-6 years) and their parents/caregivers. Although initially developed in the 1980s for children with externalizing behavior problems, it has since been empirically validated in families with other presenting problems including child maltreatment and children with internalizing disorders such as separation anxiety disorder.
PCIT involves two stages: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). CDI focuses on improving the parent-child relationship through skills designed to increase warmth, enjoyment, attention, frustration tolerance, anger management, and self-esteem. In this phase, parents/caregivers generally also begin to notice improvement in challenging behaviors. In PDI, parents learn to use structured, predictable, and consistent discipline techniques to improve compliance and reduce disruptive behaviors.
Rather than simply instructing parents on parenting techniques and talking about “how they work,” PCIT therapists actually coach parents while they practice the skills with their children using a one-way mirror and a “bug in the ear” device. These skills are also practiced each day (for 5 minutes) as Special Time homework. Families graduate from PCIT within about 12-15 sessions. However, PCIT is not time-limited; it continues until the parents have mastered skills and the children’s behavior is within the normal range on standardized measures. With successful completion of PCIT, not only do children show significant improvement in presenting problems, but marked changes in parenting stress and parent depression have also been shown to occur.
Dr. Robin Gurwitch, a faculty member at Duke University Medical Center (DUMC) and a Certified Master Trainer through PCIT-International, has been leading an initiative to bring PCIT to military families. So far, therapists at Tripler Army Medical Center, Schofield Barracks, Ft. Belvoir, and nine USMC bases have received training in PCIT from Dr. Gurwitch and her colleagues at Cincinnati Children’s Medical Center, University of Oklahoma Health Sciences Center, and DUMC. They are currently working to expand the initiative and to collect data to support the use of PCIT with military families.
Dr. Mary Brinkmeyer, who trained with Dr. Eyberg in graduate school at the University of Florida, interviewed Dr. Gurwitch about PCIT and military families.
Dr. Mary Brinkmeyer: How did you become interested in PCIT? What do you find exciting or compelling about this treatment?
Dr. Robin Gurwitch: I first became interested in PCIT in 1991 when I began working at the University of Oklahoma Health Sciences Center (OUHSC). A colleague asked me to join her in providing this evidence-based treatment to families referred to the outpatient center. I read articles about this treatment and was extremely impressed, but nothing could have prepared me for what I experienced when I actually began working with families using PCIT. The changes, which can happen very very quickly, made significant differences to everyone in the family. I continue to work with wonderful colleagues at OUHSC and the energy to push new directions, come up with fun ways to train, and continued enjoyment with this therapy is contagious all around.
Now, 23 years later, I remain as excited, if not moreso, about PCIT. With research I have conducted with colleagues as well as research of others, I continue to see the amazing benefits to families who participate in PCIT. Today, I often laugh, that PCIT is like a cult. Once you see the transformations in families through this strength-based treatment, it is my goal that new therapists in PCIT will want “an orange robe and a tambourine” too! Almost all DO!
What is exciting and compelling? I like the fact that PCIT is not only evidence-based (with more research behind it than almost any other treatment), but that it involves the parents/caregivers and the child TOGETHER. Through the parent-child relationship, new patterns in family interactions are formed. And, the gains continue, according to research, for up to six years. (It may be longer, but this is the time frame of the on-going study). That to me is mind-blowing. A child seen at 6 who successfully completes this relatively short-term treatment will continue to show the changes at 12. Of course, then the child is heading into adolescence and “all bets are off.”
Another aspect that sets PCIT apart from other parenting programs is the in-vivo component. Parents/caregivers are coached in each session by the therapist in PCIT skills. They are never asked to implement skills, which they have not practiced first. They are given immediate feedback. Finally, as PCIT is a very transparent treatment, the parents/caregivers are told what the goals for each of the two phases of PCIT are and they are given information about how close they are to meeting these goals each session. PCIT is a true partnership between the adults in the child’s life.
MB: Why should military providers become trained in PCIT?
RG: I first became interested in adapting PCIT for use with military families when I began reading the literature on the impact of deployment on military children. More than 2 million children in the United States have experienced parental deployment to Iraq or Afghanistan. The majority of the children are between the ages of 2 and 8 (PCIT targets children ages 2 to 7 years). Research findings related to the children include: increased behavior problems in young children both at home and in preschool; increased risk of child maltreatment; parental perception that the child is cold or afraid of him/her after deployment; and decreased marital satisfaction. For me, this mapped almost directly onto the goals of PCIT for non-military population: improved parent-child relationship, improved behaviors at home (and research finds these improvements generalize to school), decreased risk for physical maltreatment recidivism, and parents/caregivers being “on the same page” for parenting. PCIT is effective for families with cognitive deficits. Given this, I also began to wonder if PCIT may be beneficial for families coping with Traumatic Brain Injury (TBI). Although I don’t believe PCIT can treat TBI, I do believe that it can help those coping with TBI find success as a parent and in their relationship with their children. Lastly, given that unpredictable loud noises, yelling, screaming, etc may trigger those coping with PTSD (another negative consequence for many having served in the Middle East), I hypothesized that significant behavior problems in young children which include these very behaviors may exacerbate the service member’s PTSD. Again, I don't believe that PCIT can treat PTSD, but it may serve to complement the treatment by reducing disruptions in the home environment. Working with colleagues from Cincinnati Children’s Hospital Medical Center (CCHMC) who share my hypotheses, we began to explore these questions.
MB: We know that parent mental health is the biggest predictor of child mental health, and problems like depression and PTSD are, unfortunately, frequently seen in service members returning from combat deployment. What mental health changes to you expect to see in parents who go through PCIT?
RG: In studies with civilian populations, PCIT has been shown to significantly improve maternal depression. If some of the depression in our military families may be the result of coping with significant child behavior problems, then I believe PCIT may help with this issue. As mentioned above, I am hopeful that PCIT may also complement treatment for PTSD. Finally, early research has found a reduction in child stress reactions after successfully completing PCIT. Perhaps similar findings will be seen with military families who successfully complete this treatment.
MB: What sites are currently trained in PCIT, and what has been the response of providers and patients? Are you looking at any data from military families treated with PCIT?
RG: Through efforts with the National Child Traumatic Stress Network, my colleagues at CCHMC have been working closely with therapists from Tripler Army Medical Center. They have been fantastic and feedback from both the therapists and the families is better than we could have hoped. All are amazed at the transformations that occur. Data is being collected in a pilot study with positive outcomes. Now, in collaboration with the USMC, we have trained many therapists at Marine Corps bases and this project is moving forward into the data collection end. Therapists are pleased.
I think the biggest challenge we are facing is referrals. We know the outcome of families participating in PCIT is positive and long-lasting. For families with a history of physical maltreatment, PCIT is considered by the Kaufman Best Practices Report as one of the three best treatments available. However, those families presenting with problems clearly addressed by PCIT are rarely being referred. Services families receive are often not evidence-based. I admit to my frustration—Therapists are standing by and waiting for referrals. On the plus side, there is a renewed commitment by individuals within the USMC to PCIT delivered to families who may benefit. With their support, I believe changes will happen and families will be served in greater numbers. I am very thankful to the current USMC leadership for this project.
Also, through funding via the National Child Traumatic Stress Network, OUHSC and Duke University Medical Center (my new home) are collaborating to train therapists in PCIT at Portsmouth Naval Base and surrounding bases. I am so excited by the commitment of folks at this base and their recognition that PCIT will complement other evidence-based treatments they currently deliver. I am very much looking forward to this growing partnership.
MB: What differences, if any, have you encountered in doing PCIT with military as opposed to civilian families?
RG: I often chuckle (with some bit of seriousness) that if I could go back, I would focus solely on working with military families. Why? PCIT does require a commitment from parents/caregivers and this includes homework. As one service member explained to his therapist, “I’m in the Army, I take orders well.” In other words, homework is completed! Furthermore, families generally attend scheduled sessions. This is a challenge when working with some civilian populations (not unique to PCIT but a challenge to children’s mental health services in general). However, civilian populations do not get deployed in the middle of treatment or have to miss because of TDY. We have been impressed by some of the problem solving that families and PCIT therapists are employing to combat the obstacles. For example, several families practice skills with deployed service members via skype. Wonderful--particularly as research in PCIT is examining PCIT via telehealth. Also, as therapists are being trained across bases/states, when families PCS, they may not have to interrupt treatment, but can continue with the PCIT therapist at the family’s new duty station. This is my ultimate dream! Another unique challenge is that therapists may also get transferred or reassigned in the middle of seeing families. If there is not another PCIT therapist on base, this leaves families in limbo, usually just when they are seeing changes happening.
MB: What training is needed to do PCIT?
RG: Although training is fun, it is intensive. Following the guidelines to become a PCIT therapist certified by PCIT-International takes a commitment on the part of the therapist who must have a minimum of a Master’s degree in a mental health related field. Training is 40 hours. In addition, therapists are required to participate in regularly scheduled weekly or bi-weekly consultation calls, which generally continue for one year. (However, most PCIT therapists actually find these calls helpful and rewarding, with many requesting to continue long after they have met this training criteria). Therapists must submit videotapes (or have sessions otherwise observed) of 4 specific sessions. Finally, therapists must show competence in skills which we require parents to master as well as skills which demonstrate competence in PCIT delivery; this is assessed through observation and through a “learning experience” of multiple choice items offered through PCIT-International (for more information about these guidelines, please see www.pcit.org).
I sincerely hope that when potential new PCIT therapists learn of the requirements, they are not “scared off.” There is great support for all therapists from every PCIT-International certified trainer. Once a therapist wants to join the PCIT community, we all offer whatever support is needed to help them become a part of this collaborative and supportive community. I, and others, believe in the power of PCIT and believe that the outcomes for families (and for therapists) are worth the efforts.
Dr. Mary Brinkmeyer is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology at Portsmouth NMC and a subject matter expert in chronic pain issues.
Parent-Child Interaction Therapy (PCIT), developed by Dr. Sheila Eyberg, CEO of the newly established PCIT-International, is an evidence-based intervention for preschool children (2-6 years) and their parents/caregivers. Although initially developed in the 1980s for children with externalizing behavior problems, it has since been empirically validated in families with other presenting problems including child maltreatment and children with internalizing disorders such as separation anxiety disorder.
PCIT involves two stages: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). CDI focuses on improving the parent-child relationship through skills designed to increase warmth, enjoyment, attention, frustration tolerance, anger management, and self-esteem. In this phase, parents/caregivers generally also begin to notice improvement in challenging behaviors. In PDI, parents learn to use structured, predictable, and consistent discipline techniques to improve compliance and reduce disruptive behaviors.
Rather than simply instructing parents on parenting techniques and talking about “how they work,” PCIT therapists actually coach parents while they practice the skills with their children using a one-way mirror and a “bug in the ear” device. These skills are also practiced each day (for 5 minutes) as Special Time homework. Families graduate from PCIT within about 12-15 sessions. However, PCIT is not time-limited; it continues until the parents have mastered skills and the children’s behavior is within the normal range on standardized measures. With successful completion of PCIT, not only do children show significant improvement in presenting problems, but marked changes in parenting stress and parent depression have also been shown to occur.
Dr. Robin Gurwitch, a faculty member at Duke University Medical Center (DUMC) and a Certified Master Trainer through PCIT-International, has been leading an initiative to bring PCIT to military families. So far, therapists at Tripler Army Medical Center, Schofield Barracks, Ft. Belvoir, and nine USMC bases have received training in PCIT from Dr. Gurwitch and her colleagues at Cincinnati Children’s Medical Center, University of Oklahoma Health Sciences Center, and DUMC. They are currently working to expand the initiative and to collect data to support the use of PCIT with military families.
Dr. Mary Brinkmeyer, who trained with Dr. Eyberg in graduate school at the University of Florida, interviewed Dr. Gurwitch about PCIT and military families.
Dr. Mary Brinkmeyer: How did you become interested in PCIT? What do you find exciting or compelling about this treatment?
Dr. Robin Gurwitch: I first became interested in PCIT in 1991 when I began working at the University of Oklahoma Health Sciences Center (OUHSC). A colleague asked me to join her in providing this evidence-based treatment to families referred to the outpatient center. I read articles about this treatment and was extremely impressed, but nothing could have prepared me for what I experienced when I actually began working with families using PCIT. The changes, which can happen very very quickly, made significant differences to everyone in the family. I continue to work with wonderful colleagues at OUHSC and the energy to push new directions, come up with fun ways to train, and continued enjoyment with this therapy is contagious all around.
Now, 23 years later, I remain as excited, if not moreso, about PCIT. With research I have conducted with colleagues as well as research of others, I continue to see the amazing benefits to families who participate in PCIT. Today, I often laugh, that PCIT is like a cult. Once you see the transformations in families through this strength-based treatment, it is my goal that new therapists in PCIT will want “an orange robe and a tambourine” too! Almost all DO!
What is exciting and compelling? I like the fact that PCIT is not only evidence-based (with more research behind it than almost any other treatment), but that it involves the parents/caregivers and the child TOGETHER. Through the parent-child relationship, new patterns in family interactions are formed. And, the gains continue, according to research, for up to six years. (It may be longer, but this is the time frame of the on-going study). That to me is mind-blowing. A child seen at 6 who successfully completes this relatively short-term treatment will continue to show the changes at 12. Of course, then the child is heading into adolescence and “all bets are off.”
Another aspect that sets PCIT apart from other parenting programs is the in-vivo component. Parents/caregivers are coached in each session by the therapist in PCIT skills. They are never asked to implement skills, which they have not practiced first. They are given immediate feedback. Finally, as PCIT is a very transparent treatment, the parents/caregivers are told what the goals for each of the two phases of PCIT are and they are given information about how close they are to meeting these goals each session. PCIT is a true partnership between the adults in the child’s life.
MB: Why should military providers become trained in PCIT?
RG: I first became interested in adapting PCIT for use with military families when I began reading the literature on the impact of deployment on military children. More than 2 million children in the United States have experienced parental deployment to Iraq or Afghanistan. The majority of the children are between the ages of 2 and 8 (PCIT targets children ages 2 to 7 years). Research findings related to the children include: increased behavior problems in young children both at home and in preschool; increased risk of child maltreatment; parental perception that the child is cold or afraid of him/her after deployment; and decreased marital satisfaction. For me, this mapped almost directly onto the goals of PCIT for non-military population: improved parent-child relationship, improved behaviors at home (and research finds these improvements generalize to school), decreased risk for physical maltreatment recidivism, and parents/caregivers being “on the same page” for parenting. PCIT is effective for families with cognitive deficits. Given this, I also began to wonder if PCIT may be beneficial for families coping with Traumatic Brain Injury (TBI). Although I don’t believe PCIT can treat TBI, I do believe that it can help those coping with TBI find success as a parent and in their relationship with their children. Lastly, given that unpredictable loud noises, yelling, screaming, etc may trigger those coping with PTSD (another negative consequence for many having served in the Middle East), I hypothesized that significant behavior problems in young children which include these very behaviors may exacerbate the service member’s PTSD. Again, I don't believe that PCIT can treat PTSD, but it may serve to complement the treatment by reducing disruptions in the home environment. Working with colleagues from Cincinnati Children’s Hospital Medical Center (CCHMC) who share my hypotheses, we began to explore these questions.
MB: We know that parent mental health is the biggest predictor of child mental health, and problems like depression and PTSD are, unfortunately, frequently seen in service members returning from combat deployment. What mental health changes to you expect to see in parents who go through PCIT?
RG: In studies with civilian populations, PCIT has been shown to significantly improve maternal depression. If some of the depression in our military families may be the result of coping with significant child behavior problems, then I believe PCIT may help with this issue. As mentioned above, I am hopeful that PCIT may also complement treatment for PTSD. Finally, early research has found a reduction in child stress reactions after successfully completing PCIT. Perhaps similar findings will be seen with military families who successfully complete this treatment.
MB: What sites are currently trained in PCIT, and what has been the response of providers and patients? Are you looking at any data from military families treated with PCIT?
RG: Through efforts with the National Child Traumatic Stress Network, my colleagues at CCHMC have been working closely with therapists from Tripler Army Medical Center. They have been fantastic and feedback from both the therapists and the families is better than we could have hoped. All are amazed at the transformations that occur. Data is being collected in a pilot study with positive outcomes. Now, in collaboration with the USMC, we have trained many therapists at Marine Corps bases and this project is moving forward into the data collection end. Therapists are pleased.
I think the biggest challenge we are facing is referrals. We know the outcome of families participating in PCIT is positive and long-lasting. For families with a history of physical maltreatment, PCIT is considered by the Kaufman Best Practices Report as one of the three best treatments available. However, those families presenting with problems clearly addressed by PCIT are rarely being referred. Services families receive are often not evidence-based. I admit to my frustration—Therapists are standing by and waiting for referrals. On the plus side, there is a renewed commitment by individuals within the USMC to PCIT delivered to families who may benefit. With their support, I believe changes will happen and families will be served in greater numbers. I am very thankful to the current USMC leadership for this project.
Also, through funding via the National Child Traumatic Stress Network, OUHSC and Duke University Medical Center (my new home) are collaborating to train therapists in PCIT at Portsmouth Naval Base and surrounding bases. I am so excited by the commitment of folks at this base and their recognition that PCIT will complement other evidence-based treatments they currently deliver. I am very much looking forward to this growing partnership.
MB: What differences, if any, have you encountered in doing PCIT with military as opposed to civilian families?
RG: I often chuckle (with some bit of seriousness) that if I could go back, I would focus solely on working with military families. Why? PCIT does require a commitment from parents/caregivers and this includes homework. As one service member explained to his therapist, “I’m in the Army, I take orders well.” In other words, homework is completed! Furthermore, families generally attend scheduled sessions. This is a challenge when working with some civilian populations (not unique to PCIT but a challenge to children’s mental health services in general). However, civilian populations do not get deployed in the middle of treatment or have to miss because of TDY. We have been impressed by some of the problem solving that families and PCIT therapists are employing to combat the obstacles. For example, several families practice skills with deployed service members via skype. Wonderful--particularly as research in PCIT is examining PCIT via telehealth. Also, as therapists are being trained across bases/states, when families PCS, they may not have to interrupt treatment, but can continue with the PCIT therapist at the family’s new duty station. This is my ultimate dream! Another unique challenge is that therapists may also get transferred or reassigned in the middle of seeing families. If there is not another PCIT therapist on base, this leaves families in limbo, usually just when they are seeing changes happening.
MB: What training is needed to do PCIT?
RG: Although training is fun, it is intensive. Following the guidelines to become a PCIT therapist certified by PCIT-International takes a commitment on the part of the therapist who must have a minimum of a Master’s degree in a mental health related field. Training is 40 hours. In addition, therapists are required to participate in regularly scheduled weekly or bi-weekly consultation calls, which generally continue for one year. (However, most PCIT therapists actually find these calls helpful and rewarding, with many requesting to continue long after they have met this training criteria). Therapists must submit videotapes (or have sessions otherwise observed) of 4 specific sessions. Finally, therapists must show competence in skills which we require parents to master as well as skills which demonstrate competence in PCIT delivery; this is assessed through observation and through a “learning experience” of multiple choice items offered through PCIT-International (for more information about these guidelines, please see www.pcit.org).
I sincerely hope that when potential new PCIT therapists learn of the requirements, they are not “scared off.” There is great support for all therapists from every PCIT-International certified trainer. Once a therapist wants to join the PCIT community, we all offer whatever support is needed to help them become a part of this collaborative and supportive community. I, and others, believe in the power of PCIT and believe that the outcomes for families (and for therapists) are worth the efforts.
Dr. Mary Brinkmeyer is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology at Portsmouth NMC and a subject matter expert in chronic pain issues.