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CHILDREN'S ISSUES, LAWS AND PROGRAMS

CHILD ABUSE AND NEGLECT


PERCEPTIONS,
PSYCHOLOGICAL CONSEQUENCES
AND COPING STRATEGIES

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CHILDREN'S ISSUES,
LAWS AND PROGRAMS

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CHILDREN'S ISSUES, LAWS AND PROGRAMS

CHILD ABUSE AND NEGLECT


PERCEPTIONS,
PSYCHOLOGICAL CONSEQUENCES
AND COPING STRATEGIES

MICHELLE MARTINEZ
EDITOR

New York
Copyright 2016 by Nova Science Publishers, Inc.

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CONTENTS

Preface vii
Chapter 1 The Role of Ethnicity in Child Custodial Decisions 1
Emily R. Denne, Taylor E. Wornica
and Margaret C. Stevenson
Chapter 2 Building Relational Safety and Trust in Couple
Therapy with Adult Survivors of Childhood Abuse 19
Melissa A. Wells, Elsie Lobo, Aimee Galick,
Carmen Knudson-Martin, Douglas Huenergardt
and Hans Schaepper
Chapter 3 Parent-Child Interaction Therapy for the Treatment
and Prevention of Child Abuse and Neglect 65
Amanda H. Costello, Ria M. Travers,
Lauren B. Quetsch, Cree Robinson,
Nancy Wallace and Cheryl B. McNeil
Index 99
PREFACE

Child abuse and neglect (CAN) continues to be a serious public health


problem in the United States, affecting approximately 19% of victims and
costing approximately $124 billion to society. When a child is removed from
their parents custody due to parental abuse or neglect, the child is sometimes
placed in temporary custody through dependency court. Difficult and
emotionally laden legal decisions occur within dependency court, including
determining whether (and where) a child should be temporarily placed or
whether a child should be returned to the parents custody. Over 6 million
children experienced some type of child maltreatment in 2013, with 144,000
receiving foster care services (Child Maltreatment, 2013). Legal decision-
makers, including judges, case workers, and social workers have the important
task of determining what placement is in the best interest of the child. What
factors shape decisions in child custodial cases? Chapter One of this book
reviews empirical evidence suggesting that the race of the child and parent
plays a role in shaping child custodial decisions. Chapter Two presents a
feminist, social constructionist theoretical conceptualization, entitled relational
trust theory, that describes the effects of gendered power dynamics on the
perception of the other partner as trustworthy in adult-survivor couple
interactions; and expounds on the findings of a longitudinal grounded theory
study that identified clinical processes of Socio-Emotional Relationship
Therapy (SERT) that helped adult-survivor couples transform their gendered
power disparities and engage in relationally safe ways that supported a trusting
emotional culture. Chapter Three provides a description of Parent-Child
Interaction Therapy (PCIT), a rationale for its use with parents and children
who have experienced CAN, and an overview of PCITs evidence base for
both intervening with and preventing future CAN.
viii Michelle Martinez

Chapter 1 When a child is removed from their parents custody due to


parental abuse or neglect, the child is sometimes placed in temporary custody
through dependency court. Difficult and emotionally laden legal decisions
occur within dependency court, including determining whether (and where) a
child should be temporarily placed or whether a child should be returned to the
parents custody. Over 6 million children experienced some type of child
maltreatment in 2013, with 144,000 receiving foster care services (Child
Maltreatment, 2013). Legal decision-makers, including judges, case workers,
and social workers have the important task of determining what placement is
in the best interest of the child. What factors shape decisions in child custodial
cases? In the present chapter, we review empirical evidence suggesting that the
race of the child and parent plays a role in shaping child custodial decisions.
Indeed, African American children spend more time in the foster care system
and wait longer to be reunited with their families than White children (Elliot &
Urquiza, 2006). The current chapter will review research regarding how race is
related to decisions made involving children in dependency court contexts.
Specifically, the authors review how race shapes the likelihood of child
maltreatment allegations, the likelihood of a child being removed from a
home, and the likelihood of family reunification. They draw upon social
psychological theory with respect to stereotyping, racism, and prejudice that
help account for various effects of race in dependency court contexts.
Chapter 2 Approximately one-third of partners in couple therapy have
experienced childhood abuse, and a common impact on adult survivors is the
struggle to trust their intimate partner. Furthermore, asymmetrical gendered
power processes in current couple interactions often erode trust. Given the
likelihood that adult-survivor couples may experience a distrusting emotional
culture, this chapter presents a feminist, social constructionist theoretical
conceptualization, entitled relational trust theory that describes the effects of
gendered power dynamics on the perception of the other partner as trustworthy
in adult-survivor couple interactions. The chapter also expounds on the
findings of a longitudinal grounded theory study that identified clinical
processes of Socio-Emotional Relationship Therapy (SERT) that helped adult-
survivor couples transform their gendered power disparities and engage in
relationally safe ways that supported a trusting emotional culture.
The grounded theory analysis involved study of video and transcripts of
40 SERT sessions with four heterosexual adult-survivor couples. The findings
from the research were applied to an additional four couples to refine the final
grounded theory on how to work with the intersection of trust, gender, and
power issues of adult-survivor couples. Three key themes on gendered power
Preface ix

processes emerged: 1) gendered fear of being vulnerable, 2) unique gendered


power approaches, and 3) distrustful reactions. The analysis identified five key
clinical processes used to enhance trust: 1) recognize gendered powers effects
on relational safety, 2) comprehend the socio-emotional experience of
partners, 3) accentuate relational needs, 4) initiate partners sharing power, and
5) identify trustworthiness of partners. The study also delineated components
of shared vulnerability that augment trust. This clinical process research
demonstrates the link of trust with gender and power dynamics in adult-
survivor intimate relationships and how to sensitively address in couple
therapy the partner processes that interfere with trust.
Chapter 3 Child abuse and neglect (CAN) continues to be a serious
public health problem in the United States, affecting approximately 19% of
victims and costing approximately $124 billion to society. If left untreated,
children who experience CAN are at risk for developing multiple difficulties
across biological, emotional, psychological, and relational domains. Without
effective intervention, families may also remain at risk for future CAN.
Several evidence-based interventions have demonstrated success in treating
parents and children who have experienced CAN. One such intervention is
Parent-Child Interaction Therapy. This chapter provides a description of PCIT,
a rationale for its use with parents and children who have experienced CAN,
and an overview of PCITs evidence base for both intervening with and
preventing future CAN.
In: Child Abuse and Neglect ISBN: 978-1-63484-785-8
Editor: Michelle Martinez 2016 Nova Science Publishers, Inc.

Chapter 1

THE ROLE OF ETHNICITY IN CHILD


CUSTODIAL DECISIONS

Emily R. Denne, Taylor E. Wornica


and Margaret C. Stevenson, PhD
University of Evansville, Evansville, IN, US

ABSTRACT
When a child is removed from their parents custody due to parental
abuse or neglect, the child is sometimes placed in temporary custody
through dependency court. Difficult and emotionally laden legal
decisions occur within dependency court, including determining whether
(and where) a child should be temporarily placed or whether a child
should be returned to the parents custody. Over 6 million children
experienced some type of child maltreatment in 2013, with 144,000
receiving foster care services (Child Maltreatment, 2013). Legal decision-
makers, including judges, case workers, and social workers have the
important task of determining what placement is in the best interest of the
child. What factors shape decisions in child custodial cases? In the
present chapter, we review empirical evidence suggesting that the race of
the child and parent plays a role in shaping child custodial decisions.
Indeed, African American children spend more time in the foster care
system and wait longer to be reunited with their families than White
children (Elliot & Urquiza, 2006). The current chapter will review
research regarding how race is related to decisions made involving
children in dependency court contexts. Specifically, we will review how
2 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

race shapes the likelihood of child maltreatment allegations, the


likelihood of a child being removed from a home, and the likelihood of
family reunification. We draw upon social psychological theory with
respect to stereotyping, racism, and prejudice that help account for
various effects of race in dependency court contexts.

When a child is removed from their parents custody due to parental abuse
or neglect, the child is placed in temporary custody through dependency court.
Difficult and emotionally laden legal decisions occur within dependency court,
including determining whether or not a child should be temporarily placed in a
foster care home versus returned to the parents custody. Over 6 million
children experienced some type of child maltreatment in 2013, with 144,000
receiving foster care services (Child Maltreatment, 2013). Legal decision-
makers, including judges, case workers, and social workers, have the
important task of determining what placement is in the best interest of the
child. Unfortunately, the task of determining a childs placement is often
complex, due to the fact that a very small amount of these cases are
straightforward, and many accompany allegations of abuse and neglect that
lack physical evidence. Decisions made by dependency court judges have
serious consequences for the health and well-being of the children involved. It
is imperative and a legal requirement that these rulings be unbiased and
uninfluenced by prejudice and prejudicial emotion. Yet, social science
research has documented myriad ways in which legal decisions are influenced
by extra-legal biases stemming from prejudice and prejudicial emotion (for a
review, Sweeney & Haney, 1992). Surprisingly, little research has explored the
extent to which prejudice affects legal decisions in dependency court contexts
contexts in which emotions often run high. What factors shape decisions in
child custodial cases?
In the present chapter, we review empirical evidence exploring the
possibility that the race of the child and parent play a role in shaping child
custodial decisions. Unfortunately, research consistently reveals that African
Americans are overrepresented in the child welfare system (Hill, 2006).
Moreover, African American children spend more time in the foster care
system and wait longer to be reunited with their families than White children
(Elliot & Urquiza, 2006). On the one hand, racial differences in dependency
court experiences might, in part, be a by-product of elevated poverty rates of
African Americans, stemming from historical and institutionalized racism. On
the other hand, interpersonal discrimination within legal proceedings might
also play a role. To what extent do racial biases of legal decision-makers
(judges, social workers) contribute to the disproportionately greater number of
The Role of Ethnicity in Child Custodial Decisions 3

African American children involved in the child welfare system or help


explain why they spend more time in foster care? The current chapter will
review research regarding how race is related to decisions made involving
children in dependency court contexts. Specifically, we will review how race
shapes the likelihood of child maltreatment allegations, the likelihood of a
child being removed from a home, and the likelihood of family reunification.
We draw upon social psychological theory with respect to stereotyping,
racism, and prejudice as a theoretical framework for understanding the various
effects of race in dependency court contexts.

RACE AND THE CHILD WELFARE SYSTEM:


A HISTORICAL PERSPECTIVE
In the early 1800s African American children were excluded from the
orphanage system and were placed in care under separate institutions such as
the Association for the Care of Colored Children (Hogan & Siu, 1988). After
the Civil War, the foster care system was developed; however, anti-black
sentiment was still very pervasive and African American children were
excluded from the foster care system that emerged (Hogan & Siu, 1988). In
response, African Americans created their own institutions to provide child
welfare services. Following WWII, African Americans gradually gained
access to the child welfare service that had been available to White children
for decades. This was spurred particularly by the relocation of many African
American families to the north as well as a nationwide focus on racial
integration (Hogan & Siu, 1988). Despite African Americans inclusion in the
child welfare system, their experiences and outcomes differentiated greatly
from those of White children (Hogan & Siu, 1988). The more costly services
were dominated by White children, while African American children were
placed in cost-effective foster homes (Magura, 1979; Shyne & Schroeder,
1978).

RACE AND THE CHILD WELFARE SYSTEM:


MODERN PERSPECTIVES
While African American children make up only 13.9% of children in the
United States, they comprise 24% of children in the foster care system
4 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

(Childrens Defense Fund, 2014; AFCARS, 2014). It is important then to


explore the possible causes of the overrepresentation of African American
children in foster care. We turn to modern theories of racism to help explain
such racial inequalities.
While the overt and blatant racism of the early 1900s is less common
today, alternative and more subtle forms of racism are still pervasive. Indeed,
racism still exists in meaningful and measurable ways both at an institutional
and individual level. This form of prejudice is not limited to the unconcealed
and deliberate harming of African Americans that was much more common
before the Civil Rights Movement. Instead, racism encompasses the social
power conferred to Whites at an institutional level that causes economic,
political, and societal disparities among races (Henkel, Dovidio, & Gaertner,
2006). Indeed, racism in this form is often unintentional; however it is no less
detrimental. Although changes in law and policy spanning the past decade
have attempted to bridge racial disparities in health, mortality rates, education
and income, there are still numerous observable disparities. For instance,
African American and White patients experience different levels of care from
doctors (Henkel, Dovidio, & Gaertner, 2006). Yet, does racial discrimination
extend to children? There is some evidence that it does. Specifically, African
American children are perceived as less innocent then White children, and in
turn, African American children are recipients of higher rates of police
violence, compared to White children (Goff, Jackson, Di Leone, Culotta, &
DiTomasso, 2014). Thus, although racism today is generally explicitly
rejected, the historical discrimination of African Americans over centuries can
have far reaching implications that withstand changing public opinion
(Henkel, Dovidio, & Gaertner, 2006). Moreover, modern and more subtle yet
damaging forms of covert discrimination are responsible for the racism and
unequal care given to minorities in the present day (Hogan & Siu, 1988). We
turn next to the theory of Aversive Racism to better understand the contexts in
which racism will manifest.
According to the theory of Aversive Racism, most people are motivated to
be non-racially prejudiced, yet still harbor lingering negative racial biases
(Pearson, Dovidio, & Gaertner, 2009). When there are clear social norms and
when discriminatory behavior will be obvious, racism is unlikely to occur
(Whitley, & Kite, 2010). Yet, in ambiguous situations, when racial bias can be
expressed subtly and justified in non-racial terms, negative racial biases are
more likely to manifest (Whitley, & Kite, 2010). For instance, Sommers and
Ellsworth (2000) experimentally manipulated the race of a man (African
American vs. White) accused of physically assaulting his girlfriend and the
The Role of Ethnicity in Child Custodial Decisions 5

salience of the issue of race in the context of the study. Specifically, in the
non-race salient condition, the defendant was alleged to have said to his
girlfriend You know better than to talk that way about a man in front of his
friends and in the race-salient condition, the defendant said You know better
than to talk that way about a Black/White man in front of his friends. In the
non-race salient condition, participants convicted the African American
defendant significantly more frequently than the White defendant. Yet, in the
race salient condition, defendant race did not influence conviction rates,
presumably because participants were reminded about the issue of race, and in
turn, became motivated to avoid lingering racial biases. The theory of
Aversive Racism can then be applied to child welfare cases where evidence is
ambiguous and where a lack of standardized criteria for making unbiased
decisions welcomes discrimination and racism. Next, we review areas within
the legal system, specifically the child welfare system, where African
Americans are discriminated against. We use aversive racism to understand
these racial disparities.

UNDERSTANDING MINORITY OVERREPRESENTATION IN


THE CHILD WELFARE SYSTEM

Due to modern forms of racism, it is not surprising that race affects


outcomes of legal cases (e.g., Sommers & Ellsworth, 2001). For instance, in a
child custody dispute context, race, though never the sole factor in determining
custody, does influence judges judicial rulings (Myricks & Ferullo, 1986).
Specifically, a review of numerous custodial disputes involving biracial
marriages revealed that when both adults were equally fit parents, race played
a large role in the final custodial decision: The parent whose race most closely
resembled the race of the child was awarded custody more frequently than the
parent who was of a different race than the child (Myricks & Ferullo, 1986).
Furthermore, racial disparities exist in how frequently children are removed
from their homes. The decision to remove a child from their parents care is
certainly a complicated one, influenced by numerous factors other than those
specifically related to the parent-child relationship. Indeed characteristics as
benign as the amount of graffiti and litter in a neighborhood can influence
whether or not a social worker decides to remove the child (Rolock, Jantz, &
Abner, 2015). Such research has serious implications for poor families who
have a higher likelihood of living in impoverished areas with more graffiti and
6 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

litter. Indeed, one study found that when dealing with subjective risk
assessment in a child custodial context, social workers relied heavily on their
personal biases against lower socioeconomic status families and families of a
less prestigious ethnic origin (Enosh & Bayer-Topilsky, 2015). Specifically,
social workers were 2.5 times more likely to remove a child from a lower SES
family as compared to a child from a moderate to high SES family when the
childs familial risk level was comparably ambiguous (Enosh & Bayer-
Topilsky, 2015). Furthermore, it is well documented that African Americans
are more likely to live in poverty than Caucasians (Macartney, Bishaw, &
Fontenot, 2013). Thus it is not surprising that social workers were 2 times
more likely to remove a child from a minority ethnicity as compared to a
dominant ethnic group (Enosh & Bayer-Topilsky, 2015).
While aversive racism often operates on an individual level, institutional
discrimination operates at an organizational level. Institutional discrimination
consists of the laws and policies that contribute to segregation and
discrimination (Henkel, Dovidio, & Gaertner, 2006). Indeed, institutional
discrimination is still a serious problem in our legal system. For example,
states are more likely to have harsher rules and laws for welfare recipients in
states with a high proportion of minorities on welfare (Lin & Harris, 2009).
This results in African Americans experiencing the fewest welfare benefits
while still being a highly represented group in the welfare system (Lin &
Harris, 2009). Indeed similar trends are pervasive in the child welfare system.
Not only are African American children overrepresented, they have a different
experience within the system than do White children. Being a minority poses a
substantial risk when in the child welfare system, as minority families have
less access to the support services that are crucial in reunification (Hogan &
Siu, 1988). For example, a study conducted by Garland and Besinger (1997),
examined the court records of 142 children in foster care and found
documented ethnic differences in referral rates of children in foster care to
mental health services. Caucasian children were more likely to be referred to
psychotherapy than were either Latino or African American children- an effect
that held even when controlling for age and type of maltreatment.
There are a substantially higher number of minority children in foster care
than there are White children (Jenkins et al., 1983). Not only are African
American children more likely to enter the system, they are treated differently
within the system. Once in the child welfare system, African American
children are more likely to be placed in out of home care and remain in this
care for longer than White children (Child Welfare Information Gateway,
2011). Jenkins et al. (1983) conducted a review of the results of a nation-wide
The Role of Ethnicity in Child Custodial Decisions 7

survey including over 2,400 social service agencies. Data analysis revealed
that a significantly higher proportion of African American children were
placed in foster homes and group homes as compared to residential treatment
centers and secure facilities. Additional analysis revealed that African
American children remained in care, on average, a year longer than White
children. In a separate study examining data from the Chicago Community
Adult Health Study 20012003 (CCAHS) and administrative data from the
Illinois Department of Children and Family Services (IDCFS), result revealed
that African American children were more likely to be placed in foster care
than were White children. This specific study examined neighborhood
impoverishment, as indicated by the presence of markers like litter and graffiti,
as a predictor of out of home placement. Regardless of low or high levels of
impoverishment, African American two-year-old boys were significantly more
likely to be removed from their homes than either White or Hispanic children.
In contrast, Hispanic children were less likely than Whites to be placed in
foster care system (Rolock, Jantz, & Abner, 2015).
It is clear that there are racial disparities within child dependency system.
Yet, a child often becomes involved in dependency court after allegations of
abuse or neglect. Next, we review the role of race in child maltreatment
allegations.

RACE AND CHILD MALTREATMENT ALLEGATIONS


A child first becomes involved in the child welfare system upon a report
of maltreatment (Rolock, Jantz, & Abner, 2015). Not only are African
American children overrepresented in the child welfare system, they are
repeatedly overrepresented in child abuse and neglect reports (Hogan & Siu,
1988). Yet, it is unclear whether African American children experience more
extreme forms of abuse and neglect or whether African American families are
stereotyped as abusive and neglectful, which in turn, affects child
maltreatment report frequency. Indeed, researchers have called for future
research to explore this possibility (Elliot & Urquiza, 2006).
Specifically in neglect allegations, African American families are
subjected to increased likelihood of reporting (Hogan & Siu, 1988). Neglect
allegations can be convoluted with ambiguity and uncertainty, often lacking
substantiating evidence (Rolock, Jantz, & Abner, 2015). In legal cases, as
evidence becomes less clear, individuals are more likely to rely on their own
heuristics and schemas - a clear path for bias and prejudice (e.g., Levinson &
8 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

Young, 2010). Therefore, it is possible that the negative stereotypes


surrounding African American families may contribute to the high rates of
reported abuse incidents. For instance, Devine (1989) assessed White college
students knowledge of various stereotypes regarding African Americans. The
most common theme reported by participants regarding stereotype knowledge
was that Blacks are aggressive, criminal-like, and hostile (Devine, 1989). The
belief that African Americans are more aggressive can explain the higher rates
of reported abuse incidents. That is, participants might be more likely to
interpret ambiguously abusive behavior toward children as abusive if a parent
is stereotypically considered to be aggressive (as African Americans are) (e.g.,
Devine, 1989). Further, participants also commonly reported the stereotype
that African Americans are poor, and previous research has shown that social
workers biases against lower socio-economic status families have influenced
their decisions when determining whether the child should be removed from
the home (Devine, 1989; Enosh & Bayer-Topilsky, 2015).
African American children experience reportedly higher rates of physical
abuse than do White children (DHHS, 2005). However, research has also
revealed that people are also more likely to report physical abuse if the victim
is of color than if the victim is White (Hampton & Newberger, 2005).
Specifically, Hapmton and Newberger examined data from the National Study
of the Incidence and Severity of Child Abuse and Neglect to examine hospital
personnel reports of suspected child abuse. Result revealed that emergency
room, pediatric departments, and social service staff were significantly more
likely to report black children for suspected abuse when compared to white
children. Indeed, it is still unclear whether the higher rates of reported abuse
targeting African American parents stems from negative anti-African
American stereotypes or said parents actually being more abusive. That is, it is
possible that African American parents are stereotyped as more abusive, and in
turn, cause people to report them more frequently for child maltreatment as
compared to equally abusive White parents. Similarly, it is possible that case
workers may be more likely to perceive a situation as abuse if the victim is an
ethnic minority (Barth, 2005). Moreover, case workers might also administer
more punitive or drastic actions for families of color, such as removing the
child from the parents home (Barth, 2005). Of course, allegations of abuse are
simply the first step in dependency court. The abuse allegation must then be
substantiated. Thus, we turn to the role of race in abuse substantiations next.
The Role of Ethnicity in Child Custodial Decisions 9

RACE AND ABUSE SUBSTANTIATION


Research reveals that abuse claims made against African American
children are substantiated disproportionally more often than those made
against other races (Dettlaff et al., 2011). The Racial Disproportionality
Movement in Child Welfare: False Facts and Dangerous Directions suggested
that the racial differences found in the foster care system happen because
African American children are more likely to be victims of abuse (Dettlaff et
al., 2011; Korbin & Krugman, 2013). Subsequent data from the National
Incidence Studies of Child Abuse and Neglect 4 (2004-2009) has supported
this claim (Sedlak et al., 2010). Yet, it is possible that negative stereotypes
about African Americans being violent and aggressive might cause people to
be more likely to believe claims of abuse from African American parents than
White parents. In support, Ards et al., (2003) examined data from Minnesota
in 2000, which revealed that even when controlling for various factors
including type of maltreatment, and characteristics of the child and parents,
abuse by African American parents was more likely to be substantiated than
that of Whites. This appears to be some evidence that racial biases might play
a role in abuse substantiation outcomes.
Yet, not all studies have found race to predict the substantiation of abuse
(Dettalff et al., 2011). Specifically, Dettalff and colleagues examined data
from the Texas child welfare system to examine the ethnic discrepancies in
abuse substantiation. When authors controlled for family income in the
substantiation of physical abuse, sexual abuse, neglect, abandonment, and a
combination of abuse types, race did not emerge as a predictor of
substantiation. However, family income was a strong predictor of
substantiation, with low income cases having increased likelihood of
substantiation (Dettlaff et al., 2011). This effect was not only significant but
also large in size, with the lowest income groups (less than $10,150 in annual
salary) being over 95% more likely to have an abuse report substantiated when
compared to the highest income group (over $40,550 in annual salary)
(Dettlaff et al., 2011). This research suggests that elevated poverty rates
experienced by African Americans might ultimately drive their higher rates of
substantiated abuse.
10 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

RACE AND REUNIFICATION


After a child is removed from their parents care, child welfare agencies
work to determine the safest placement for the child. One such option is to
provide services that address parent and child problems, ultimately facilitating
familial reunification. Both family and child characteristics contribute to a
childs chances of family reunification (Hines, Lee, & Osterling, & Drabble,
2007). Children with disabilities, minority children, and older children are less
likely to be reunited with parents than are healthy children, White children,
and infants, respectively (Wells & Guo, 1999, Hines, Lee, & Osterling, 2007).
Family-related characteristics, including socioeconomic status, further predict
reunification, such that lower-income families are less likely to be reunified
with their child than higher-income families (Courtney, 1994, Hines, Lee, &
Osterling, 2007). Family structure is an additional factor that predicts
reunification: Two-parent families are reunified more frequently and faster
than single-parent families (Wells & Guo, 1999; Hines, Lee, & Osterling,
2007). This seems to be particularly true for single African American parents,
regardless of gender, in comparison to single White parents (Harris &
Courtney, 2003; Hines, Lee, & Osterling, 2007). However, research is mixed
in determining whether race contributes to a childs chances of reunification.
Some studies have found ethnicity to be a significant predictor of
reunification, with White children being reunited more frequently than African
American children (Courtney, 1994). Indeed, further studies have found that
once involved in the child welfare system, African American children spend
more time in foster care and wait longer to be reunited with their families (for
a review, see Elliot & Urquiza, 2006). However, Hines, Lee, Osterling, and
Drabble (2007), reviewed 403 child welfare case records contained in the
Child Welfare System, finding no specific racial trend in a childs chances of
reunification, when controlling for other related factors (e.g., maternal
substance abuse, childs age, and family structure). Overall trends revealed
that maternal substance abuse was related to decreased likelihood of
reunification. Additionally, the younger the child was, the more likely the
child was to be reunited with their parents (Hines, Lee, Osterling & Drabble,
2007).
The Role of Ethnicity in Child Custodial Decisions 11

RACE AND ADOPTION


If the child is not reunited with the parent, the child is placed in foster care
while they await possible adoption. Several studies have indicated that African
American children are not as likely to be adopted as compared to White or
Latino children (Barth, 1997; Smith, 2003; Snowden, Leon, & Sieracki, 2008;
Akin, 2011). For instance, a study conducted by Akin (2011) found that
African American children were 38% less likely to be adopted, as compared to
White children. Race was even shown to be a stronger predictor than the
childs age when examining reunification and adoption rates, which has
notably been associated with a childs likelihood of adoption (Barth, 1997).
Anti-Black stereotypes and aversive racism might form the basis for the
discrimination that African-American children encounter and might help
explain their diminished likelihood of being adopted. For example, African
American children might be perceived as less innocent when compared to
White children (Goff et al., 2014), in turn, negatively affecting their chances of
adoption. Also, case workers might more vigilantly manage families of color
in the child welfare system by, for instance, making more unannounced visits
to the parents home, in turn, making it more difficult for reunification to
occur (Barth, 2005). Indeed, studies have shown that African American
children are the least likely to be reunified as compared to White and Latino
children, especially in single parent homes (Harris & Courtney, 2003). These
forms of discrimination that African Americans face ultimately might also
help explain why children of color are in the foster care system longer. While
studies have shown that remaining in foster care longer actually increases the
likelihood of adoption, conversely, as a childs age increases, the likelihood of
adoption decreases (Leathers et al., 2012; Akin, 2011).

ALTERNATIVE EXPLANATIONS FOR THE EFFECTS


OF RACE IN THE CHILD WELFARE SYSTEM

As previous research has demonstrated, the knowledge that African


Americans are aggressive, criminal-like, and hostile might lead to beliefs that
African American parents, especially those on welfare, are dysfunctional,
resulting in a greater likelihood for abuse to be reported and investigated, the
child to be removed from the home, and diminishing chances of family
reunification (Devine, 1989). Further, African Americans are also stereotyped
12 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

as poor and lazy (Devine, 1989) -- beliefs that might also negatively influence
the likelihood of reunification.
Whereas negative stereotypes and modern forms of racism represent one
explanation for the overrepresentation of African Americans in the child
welfare system, we should also consider the role of poverty, particularly
because African Americans are at heightened risk of living in conditions of
poverty. Poverty has far-reaching implications for a childs education, health,
and living conditions, all of which are considered when determining the proper
placement of a child involved in dependency court (Lin & Harris, 2009).
Unfortunately, African American children are twice as likely to live in poverty
as White children (Lin & Harris, 2009). Poverty is a predictor of numerous
negative outcomes, including a child being removed from their home as well
as serving as a risk factor for child maltreatment itself (Hill, 2006; Lin &
Harris, 2009; Freisthler, Bruce, & Needell, 2007). Cumulative deprivation that
African Americans have experienced as a result of a history of racism
contributes to African Americans susceptibility to poverty and welfare
experiences. This is supported in the Fourth National Incidence Study of Child
Abuse and Neglect (NIS-4) which finds children from low-income families to
be victims of abuse at significantly higher rates that those of higher-income
families (Sedlak et al., 2010). It is possible then that the higher poverty rates
for African Americans, especially African American children, can in part
explain their overrepresentation in the child welfare system. In support, one
study using child welfare data from Missouri found no racial disparities in
child maltreatment reporting, after controlling for poverty (Drake, Lee, &
Jonson-Reid, 2009). On the other hand, poverty does not appear to fully
explain all racial discrepancies in dependency court. Consider, for instance,
that various studies have shown that minority children are still less likely to be
reunited with their biological parents than non-minority children, even after
controlling for various factors, including parental substance abuse, child age,
parental employment, etc. (Hill, 2006). In support, a review of over 137,000
children who had at least one substantiated maltreatment referral revealed that
when controlling for age, maltreatment, and poverty, African American
children were still more likely to be placed in foster care than White children
(Needell, Brookhart, & Lee, 2003). Thus, there is indeed evidence that
ethnicity appears to be a contributing factor to discrepant treatment within
dependency court, independent of other confounding factors (e.g., poverty).
Even so, more research is needed to help parse apart the confounding
influence of both race and poverty on outcomes in child dependency court.
The Role of Ethnicity in Child Custodial Decisions 13

CALL TO ARMS FOR FUTURE RESEARCH


In the present chapter we have reviewed much of the descriptive research
exploring the effects of race in child welfare system. It is important to continue
to conduct this type of correlational and archival research to develop a more
thorough understanding of the real-life racial discrepancies in dependency
court. However, it is important that this research be conducted in a careful and
considered way, attending to, measuring, and controlling for various potential
confounds. Importantly, there is a need for experimental, highly controlled lab
research to get at the root of causality. It is only with true experimental
research that we can fully understand the effects of child race on dependency
court outcomes, by eliminating various inevitable, natural confounds (e.g.,
poverty and abuse frequency/severity). Moreover, it is important that future
experimental research be conducted in methodologically appropriate ways,
ensuring that race is not made experimentally salient so that participants do not
become suspicious of the purpose of the research, which in turn, will
undermine race effects. In line with aversive racism theory and research
(Pearson, Dovidio, & Gaertner, 2009), making race salient (by calling
participants attention to the issue of race) increases participants motivation to
avoid racial biases. In support, previous research attempting to manipulate
juvenile defendant race (African American or White) using photos revealed no
effects of race on conviction rates (Reppuci, Scott, Tweed, & Antonishak,
2004), but other research manipulating juvenile defendant race, using more
subtle written embedded descriptors, revealed the hypothesized effects of anti-
African American biases on conviction rates (Stevenson & Bottoms, 2009). It
is imperative that we conduct this kind of experimental research to bolster the
correlational research that already exists. Only when we rely on multiple
methodological approaches will we truly be able to understand both the causal
influence of race in custodial decisions and the actual effects of race in the real
world. Future research should also explore other potential extra-legal biases
that play a role in child dependency court context, including, for instance,
parental gender, parental sexual orientation, and parental mental illness. Only
when researchers understand the prejudicial biases influence dependency court
decisions can interventions to undermine these biases be developed, resulting
in more fair and just decisions not only for the child, but also for families.
14 Emily R. Denne, Taylor E. Wornica and Margaret C. Stevenson

CONCLUSION
Myriad studies reveal that African Americans and Caucasians are not
treated equivalently in legal settings, and that this might be driven by aversive
racism and anti-Black stereotypes (e.g., Lane, 2009; Sommers & Ellsworth,
2003). Indeed, African American families are stereotyped as being
dysfunctional and violent (Lane, 2009). In turn, Whites tend to make more
pro-prosecution judgments (i.e., vote guilty) when the defendant is African
American than White and when the victim is White than African American
(Sommers & Ellsworth, 2003). Racial biases are particularly likely to manifest
when the issue of race is not made salient, as explained by aversive racism
(Sommers & Ellsworth, 2003). It is possible that stereotypes and racial biases
might help explain why African American children experience more abuse
allegations and are less likely to be reunited with their parents than their White
counterparts. The historic discrimination of African Americans has led to anti-
African American sentiment which persists despite changing law, policy, and
societal condemnation. Importantly, historical racial discrimination has led to
racially disparate treatment in the child welfare system, such that African
American children are more likely to enter the system (Childrens Defense
Fund, 2014; AFCARS, 2014), spend longer in the child welfare system (Elliot
& Urquiza, 2006), and are less likely to be reunified with their families as
compared to White children (Courtney, 1994). Child custody rulings, like
other legal decisions, are vulnerable to the influence of personal prejudices,
perhaps particularly because they are often subjective and involve substantial
judicial discretion. It is particularly important that we eradicate prejudice and
its effects in the child welfare system to facilitate rulings that are unbiased and
in the best interest of the child.

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Editor: Michelle Martinez 2016 Nova Science Publishers, Inc.

Chapter 2

BUILDING RELATIONAL SAFETY AND


TRUST IN COUPLE THERAPY WITH ADULT
SURVIVORS OF CHILDHOOD ABUSE

Melissa A. Wells1 , Elsie Lobo1, Aimee Galick3,


*

Carmen Knudson-Martin2, Douglas Huenergardt1


and Hans Schaepper1
1
Loma Linda University, Loma Linda, California, US
2
Lewis and Clark College, Portland, Oregon, US
3
University of Louisiana Monroe, Monroe, Louisiana, US

ABSTRACT
Approximately one-third of partners in couple therapy have
experienced childhood abuse, and a common impact on adult survivors is
the struggle to trust their intimate partner. Furthermore, asymmetrical
gendered power processes in current couple interactions often erode trust.
Given the likelihood that adult-survivor couples may experience a
distrusting emotional culture, this chapter presents a feminist, social
constructionist theoretical conceptualization, entitled relational trust
theory, that describes the effects of gendered power dynamics on the
perception of the other partner as trustworthy in adult-survivor couple
interactions. The chapter also expounds on the findings of a longitudinal

*
Corresponding author: Email: purrzha@gmail.com (Melissa A. Wells).
20 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

grounded theory study that identified clinical processes of Socio-


Emotional Relationship Therapy (SERT) that helped adult-survivor
couples transform their gendered power disparities and engage in
relationally safe ways that supported a trusting emotional culture.
The grounded theory analysis involved study of video and transcripts
of 40 SERT sessions with four heterosexual adult-survivor couples. The
findings from the research were applied to an additional four couples to
refine the final grounded theory on how to work with the intersection of
trust, gender, and power issues of adult-survivor couples. Three key
themes on gendered power processes emerged: 1) gendered fear of being
vulnerable, 2) unique gendered power approaches, and 3) distrustful
reactions. The analysis identified five key clinical processes used to
enhance trust: 1) recognize gendered powers effects on relational safety,
2) comprehend the socio-emotional experience of partners, 3) accentuate
relational needs, 4) initiate partners sharing power, and 5) identify
trustworthiness of partners. The study also delineated components of
shared vulnerability that augment trust. This clinical process research
demonstrates the link of trust with gender and power dynamics in adult-
survivor intimate relationships and how to sensitively address in couple
therapy the partner processes that interfere with trust.

Keywords: trust, gender, power, relational safety, childhood abuse, couple


therapy

INTRODUCTION
Trust is a crucial aspect of emotional connection (Gottman, 2011;
Hargrave & Pfitzer, 2011), and is considered the most important resource for
functioning between intimate partners (Hargrave & Pfitzer, 2003). Yet, two
confounding influences that restrict a trusting emotional culture can
significantly affect couples in which one or both partners experienced
childhood abuse, referred to here as adult-survivor couples. First, gendered
power dynamics of couples often erode trust (Gottman, 2011; Knudson-
Martin, 2013, 2015) when one or both partners discern a disruption of a sense
of justice or balance in the relational give-and-take (Hargrave & Pfitzer,
2011, p. 17). Second, difficulty trusting ones intimate partner can be a long-
term interpersonal effect of childhood abuse and neglect (Follette & Pistorello,
1995; Johnson, 1989; Liang, Williams, & Siegel, 2006; MacIntosh & Johnson,
2008).
Building Relational Safety and Trust in Couple Therapy 21

Although love between partners can be strong, the lack of trust can
nevertheless destroy couple relationships (Hargrave & Pfitzer, 2011). Liem,
OToole, and James (1992) noted that the feelings of powerlessness and
betrayal experienced as a result of childhood victimization are linked to the
adult survivors struggle to trust significant others and preoccupation with
dominance and influence in adult intimate relationships. Given the propensity
for adult-survivor couples to experience a distrusting emotional culture, it is
essential that couple therapists sensitively address the unique relational needs
of partners abused in childhood (Basham & Miehls, 2004; MacIntosh &
Johnson, 2008; Trepper & Barrett, 1989). Furthermore, while the study of
treatment for trauma has proliferated over the past two decades, the couple and
family therapy (CFT) field can benefit from research focused on relational
processes impacted by the trauma resulting from childhood abuse (Basham &
Miehls, 2004).
In this chapter, we will review relational trust theory, a theoretical
conceptualization based upon feminist, social constructionist views of the
intersection of gendered power dynamics and distrust in partner interactions of
adult-survivor couples (author, 2015a; author & Kuhn, 2015). We will then
present findings of a longitudinal grounded theory study that identified how to
clinically address gendered power processes interfering with trust in order to
establish relational safety between partners (author, 2015b).

INTERSECTING GENDERED POWER WITH


CHILDHOOD TRAUMA
About one-third of partners in couple therapy have a history of childhood
maltreatment (Anderson & Miller, 2006). However, couple therapists can fail
to observe how this history may contribute to a couples presenting issues
(Cobia, Sobansky, & Ingram, 2004; Mennen & Pearlmutter, 1993), especially
when clients may not electively disclose this experience (Little & Hamby,
1999). While the long-term interpersonal effects of childhood abuse can
appear to be insignificant for some adult survivors, for many the impact of
childhood trauma can persistently and deleteriously color current interactions
in their intimate relationships (Lindauer, 2012; Millwood, 2011).
22 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Effects of Childhood Abuse on Relational Processes

We define child maltreatment as the abuse and neglect of children under


age 18 resulting in harm to the childs health, development, dignity, and
survival in a relational context involving responsibility, trust, and power.
Although childhood abuse occurs at the level of the individual family, socio-
contextual factors contribute to this problem; e.g., high levels of
unemployment and poverty, gender and social inequality, rigid gender roles,
and societal norms glorifying violence toward others (World Health
Organization, 2010).
When the perception of safety has been skewed by childhood trauma, this
can prevent adult survivors from experiencing a secure and trusting
relationship (Brown, Banford, Mansfield, Smith, Whiting, & Ivey, 2012). In
addition to difficulty trusting their intimate partner (Kochka & Carolan, 2002;
Nelson & Wampler, 2002), other relational challenges of adult survivors can
be, for instance, anger issues and emotional dysregulation, fear of intimacy,
sexual problems, and reluctance to confide in their partner (Cobia, et al., 2004;
Liang, et al., 2006; MacIntosh & Johnson, 2008). In a study of heterosexual
adult-survivor couples, husbands of women sexually abused in childhood
described feeling challenged to balance their own needs with those of their
wife, holding rage at the perpetrator, and questioning their ability to treat their
wife appropriately (Chauncey, 1994). Indeed, the experience of being of
abused in childhood can be viewed as a shared trauma of the couple (Wiersma,
2003).

Gendered Power Processes of Abused Partners

We view power as relational, in that power reflects how each partner


influences the other to attend to his or her interests and needs in the
relationship (Knudson-Martin, 2013, 2015). Power disparities of couples often
undermine connection, as one partner then carries the excess burden to
maintain the relationship. Power differences can be gender-based (Lips, 1991)
and covert as a result of taken-for-granted cultural and societal discourses that
influence a persons identity and emotions in the give-and-take between
partners (Knudson-Martin, 2013, 2015).
The power processes occurring in adult-survivor couple interactions can
also be viewed as tied to the experience of childhood abuse. Regardless of
gender, the lack of empowerment associated with childhood maltreatment can
Building Relational Safety and Trust in Couple Therapy 23

drive the need for power in adult intimate relationships (Henry, Smith,
Archuleta, Sanders-Hahs, Goff, & Scheer, 2011; Liem, OToole, & James,
1996). Furthermore, an abused persons sensitivity to power can fuel couple
problems (Hill & Alexander, 1993) arising from, for instance, one partner
controlling most of the important aspects of the relationship and the other
partner having little or no say in those matters (Nelson, Yorgason,
Wangsgaard, Kessler, & Carter-Vassol, 2002). Yet some adult survivors may
relinquish power to their partner for fear of abandonment (Reyome, 2010).
Importantly, the power disparities embedded in childhood maltreatment can
contribute to a distrustful attitude in the abused person, and thereby foster
suspicion and hostility in current interactions of adult-survivor couples
(Wright, Crawford, & Sebastion, 2007).
In making sense of gendered power processes of the couple, it is critical to
also consider the social contexts of abused persons (Brown, 2004). For male
adult survivors, for instance, the powerlessness of victimhood in childhood
(Lisak, 1995) can clash against messages of masculinity discourses that
compel men to be independent, autonomous, and invulnerable (Bergman,
1995), leaving abused males with limited coping strategies (Mejia, 2005).
Conversely, female adult survivors who strive to maintain power and control
in their intimate relationship can run counter to femininity discourses that
relegate to the woman her function as the vulnerable, self-sacrificing partner
responsible for making the relationship work (Aronson & Buccholz, 2001;
Miller, 1976).

Relational Perspective on Gendered Power

When examining current interactions of adult-survivor couples, the


partners can find it difficult to recognize how gendered power dynamics
operate since taken-for-granted societal discourses that inform men and
women on how they should enact gender tend to reinforce gender stereotypes,
while also communicating expectations of equality between partners
(Knudson-Martin, 2013, 2015). Couple therapy approaches focused on shifting
gendered power disparities can be particularly pertinent to address issues of
adult-survivor couples that impede a trusting emotional culture between
partners (Knudson-Martin & Huenergardt, 2010, 2015). We view mutual trust
as occurring when both partners perceive the other as reliable and responsive
to their needs (Hargrave & Pfitzer, 2011; Wieselquist, 2009). The next section
presents a theoretical conceptualization regarding gendered power processes
24 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

that evoke distrustful reactions of adult survivors in interactions with their


partner, and provides suggestions on how to work with these intertwining
influences in couple therapy.

RELATIONAL TRUST THEORY


Relational trust theory (RTT) explains how gendered power disparities
impact the adult survivors perception of the other partner as untrustworthy
when he or she feels unfairly treated. The adult survivor then expresses
distrust as externalized emotions, internalized emotions, or symbolic actions
that then have a deleterious influence on the couples interactions. In general,
the intermingling of gendered power interactions with these distrustful
reactions, designated as adult-survivor power responses (ASPRs), negatively
affects emotional connection and promotes distress in the relationship. RTT
also provides suggestions for recognizing and working with the gendered
power context of adult-survivor couples so that clinicians can help partners
shift power disparities to processes of mutuality that enhance a sense of
emotional safety and the perception of trustworthiness (author, 2015a; author
& Kuhn, 2015).

Gendered Powers Effects

Perceiving the partner as unfair or untrustworthy triggers the adult


survivor to become concerned with his or her power position in the
relationship (Silverstein, Bass, Tuttle, Knudson-Martin, & Huenergardt, 2009)
and, thereby fosters engaging through ASPRs of self-protection, self-
abnegation, or marginalizing the needs of the other partner. The theoretical
concept of ASPRs is drawn from Hargrave & Pfitzers (2003) views on the
ties of neurobiology to emotions when partners feel unsafe in the relationship.
At such times, the brains amygdala, which constantly scans for trouble,
generates bodily responses of fight, freeze, or flight that affect interpersonal
exchanges (Fishbane, 2007, 2013; Fishbane & author, 2015). While ASPRs
can be considered as coping mechanisms developed in reaction to the
powerlessness of being abused as a child, in current couple interactions they
typically lead to emotional distancing and isolation, conflict, or power
struggles between intimate partners (see Figure 1).
Building Relational Safety and Trust in Couple Therapy 25

Figure 1. Adult-Survivor Power Responses triggered by human brain amygdalas


reaction of freeze, fight, or flee (author, 2015a; author & Kuhn, 2015).

Drawing upon the metaphor of the human brains amygdala response to


danger, self-protection is a fight reaction that is an explicit expression of
distrust in the form of anger and reactivity, suspicion, jealousy, or the need to
control. Both male and female adult survivors often use self-protection when
they sense unfair treatment from the other partner. Conversely, self-
abnegation, a freeze response of the amygdala, is an implicit experience of
distrust that is observable as a sense of internalized helplessness, mostly with
males, or overly accommodating the other partner, more often used by
females. The third category is a flee (from the relationship) response, referred
to as marginalizing the other partners needs, which occurs when distrust
instigates the male or female adult survivor to focus solely on his or her own
needs or interests without concern for the effects of these self-oriented actions
on the partner (author, 2015a; author & Kuhn, 2015).

RTT Clinical Guidelines

A key guideline of RTT is the prerequisite that clinicians establish a


foundation of mutuality between partners in order to create the relational
safety necessary for processing vulnerable emotions tied to partner interactions
or a history of childhood abuse (author, 2015a; author & Kuhn, 2015). As a
26 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

founding member of a university-sponsored clinical research team, I (Melissa)


drew upon Socio-Emotional Research Therapy (SERT; Knudson-Martin &
Huenergardt, 2010, 2015), since I witnessed the applicability of this couple
therapy models feminist approaches to the gendered power relations of adult-
survivor couples. SERT, which works to equalize gendered power disparities
so that both partners are mutually supported in the relationship, examines the
link between partner emotions and the influence of societal discourses that
inform each partners identity and ways of relating. These clinical approaches
help partners shift power imbalances and identify alternative ways of relating
that are based on shared attunement and relational responsibility, mutual
influence, and shared vulnerability (Knudson-Martin, Huenergardt, Lafontant,
Bishop, Schaepper, & author, 2014). These mutuality processes also link with
the components of trustworthiness; namely, promoting safety through
reliability between partners, fair give and take, security and hope arising from
each partner attending to the other partners needs, and authenticity and
openness (Hargrave & Pfitzer, 2011).
SERTs mutuality processes can be specifically applied to each ASPR (see
Figure 2) in the following ways:

Addressing self-protection involves the need for mutual influence


between partners, that is, making space for the voice of the one-down
partner whose needs may be obscured in response to the anger,
control, and reactivity exhibited in the fight response of distrust.
Attending to the needs of an adult survivor who uses self-abnegation
involves helping the other partner attune to and authentically respond
to that persons concerns that have been withheld due to the
perception of the absence of relational safety in the couples gendered
power processes.
Examining opportunities for engaging more responsibly with the
adult-survivor partner who marginalizes the needs of the other
partner.

By facilitating partners in engaging through these relational processes that


enhance shared power and emotional safety (Knudson-Martin, et al., 2014;
author, 2015a; author & Kuhn, 2015), adult-survivor couples are all the more
likely to experience a trusting emotional culture that supports intimacy
(Weingarten, 1991).
Building Relational Safety and Trust in Couple Therapy 27

ASPRs Circle of Care

Self- Attunement
abnegation Mutual vulnerability

Mutual influence
Self-protection
Dialogical give and take

Marginalize
partner's needs
Relational responsibility

Figure 2. Components of SERTs Circle of Care to attend to Adult-Survivor Power


Responses (Knudson-Martin & Huenergardt, 2010, 2015; author, 2015a; author &
Kuhn, 2015).

In the next section we present the findings from our grounded theory study
that identified clinical processes that helped adult-survivor couples disentangle
from their gendered power processes and augment their levels of trust, which
has been articulated as a need in the CFT field (MacIntosh & Johnson, 2008).

GROUNDED THEORY STUDY


This longitudinal grounded theory study examined 40 de-identified
transcripts of Socio-Emotional Relationship Therapy (SERT) sessions to better
understand the impact of gendered power interactions on four adult-survivor
couples, the ways in which SERTs clinical approaches worked to transform
gendered power disparities of the couples, and the partners sense of trusting
each other after approximately two years of couple therapy. The findings were
then applied to an additional four adult-survivor couples to confirm the
credibility of the grounded theory (author, 2015b).

Method

We conducted a longitudinal study of couple therapy with four


heterosexual adult-survivor couples using a grounded theory approach (Corbin
28 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

& Strauss, 2008) for a twofold purpose. First, we wanted to observe how
gendered power disparities intersected with distrustful reactions between
partners. Second, we sought to identify clinical processes of Socio-Emotional
Relationship Therapy (SERT) that facilitated adult-survivor couples
developing more trusting approaches with one another in their current
interactions. We viewed this qualitative method as a suitable way to analyze
couple and therapist processes in order to construct a theory grounded in the
data (Charmaz, 2006). This longitudinal study was part of a larger action
research project, which had received the sponsoring universitys institutional
review board (IRB) approval, focused on how to improve attention to societal
context, gender, and power in the practice of couple therapy (author, 2015b).

Participants

Our sample consisted of therapy sessions with four heterosexual couples


in which one or both partners experienced childhood abuse. Three couples
attended approximately 60 sessions each over a period of two years. The
fourth couple attended 10 sessions. We analyzed 40 transcripts of sessions
with these couples, including a post-therapy interview with two couples to
verify that the emerging grounded theory fit their perception of couple therapy
processes and outcomes. Two doctoral-student therapists conducted couple
therapy with each of the couples as part of the SERT clinical research group,
which included two faculty supervisors and another eight doctoral students
observing sessions from behind a one-way mirror. All of the clients and
therapists signed informed consents permitting the researchers to transcribe
videotape of the sessions in order to study couple dynamics and clinical
processes as part of our larger goal of improving couple therapy approaches
(author, 2015b).
Clients. Three couples were married from two to 20 years; the fourth
couple had been living together for three years. Males ages ranged from 28 to
58, and females from 29 to 56. All of the couples were of diverse ethnic origin,
with partners identifying as Latin American, Euro-American, and African
American. Three couples came to therapy because of distressed relations; the
other couple sought to resolve issues related to each partners history of
childhood abuse. All of the partners had experienced some form of childhood
abuse and neglect. In order to maintain confidentiality, we have changed the
clients names.
Building Relational Safety and Trust in Couple Therapy 29

Therapists. Three males and nine females, including ten doctoral-student


pre-licensed therapists and two faculty supervisors, composed the SERT
clinical research group. Ages ranged from 28 to 63, and ethnic backgrounds
included Euro-American, Canadian American, Mexican American, African
American, Asian American, and Middle Eastern American.
Additional Cases. In the course of our analysis, we tested the fit of
emerging findings in work with current cases. As a result, another four adult-
survivor couples signed informed consents as part of our process of enhancing
this grounded theorys credibility. Three couples identified as Euro-American
and one as African American. Partners were ages 26 to 60, and all had
experienced childhood abuse except the African American female.
SERT Clinical Research Group. In sessions with the four couples in the
sample, the co-therapists used Socio-Emotional Relationship Therapy (SERT),
a couple therapy model that has emerged from the larger action research
project (Knudson-Martin & Huenergardt, 2010, 2015). The primary focus of
SERT is to address the influence of the larger social context on gendered
power processes as these impact partners interactions. The two faculty
supervisors briefly joined sessions to engage with partners and co-therapists on
issues related to socio-emotional processing and sociocultural context. The
researchers involved in the grounded theory study had been members of the
SERT group, thereby enabling them to code guided by a clear theoretical
framework that informed them of which clinical processes to follow
(Greenberg, 2007). Since this study was part of action research in which the
participants were seeking to improve their work by systematically studying
their actions while also contributing to the field (Coghlan & Brannick, 2005),
the researchers engaged in some of the therapy sessions conducted as part of
this study. As a result, the analysis between the researchers and data was
interactive (Charmaz, 2006; author, 2015b).

Data Analysis

The researchers transcribed all ten sessions of the short-term couple and
randomly selected ten sessions from early, mid, and latter stages of therapy for
two of the long-term couples. Then we used theoretical sampling with the final
long-term couple as our ongoing analysis identified concepts emerging from
the data (Corbin & Strauss, 2008). I (Melissa) conducted a summary analysis
of the 40 transcripts in order to identify session themes, client discourses,
partner emotions, therapist approaches, and indicators for change. Studying
30 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

partner discourses helped us understand the nuances of power dynamics


occurring in session. For instance, the men in our sample spoke in terms that
helped us identify what we have designated as disentitled power: I go
against the grain, I know my attitude sucks, Im worthless, its like Im
a jerk (author, 2015b).
Three researchers then conducted line-by-line coding of the transcripts.
We used the constant comparison method to compare data with data to find
similarities and differences (Charmaz, 2006, p. 54). Codes included, for
example, examining effects of husband not attuning to wife, linking larger
social context to wifes understanding of sacrifice, examining ways to
express need to feel heard by partner (author, 2015b). Throughout the coding
process, the researchers wrote analytic memos to make sense of our
observations on how gender, power, and trust worked between partners and
the effects of clinical approaches used with the couples. Although I (Melissa)
had previously articulated relational trust theory for understanding gender,
power, and trust issues of adult-survivor couples in couple therapy (author,
2015a; author & Kuhn, 2015), the researchers bracketed these understandings
so that we could be open to whatever emerged from the data (Charmaz, 2006).
We engaged in focused coding (Charmaz, 2006) as our analysis revealed
the importance of relational safety to adult-survivor couples. The researchers
then used axial coding to identify themes and categories of partners relational
processes and key clinical processes used to attend to gendered power
approaches in order to create relational safety. In the final stage of developing
the grounded theory, we created diagrams and wrote analytic memos on how
these concepts were related to each other and to explain variations in the data,
which resulted in identifying the grounded theorys major components. We
then arrived at a consensus on how these components linking together in the
grounded theory (author, 2015b).

Credibility and Trustworthiness


We used triangulation to build credibility into the findings of our
grounded theory in a number of ways. The coding and analysis of the data
involved three researchers, which added different perspectives and a variety of
interpretations of the observed phenomena (Daly, 2007). Over the course of
our analysis, we checked with members of the SERT clinical research group to
determine that the emerging concepts and theory fit with their experience,
which helped to refine the theory. We also analyzed post-therapy interviews
with two couples from our sample and then tested our findings with four
Building Relational Safety and Trust in Couple Therapy 31

current cases to confirm the applicability of the grounded theory (author,


2015b).

Results

The grounded theory identified three significant processes embedded in


the gendered power dynamics of adult-survivor couples: 1) gendered fear of
being vulnerable; 2) unique gendered power approaches; and 3) distrustful
reactions. We also noted five clinical approaches used to transform these
gendered power dynamics so that partners became able to engage with one
another in relationally safe ways supporting trust: 1) recognize gendered
powers effects on relational safety; 2) comprehend the socio-emotional
experience of partners; 3) accentuate relational needs; 4) initiate partners
sharing power; and 5) identify trustworthiness of partners (see Figure 3).

Gendered Power Dynamics


The three processes of gendered power operations appeared to be
interlocked and contributed to significant relational distress in the form of
conflict, power struggles, and impasses as each partner attempted to protect
her or his own emotional safety.
Gendered fear of being vulnerable. The fear of being vulnerable was
gendered in that the males in our sample appeared to function in such ways as
to meet the requirements of masculinity discourses that endorse independence
and autonomy, alienate men from their emotions, and influence men to deny
admissions of weakness or vulnerability (Bergman, 1995; Levant, 1997; Lisak,
1995). Conversely, for the females the fear of being vulnerable seemed to
place them in conflict with femininity discourses ascribing women as the
accommodating partner bearing the responsibility to make the relationship
work (Hare-Mustin & Maracek, 1988; Miller, 1976).
This fear of appearing vulnerable in the relationship seemed to operate in
a variety of ways, e.g., each partner viewed couple problems as the other
partners fault; both partners tended to assume that the other partner would
dismiss their concerns; and neither partner would reflectively listen to the
others perspective. Most noticeably, the fear of being vulnerable often evoked
the silencing of the offended partner or attack-oriented comments instead of
sensitive self-disclosure of the effects of the other partners behavior on that
person. Accordingly, the gendered fear of being vulnerable seemed to
constrain any sense of give and take in partner interactions.
Figure 3. Adult-survivor couples experience of distrust and clinical goals and processes for relational safety and trust (author, 2015b).
Building Relational Safety and Trust in Couple Therapy 33

For instance, Anthony, who identified as African American and had


experienced emotional and physical abuse from his father during childhood,
found himself in the doghouse with his Latina wife, Marisa, who had been
sexually abused by extended family members as an adolescent, when he did
not reliably communicate with her after his freelance assignment as a
professional photographer with beautiful female models. Rather than take in
Marisas perspective and validate her concerns, Anthony responded to her
complaints from his gendered fear of being vulnerable.

Marisa: I feel jealous. Theres nothing wrong with that.


Anthony: There is when youre making an issue of it. Whos this?
Whos that? You accuse me that makes me want to do it.

In another married couple, Jazmyn, who identified as African American


and had experienced sexual abuse as an adolescent, became fearful of how her
Euro-American husband, Barry, would spend a financial windfall. Over the
course of their 20-year relationship, these parents of four children, ranging
from 8 to 16 years of age, had experienced financial ups and downs, most
recently downward because both partners had become physically disabled in
the past several years. Jazmyn displayed her gendered fear of being vulnerable
in response to Barrys request to manage these funds.

Jazmyn: (to Barry) I hope when this (money) comes, you dont flip
out.
Barry: (to therapist) Shes worried saying, Youre just going to
blow 50 grand on weed.
Jazmyn: (to Barry) You were a different person (when working)
but now its me, me, me. (to therapist) Hes got on his me goggles.

Unique gendered power approaches. The fear of appearing vulnerable in


the relationship then generated power approaches between the partners that
were different from traditional views of gender relations.
Male disentitled power approaches. The men in our sample operated from
a sense of disentitled power in contradistinction to the entitled power and
privilege that Western societal standards confer upon males (Levant &
Pollack, 1995). A male informed by masculinity discourses holds entitled
power by virtue of societally endorsed privileges that are taken for granted
and determine his status as the one-up partner in an intimate heterosexual
relationship (Knudson-Martin, 2013, 2015). Hence, entitled power influences
34 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

men to assume that their interests and needs are more important than their
female partners, that the man should set the agenda for what the couple does,
that the man is the primary decision-maker on important matters, etc.
(Mahoney & Knudson-Martin, 2009).
Yet, all of the men in the eight couples, four in the sample and another
four for case review, described their sense of having no power. Instead of
interacting from privileged entitlement, each male engaged through disentitled
power that seemed to be informed by nihilistic beliefs about themselves in the
world. In this grounded theory analysis we interpreted disentitled power as
being linked to the intersection of male gender socialization, which privileges
the mans focus on his own needs and autonomy rather than on his intimate
relationship (Jordan & Carlson, 2013), with the long-term effects of the
relational injuries of childhood abuse (Lisak, 1995). Beyond the experience of
powerlessness and vulnerability as a result of being abused in childhood, the
mens nihilistic views reinforcing a disentitled power perspective could also be
attributable to adult experiences of the powerlessness associated with racism,
classism, disability, and wartime military service (Mejia, 2005). Nonetheless,
the impact of disentitled power on their female partners was similar to that
seen in gender-traditional couples in which the female is required to attend to
the mans concerns (see Figure 4).
This disentitled power approach appeared to insulate the men from
addressing the concerns of their partner. Demonstrations of disentitled power
included self-deprecating narratives, use of dismissive body language,
ignoring or minimizing his partners feedback, and focusing solely on the
justification of his own point of view. For example, Barry used a disentitled
power approach with Jazmyn to avoid attending to her concerns about wise
money management for their family. His comments demonstrated the one-
sided nature of the disentitled power perspective.

Jazmyn: He has to have what he wants. Now that this (money) is


coming, hes going to act like a damn fool and hell ruin it. Nothing in
my heart tells me he wants to take care of (our family).
Therapist: (to Barry) Youve got a partner here whos expressed,
like, a Sherpa on overload (that) shes carrying a very heavy load
Barry: I dont give a (expletive)? I dont help? Then Im worthless.
Building Relational Safety and Trust in Couple Therapy 35

Entitled Disentitled
Power Power

Opportunistic Defeated
relational relational
approach approach

Partner focus Partner focus


on my needs on my needs

Figure 4. Effects of male power on intimate relationship (author, 2015b).

Relational Reactive
Power Power
Interdependent Defensive
relational relational
approach approach

Focus on our Focus on my


needs needs

Figure 5. Effects of female power on relationship (author, 2015b).

Female use of reactive power. The disentitled power used by the men
appeared to evoke from the women a reactive power by which they positioned
themselves against the males in order to somehow have influence with them.
This reactive power operated counter to femininity discourses that inform
36 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

women of the importance of sacrificing their own needs for the sake of
maintaining their relationship (Goldner, 1989; Lips, 1991). The women
demonstrated reactive power in myriad ways, including anger and control,
emotional distancing, becoming hypercritical, arguing, and use of sarcasm (see
Figure 5).
For instance, a Euro-American couple in their late 40s, Scott and Anna,
who had experienced child neglect and emotional abuse, seemed to be locked
into reactive exchanges. Scott, who had suffered child sexual abuse while
growing up in foster care, routinely dismissed Annas concerns by engaging
through his disentitled power perspective. Annas reactive power then readily
surfaced as a sarcastic attitude toward Scott.

Scott: Im burned out, man. She wont stop. She comes at me like a
damn freight train. I dont need this!
Anna: (lifts her cellphone to show therapist) Do you want me to start
the timer for two hours so you can get screamed at, too?

We observed that the use of reactive power seemed to take a toll on the
womens sense of relational adequacy since they were in the conflicted
position of not upholding societal messages on being the vulnerable partner
(Knudson-Martin, 2013, 2015; Miller, 1976). For instance, Anna described the
emotional impact on herself when she engaged with Scott through reactive
power.

Anna: I started getting I call it ugly.


Therapist: You feel like its ugly?
Anna: Yeah, its very ugly (singing voice) warning sign I feel
bad because of the arguing. I dont like it.
Therapist: Do you feel guilty sometimes?
Anna: I feel guilty all the time. What could I have done to stop it?
What could I have said, you know? How am I triggering it?
Therapist: You feel really responsible in some way.
Anna: (tearful) All the time.

Distrustful reactions. As these gendered power processes operated


between the partners, emotional reactions of distrustvariously demonstrated
as adult-survivor power responses (ASPRs) of self-protection, self-abnegation,
Building Relational Safety and Trust in Couple Therapy 37

or marginalizing the other partner (author, 2015a; author & Kuhn, 2015)
polarized the partners in conflict and impasses (see Figure 6).
We observed ASPRs occurring in three patterns with the couples in our
sample: 1) both partners engaging through self-protection; 2) the male
marginalizing the needs of the female and the female responding with self-
abnegation; and 3) female self-protection and male self-abnegation.

Male use of
disentitled
power with
female

Female use of
reactive power
with male

Figure 6. Power clashes of adult-survivor couples (author, 2015b).

Self-protection by both partners. As a result of their gendered power


dynamics, two couples in our sample frequently engaged through self-
protection, which is a fight response involving displays of anger, control,
jealousy, or suspicion that then generated conflict between partners. The
gendered power processes between partners perpetuated their problems, and
escalations tended to occur as the male elected not to respond to female bids
for his attention to needs in the relationship. For instance, in Scott and Annas
highly conflicted relationship, each partners self-protective response triggered
accusations of wrongdoing by the other.

Anna: Since the day I came into this relationship all Ive heard is
yelling. I cant handle it.
Therapist: What would be most helpful from (Scott) right now for
you?
Anna: I cant tell you because I dont know.
Therapist: (to Scott) What did you learn about what she needs from
you?
Scott: She pushes all my buttons I put up with a lot with (Anna),
more than most men would. I dont need this stress. She wont stop
misbehaving.
38 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Male marginalizing female and female use of self-abnegation. One


couple in the sample displayed this pattern of ASPRs in their interactions.
Barry typically marginalized Jazmyns needs by dismissing his responsibilities
in the relationship, and she usually responded with a form of self-abnegation
displayed as overly accommodating him. While partners using self-protective
responses seemed to be actively expressing their distrust, those using self-
abnegation tended to withhold their voice as a result of feeling unfairly treated
by their partner. Jazmyn described suffering in silence when subjected to
racism by members of Barrys family and her disappointment when Barry
accepted this derogatory treatment rather than help her address the issue.

Jazmyn: Barry wouldnt intervene he knew that the family didnt


really accept me because I was black and I was, like, a scapegoat for
everything.
Therapist: (to Barry) Help me understand. How have you managed
the issue of racism?
Barry: It doesnt bother me she perceives things differently than I
do.
Therapist: (to Jazmyn) How have you dealt with that?
Jazmyn: I was hurt.
Therapist: (to Barry) You kind of assumed an attitude to protect
yourself that maybe is not a way that joins with Jazmyn around her
experience of this?
Barry: (drinks from his cup and uses dismissive body language) I
thought Ive tried and obviously failed.

Throughout the course of therapy of approximately two years, we noticed


that when Jazmyn reached her limits with accommodating Barry, she then
engaged through a self-protective mode of anger and control.
Female self-protection and male self-abnegation. When gendered power
processes flared distrust between Anthony and Marisa, she typically engaged
through use of a self-protective approach of control and Anthony in turn
displayed a sense of internalized helplessness, which we observed to be a
predominately male performance of self-abnegation. We identified Anthonys
self-abnegation as silent disengagement, no visible emotional reaction, and
lack of eye contact with Marisa during conflict-laden interactions. Marisa
acknowledged that at such times she became more frustrated and angrier with
Anthony, as she interpreted his lack of engagement as ignoring her concerns.
In the following conversation about Marisas issue with disordered eating, it
became apparent how ASPRs fueled conflict between the partners.
Building Relational Safety and Trust in Couple Therapy 39

Marisa: (to Anthony) When you ask (about my) eating, your tone is
implying that youre expecting me to say I binged even though I had a
good day.
(Anthony is looking down at the floor.)
Therapist: Anthony, whats going on?
Anthony: Im listening and internalizing it, but I started to get
aggravated like Im being dismissed.
Therapist: Youre not intentionally being negative with Marisa?
Anthony: At the end of the day if our conversation is dismissed
that hour-long conversation was basically wasted (author, 2015b).

Clinical Processes Fostering Relational Safety


The grounded theory study identified five key clinical approaches for
establishing relational safety, which involved helping partners become more
vulnerable with each other and open to processes of give and take. The
therapists worked to increase trust and facilitate the mutuality processes of
shared attunement and relational responsibility, mutual influence, and shared
vulnerability, referred to as the Circle of Care in Socio-Emotional Relationship
Therapy (SERT; Knudson-Martin & Huenergardt, 2010, 2015), in the
following ways: 1) recognize effects of gendered power dynamics on partners
perceptions of relational safety; 2) work with the socio-emotional experience
of partners through sociocultural attunement; 3) accentuate partners relational
needs; 4) initiate partners sharing power; and 5) identify partners
trustworthiness.
The new relational dynamics of the adult-survivor couples in response to
therapist approaches seemed to unshackle both partners from the gridlock of
interacting through disentitled power and reactive power, and to shift from a
position-oriented approach to a relational orientation of mutuality (Silverstein,
et al., 2009). A central aspect of this shift between partners involved
developing a sense of shared vulnerability. The grounded theory analysis
delineated five aspects of becoming relationally vulnerableopen, authentic,
and emotionally transparentwith ones intimate partner: 1) being in touch
with ones own emotions and their effects on the partner; 2) attaining capacity
for self-reflection; 3) recognizing positive relational intent of self and partner;
4) accepting partners feedback; and 5) desiring to tend to partners needs and
interests.
40 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Clinical Outcomes
Three couples from the sample favorably responded to SERTs clinical
processes that attended to building relational safety between partners. The
fourth couple appeared to remain entrenched in their gendered power
dynamics. In this section, we will describe the clinical approaches used to
transform the gendered power disparities between Jazmyn and Barry, and then
examine our understanding of what hampered progress with Scott and Anna,
who did not have a successful outcome.

Case History of a Positive Relational Outcome Case


Jazmyn and Barry were in their early 40s, had been married 20 years, and
had four children. Jazmyn had been sexually abused as an adolescent, and
Barry had suffered emotional abuse and neglect from his stepparents
throughout his youth. They came to couple therapy to resolve long-standing
distress between the partners. Barry had not worked for several years as a
result of a work-related injury to his back that resulted in his status of
permanent disability, and Jazmyn, who had been a nursing student, had also
become unable to work in the past year due to a physical disability. As a
result, the couple continually struggled to make ends meet on their limited
income.
Therapeutic process. Two doctoral-student therapists conducted
approximately 60 SERT sessions with Barry and Jazmyn over the course of
two years. Two faculty supervisors and another eight doctoral students
observed behind the one-way mirror. Pre- and post-session debriefings with
the SERT clinical research group guided the development of clinical
approaches session by session (Estrella, Kuhn, Freitas, & author, 2015).
Gendered power assessment. In the initial SERT sessions it became
apparent that this adult-survivor couple engaged through gender-stereotypic
approaches in which the male used his one-up position to make individualistic
choices focused solely on his own needs. Both partners, but particularly Barry,
often displayed a fear of appearing vulnerable in their couple interactions. This
fear on Barrys part was noticeable in that comments from Jazmyn expressing
her disapproval of his behavior moved him to assume a disentitled power
perspective as a way to deflect her concerns. Barry demonstrated his nuanced
approach to disentitled power as a pervasive negative outlook that included a
great deal of self-condemning, all the while stringently justifying his own view
on the couples problems instead of taking in Jazmyns emotionally laden
critiques. Jazmyns reactive power in response to Barrys self-deprecating
narratives and dismissive body language involved crying and expressing her
Building Relational Safety and Trust in Couple Therapy 41

hurt and sense of hopelessness. But when her frustration became too
overwhelming, Jazmyn then engaged through arguing and a hypercritical
attitude toward Barry.
As already discussed, Barry refused to use his influence to protect Jazmyn
and their children from racist attitudes displayed by members of his extended
family. This history and other egregious behaviors by Barry had significantly
undermined trust between the partners. We viewed Barry as not being
relationally responsible as an intimate partner and that he had been
marginalizing Jazmyns needs. Her view on Barrys avoidant approach was, I
have to be the one that takes care of everything.
Key clinical processes for relational safety. Drawing on SERTs clinical
competencies, the therapists engaged with the partners to establish an
equitable foundation for therapy, interrupt the flow of gendered power, and
then facilitate alternative relationship experiences of mutuality (Knudson-
Martin, et al., 2014). Attending to gendered power dynamics of the partners
throughout therapy created a foundation of trust for the rest of the work that
followed (author, 2015b).
Recognize gendered powers effects. The therapists began by examining
the effects of Barrys use of disentitled power to avoid dealing with Jazmyns
distress. Jazmyn indicated early on in SERT sessions that Barrys self-oriented
behaviors made her feel unable to trust him. These behaviors had involved,
among other things, isolating, smoking copious amounts of marijuana, lying to
Jazmyn, and occasionally stealing money from the familys general funds in
order to purchase items for himself. Jazmyn appeared to be using her reactive
power to draw the line with Barry about changing for the sake of the
relationship.

Jazmyn: All these years Ive had to give up things that I want to
make him happy. I was real careful about making sure, you know, I didnt
offend his manhood and being real sensitive about the fact that hes not
working he just kept, you know, causing me problems (shrugs her
shoulders). I just dont care.
Therapist: (to Jazmyn) Thats a really tough spot to be in, youve
been keeping the family together with chewing gum string.
Jazmyn: Im still sacrificing what I want for him. Still doing it!
Therapist: (to Barry) Does all this make you feel as if there is a way
now for you to step up?
Barry: No, Im just taking it day by day. I cant, cant have a vision.
42 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Jazmyn: Me and the kids, we have to do without because I have to


do for him. The only thing he focuses on is what hes not getting
(shakes her head) and Im tired of it. If I have money for something he
wants, he makes my life a living hell.
Barry: Okay, oftentimes Im going through stuff
Therapist: (to Barry) Let her finish.
Jazmyn: Youre supposed to be my husband, the father of our kids,
and you dont even want to provide for us. Nothing in my heart tells me
that he wants to take care of us.

By making space for Jazmyns perspective on the couples problems and


validating her need for Barry to help carry the load for the familys well-being,
the therapists were beginning to equalize gendered power processes between
the partners (Ward & Knudson-Martin, 2012).
While many clinicians could be inclined to view Barrys problems from
an individualistic perspective of substance dependence (on marijuana) or some
other form of psychopathology, the SERT team continually shared with the
partners their perspective of the problem as relational and the need to address
the relational effects. This systemic perspective highlighted the couples
problems as a symptom that could be addressed by attending to the power
dynamics between the partners, more specifically, by Barry becoming attuned
to Jazmyns needs in the relationship and somehow responding.
From the earliest sessions the therapists worked to link each partners
emotions arising from the problem to the effects of gender socialization and
the influence of the larger social context. They named the primary issue for
Barry as one of relational responsibility. The clinical guidelines in relational
trust theory recommend that when an adult survivor marginalizes the needs of
the other partner the focus of therapeutic approaches should be to help that
partner, in this case Barry, to recognize the effects of his behavior on the other
partner, Jazmyn, and become accountable, which is part of engaging
responsibly in an intimate relationship (Knudson-Martin, et al., 2014; author,
2015a; author & Kuhn, 2015).
Comprehend the socio-emotional experience of partners. The therapists
worked to understand how the partners had internalized the influence of
societal discourses regarding masculinity and femininity and how this then
affected the couples ways of relating. While the therapists examined how
socio-contextual factors influenced Barrys use of disentitled power with
Jazmyn, they also worked to help him connect to his own emotions and
Building Relational Safety and Trust in Couple Therapy 43

become self-reflective in disclosing his feelings rather than resort to his


disentitled power process of dismissing Jazmyns concerns.

Barry: I constantly get told Im this bad, evil person, and Im just a
detriment to this family. And I know my attitude sucks.
Therapist: Would you say its hard to hear Jazmyn right now because

Barry: Im just miserable and depressed, and tired of all the crap.
Therapist: So, youre feeling as though things arent going the way
that youd like them to go?
Barry: Yeah.
Therapist: And when things dont go the way youd like would
you say that its maybe hard for you to connect or maybe even listen to
whats going on in your relationship with Jazmyn because youre in a lot
of pain?
Barry: Its just, you know, maybe more effort on each of our parts
not to be so negative towards each other ...

In helping Barry get in touch with his own emotions, the therapists
thereby facilitated enough safety so that both partners could become reflective
and more open to understanding their relationship dynamics without blaming
the other partner for their distress. Importantly, the SERT team was aware that
Jazmyn was carrying the relational burden and wanted to address this. Hence,
they worked to comprehend how the larger social context fueled Barrys
understanding of this problem and his own masculine identity conclusions
supporting his hierarchical position with his wife.

Therapist: (to Barry) When you talk about having expectations


around what your life would be, what kinds of things shape those
expectations? What kinds of values or beliefs inform the position that
youre presenting to Jazmyn?
Barry: Its not that I dont want to provide for the family (and) not
that I dont wanna work, because I dont mind work (pause) I dont
wanna take it from people anymore.
Therapist: And that values connected to what you were talking
about not compromising?
Barry: Yeah, to be who I am without, you know, having to act a
certain way just to get by.
44 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Therapist: Where did that value come from? Is it something you


believe in terms of your ethnicity as a (Euro-American) male? Do you
feel thats rooted in how you were raised as a child?
Barry: It had a lot to do with my (parents), when they got married the
second time they had to push me away to get the new spouse, you
know? I was always the sacrifice. It was me giving up something of mine
for the whole.

Accentuate relational needs. In the course of Barry attuning to his own


feelings and the influence of societal context on his ways of relating, this
helped him attune to Jazmyns emotions. As Barry became better able to take
in Jazmyns experience in their marriage, the therapists underscored the
strengths they observed in the couples relational approaches and tied these to
each partners need for safe emotional connection.

Therapist: (to Barry) There are moments that take place between the
two of you that are shared and wonderful.
Barry: Its been good. I mean, Im happy when were not fighting.
Jazmyn: Weve been trying to get along and be nice.
Therapist: What have you noticed?
Jazmyn: (sighs) Like holding hands and snuggling being silly
Thats what I want.

We found with all of the couples in our sample that partners responded
positively to these therapeutic conversations that tended to offset negative
messages about not measuring up in the relationship, particularly in the case of
the men, and an opportunity for the women to articulate what theyd prefer to
experience in the relationship. For both partners, accentuating their relational
needs appeared to alter the trajectory of their dynamics beyond the fear of
being vulnerable toward desiring more emotional connection (author, 2015b).
Initiate partners sharing power. With the couples in our sample, the
therapists worked with the male as the one-up partner to attune to his female
partner. Change in SERT is viewed as experiential and relational; for instance,
change needed to occur not at an individual level with Barry but in his power
relations with Jazmyn. Furthermore, emotions that generate change are
contextually driven (Knudson-Martin, et al., 2014). In other words, emotions
take on their meaning from what it is like to be a man or a woman, and what
makes each man or woman feel angry, guilty, happy, etc. as a result of
internalized societal messages. From these socio-contextual perspectives the
Building Relational Safety and Trust in Couple Therapy 45

therapists worked to help Barry listen to Jazmyns concerns and then to


authentically respond to them.

Therapist: Are there concerns about talking about things at home?


That it doesnt feel emotionally safe to address these things?
Barry: When were not seeing eye to eye its a personal offense.
Jazmyn: (to Barry) I feel like you just have to butt heads with me.
Therapist: (to Jazmyn) I hear you describing your experience of
Barry is part of that just wanting to feel like you are enough?
Jazmyn: Yeah.
Barry: I dont want her to be sad and upset all the time.
Therapist: Both of you have formulated ideas about (your position)
and then it prevents you from hearing what the other has to say (to co-
therapist) I think Barry experiences it as Jazmyn wants him to be
someone other than who he is, or who he identifies himself as. And
Jazmyn doesnt understand because what shes really asking for are
changes in behavior. Its like a tug-of-war between ideas and neither
one is going to give in, but theyre both miserable. (to Barry) What would
help it change so that you can have a moment something thats
shared between the two of you?
Barry: I just think my wife sees me as a (expletive) and thats just
something Im going to have to deal with.
Jazmyn: (to Barry) I wouldnt be hanging on if I felt like you were a
(expletive). (to therapist) I probably see more in him than he sees in
himself.
Therapist: (to Barry) Im interested in what you think then you can
bring to the relationship thats you.
Barry: I was feeling sad that she felt that So, I just try to keep
doing (things for her) I like seeing her happy.

Several sessions were devoted to supporting Barry in recognizing how he


does measure up in the relationship, on the one hand, and, on the other hand,
to acknowledge how his avoidance of dealing with family challenges led to his
distressing behavior of isolating from Jazmyn and his children, and the need to
become accountable for the effects of this on his wife. We found that as the
male in our couples engaged through attunement to the female partner, she
tended to reciprocate. However, in those cases in which trust had been
damaged by egregious behaviors, as was the case with Barry, repeated
enactments of his attunement were needed to solidify these new efforts at
connection for Jazmyn to feel safe enough to relax her vigilance.
46 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

As Barry worked to be in touch with his emotions and become more


involved at home with Jazmyn, it became progressively safer for her to
disclose her vulnerable emotions for intimate connection. The therapists
explored the effects on her of Barrys efforts to engage more responsibly with
her.

Therapist: Did you feel yourself opening up to Barry in the last


week?
Jazmyn: Yeah, when he came and helped me (with tasks at home),
and I didnt even have to ask him.
Therapist: Oh, he stepped up to the plate. And what was that like for
you to know that he was responding to you in that kind of way?
Jazmyn: I just felt, like, positive like, a sense of maybe this will
work.
Therapist: (to Barry) Im assuming that you were operating out of
this genuine wanting to be there for her?
Barry: Yeah, (softens voice) what I wanted her to understand is I do
want to be (with her).

Enactments of attunement to Jazmyn supported Barrys move away from


the masculinity discourses that kept him focused on his own needs; instead, he
became able to engage in new relational processes of being present with his
wife in the moment and responsive to her needs.
Identify partners trustworthiness. The final sessions focused on
highlighting the mutuality shared by the partners and efforts by Barry to
maintain his shift from an I perspective to one of we (Hargrave, 2000;
Samman & Knudson-Martin, 2015). In one session Barry and Jazmyn shared
an engaging conversation that involved 25 turns of dialogue without therapist
intervention on a topic that earlier in therapy had been a trigger for conflict.
Barry displayed receptivity to Jazmyns perspective that would have been
unimaginable at the start of couple therapy. Absent were the smoldering anger,
frustration, sense of self-disparagement, lack of eye contact, and dismissive
remarks by which Barry had previously engaged in conversations. He no
longer readily interpreted Jazmyns comments to him as judgmental and
condemning. Instead he took in her perspective and engaged in dialogue with
her in a way that furthered the conversation. Indeed, each partners perspective
now seemed to matter, and both listened and responded to one another.
These new relational processes involved a more lighthearted approach by
the couple. In their moments of dialogue, mutual listening helped build the
Building Relational Safety and Trust in Couple Therapy 47

relational safety that brought with it a sense of security between partners. As


Barry became more involved in family activities with Jazmyn and the children,
Jazmyn appeared to feel as though the burden of family care was becoming a
shared experience to a greater degree. The perception of one anothers
trustworthiness began to show in their interactions.

Barry: I havent been feeling like Ive been pressured into having to
be able to live up (to Jazmyns expectations) she doesnt question my
motives as much. I try not to get too upset at things and try to see how
I can better interact and involve myself without just isolating.
Jazmyn: I feel like I can trust him more. I do feel, like, sometimes
Im on the edge. Like, is he going to betray my trust? But weve been
fighting less, and its been more of a healthy environment for the kids.

Components of Vulnerability
In making sense of the challenges in shifting the gendered power
processes of Scott and Anna, the grounded theory analysis identified five
components of shared vulnerability for establishing relational safety and an
ambiance of trust between partners: 1) in touch with ones own emotions and
their effect on the partner; 2) capacity for self-reflection; 3) affirm ones
positive relational intentions; 4) accept partners feedback; and 5) desire to
tend to partners needs (author, 2015b). Relational vulnerability is gendered in
that SERT therapists intentionally work with the one-up partner, typically the
male, to support his taking the lead to construct a foundation of equality for
the couple (Knudson-Martin, et al., 2014).
In touch with ones own emotions. In this sample of couples, we
observed that the move toward shared vulnerability began as the male
willingly identified his own emotions and noticed their effects on his partner.
Scott seemed unable to respond reciprocally whenever Anna demonstrated her
willingness to engage in emotional processing. For instance, when the
therapist attempted to understand Scotts experience of Anna, instead of
acknowledging his own feelings, his response typically involved a self-
protective form of blaming her for his emotional discomfort.

Therapist: Its obvious how painful this is almost discounting who


you are as a man who has gone through this effort to be honest.
Scott: She wont stop these stupid allegations. I dont need this stress
what kind of lifestyle is that? (voice escalates) I cant deal with these
allegations!
48 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Although it was equally challenging for other males in the sample to


connect with their emotions, they became able to feel enough safety in session
to follow the therapists efforts to understand their sociocultural experience.
As the males then attuned to their own emotions, we observed that this made it
more possible for the therapists to support the partners in working through
impasses (author, 2015b).
Capacity for self-reflection. As therapy progressed in establishing
emotional safety between partners, we noticed that partners became able to
reflect on their own ways of engaging that detracted from or moved toward
connection. Yet, Scott maintained his defenses and avoided becoming
reflective on his part in the couples gendered power processes. He deflected
therapist queries by engaging in lengthy monologues focused on his need for
honesty or the horrible abuse Anna had suffered in her previous marriage.
While Anna was willing to become self-reflective, it was not safe for
therapeutic conversations to encourage her additional vulnerability as the one-
down partner. This type of engagement best occurs when the more powerful
partner takes the lead in becoming vulnerable and accountable (Knudson-
Martin, et al., 2014).
Recognize positive relational intent. The grounded theory analysis
identified that therapeutic conversations attributing positive intention to the
males actions somehow liberated them to try to become more relational.
Feeling loved, valued, and regarded as a good person appeared to provide a
counter narrative to the disentitled power perspective of themselves as
worthless and not measuring up as an intimate partner. While the other males
in the sample appeared to benefit from and resonate with therapists positive
attributions, Scott did not favorably respond to the therapists efforts at
noticing his positive relational intent.

Therapist: Something happened when Anna was talking that had you
feeling connected to her, listening to her what happened as you
listened to Anna?
Scott: This relationships going totally bad. Weve got to stop the
nonsense and figure out whats not working. (author, 2015b)

Accept partners feedback. The males in our sample with positive


outcomes eventually were able to listen to their partner about issues in the
relationship. But Scott habitually used his disentitled power perspective to
avoid becoming accountable to Anna.
Building Relational Safety and Trust in Couple Therapy 49

Therapist: I had the sense that as (Anna) is relating something the


result is you feel, this person doesnt love me, doesnt treasure me, value
what Im offering, so the pain
Scott: I cant deal with these things (they) have to stop.
Therapist: She says something and you get really irritated.
Scott: I cant have a relationship with this lady until she deals with
her issues. (author, 2015b)

Desire to tend to partners needs. This fifth aspect of shared vulnerability


surfaced as couples shifted their gendered power disparities to processes of
mutuality, thereby opening possibilities for connection in this act of giving
(Hargrave & Pfitzer, 2011, p. 27). Scott and Anna, having attended only ten
SERT sessions, made no progress toward shared vulnerability and remained
locked in their gendered power dynamics. They were unable to experience
enough relational safety to engage through new relational processes and
instead maintained the high-conflict, high-stress exchanges that debilitated
trust between the partners.

DISCUSSION
Determining effective clinical processes for adult-survivor couples has
been considered an underdeveloped field (Basham & Miehls, 2004, p. 24).
Several CFT models that have laid groundwork include emotionally focused
therapy (Johnson, 2002; MacIntosh & Johnson, 2008), a blending of object
relations with feminist-based trauma work (Basham & Miehls, 2004),
acceptance and commitment therapy (Follette & Pistorello, 1995), and
structural approaches (Trepper & Barrett, 1989), among others using a systems
theory perspective (Chen & Carolan, 2010; Hunt-Amos, Bischoff, & Pretorius,
2004; Nelson & Wampler, 2002). Some assumptions and clinical approaches
identified in relational trust theory (RTT) and the grounded theory study are
shared with these CFT models. The clinical processes for building relational
safety and trust articulated in this chapter extend current work in our field by
integrating feminist perspectives on trauma (Brown, 2004; Webster & Dunn,
2005) and couple therapy (Hecker, 2007). Indeed, the grounded theory
identified the need to focus clinical approaches on attending to the partners
gendered fear of being vulnerable, unique gendered power approaches of
adult-survivor couples, and distrustful reactions that then perpetuate
disconnection.
50 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

The theoretical conceptualization of RTT occurred concurrently with


transcribing videotape sessions of adult-survivor couples in the grounded
theory study. Partner dynamics observed in these sessions and other pertinent
cases informed my (Melissa) ideas on adult-survivor power responses
(ASPRs). While the grounded theory research confirmed these views on
ASPRs, a surprising finding that emerged was a nuanced approach to power
by the males and females not envisioned in RTT. The analysis revealed a
distinct approach to power used by male adult survivors that departs from
traditional views of male power and privilege, which we named disentitled
power, and the correspondingly unique power operation this evokes in their
female partners, which we identified as reactive power. The analysis also
pinpointed SERT clinical processes that promoted establishing relational
safety between partners, which was instrumental in shifting power imbalances
in three cases with a positive relational outcome of increased trust. The
grounded theory explained variations on power processes with one couple that
did not have a positive relational outcome and helped us identify the
characteristics of shared vulnerability that can occur as relational safety is
established.

Clinical Implications

By placing gender, power, and trust at the forefront of couple therapy


approaches, CFT clinicians can benefit by focusing on the effects of
sociocultural contexts on partner dynamics in the following ways.

Linking Gendered Power with Trust


The grounded theory analysis revealed the critical role that gendered
power dynamics played in perceiving ones intimate partner as untrustworthy.
When the couples in the sample engaged through the males use of disentitled
power and the females reactive power, their interactions were marked by each
persons need to protect him- or herself. This invariably resulted in distrust
between partners and distress in the relationship.
Recognizing invisible gendered power processes of adult-survivor couples
is critical to helping partners relate more equitably. Gendered power processes
tend to be invisible in heterosexual relationships because they are embedded in
masculinity and femininity discourses and taken for granted (Knudson-Martin,
2013, 2015). Yet, these influences can be identified by noticing relational
processes between partners, such as who attends to whom, whose needs and
Building Relational Safety and Trust in Couple Therapy 51

interests are more important, how decisions are made, whose opinion matters
more, etc. (Mahoney & Knudson-Martin, 2009). The grounded theorys
analysis of SERTs clinical processes addressing gendered power disparities
showed that the abused partners gradually became able to experience the
capacity for becoming vulnerable with one another in an emotional ambiance
of relational safety. This shared vulnerability increased each partners
perception of the other as trustworthy because the partners were more open
and emotionally transparent with one another so that each felt heard and
validated by the other.

Establishing Relational Safety


The key clinical processes identified in the grounded theory analysis
worked together to facilitate the relational safety that is requisite to a sense of
shared vulnerability between partners. Examining the effects of disentitled
power and reactive power performances on the relationship began to shift
power disparities by making space for the voice of the one-down partner
(Ward & Knudson-Martin, 2012) and facilitating self-reflectivity of the more
powerful partner, usually the male, to become accountable for his part in the
couples problems (Knudson-Martin, et al., 2014). Linking partner emotions to
the effects of societal influences on identity conclusions and position-oriented
approaches that support conflict and power struggles facilitated a move away
from blaming the partner and thereby generated in-session safety to become
more transparent about ones own emotions. Identifying each partners
perspectives on what they needed in their intimate relationship helped both
recognize the others positive relational intentions and made it safer to become
open to emotional connection.
Upon this foundation the therapist was able to help the more powerful
partner shift from gendered power performances of disconnection and to
engage in new relational experiences of attuning to the other partner and
becoming responsive to that partners needs. This fostered a sense of shared
responsibility for making the relationship work. As power differentials
receded, mutuality processes made it safer to be authentic, open, and
emotionally transparentvulnerable. Assessing the impact of new relational
processes of mutuality between partners helped both to acknowledge one
anothers trustworthiness in being responsible for maintaining emotional
connection or recovering more immediately when disconnection did occur
(Knudson-Martin, et al., 2014). In other words, partners felt safe to connect as
they worked together to meet each others needs and interests in the
relationship (author, 2015b).
52 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Addressing the Effects of Male Gender Socialization


Trauma researchers have noted the need to unpack with male adult
survivors the effects of gender socialization on their own experience of the
vulnerability and powerlessness that resulted from childhood victimization in
order to help them become more open to processing emotions in therapy
(Lisak, 1995; Mejia, 2005). Findings from the grounded theory analysis
suggest a way to attend to this need. By describing the operations of disentitled
power in adult-survivor couple interactions and the components of relational
vulnerability, these findings provide guidelines to clinicians for sensitively
working with abused males to facilitate alternate relational experiences beyond
the coping mechanisms they have habitually resorted to when using disentitled
power to ward off their partners concerns (author, 2015b).

Differentiating Disentitled Power


An important finding that emerged from the grounded theory analysis is
the concept of disentitled power used by males. While the male may have
internalized emotions tied to his experience of powerlessness and weakness as
an abused child, he still holds latent power associated with his one-up social
location (Knudson-Martin, 2013, 2015). As previously noted, this power
operation is similar to the gender-traditional view of the male as entitled and
privileged in that it has the effect of placing the man in a hierarchical position
in the relationship. Although disentitled power is a quite different emotional
experience for the male adult survivor from that of entitled power, it is
nonetheless his use of power to control or dominate his partner.
Feeling disempowered. The males use of disentitled power is distinct
from feeling disempowered, which can occur with both men and women
(Fishbane, 2011; Scheinkman & Fishbane, 2004). While the emotion linked to
disentitled power may appear as the male feeling disempowered, the use of
disentitled power by the man is a far different experience in that being
disempowered is situational. As factors that lead to disempowerment diminish,
the male (or female) becomes empowered. Disentitled power, however,
involves negative identity conclusions internalized by the male that developed
as a result of his exposure to the powerlessness experienced in childhood
abuse colliding with the mans sense of how he measures up to masculinity
discourses.
Destructive entitlement. Drawing from contextual therapy (Boszormenyi-
Nagy & Krasner, 1986), destructive entitlement involves damaging emotions
or actions resulting from a persons claim to self-justified compensation for an
unbalanced or unjust relational ledger (Hargarve & Pfitzer, 2003). This varies
Building Relational Safety and Trust in Couple Therapy 53

from disentitled power in that both men and women can engage through
destructive entitlement in their closest relationships. Disentitled power is a
male experience that may involve destructive entitlement, however, disentitled
power is tied to masculinity discourses by which the male gauges his own
sense of gender conformity.
When attending to disentitled power it is crucial to unpack the internalized
values and beliefs influenced by societal discourses that the male adult
survivor may rigidly hold regarding himself, his partner, and the world as a
result of the intersection of his early-life relational injuries and male
socialization (author, 2015b).

Cultivating Male Relational Vulnerability


The grounded theory analysis provided a map for facilitating relational
processes to help partners deal with the gendered fear of being vulnerable,
particularly the abused male. Focusing on the male is crucial because, while
femininity discourses influence female partners to relate vulnerably,
masculinity discourses influence men not to be vulnerable from an early age
(Bergman, 1995; Miller, 1976). Deviating from masculinity discourses has
been another source of trauma for boys who have been punished for this by
male peers, their parents, or others in their social network (Mejia, 2005).
While attending to gendered power operations and facilitating new
experiences of alternate ways of engaging with his female partner, it is
essential to help the abused male manage the emotions linked to the fear of
being vulnerable. Becoming aware of how his emotions and the use of
disentitled power affect his partner creates an opening for the male to try
different relational approaches of attuning to and accepting her influence.
Oftentimes, the therapist engages with the male by reflecting on how his
actions and narratives indicate his positive relational intent. At other times, the
therapist assists the male in attending to the females concerns. These new
relational experiences can help the male dispel the fear of appearing weak;
instead, the therapist emphasizes vulnerability as a positive when the male
engages through open and authentic disclosures (author, 2015b).

Attending to Female Reactive Power


Gender-traditional femininity discourses position the females social
location as the subordinate, vulnerable partner (Miller, 1976), but the
grounded theory study analysis identified this as quite challenging for each
abused female in the sample when confronted with gendered power disparities.
Even though the womans reactive power at times appeared to position her as
54 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

the one-up partner, the males use of disentitled power to dismiss her concerns
or to disengage from her nonetheless maintained his hierarchical position in
the relationship. Therefore, it became essential to make space for her voice on
important matters, affirm her needs, and help the male partner take in her
concerns and respond authentically (Knudson-Martin, et al., 2014; Ward &
Knudson-Martin, 2012).

FUTURE RESEARCH
The grounded theory has identified a unique power approach affecting
heterosexual adult-survivor couples in the form of male disentitled power and
female reactive power that needs more study. Future research could focus on
the circumstances in which males use disentitled power, how males make
sense of the effects of disentitled power, how men in marginalized societal
contexts use disentitled power, the link of socio-contextual stressors to
disentitled power performances, and clinical processes to help males manage
emotions that are triggered when they engage through disentitled power. For
those cases in which the male has significant difficulty lowering his defenses
in order to become self-reflective on his power performances, what are
therapeutic approaches to help him feel safe enough to expose the perception
of his own weakness that masculinity discourses have informed him to
suppress? This is a particular relational need of abused males (Lisak, 1995;
Mejia, 2005).
More research is also needed on how females make sense of their use of
reactive power and the deviation of that from femininity discourses, how they
recognize and respond to emotional safety in the relationship, and their process
of moving away from use of reactive power as males begin to engage through
vulnerability processes. Do the females likewise become vulnerable in
response to the males attunement or are clinical processes needed to help
them lower their defenses in order to also become vulnerable? The grounded
theory study focused on process research, but outcome research is also needed
with adult-survivor couples. Also, the sample in the grounded theory study
was small. There is a need to continue this research across a wider population
and with same-sex couples (author, 2015b).
Building Relational Safety and Trust in Couple Therapy 55

CONCLUSION
The intersection of gender and power with trust dramatically impacts
current interactions of adult-survivor couples. Relational trust theory presented
functional conceptualizations of the impact of adult-survivor power responses
on gendered power dynamics of partners and suggested clinical approaches for
addressing the effects of self-protection, self-abnegation, and marginalizing
the needs of the other partner (author, 2015a; author & Kuhn, 2015). As part
of recognizing the disinclination of adult survivors to show vulnerability in
interactions with their intimate partner, the grounded theory analysis identified
clinical processes from Socio-Emotional Relationship Therapy (SERT,
Knudson-Martin & Huenergardt, 2010, 2015) that helped these couples
cultivate relational safety. Attending to the impact of the males use of
disentitled power and the reactive power this evoked from his female partner
was vital to helping adult-survivor couples change their gendered power
dynamics that perpetuated distrust, particularly by helping the partners expand
their ways of relating beyond the limits of gender-stereotypic masculinity and
femininity discourses. The move away from distrustful partner reactions
involved working with the key characteristics comprising shared vulnerability
by supporting partners to interact in emotionally safe ways that permitted
respectful self-disclosure. In most cases, engaging in these mutually
supportive processes resulted in a more trusting emotional ambiance shared by
these intimate partners who had been unjustly treated in their childhood.

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BIOGRAPHICAL SKETCH
Melissa Wells, Ph.D., is a recent graduate of the marital and family
therapy program at Loma Linda University in Loma Linda, California. She
provides relational therapy to individuals, couples, and families at Mt. Vision
Family Therapy in Redlands, California, and has expertise as a medical family
therapist with those who are experiencing high-risk pregnancy and perinatal
bereavement. She also specializes in issues related to trauma, child abuse,
eating disorders, grief and bereavement, and recovery from substance
dependence. She is a member of the American Association for Marital and
Family Therapy (AAMFT) and the American Family Therapy Academy
(AFTA).
Her publications in the last three years include:

Wells, M. A. (2015). Gender, power, and trust issues in couple


therapy with adult-survivor couples (Doctoral dissertation). Available
from ProQuest Dissertations and Theses database. (UMI No. 10293)
Wells, M. A. (2015). Gender, power, and trust issues in couple
therapy with adult survivors of child abuse. Journal of Couple &
62 Melissa A. Wells, Elsie Lobo, Aimee Galick et al.

Relationship Therapy. Published online: 21 Aug 2015. doi:


10.1080/15332691.2014.962210.
Knudson-Martin, C., Wells, M. A., & Samman, S. K. (Eds.) (2015).
Socio-Emotional Relationship Therapy: Bridging emotion, societal
context, and couple interaction. New York, NY: Springer.
Wells, M. A., & Kuhn, V. P. (2015). Couple therapy with adult
survivors of child abuse: Gender, power, and trust. In C.
Knudson-Martin, M. A. Wells, & S. K. Samman (Eds.), Socio-
Emotional Relationship Therapy: Bridging emotion, societal
context, and couple interactions. (pp. 107-120). New York, NY:
Springer.
Knudson-Martin, C., Wells, M. A., & Samman, S. K. (2015).
Engaging power, emotion, and context in couple therapy: Lessons
learned. In C. Knudson-Martin, M. A. Wells, & S. K. Samman
(Eds.), Socio-Emotional Relationship Therapy: Bridging emotion,
societal context, and couple interactions. (pp. 145-153). New
York, NY: Springer.
Fishbane, M. D., & Wells, M. A. (2015). Toward relational
empowerment: Interpersonal neurobiology, couples, and the
societal context. In C. Knudson-Martin, M. A. Wells, & S. K.
Samman (Eds.), Socio-Emotional Relationship Therapy: Bridging
emotion, societal context, and couple interactions. (pp. 27-40).
New York, NY: Springer.
Estrella, J., Kuhn, V. P., Freitas, C. J., & Wells, M. A. (2015).
Expanding the lens: How SERT therapists develop interventions
that address the larger context. In C. Knudson-Martin, M. A.
Wells, & S. K. Samman (Eds.), Socio-Emotional Relationship
Therapy: Bridging emotion, societal context, and couple
interactions. (pp. 53-66). New York, NY: Springer.

Date of Birth: November 4, 1950


Address: 2791 Shadow Dancer Trail Reno, NV 89511-5334
Phone: 775.360.6450 home 949.573.8557 cell
Email: purrzha@gmail.com

Elsie Lobo, M. Sc., is a doctoral student in the Marital and Family


Therapy program at Loma Linda University in Loma Linda, California.
Aimee Galick, Ph.D., is assistant professor in the School of Health
Professions at the University of Louisiana at Monroe, Monroe, Louisiana.
Building Relational Safety and Trust in Couple Therapy 63

Carmen Knudson-Martin, Ph.D., professor, directs the Marriage,


Couple, and Family Therapy program in the Graduate School of Education and
Counseling at Lewis and Clark College, Portland, Oregon.
Douglas Huenergardt, Ph.D., professor, directs the Doctor of Marital and
Family Therapy program and is associate chair of Counseling and Family
Sciences in the School of Behavioral Health at Loma Linda University, Loma
Linda, California.
Hans Schaepper, M.S., M. Div., is a doctoral student in the Marital and
Family Therapy program at Loma Linda University, Loma Linda, California.
In: Child Abuse and Neglect ISBN: 978-1-63484-785-8
Editor: Michelle Martinez 2016 Nova Science Publishers, Inc.

Chapter 3

PARENT-CHILD INTERACTION THERAPY


FOR THE TREATMENT AND PREVENTION
OF CHILD ABUSE AND NEGLECT

Amanda H. Costello1,*, Ria M. Travers2,


Lauren B. Quetsch2, Cree Robinson2,
Nancy Wallace2and Cheryl B. McNeil2
1
Department of Psychological and Brain Sciences,
University of Delaware, Newark, DE, US
2
Department of Psychology,
West Virginia University, Morgantown, WV, US

ABSTRACT
Child abuse and neglect (CAN) continues to be a serious public
health problem in the United States, affecting approximately 19% of
victims and costing approximately $124 billion to society (Fang, Brown,
Florence, & Mercy, 2013; Norman, Byambaa, De, Butchart, & Vos,
2012; U.S. Department of Health and Human Services, 2010). If left
untreated, children who experience CAN are at risk for developing
multiple difficulties across biological, emotional, psychological, and
relational domains (Alink, Cicchetti, Kim, & Rogosch, 2012; Norman et
*
Corresponding author: Dr. Amanda Costello: University of Delaware; Department of
Psychological and Brain Sciences; 108 Wolf Hall; Newark, DE 19716. E-mail:
acostello@psych.udel.edu.
66 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

al., 2012; Runyon, Deblinger, & Thakkar-Kolar, 2004). Without effective


intervention, families may also remain at risk for future CAN. Several
evidence-based interventions have demonstrated success in treating
parents and children who have experienced CAN. One such intervention
is Parent-Child Interaction Therapy (PCIT; Eyberg & Robinson, 1982;
McNeil & Hembree-Kigin, 2010). This chapter provides a description of
PCIT, a rationale for its use with parents and children who have
experienced CAN, and an overview of PCITs evidence base for both
intervening with and preventing future CAN.

Keywords: parent-child interaction therapy, child abuse and neglect,


evidence-based treatments, behavioral parent training

INTRODUCTION AND SCOPE OF THE PROBLEM


Child abuse and neglect (CAN) is one of the largest public health issues in
the United States, costing an average of $210,012 per victim. In 2011 alone,
1,500 of the 700,000 reported cases of child maltreatment and neglect resulted
in fatality (U.S. Department of Health and Human Services, Administration
for Children and Families, 2011; U.S. Department of Health and Human
Services, Administration for Children and Families, 2012). In addition to the
significant societal burden of CAN, children who are victims of abuse and
neglect are placed at an increased risk for various negative behavioral,
physical, social, and psychological outcomes (Poole, Seal, & Taylor, 2014).
Specifically, these children report higher rates of depression, anxiety, suicide,
post-traumatic stress disorder, and disruptive behavior problems than children
who do not experience CAN. Research has demonstrated that CAN has the
ability to negatively impact a childs physical brain development and
functioning (Hart & Rubia, 2012). Unfortunately, many of these problems that
occur during childhood, also persist throughout adulthood and continue to
negatively impact functioning across multiple domains. For instance, in
addition to experiencing negative psychological outcomes, such as anxiety,
depression, and increased rates of suicide, adults who have experienced CAN
also experience higher rates of diabetes, smoking, and alcoholism (Felitti,
Anda, Nordenberg et al., 1998; Shonkoff, Boyce, & McEwen, 2009; Widom,
Czaja, Bentley, & Johnson, 2012). Children who have been abused are also at
risk of abusing their romantic partners and their own children when they
become parents (Runyon, Deblinger, Ryan, & Thakkar-Kolar, 2004;
Thornberry, Knight, & Lovegrove, 2012). In addition, they are more likely to
Parent-Child Interaction Therapy for the Treatment 67

have children with severe behavior problems (Collishaw, Dunn, OConnor, &
Golding, 2007). Therefore, due to myriad negative consequences of CAN, it is
critical to intervene effectively with families. One such area of intervention is
addressing the role of parent-child interactions to help mitigate risk for CAN.

THE ROLE OF PARENTING


Positive parenting methods, defined by Baumrinds authoritative parenting
style (Baumrind, 1967), incorporate both warmth and consistent limit setting.
This parenting style has been linked to prosocial outcomes for children
including higher self-esteem, higher life-satisfaction, and lower rates of
depression (Milevsky, Schlechter, Netter, & Keehn, 2006). When patterns of
negative behavior emerge in parents, the consequences can be severe and can
lead to continued negative interactions between a parent and child (Bousha &
Twentyman, 1984). Literature suggests a number of factors have been
associated with parents reported for CAN including low income (Sedlak &
Broadhurst, 1996), young maternal age, and low maternal education level
(Sidebotham, Golding, & The ALSPAC Study Team, 2001; Stier, Leventhal,
Berg, Johnson, & Mezger, 1993). Maltreating parents typically experience
higher levels of psychopathology including depression, substance use, history
of trauma, and personality disorders (Ammerman, Kolko, Kirisci, Blackson, &
Dawes, 1999; DiLillo, Tremblay, & Peterson, 2000; Downey & Coyne, 1990;
Perepletchikova, Ansell, & Axelrod, 2012). Children can also have
characteristics placing them at increased risk for abuse and neglect.
Specifically, children with significant problem behaviors including common
issues of irritability, hyperactivity, or high needs are more frequently
maltreated than peers without similar problems (Black, Heyman, & Smith
Slep, 2001; Crosse, Kaye, & Ratnofsky, 1993).
Maltreating parents repeatedly implement ineffective techniques to
communicate with and discipline their children, resulting in the use of physical
discipline as a consequence (Bousha & Twentyman, 1984; Hickox & Furnell,
1989). Parents with a history of CAN often believe that only harsh discipline
strategies (e.g., verbal threats, physical punishment) will be effective with their
children, who they view as having uncontrollable levels of behavior problems
(Crouch & Behl, 2001). These parents report greater amounts of hostile
emotionality (Lesnik-Oberstein, Koers, & Cohen, 1995) alongside higher
levels of verbal aggression and lower overall emotional responsiveness (Moser
& Jacob, 1997). Maltreating parents have misconceptions of the childs
68 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

developmental capabilities, misattributing their actions to be purposeful or


vengeful. A long-term consequence for parental use of extreme discipline is
the increased risk of children to have behavior problems as they grow older,
including aggression and delinquency. These disruptive and conduct-related
behaviors serve to increase the risk of CAN, particularly physical abuse, which
occurs within parent-child interactions.
Parents and children can become trapped in a coercive cycle, defined as
the escalation of extreme hostility and aggression by the parent-child dyad
over time (Patterson, 1982). Parents utilize ineffective and inconsistent
methods of discipline (as described previously) in response to a childs
misbehavior. The child responds with increasingly extreme behaviors until the
parent gives in to the childs demands. Eventually, the parent cannot control
the childs elevated behavioral outbursts and resorts to increasingly severe
discipline strategies, which can result in physical abuse (Urquiza & McNeil,
1996). Years of research have been dedicated to breaking the coercive cycle
that characterizes the extreme dysfunctional pattern of these parent-child
interactions (Kaminski, Valle, Filene, & Boyle, 2008). Behavioral treatment
interventions have been developed to intervene within the parent-child
relationship. These interventions are characterized by the replacement of
negative interaction styles between parents and children with more positive
behaviors, the implementation of a consistent discipline strategy (i.e., time-
out), and the practice of new skills during therapy sessions (see Kaminski
et al., 2008).
Several evidence-based interventions have demonstrated success in
treating parents and children who have experienced maltreatment. One such
intervention is Parent-Child Interaction Therapy (PCIT; Eyberg & Robinson,
1982; McNeil & Hembree-Kigin, 2010). PCIT is a behavioral parent training
program and one of three evidence-based treatments identified by the
Kauffman Best Practice Project to target consequences of trauma and prevent
further abuse from occurring (Chadwick Center on Children and Families,
2004). The two other evidence-based programs identified by the Kauffman
Best Practice Project include Trauma-Focused Cognitive Behavior Therapy
(TF-CBT; Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011) and
Alternatives for Families: A Cognitive Behavior Therapy (AF-CBT; Kolko et
al., 2012). Both TF-CBT and AF-CBT incorporate psychotherapy, skill
building exercises (e.g., relaxation training), systematic desensitization to
experienced trauma, and cognitive coping and processing to treat instances of
child trauma and maltreatment while also reducing chances for recidivism of
maltreatment. In contrast, PCIT teaches parents to utilize a unique set of skills
Parent-Child Interaction Therapy for the Treatment 69

to improve the parent-child relationship and increase child compliance through


a time-out sequence. PCIT has been shown to be an efficacious treatment for
trauma by reducing the use of severe discipline strategies and promoting
positivity within the parent-child relationship for families with a history of
CAN (Chaffin et al., 2004).

OVERVIEW AND APPLICATION OF PCIT TO CAN


Foundation of PCIT

PCIT was originally developed for preschool-aged children presenting


with disruptive behaviors (e.g., noncompliance; Eyberg, 1988; For a review,
see Borduin-Quetsch, Wallace, Norman, Travers, & McNeil, 2015). It was
adapted from an operant behavioral (i.e., the use of reinforcement and
punishment) two-stage model created by Constance Hanf (Hanf 1969;
Reitman & McMahon, 2012); this model has been the foundation of several
behavioral parent-training programs. Hanfs two-stage model included a child-
directed phase followed by a parent-directed phase, in which the parent was
taught to selectively attend to appropriate child behaviors, ignore minor
misbehavior (e.g., whining, talking back), and provide clear and predictable
consequences for both child compliance and noncompliance (Eyberg, 1988).
These skills were typically taught in a naturalistic play setting to closely
mirror real world parent-child interactions. The therapist provided coaching
and feedback to the parent regarding the parents skill use (Eyberg, 1988).
PCIT is structured in the same way, with parents receiving the Child-
Directed Interaction (CDI) phase (relationship building), followed by the
Parent-Directed Interaction (PDI) phase (discipline implementation) in
treatment. Research has demonstrated that including both phases in PCIT leads
to not only a stronger parent-child relationship, but also the use of more
effective behavior management skills and greater child compliance
(Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993). Theoretically,
PCIT incorporates both operant behavioral strategies to help parents learn and
use safe and consistent discipline skills and relationship-building skills
typically used by therapists to build rapport with their child clients. These
skills include being nondirective and letting the child lead the play, while also
supporting the childs decisions through positive attention, such as praise,
conveying warmth, reflecting the childs speech, and describing the childs
behaviors (Costello, Chengappa, Stokes, Tempel, & McNeil, 2011; Eyberg,
70 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

1988). In PCIT parents are taught these relationship-building skills, with the
expectation that they become a co-therapist in the process (Herschell &
McNeil, 2005). Similar to Hanfs (1969) model, parents interact with their
children in a play setting and receive in-vivo coaching (typically via a bug-in-
the-ear device) from the therapist, getting real-time feedback about their
application of skills learned in PCIT.
The overarching goal of including both operant behavioral principles and
relationship-building skills is to promote an authoritative parenting approach
(Baumrind, 1966). As described previously, Baumrinds (1966) authoritative
parenting approach is one in which parents provide structured, predictable
rules and consequences for both positive and negative child behavior, while
also remaining warm, supportive, and nurturing to their child. Thus, parents
are not only viewed as the authority figure, responsible for enforcing rules, but
are also a base of safety and support for the child.
Years of research have been dedicated to developing interventions (e.g.,
behavioral parent training programs) to improve the quality of parent-child
relationships. To understand why these interventions are effective, Kaminski
et al. (2008) identified the four most effective components of behavioral parent
training programs: (a) using in-vivo practice, (b) teaching parents emotional
communication skills, (c) teaching parents to interact positively with their
child, and (d) using safe and consistent discipline. PCITs success with
children and families is largely contributable to the incorporation of all four of
these components into the treatment program. The parent-child relationship is
prioritized in PCIT, with sessions being structured so that parents not only
learn relationship-building, emotional communication, and appropriate
discipline skills, but also spend the majority of session time practicing these
strategies with their children. Parents receive in-vivo coaching from their
PCIT therapist, which gives them real-time, individualized feedback about
their use of skills (Herschell, Calazda, Eyberg, & McNeil, 2002). Coaching is
considered to be an integral component of PCIT (Barnett, Niec, & Acevedo-
Polakovich, 2014), and one that differentiates it from other behavioral parent
training programs. Because coaching is such a powerful tool for changing
behavior, improvements in positive parenting has been found to occur in as
early as two sessions (Shanley & Niec, 2010).
In addition to the use of coaching, parents are considered the agent of
change in PCIT, and this approach is meant to foster empowerment in
caregivers (Herschell & McNeil, 2005). PCIT is structured as an idiographic
treatment approach, with treatment success guided by parent performance and
mastery of skills, not by a previously determined number of sessions. Mastery
Parent-Child Interaction Therapy for the Treatment 71

of skills is assessed weekly by coding parental behavior during a five-minute


segment at the beginning of each session. These data are tracked and shared
with parents each session so they can follow their own progression throughout
treatment. Parents cannot move from the CDI phase to the PDI phase until
they have successfully mastered the skills taught in CDI (McNeil & Hembree-
Kigin, 2010); thus building the foundation of a strong parent-child relationship
that is so critical in PDI. Similarly, families do not graduate from PCIT until
parents have successfully mastered the skills in PDI. In addition to feedback
received within the session, parents are also asked to engage in daily
homework exercises that are structured to implement skills in a gradual
process. Parents are encouraged to over-learn skills in PCIT, with the goal of
generalizing these skills across the day and throughout the week (Eyberg &
Funderburk, 2011; Herschell & McNeil, 2005; McNeil & Hembree-Kigin,
2010). Given the high level of practice and coaching in PCIT, on average,
parents have been found to complete PCIT in about 12-16 sessions (Eyberg,
Nelson, & Boggs, 2008).

Research Support for PCIT

Research support for the effectiveness of PCIT in improving both child


and parent outcomes has been building for approximately twenty years. PCIT
has demonstrated improved child outcomes in children presenting with
disruptive behavior disorders, including oppositional defiant disorder (Eyberg
& Robinson, 1982; Hood & Eyberg, 2003; Schuhmann, Foote, Eyberg, Boggs,
& Algina, 1998), conduct disorder (Eyberg & Boggs, 1998), and Attention-
Deficit/Hyperactivity Disorder (Matos, Bauermeister, & Bernal, 2009; Wagner
& McNeil, 2008). Gains have been found to maintain from three to six years
after treatment (Hood & Eyberg, 2003), and skills learned in therapy have
generalized both to the school setting (Funderburk, Eyberg, Newcomb,
McNeil, Hembree-Kigin, & Capage, 1998; McNeil, Eyberg, Eisenstadt,
Newcomb, & Funderburk, 1991), and to untreated siblings of children who
received PCIT (Brestan, Eyberg, Boggs, & Algina, 1997). As such, PCIT has
been identified as a probably efficacious treatment for children aged 3-6
years old (Eyberg et al., 2008). Additionally, PCIT has been successfully
adapted for a number of additional presenting problems, including anxiety
disorders (Comer et al., 2012; Pincus, Santucci, Ehrenreich, & Eyberg, 2008),
depression (Lenze, Pautsch, & Luby, 2011), and autism spectrum disorders
72 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

(Masse, 2010; Masse, McNeil, Wagner, & Chorney, 2008; Solomon, Ono,
Timmer, & Goodlin-Jones, 2008).

PCIT as an Effective Intervention for CAN

As previously mentioned, PCIT was named by the Kauffman Best


Practices Project one of three best practice treatments for treating children
and families with a history of child maltreatment (Chadwick Center for
Children & Families, 2004). Additionally, it is listed on the SAMSHA
National Registry of Evidence-based Programs and Practices (Substance
Abuse and Mental Health Services Administration National Registry for
Evidence-based Programs and Practices, 2009), namely for its application to
working with parents of children previously exposed to physical abuse. When
first applying PCIT to families with a history of child physical abuse and
neglect, Chaffin et al. (2004) outlined three major foci of treatment:
strengthening and improving the parent-child relationship, stopping the use of
any physical discipline and negative communication (e.g., criticism and
sarcasm), and teaching parents safe, consistent, and predictable discipline
skills. Thus, by reducing (or eliminating altogether) punitive and physical
discipline and teaching parents how to provide warmth and support to their
children, parents who received PCIT effectively learned how to be an
authoritative parent.
Of note, when PCIT is implemented with parents with a history of child
maltreatment, parent behavior is typically thought of as the focus of treatment,
not child behavior (Chaffin et al., 2004). However, PCIT still is effective as
parents learn and practice skills necessary to break the entrenched negative
interactions typically formed in a physically abusive parent-child relationship.
Research support has also demonstrated the effectiveness of PCIT with
children and caregivers presenting with a history of CAN and/or trauma
symptoms (Chaffin et al., 2004; Chaffin, Funderburk, Bard, Valle, &
Gurwitch, 2011; McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005;
Pearl et al., 2012; Thomas & Zimmer-Gembeck, 2011; Timmer, Urquiza, &
Zebell,, 2006), and these studies will be discussed in more detail later in the
chapter.

Child-Directed Interaction (CDI)


The overarching goal of Child-Directed Interaction (CDI), the first phase
of PCIT, is to strengthen the parent-child relationship (McNeil & Hembree-
Parent-Child Interaction Therapy for the Treatment 73

Kigin, 2010). Parents are taught skills to reinforce appropriate child behavior
and ignore minor, non-harmful misbehavior. Additionally, parents learn how
to increase their warmth, support, and respect within their parent-child
interactions. In CDI, the expectation is that the child leads the play, with the
parent following the childs lead by giving positive attention for his/her
behaviors. Parents first receive a didactic teach session, in which they learn
the principles and skills in CDI. This initial didactic session is then followed
by a series of coach sessions in which parents practice CDI skills and
receive live feedback from their therapist until they reach skill mastery
(Eyberg & Funderburk, 2011; McNeil & Hembree-Kigin, 2010).
Parents are taught to give positive attention to their childs appropriate
behavior through the use of the PRIDE skills (Praise, Reflection, Imitation,
Behavioral Description, and Enjoyment; Eyberg & Funderburk, 2011; McNeil
& Hembree-Kigin, 2010). For example, when implementing the PRIDE skills,
parents are taught to give labeled praises for appropriate child behavior (e.g.,
Thank you for sharing the toys with me); to reflect childrens appropriate
speech (e.g., child says I built a tower, and parent says Yes, you built a
tower); to imitate appropriate child play (child draws a picture of a flower
and parent also draws a picture of a flower); to describe their childrens
behavior (e.g., parent says You are coloring that picture as child colors); and
show enjoyment (e.g., warmth, enthusiasm) in their play with their child.
Additionally, to further promote a positive and nurturing relationship, parents
are taught to avoid the use of questions, commands, and critical statements
(McNeil & Hembree-Kigin, 2010). Critical statements are thought to break
down a childs self-esteem and lead to higher levels of frustration and/or
disruptive behavior. Commands and questions take the lead away from the
child and can also lead to frustration and noncompliance. Additionally, the use
of parent questions may give the child the impression that the parent is not
attending to him/her.
In addition to teaching parents to selectively attend to appropriate child
behavior, therapists also teach parents to ignore minor, non-harmful
misbehavior (i.e., behavior that does not hurt the child, another person, or
property). Examples of minor misbehavior include whining, playing roughly
with toys, yelling, and talking back (Eyberg & Funderburk, 2011; McNeil &
Hembree-Kigin, 2010). Parents are coached to follow up ignoring of minor
misbehavior with using the PRIDE skills when appropriate child behavior
occurs. During CDI, parents are asked to implement daily 5-minute special
play time in which they utilize the PRIDE skills (and avoid questions,
commands, and critical statements) at home (Eyberg & Funderburk, 2011;
74 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

McNeil & Hembree-Kigin, 2010). Parent behaviors are coded at the beginning
of each therapy session and parents are considered to have met mastery in CDI
when they use a high level of the PRIDE skills (i.e., 10 labeled praises, 10
reflections, 10 behavioral descriptions) and a low level of the avoid skills
(i.e., less than three questions, commands, and critical statements) during a
five-minute period.
CDI is critical in breaking the coercive cycle of interactions found in child
maltreatment for many reasons. Perhaps, most importantly, it fosters a sense of
warmth and respect between parents and their child, which is often absent in
abusive relationships (Boshua & Twentyman, 1984). Parent use of the PRIDE
skills, such as labeled praise for appropriate child behavior can serve to
strengthen the childs self-esteem and make interactions with his/her parent
desirable (McNeil, Costello, Travers, & Norman, 2013). Thus, children begin
to want to work for the positive attention they get from their parents, leading
to increased appropriate behaviors and decreased noncompliance and
disruptive behaviors (McNeil et al., 2013). Building the foundation of a warm,
nurturing, and strong parent-child relationship is important to establish before
parents begin to learn and utilize behavior management strategies.
In addition to the benefits for children in CDI, parents also begin to feel
increased pride and mastery in their parenting, thus making interactions with
their children more desirable (McNeil et al., 2013). Anecdotally, parents with
a history of child maltreatment typically receive highly negative feedback
about their parenting, their child, and/or their family. Through coaching in
PCIT, therapists are able to provide positive feedback to parents regarding
their use of skills, including identifying the benefits these skills have on the
child and parent-child relationship (Barnett et al., 2014). Indeed, researchers
have demonstrated that, with families who have experienced child
maltreatment, 70% of parents demonstrated the improved use of positive
reinforcement in response to appropriate child behavior within the first three
sessions of PCIT (Hakman, Chaffin, Funderburk, & Silovsky, 2009). Thus,
even in early CDI sessions, coaching can be a powerful tool to improve parent
self-esteem and increase positivity in the parent-child relationship.
Finally, even though the focus is on building positivity within the parent-
child relationship, this first phase of PCIT may elicit changes in child
disruptive behaviors. Pearl et al. (2012) demonstrated improved child
behaviors when implementing PCIT with high risk families with children
who had experienced traumatic events midway through PCIT (i.e., after the
completion of CDI) as measured by the Eyberg Child Behavior Inventory
(ECBI; Eyberg & Pincus, 1999). Parents who participate in CDI may already
Parent-Child Interaction Therapy for the Treatment 75

begin to see positive changes in their childs disruptive behaviors by utilizing


appropriate behavior management skills (i.e., PRIDE skills for appropriate
behavior; selective attention for minor misbehavior) taught in CDI (McNeil et
al., 2013). The use of these skills may serve to reduce or even prevent some of
the presenting child disruptive behaviors, opening up more opportunities for
positive parent-child interactions, furthering the breakdown of the coercive
cycle.

Parent-Directed Interaction (PDI)


The overarching goal of the second phase of PCIT, parent-directed
interaction (PDI) is to teach parents calm, safe (e.g., non-aggressive),
structured, and predictable discipline strategies (Eyberg & Funderburk, 2011;
McNeil & Hembree-Kigin, 2010). Parents learn to both reward appropriate
child behavior using PRIDE skills and to manage inappropriate behavior (e.g.,
noncompliance, aggression) using a time-out sequence (Herschell & McNeil,
2005; Timmer et al., 2006). Similar to CDI, parents receive a didactic PDI
teach session, in which they learn the PDI skills, and then subsequent
coach sessions where they practice the skills and are given feedback through
in-vivo coaching. Parents are expected to over-learn PDI skills in the clinic
before they implement these skills in the home to develop confidence in their
use of these strategies before implementing them into a real-world setting
(McNeil et al., 2013).
Parents are first taught how to deliver effective commands. Effective
commands typically begin with the word please to sound respectful, are
direct (e.g., Please hand me the block instead of Can you hand me the
block?), are positively stated (e.g., telling the child what to do, not what not
to do), and are developmentally appropriate so that children are given the
opportunity to be able to understand and comply (McNeil & Hembree-Kigin,
2010). Parents are also coached to deliver commands in a calm and neutral
manner (Costello et al., 2011). When children comply with parental
commands, parents are taught to follow this compliance with a labeled praise.
If children are non-compliant with the command, therapists teach and then
coach parents to implement a safe and structured time-out sequence, with
opportunities for the child to comply or not comply with the parental
command. Prior to practicing the time-out sequence in the clinic, it is
presented to the child, typically through a role-play activity.
The first step of the time-out sequence is for the parent to provide a
warning for the time-out chair (McNeil & Hembree-Kigin, 2010). If children
continue to be noncompliant, then parents are coached by their PCIT therapist
76 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

to safely take their child to the time-out chair; if parents initially have
difficulty walking their child to the time-out chair, they are instructed to use a
barrel carry, (i.e., holding the child under his/her armpits, facing the child
away from the parent) as a safer alternative to pulling the childs arm or other
physically coercive strategies (Eyberg & Funderburk, 2011). Children then sit
on the time-out chair for a set amount of time; at the end of this time period,
the child is again presented with the opportunity to comply with the original
command (Eyberg & Funderburk, 2011; McNeil & Hembree-Kigin, 2010).
During the time-out sequence, if the child engages in dangerous behavior
or attempts to escape sitting on the time-out chair, the parent is coached to
give a time-out back-up room warning. The back-up room is typically the
childs bedroom or a spare room in the familys house, and the parent and
PCIT therapist work closely together to identify this space prior to
implementing the time-out procedure in the home. If needed, the child waits in
the back-up room, and after the elapsed time, the child is then taken back to
the time-out chair before being given the opportunity to comply with the
original parental command (Eyberg & Funderburk, 2011; McNeil & Hembree-
Kigin, 2010). Once the time-out procedure is finished, PCIT therapists coach
parents to use a high level of CDI skills with their child; therefore, consistent
with an authoritative approach to parenting (Baumrind, 1966), parents are
taught to deliver firm, structured, and predictable consequences for child
noncompliance and disruptive behavior, while still maintaining warmth,
positivity, and support. To achieve mastery in PDI, over a five-minute period,
parents are required to deliver at least four commands, with 75% of those
commands being effective, and 75% correct follow-through with the
commands and with the time-out sequence if utilized (Eyberg & Funderburk,
2011; McNeil & Hembree-Kigin, 2010). Once PDI skills are mastered by the
parents, the parent and child are considered to have successfully completed
PCIT and graduate from treatment.
Similar to CDI, PDI effectively breaks down the coercive cycle between
parents and children in a number of ways. To begin, the goal of PDI is to
utilize safe, non-aggressive, and non-violent behavior management strategies
to deal with child disruptive behavior (Chaffin et al., 2004). Maltreating
parents, namely those engaging in child physical abuse, have been found to
use higher rates of physically aggressive, controlling, verbally threatening, and
punitive discipline practices (Boshua & Twentyman, 1984; Susman, Trickett,
Iannotti, Hollenbeck, & Zahn-Waxler, 1985). The skills taught in PDI are
critical in giving parents a range of safe, non-aggressive, and developmentally
appropriate behavior management skills to use with their children (Herschell
Parent-Child Interaction Therapy for the Treatment 77

& McNeil, 2005). Both parents and children are taught the time-out procedure,
typically through role-play exercises, and these skills are overlearned in the
clinic before the parent implements them in the home. This transparent
approach is critical for families who have experienced maltreatment, such that
expectations for both the parent and child are discussed and understood before
the process is implemented, setting the parent and child up for the greatest
amount of success.
In addition to a higher rate of physically punitive practices, parents
presenting with a history of CAN have been found to demonstrate greater
inconsistency in the delivery of behavior management strategies, compared to
parents with no history (Reid, Taplin, & Lorber, 1981). This inconsistency in
behavior management can be confusing and frustrating for children, thus
potentially worsening child disruptive behaviors and escalating parental
responses to the child behavior over time. In PDI, parents are taught to deliver
a consistent and predictable set of skills, from the use of effective commands
to utilizing the structured time-out sequence. Within the time-out sequence,
parents are required to use the same language and consequences each time so
that children clearly and consistently learn the expectations and rules. Indeed,
the time-out chair warning used in PCIT often becomes a clear signal for
compliance, and as treatment progresses, this is often the only consequence
that children need to comply with parental commands (McNeil et al., 2013).
Although concerns about time-out have been raised for children who have
experienced maltreatment or trauma, the procedure creates a sense of safety
and predictability not otherwise experiences for these children (McNeil et al.,
2013; For further misconceptions about time-out, please see Quetsch, Wallace,
Herschell, & McNeil, 2015).
Finally, as discussed previously, within the context of a coercive parent-
child relationship, children often develop a high rate of disruptive behaviors,
thus potentially leading to a higher risk for maltreatment (e.g., physical abuse;
Ammerman, 1990; Herschell & McNeil, 2005). PCIT has amassed a large and
strong research base for its effectiveness in treating disruptive behaviors in
young children. Decreases in child disruptive behaviors have been found to
occur as early as CDI (Pearl et al., 2012), and by the end of receiving PDI,
parents have been found to report subclinical levels of disruptive behavior in
their children, as well as reduced stress, and greater feelings of efficacy
(Chaffin et al., 2004; Thomas & Zimmer-Gembeck, 2011). The behavior
management strategies taught and used in PDI are essential to reducing
disruptive child behavior, while also making parents strong role-models to
78 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

their children in behavioral and emotional regulation, effectively decreasing


the risk of child maltreatment in the future.

Emotion Regulation in PCIT


Children who experience disruptive behaviors often are believed to have
difficulty with emotional control. Tantrums, aggressive behaviors, and other
outbursts may be signs of a lack of skill to regulate emotions. Emotion
regulation, defined as the ability to monitor, change and successfully adapt
one's emotions to his or her environment (Gratz & Tull, 2010) may serve as a
primary mechanism behind the parent and child's ability to accomplish such
goals and thereby help reduce the chance of potential CAN. Emotion
regulation may also include increasing or decreasing the intensity or
expression of emotions, depending on context and the individuals goals (see
Gratz & Tull, 2010; Gross, 1998, Gross & Muoz, 1995 for a review). The
development of emotion regulation has been extensively explored across
childhood and adulthood (Cole, Teti, & Zahn-Waxler, 2003; Dix, 1991;
Macklem, 2008; Morris, Silk, Steinberg, Myers, & Robinson, 2007). The
critical role of emotion regulation has also been conceptualized in the context
of a number of serious psychopathological disorders (Gross & Levenson,
1997) including depression (Campell-Sills & Barlow, 2006) and borderline
personality disorder (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006).
Parents of children with behavior problems, such as those referred to PCIT,
have been found to display high rates of negative emotions in reaction to their
childrens behavior problems (Ben-Porath, 2010), which may be exacerbated
by particularly high levels of parenting stress (Abidin, 1990; Deater-Deckard,
2004) and serve as a risk factor for child abuse (Dishion, French, & Patterson,
1995).
Past research has specifically examined the effect of positive parental
emotion regulation strategies (e.g., emotion coaching, emotional awareness,
emotional identification) on children and found significant correlations
between parents who engage in such strategies and children with adaptive
emotion regulation abilities (Gottman, Katz, & Hooven, 1996; Katz &
Windecker-Nelson, 2004). The role of emotion regulation has also been
specifically explored in the context of parent-child training and more
specifically, PCIT (See Wallace, Quetsch, Robinson, Gentzler, & McNeil, in
press, for a review). Graziano, Bagner, Sheinkopf, and Lester (2012) examined
the effect of PCIT upon the vagal regulation of young children with disruptive
behaviors who had been born prematurely. Results indicated that children of
parents trained in PCIT skills had improved vagal regulation as compared to
Parent-Child Interaction Therapy for the Treatment 79

children randomized to a waitlist comparison group. Additional studies have


expanded the PCIT model to include an emotion regulation specific phase for
young children with depression (Luby, Lenze, & Tillman, 2012) and
Attention-Deficit/Hyperactivity Disorder (Chronis-Tuscano, et al., 2014).
Results of both studies indicated improvements across a range of behavioral
and emotion-based variables. Taken together, the parent training and emotion
regulation literatures suggest that emotion regulation may serve as a primary
mechanism of the development and treatment of child behavior problems.
The use of consistent, effective behavioral strategies enables parents to
modulate their emotional reactions to the childs behavior. This technique
allows parents to intentionally disengage from the childs minor misbehavior,
and may prevent parents from experiencing emotional escalation in reaction to
the childs actions. This technique may prevent parents from experiencing
emotional escalation in reaction to the childs behavior. The consistent use of
selective attention may also assist children in maintaining and re-gaining
emotional control by obtaining parental attention solely for appropriate
behavior. Therefore, children learn to replace ineffective emotional responses
with appropriate responses to maximize the quality and quantity of parental
attention.
PDI is thought to serve as the primary treatment mechanism to improve
both childrens and parents and caregivers emotion regulation. The clear,
predictable procedure provides parents with a consistent strategy to manage
childrens defiance. During the procedure, parents are taught to behave calmly
and follow a script in which they maintain a neutral affect. Therefore, parents
do not have to resort to alternative methods (e.g., harsh discipline) in an
attempt to control their childrens misbehavior, which may have otherwise
resulted in dysregulated emotional responses. Children learn to modulate their
emotional reactions to consequences during each step of the discipline
procedure. The predictability of the procedure gives children the power to
independently gain emotional control and engage in appropriate behavior (e.g.,
compliance). Should repeated noncompliance occur, the time-out procedure
allows the child to independently utilize his/her own emotional resources to
regain emotional control (McNeil et al., 2013; Quetsch et al., 2015). Finally,
parents are taught to provide positive attention contingent upon the childs
ability to demonstrate calm, quiet behavior, indicative of emotion regulation.
Throughout both phases of PCIT, the bug-in-the-ear coaching model
allows a therapist to use both active and passive coaching strategies to promote
effective emotion regulation in both parents and children. For example, a
therapist may use a calm, soft voice while coaching the parent of a child
80 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

screaming in a time-out chair, thereby modeling emotion regulation. The


therapist may also coach the parent to engage in deep breathing exercises to
decrease his/her physiological reaction to a childs misbehavior. A coach may
model appropriate speech (e.g., Tell Johnny, thank you for using your indoor
voice) or direct a parent to rub a childs back following a temper tantrum to
help the child physiologically calm himself/herself down. Taken together, such
evidence suggests that emotion regulation serves a key role in each phase of
PCIT by providing parents with safe, effective strategies to manage childrens
behavior, thereby decreasing the chances that caregiver may resort to harsh
and potentially abusive methods.

RESEARCH SUPPORT FOR PCIT AND CAN


The use of PCIT to address CAN continues to be an emerging but
promising area of research. Early publications primarily provided theoretical
rationale for the use of PCIT with families who experienced CAN (Herschell
& McNeil, 2005; Urquiza & McNeil, 1996). As demand increased to identify
evidence-based interventions for CAN, randomized outcome trials were
completed. Researchers have continued to explore the generalizability and
applicability of PCIT with child maltreatment populations through treatment
studies implemented in community mental health settings. Previous studies
have included parents and caregivers with past reports of abuse as well as
families at-risk for abuse, which provide support for the use of PCIT in both
intervention and prevention of CAN. In addition to focusing on parents
involved in the child welfare system, PCIT has also been implemented with
foster care populations because children often enter this system having
experienced child maltreatment.
Chaffin et al., (2004) conducted the first randomized control trial to
explore the efficacy of PCIT in preventing re-reports of physical abuse in a
CAN sample. Standard PCIT was compared to services as usual and an
enhanced PCIT intervention that included individual parent services to address
risk factors for abuse. An additional motivation enhancement component
preceded both PCIT conditions with the goal of increasing parent motivation
and active participation. Referred by the child welfare system following a
confirmed report of physical abuse, 110 parent-child dyads participated in
approximately 6 months of treatment. Re-reports of abuse were assessed at a
median of 850 days post-treatment. Participants in the PCIT condition had
fewer re-reports of abuse compared to those in the enhanced PCIT and
Parent-Child Interaction Therapy for the Treatment 81

services as usual conditions. The inclusion of enhanced individual services


with PCIT may have lessened the positive impact of PCIT, which suggests that
PCIT is sufficient to reduce abuse recidivism without additional services to
address individual parental factors.
The experimental nature of this study allowed researchers to analyze the
mechanism through which change occurred in parents and families. PCIT is
theorized to modify the negative, coercive patterns underlying parent-child
interactions in families with an abuse history (Herschell & McNeil, 2005). The
positive effect of PCIT was mediated by a greater decrease in negative parent-
child interactions in the PCIT condition indicating positive support for this
mechanism. An additional study utilizing the same data sought to determine
the stage of treatment when these changes in interaction style occurred for
families receiving PCIT (Hakman et al., 2009). For 22 families from the two
PCIT conditions, parent-child interactions were analyzed using a structured
coding system, the Dyadic Parent-Child Interaction Coding System-II
(DPICS-II; Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994).
Dramatic increases in positive parental reactions and decreases in negative
parental reactions were observed in response to childrens appropriate
behavior. These changes occurred early in treatment, primarily within the first
three sessions. The authors reasoned that these immediate and significant
changes in parental behavior were facilitated by the use of direct practice and
coaching in PCIT, which differentiated PCIT from standard treatment services.
A follow-up study dismantled the effective components of the PCIT
protocol used in the initial randomized control trial by Chaffin et al. (2004).
The PCIT protocol used in this original outcome study differed from
traditional PCIT because it included a motivation enhancement orientation
prior to initiating standard PCIT. In the follow-up study, 192 families with a
history of child abuse reports were randomized to a self-motivational
orientation or a services as usual orientation (Chaffin et al., 2011). Families
were then randomized to receive standard PCIT or services as usual. Re-
reports of abuse were assessed at a median of 904 days following treatment.
PCIT combined with the self-motivational orientation significantly reduced
abuse recidivism, replicating the results of the original trial. These results
provided support for the inclusion of a motivational component to augment
standard PCIT, as it may increase parental generalization of skills to the home.
Chaffin et al., (2004) only sampled participants with a history of reported
child physical abuse. The second outcome study in this area of research sought
to compare PCIT outcomes for families with and without a history of child
abuse, to determine if risk for child maltreatment impacted the effect of the
82 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

intervention (Timmer, Urquiza, Zebell, & McGrath, 2005). The efficacy of


PCIT was compared for 193 parent-child dyads with a child maltreatment
history and 114 parent-child dyads without such history. PCIT was found to
improve childrens behavior, reduce parents stress, and decrease risk of future
child abuse in both groups. Similar positive outcomes were obtained for
families with and without an abuse history, providing further efficacy for the
use of PCIT with a child maltreatment population.
An additional randomized control trial examined the efficacy of PCIT for
families without a documented history of CAN that were determined to be at
high risk for child maltreatment. Thomas and Zimmer-Gembeck (2011)
utilized PCIT with 150 mothers who either had a confirmed history of abuse
reports or were identified as at-risk for child abuse. In this study, PCIT
improved parent-child interactions, reduced child abuse potential, and was
associated with fewer child welfare reports of abuse following treatment.
These outcomes provided additional support that PCIT can be used an as
intervention for parents who have perpetrated abuse and as an effective
preventative technique to reduce the potential of future abuse for families at-
risk for child maltreatment.
Unlike the first randomized control trial of PCIT for child abuse, this
second trial did not use a motivation enhancement orientation to supplement
PCIT (Thomas & Zimmer-Gembeck, 2011). The intervention was found to be
effective without a motivational component, providing evidence that PCIT
alone may be a sufficient treatment for child maltreatment without the
inclusion of additional services. A follow-up randomized control trial further
explored the use of a standard PCIT protocol to address child abuse (Thomas
& Zimmer-Gembeck, 2012). Although standard PCIT generally consists of
approximately 12 sessions, previous maltreatment studies had often used much
longer treatment lengths and included supplemental services. Thomas and
Zimmer-Gembeck (2012) implemented a 12-session PCIT protocol with 151
caregivers who endorsed a history of abuse or high risk for maltreatment.
Families who received the 12-session PCIT protocol had equivalent
improvements in parent-child interactions, as compared to families who
received a longer length of PCIT treatment in the researchers previous
outcome study. Taken together, the results of these trials indicate that PCIT
can be an effective intervention for the treatment and prevention of child
maltreatment without the inclusion of additional services or lengthened
treatment course.
The next step for researchers was to determine if PCIT was effective at
decreasing abuse recidivism in community settings (where child maltreatment
Parent-Child Interaction Therapy for the Treatment 83

interventions are most often implemented with families). Chaffin et al. (2011)
examined the effectiveness of PCIT administered in a field agency setting
(instead of the laboratory setting utilized in their initial randomized control
trial). As previously discussed, the results of the original randomized control
trial (i.e., Chaffin et al., 2004) were replicated in this trial and PCIT was found
to be effective in a community setting.
Pearl et al. (2012) continued this exploration of PCITs effectiveness in
community settings. PCIT was implemented with 53 families at-risk for child
maltreatment in 15 community agencies throughout the United States. At the
conclusion of treatment, reductions in child behavior problems and parental
stress were found. Although follow-up data regarding abuse reports following
treatment were not included, there was a reduction in the parent and child
factors (e.g., parental stress, child disruptive behaviors) that often lead to child
maltreatment. This suggests a decreased potential for child abuse and lowered
likelihood of future abuse reports. It should be noted that therapists in this
study had recently completed an initial training for PCIT. Therefore, the
intervention was found to be effective even when implemented by
inexperienced therapists.
To further examine the effectiveness of PCIT in settings where child
maltreatment interventions are most likely to occur, in-home PCIT was
compared to standard PCIT administered in a community agency office
(Lanier, Kohl, Benz, Swinger, Moussette, & Drake, 2011). PCIT was
originally developed for delivery in an office setting and in-home PCIT serves
as an adaptation of standard PCIT. In both settings, PCIT was associated with
similar improvements in child behavior and parental functioning and stress.
However, there was a greater decrease in parental stress for PCIT conducted
in-office. Follow-up conducted 13-40 months after completion of treatment
found a low rate of future abuse reports for both groups (Lanier, Kohl, Benz,
Swinger, & Drake, 2014). Although a randomized control group was not
included in this study, this rate of abuse reports was lower than could be
expected for at-risk families who have not received PCIT. There was also no
difference in abuse report rates based on the location where families received
services (i.e., in-home or in-office), suggesting that PCIT can effectively
reduce child abuse potential in both settings.
PCIT has also been used as an intervention for children in foster care
because many of these children have experienced CAN (McNeil et al., 2005).
Children in the child welfare system often exhibit clinically significant
disruptive behaviors, perhaps as a consequence of child maltreatment (McNeil,
et al., 2005). These children regularly experience negative outcomes, such as
84 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

longer and less stable placements, and their foster parents may not be equipped
to manage their problem behaviors (McNeil et al., 2013). Subsequently, PCIT
can be used to treat trauma and behavior problems while reducing the potential
for future abuse (McNeil, et al., 2005). The first study to explore the use of
PCIT with a foster care population provided PCIT to foster families through a
two-day workshop (McNeil, et al., 2005). Although this format differed
significantly from standard PCIT because it was conducted in a group over a
shorter time period than traditional treatment, foster parents reported a
reduction in childrens behavior problems following the workshop. These
results provided preliminary support for the use of PCIT with a foster care
population.
A second study examined the effectiveness of standard PCIT with foster
parents and their foster children (Timmer et al., 2006). The outcomes of 75
foster parent-child dyads were compared to 98 biological parent-child dyads.
PCIT was associated with improved child behavior problems and reduced
parent distress in both groups, indicating that PCIT is equally effective with
foster and biological families. Comparable positive effects of PCIT have been
found in a similar sample of 85 adoptive families (Allen, Timmer, & Urquiza,
2014). These studies suggest that PCIT may be beneficial for children at all
levels of the child welfare system who have been affected by child
maltreatment.
Although the previously discussed research is not extensive, the studies
clearly support the use of PCIT for intervention and prevention in cases of
CAN. PCIT has been found to improve child and parent risk factors for abuse,
including decreasing child behavior problems and parental stress (Chaffin et
al., 2004; Thomas & Zimmer-Gembeck, 2011). Evidence also suggests that
PCIT effectively lowers the potential for future abuse, as evidenced by
reduced rates of abuse reports or re-reports following treatment (Chaffin et al.,
2004; 2011). These outcomes have been found in randomized control trials
conducted in laboratory settings as well as in community agencies that are
more similar to real-life treatment settings for child maltreatment populations
(Lanier et al., 2011; 2014). The child maltreatment field will benefit from
continued examination of the use of PCIT to treat and prevent CAN.

CONCLUSION
Child abuse and neglect (CAN) continues to be a serious public health
problem, resulting in large societal costs and the risk for serious injury and
Parent-Child Interaction Therapy for the Treatment 85

fatalities of victims (Fang et al., 2013; Norman et al., 2012; U.S. Department
of Health and Human Services, 2010; 2011; 2012). Additionally, parents with
a history of CAN typically present with depression, substance use, history of
trauma, and personality disorders (Ammerman et al., 1999; DiLillo et al.,
2000; Downey & Coyne, 1990; Perepletchikova et al., 2012). If left untreated,
children exposed to CAN are at high risk for developing psychological
disorders (e.g., depression, Posttraumatic Stress Disorder, anxiety disorders,
disruptive behaviors; Norman et al., 2012; Thornberry et al., 2012), physical
and medical concerns (e.g., Type II diabetes, cardiovascular disease,
hypertension; Felitti et al., 1998; Norman et al., 2012; Shonkoff et al., 2009;
Widom et al., 2012), a dysregulated stress response system (Alink et al.,
2012), and for abusing their own children and romantic partners in the future
(Runyon et al., 2004). Years of research have been devoted to developing
effective interventions to reduce, and even prevent, CAN within families. One
such class of interventions is behavioral parent training programs. Typically,
these programs target dysfunctional parent-child relationships, which can
result in both risky parent and child behaviors. An underlying concept of CAN
is that parents and children are caught in a coercive cycle, whereby
increased child noncompliance and aggression yields more punitive, coercive,
and physically punishing discipline from the parent (Chaffin et al., 2004;
Urquiza & McNeil, 1996). PCIT is a probably efficacious behavioral parent-
training program originally developed for preschool-aged children presenting
with disruptive behavior disorders (Eyberg et al., 2008), and it has been
implemented with families with a history of CAN. Indeed, PCIT was named
one of three best practice treatments by the Kauffman Best Practices Project,
and is listed on the SAMSHA National Registry of Evidence-based Programs
and Practices for the treatment of CAN in families (Chadwick Center for
Children & Families, 2004; Substance Abuse and Mental Health Services
Administration National Registry for Evidence-based Programs and Practices,
2009).
Through randomized controlled trials, PCIT has demonstrated evidence
for strengthening parent-child relationships and teaching parents effective
behavior management skills, including safe, non-violent, and appropriate
discipline skills, thus effectively breaking the coercive cycle in abusive
parent-child relationships and preventing future re-reports of child physical
abuse (Chaffin et al., 2004; Thomas & Zimmer-Gembeck, 2011; Toth,
Gravener-Davis, Guild, & Cicchetti, 2013). Additionally, PCIT has
demonstrated effectiveness in reducing risk of CAN in community-based
clinic settings (Chaffin et al., 2011; Pearl et al., 2012), within home-based
86 Amanda H. Costello, Ria M. Travers, Lauren B. Quetsch et al.

delivery (Lanier et al., 2011; 2014), and in the foster care system (Allen et al.,
2014; McNeil et al., 2005; Timmer et al., 2006). In addition to improving
parental discipline practices, parenting stress and efficacy, and child disruptive
behaviors, PCIT is also a promising intervention to help with the development
of more effective emotion regulation of both the parent and child in treatment.
Thus, with its strong empirical success in effectively breaking the coercive
cycle between parents and children, as well as promoting positivity within the
parent-child relationship, PCIT remains a critical intervention for parents and
children with a history of CAN.

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Science Publishers.

BIOGRAPHICAL SKETCH
Name: Amanda H. Costello, Ph.D.
Affiliation: Department of Psychological and Brain Sciences, University
of Delaware
Date of Birth: 07/03/1985
Education: Ph.D. West Virginia University (clinical child psychology)
M.S. West Virginia University
B.S. University of Pittsburgh
Address: 108 Wolf Hall; Newark, DE 19716
Research and Professional Experience:

Postdoctoral Researcher- 2015


Department of Psychology, University of Delaware, Newark, Delaware
Postdoctoral Appointee 2014-2015
CARES Institute at the Rowan University School of Osteopathic Medicine
Professional Appointments: N/A (postdoctoral position)
Honors: N/A
Publications Last Three Years:

Costello, A. H., Moreland, A.D., Jobe-Shields, L., Hanson, R. F., & Dumas J.
E. (in press). Change in child abuse potential as a predictor of post-
assessment child disruptive behaviors after participation in PACE. Journal
of Child and Family Studies.
Parent-Child Interaction Therapy for the Treatment 97

Jobe-Shields, L., Costello, A. H., Jackson, C., & Hanson, R. F. (in press).
Evaluating treatments and interventions: What constitutes
evidencebased treatment? In S. Maltzman (Ed.), The Oxford Handbook
of Treatment Processes and Outcomes in Counseling Psychology.
Tempel, A. B., McNeil, C. B., Chengappa, K., & Costello, A. H. (2014).
Evaluation of a standard parenting class within a women's state
correctional facility and a parent-training class modeled from Parent-Child
Interaction Therapy. Children and Youth Services Review, 46, 238-247.
Costello, A. H., & McNeil, C. B. (2014). Differentiating parents with faking-
good profiles from parents with valid scores on the Child Abuse Potential
Inventory. Journal of Family Violence, 29(1), 79-88.
McNeil, C. B., Costello, A. H., Travers, R. N., & Norman, M. A. (2013).
Parent-child interaction therapy with children traumatized by physical
abuse and neglect. In S.Kimura & A. Miyazaki (Eds.), Physical and
Emotional Abuse: Triggers, Short and Long-Term Consequences and
Prevention Methods. Nova Science Publishers: Hauppauge, NY.
Chengappa, K., Stokes, J. O., Costello, A. H., Norman, M. A., Travers, R., &
McNeil, C. B. (2012). Parent-child Interaction Therapy for severe sibling
conflict in young children. In M. Dupont & J-P. Renaud (Eds.), Siblings:
Social Adjustments, Interaction and Family Dynamics. Nova Science
Publishers: Hauppauge, NY.
INDEX

anxiety disorder, 71, 85, 88


A assessment, 6, 15, 40, 60, 96
attachment, 58, 86
abuse, vii, viii, ix, 1, 2, 7, 8, 9, 10, 11, 12,
attitudes, 41
13, 14, 16, 17, 19, 20, 21, 22, 25, 28, 29,
authenticity, 26
33, 34, 36, 40, 48, 52, 56, 59, 60, 61, 62,
authority, 70
65, 66, 67, 68, 72, 76, 77, 78, 80, 81, 82,
autism, 71, 92, 94
83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93,
autonomy, 31, 34
94, 96, 97
avoidance, 45
access, 3, 6
awareness, 61, 78
action research, 28, 29, 56
adaptation, 83
ADHD, 92, 96 B
adjustment, 56, 88
Administration for Children and Families, base, vii, ix, 16, 66, 68, 70, 77, 80, 85, 86,
18, 66, 95 95
adolescents, 89, 92 behavior therapy, 87
adulthood, 66, 78 behaviors, 41, 45, 67, 68, 69, 73, 74, 77, 78,
adults, 5, 66, 89 83, 85, 86, 96
African American(s), 2, 3, 4, 5, 6, 8, 9, 11, benefits, 6, 74
12, 14 benign, 5
age, 6, 10, 11, 12, 15, 22, 33, 53, 67, 69, 85, bias, 4, 7, 15, 16, 18
92 black stereotype, 11, 14
agencies, 7, 10, 83, 84 blacks, 8
aggression, 67, 68, 75, 85 bonds, 58
aggressive behavior, 78 borderline personality disorder, 78, 90
alcoholism, 66 brain, 24, 25, 56, 66
amygdala, 24, 25 breakdown, 75
anger, 22, 25, 26, 36, 37, 38, 46, 88 breathing, 80
antisocial behavior, 88 buttons, 37
anxiety, 66, 71, 85, 87, 88
100 Index

consensus, 30
C control group, 83, 87
controlled trials, 85
campaigns, 93
conversations, 44, 46, 48
cardiovascular disease, 85
conviction, 5, 13
caregivers, 70, 72, 79, 80, 82, 96
coping strategies, 23
case study, 58
correlations, 78
caucasians, 6, 14
cortisol, 86
causality, 13
cost, 3
census, 17
critical state, 73
challenges, 22, 45, 47, 58
criticism, 72
Chicago, 7
culture, vii, viii, 15, 19, 20, 21, 23, 26
child abuse, 7, 8, 14, 17, 61, 62, 66, 78, 81,
82, 83, 87, 88, 96
child maltreatment, vii, viii, 1, 2, 3, 7, 8, 12, D
15, 22, 66, 72, 74, 78, 80, 81, 82, 83, 84,
86, 89, 95 danger, 25
child protective services, 93 database, 60, 61
childhood, viii, 19, 20, 21, 22, 23, 25, 28, defendants, 18
29, 33, 34, 52, 55, 56, 57, 58, 59, 60, 61, delinquency, 68
66, 78, 88, 89, 93, 94 Department of Health and Human Services,
childhood sexual abuse, 55, 56, 58, 59, 60, 15, 17, 18, 65, 66, 85, 94, 95
61, 88 depression, 66, 67, 71, 78, 79, 85, 91, 92, 93
children, vii, viii, ix, 1, 2, 3, 4, 5, 6, 7, 8, 9, deprivation, 12
10, 11, 12, 14, 15, 16, 17, 18, 22, 33, 40, desensitization, 68
41, 45, 47, 59, 65, 66, 67, 68, 69, 70, 71, developmental psychopathology, 88
72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, deviation, 54
83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 94, diabetes, 66, 85
96, 97 dignity, 22
Civil War, 3 disability, 34, 40
classification, 17 disappointment, 38
clients, 21, 28, 69 disclosure, 31, 55
coding, 30, 71, 81 discomfort, 47
cognitive-behavioral therapy, 94 discrimination, 2, 4, 5, 6, 11, 14, 16
college students, 8 disorder, 66, 71, 86, 93, 94
color, 8, 11, 21 distress, 24, 31, 40, 41, 43, 50, 84
communication, 70, 72 doctors, 4
communication skills, 70 dominance, 21
community, 80, 82, 83, 84, 85, 91, 93
compensation, 52
compliance, 69, 75, 77, 79 E
conceptualization, vii, viii, 19, 21, 23, 50
conduct disorder, 71 eating disorders, 61
confidentiality, 28 ecology, 88
conflict, 24, 31, 37, 38, 46, 49, 51, 97 economic status, 8
conformity, 53 education, 4, 12, 67, 93
Index 101

emergency, 8
emotion, 2, 52, 56, 57, 58, 60, 61, 62, 78,
G
79, 86, 87, 88, 90, 91, 92, 93
gender role, 22
emotion regulation, 78, 79, 86, 87, 88, 90,
generalizability, 80
92, 93
graffiti, 5, 7
emotional experience, ix, 20, 31, 39, 42, 52
guidelines, 42, 52
emotional reactions, 36, 79, 90
guilt, 17
emotional responses, 79
guilty, 14, 36, 44
emotionality, 67
employment, 12
empowerment, 22, 57, 62, 70 H
environment, 47, 78
equality, 23, 47, 55, 58 healing, 57
equity, 59 health, vii, ix, 2, 4, 6, 12, 15, 22, 65, 66, 80,
ethnic background, 29 84, 90, 91, 93, 94
ethnic minority, 8 Health and Human Services, 15, 18, 65, 66,
ethnicity, 6, 10, 12, 16, 44 85, 95
evidence, vii, viii, ix, 1, 2, 4, 5, 7, 9, 12, 16, health promotion, 94
66, 68, 80, 82, 85, 90, 95, 96 health services, 6, 15
evidence-based program, 68 helplessness, 25, 38
evil, 43 history, 12, 21, 25, 28, 41, 55, 67, 69, 72,
exercises, 68, 71, 77, 80 74, 77, 81, 82, 85, 86, 93
expertise, 61 homes, 3, 5, 7, 11
exposure, 52 homework, 71
honesty, 48
hopelessness, 41
F hostility, 23, 68, 92
human, 25, 56
families, viii, ix, 1, 2, 3, 5, 6, 7, 8, 10, 11,
human brain, 25
12, 13, 14, 15, 16, 57, 61, 66, 67, 69, 70,
human development, 56
71, 72, 74, 77, 80, 81, 82, 83, 84, 85, 91,
Hurricane Katrina, 16
93, 94, 95
husband, 30, 33, 42, 58
family functioning, 89
hyperactivity, 67
family income, 9
hypertension, 85
family members, 33
family studies, 56
family therapy, 21, 57, 58, 61 I
fear, ix, 20, 22, 23, 31, 33, 40, 44, 49, 53
feelings, 21, 43, 44, 47, 77, 90 identification, 78
female partner, 34, 44, 45, 50, 53, 55 identity, 22, 26, 43, 51, 52, 57
femininity, 23, 31, 35, 42, 50, 53, 54, 55 imbalances, 26, 50
financial, 33 improvements, 70, 79, 82, 83
flight, 24 impulsivity, 96
Ford, Gerald Rudolph, 16 in vivo, 94
funds, 33, 41 incidence, 17
income, 4, 9, 10, 12, 15, 40, 67
102 Index

independence, 31 lying, 41
individuals, 7, 61
inequality, 22
infants, 10 M
informed consent, 28, 29
majority, 70
injuries, 34, 53
maltreatment, vii, viii, 2, 3, 6, 7, 8, 9, 12,
injury, 40, 84
15, 21, 22, 59, 60, 61, 66, 68, 72, 74, 77,
innocence, 15
80, 82, 83, 84, 86, 88, 89, 93, 94, 95
institutions, 3
management, 34, 69, 74, 75, 76, 77, 85, 88,
integration, 3, 16
93
internalizing, 39
marijuana, 41, 42
interpersonal relationships, 59
marriage, 44, 48, 57
intervention, ix, 46, 66, 67, 68, 80, 82, 83,
masculinity, 23, 31, 33, 42, 46, 50, 52, 53,
84, 86, 89, 90, 92, 95
54, 55
intimacy, 22, 26, 60
maternal control, 90
investment model, 61
matter, 46
irritability, 67
median, 80, 81
isolation, 24
mediation, 56
issues, viii, 20, 21, 22, 23, 28, 29, 30, 48,
medical, 61, 85
49, 60, 61, 66, 67
mental health, 6, 15, 80, 90, 91
mental illness, 13
J mentor, 93
messages, 23, 36, 44
Jordan, 34, 58 meta-analysis, 93
juries, 18 metaphor, 25
juror, 18 Middle East, 29
justification, 34 military, 34
minorities, 4, 6
misconceptions, 67, 77
K Missouri, 12
models, 33, 49, 77, 86
kill, 68
molecular biology, 94
mood disorder, 87
L mortality rate, 4
motivation, 13, 80, 81, 82, 87
Latin America, 28 mutuality, 24, 25, 26, 39, 41, 46, 49, 51
laws, 6
learning, 93
N
lens, 56, 62
life satisfaction, 93
narratives, 34, 40, 53
live feed, 73
National Poverty Center, 16
living conditions, 12
negative consequences, 67
longitudinal study, 27, 59, 94
negative emotions, 78, 90
Louisiana, 19, 62
negative outcomes, 12, 83
love, 21, 49
Index 103

neglect, vii, viii, ix, 1, 2, 7, 9, 14, 17, 20, 22, positive feedback, 74
28, 36, 40, 65, 66, 67, 72, 84, 87, 92, 93, positive reinforcement, 74
97 postmodernism, 57
neighborhood characteristics, 15 posttraumatic stress, 94
Netherlands, 16 post-traumatic stress disorder (PTSD), 59,
neurobiology, 24, 57, 62 66
neutral, 75, 79 poverty, 2, 6, 9, 12, 13, 22
nursing, 40 power relations, 26, 44
predictability, 77, 79
pregnancy, 61
O prejudice, viii, 2, 3, 4, 7, 14, 15, 17, 18
preschool, 69, 85, 86, 91, 92
offenders, 18
preschool children, 91, 92
openness, 26
preschoolers, 87
operations, 31, 52, 53
prevention, 80, 82, 84, 89, 93, 94, 95
opportunities, 26, 75
principles, 70, 73
problem behavior(s), 67, 84
P problem children, 89, 90, 91, 92
project, 28, 29
pain, 43, 49 protection, 24, 25, 26, 36, 37, 38, 55, 58
parental control, 86 psychological development, 56
parental employment, 12 psychology, 15, 56, 57, 58, 59, 96
parent-child relationship, 5, 68, 69, 70, 71, psychopathology, 42, 67, 88
72, 74, 77, 85 psychotherapy, 6, 68
parenting, 67, 70, 74, 76, 78, 86, 88, 92, 97 public health, vii, ix, 65, 66, 84
parenting styles, 92 public opinion, 4
parents, vii, ix, 5, 8, 9, 10, 11, 12, 14, 33, punishment, 67, 69, 88
44, 53, 66, 67, 68, 69, 70, 72, 73, 74, 75,
76, 77, 78, 79, 80, 81, 82, 84, 85, 86, 87,
Q
88, 89, 92, 94, 97
participants, 5, 8, 13, 29, 81
qualitative research, 56
pathways, 15
questioning, 22
perinatal, 61
personality, 15, 67, 78, 85, 90, 93
personality disorder, 67, 78, 85, 90, 93 R
physical abuse, 8, 9, 33, 68, 72, 76, 77, 80,
81, 85, 87, 90, 91, 92, 93, 94, 97 race, vii, viii, 1, 2, 4, 5, 7, 8, 9, 10, 12, 13,
physiology, 90 14, 15, 16, 17, 18
play activity, 75 racial differences, 2, 9
playing, 73 racism, viii, 2, 4, 5, 6, 11, 12, 13, 14, 16, 17,
police, 4 34, 38
policy, 4, 14 reactions, ix, 20, 24, 28, 31, 36, 49, 55, 79,
politics, 58 81, 90
population, 54, 82, 84 reactivity, 25, 26
positive behaviors, 68 recidivism, 68, 81, 82, 87
104 Index

recovery, 59, 61 shape, vii, viii, 1, 2, 43


reflectivity, 51 sibling(s), 71, 87, 97
registry, 72, 85, 94 signs, 78
reinforcement, 69, 74 skills training, 87
relaxation, 68 smoking, 41, 66
reliability, 26 social construct, vii, viii, 19, 21, 60
requirement(s), 2, 31 social context, 23, 29, 30, 42, 43, 58
researchers, 7, 13, 28, 29, 30, 52, 74, 81, 82 social interaction, 93
resolution, 61 social learning, 93
resources, 79 social network, 53
response, 3, 25, 26, 33, 37, 39, 40, 47, 54, social norms, 4
68, 74, 81, 85, 90 social psychology, 15
responsiveness, 67 social workers, vii, viii, 1, 2, 6, 8
rights, 17 socialization, 34, 42, 52, 53
risk(s), ix, 6, 12, 14, 15, 61, 65, 66, 67, 68, societal cost, 84
74, 77, 78, 80, 81, 82, 83, 84, 85, 94 society, vii, ix, 65
risk assessment, 6 sociocultural contexts, 50
risk factors, 80, 84, 94 socioeconomic status, 6, 10
root(s), 13, 94 speech, 69, 73, 80
rules, 6, 70, 77 state(s), 6, 17, 97
statistics, 95
stereotypes, 8, 9, 11, 12, 14, 16, 23
S stereotyping, viii, 2, 3
stress, 37, 47, 49, 56, 66, 77, 78, 82, 83, 84,
safety, ix, 15, 20, 21, 22, 24, 25, 26, 30, 31,
85, 86, 88, 94
32, 39, 40, 41, 43, 47, 48, 49, 50, 51, 54,
stress response, 85
55, 56, 70, 77
stressors, 54
SAMSHA, 72, 85
structure, 10, 16
sarcasm, 36, 72
style(s), 67, 68, 81, 87, 92
school, 71, 90, 92
substance abuse, 10, 12, 86
science, 2, 18, 57
Substance Abuse and Mental Health
security, 26, 47
Services Administration, 72, 85, 94
segregation, 6
substance use, 67, 85
selective attention, 75, 79
suicide, 66
self-esteem, 67, 73, 74, 92
supervisors, 28, 29, 40
self-reflection, 39, 47, 48
support services, 6
sensitivity, 23
survival, 22
sentencing, 18
survivors, viii, 19, 21, 22, 23, 24, 25, 50, 52,
services, vii, viii, 1, 2, 3, 6, 10, 15, 80, 81,
55, 56, 58, 59, 60, 61, 62
82, 83, 93
susceptibility, 12
SES, 6
symptoms, 56, 72
sex, 54
systematic desensitization, 68
sexual abuse, 9, 33, 36, 55, 56, 58, 59, 60,
61, 88
sexual orientation, 13
sexual problems, 22
Index 105

US Department of Health and Human


T Services, 17, 94
target, 68, 85
techniques, 67 V
technology, 95
therapeutic approaches, 42, 54 variables, 79
therapeutic conversation, 44, 48 variations, 30, 50
therapist, 28, 29, 33, 36, 39, 45, 46, 47, 48, victimization, 21, 52
51, 53, 59, 60, 61, 69, 70, 73, 75, 76, 79 victims, vii, ix, 9, 12, 58, 65, 66, 85
therapy, viii, ix, 19, 20, 21, 23, 26, 27, 28, videotape, 28, 50
29, 30, 38, 40, 41, 46, 48, 49, 50, 52, 55, violence, 4, 22
56, 57, 58, 59, 60, 61, 62, 66, 68, 71, 74, violent behavior, 76
87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97 vision, 41
threats, 67 vote, 14
toys, 73 vulnerability, ix, 20, 26, 31, 34, 39, 47, 48,
traditional views, 33, 50 49, 50, 51, 52, 53, 54, 55, 60
training, 66, 68, 69, 70, 78, 83, 85, 87, 88,
89, 91, 96, 97
training programs, 69, 70, 85 W
trajectory, 44
transcripts, viii, 20, 27, 28, 29, 30 walking, 76
trauma, 21, 22, 49, 53, 55, 56, 58, 59, 60, war, 45
61, 67, 68, 72, 77, 84, 85 Washington, 15, 16, 17, 18, 88, 94
traumatic events, 74 weakness, 31, 52, 54
treatment, 7, 12, 14, 21, 25, 38, 56, 58, 59, welfare, 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14,
60, 68, 69, 70, 71, 72, 76, 77, 79, 80, 81, 15, 16, 80, 82, 83, 84, 87, 91
82, 83, 84, 85, 86, 87, 89, 90, 91, 92, 93, welfare system, 2, 3, 5, 6, 7, 9, 10, 11, 12,
94, 95, 96 13, 14, 16, 80, 83, 84
trial, 80, 81, 82, 83, 87, 91, 92, 94 well-being, 2, 42
triangulation, 30 workers, vii, viii, 1, 2, 6, 8, 11
triggers, 24 World Health Organization, 22, 61
trustworthiness, ix, 20, 24, 26, 31, 39, 46, wrongdoing, 37
47, 51
Y
U
Yale University, 88
United States, vii, ix, 3, 65, 66, 83, 89