Section 1: General principles
There were three general principles that cut across the four elements of parent involvement: variability, goodness of fit, and the benefits of parent involvement in child mental health treatment.
1.1. Variability of Parent Involvement
Although all parents were seeking therapy for their children, not all parents demonstrated the same level of involvement in therapy activities. Therapists spoke of a range of parent involvement during sessions (e.g., participating in activities and discussions, attentive listening, following along in the parent handbook, helping the child understand therapy content), as well as outside sessions (e.g., facilitating skill practice at home, communicating with school staff).
Parents who were involved in a helpful way during therapy were noted as being committed, motivated, positive, supportive, and mindful. They demonstrated their commitment to therapy through completing in-session tasks and after-session homework, arriving to sessions on time, having therapy materials organized (e.g., bringing workbooks to and from home), implementing an at-home reward system for skill generalization, and being responsive to email or phone communication with the therapist outside of session time. Highly-involved helpful parents also tended to be motivated to engage with therapy content, were excited to attend sessions, eager to learn new skills alongside their child, were willing to try therapists’ ideas and suggestions, and were “immersed” in the program (e.g., learning the cognitive-behavioral language and using it at home). In addition, it was helpful when parents maintained a positive attitude towards therapy, demonstrated warmth towards their child, noticed and reflected on their child’s successes, and were supportive of their child’s progress. Helpful or involved parents demonstrated a level of mindfulness during sessions; they were present, “tuned in,” or “checked in to what was happening in the room,” and remained compassionate and non-judgmental during the therapeutic process.
There were also ways in which parents were unhelpful when included in treatment, such as being disengaged or distracted, frequently interrupting, or having a negative attitude or misaligned session goals. Therapists noted that some parents were disengaged or assumed that they were not needed in the session, and as a result could miss opportunities to step in and assist their child. There were also some therapy activities that participants noted seemed geared to the child alone (e.g., didactic psychoeducation, video games), which can send mixed messages given the program’s expectation to involve parents in all aspects of therapy sessions. While therapists understood that parents were busy and juggling multiple responsibilities, there were times when some parents used their phones, left the room, or were otherwise distracted, missing opportunities to support their child in activities. Therapists also found that parents who frequently interrupted their children or stepped in without letting their child speak first were unable to see what the child could achieve on their own. It was unhelpful to the therapeutic process when parents had a consistent negative attitude or affect in session, or when they had misaligned session goals leading them to be overly focused on details that took away from the session aim (e.g., making sure the child sat in the chair properly or spelled words correctly).
Of note, the quality of parental involvement seemed of greater importance than the quantity of involvement. For example, while some parents could be less talkative than other parents, they could still provide valuable contributions. Because of the many pre-intervention factors that can influence any given presentation of parent involvement, it may not be useful to try to describe an exact ‘rule’ or guideline as to how much or little parents should be involved in therapy.
1.2. Goodness of Fit of Parent Involvement
To fit with their child’s needs, parents adapted their involvement in therapy depending on child factors, such as age, developmental level (e.g., understanding of abstract concepts), executive functioning (e.g., organization, memory, problem solving skills), attention or behavioral problems, temperament, or motivation to engage in therapy. Participants noted how parents might not need or want to be present for the entire session if their child was older, capable of understanding the abstract concepts, or desired independent connection with therapists. In that case, parents could benefit from having the flexibility to attend the beginning and end of their child’s sessions, or to have some sessions without the parent to give the child some autonomy in the therapeutic process and the freedom to have their own ‘space’ with the therapist. Parents of children with executive functioning difficulties found they needed to provide their children with further support, such as breaking down tasks into smaller steps for their child, providing prompts and reminders to help support their children’s problem solving, help them stay organized, and plan home practice.
1.3. Benefits of Parent Involvement
Parent involvement was associated with benefits during and outside of session. During session, therapists noticed that when parents were actively engaged, children also seemed more motivated, had more fun, and were more likely to complete therapy homework. In effect, children learned from parents’ modelling of positive behaviors. In addition, learning and practicing emotion regulation strategies was challenging for many families, and the child’s persistence and motivation seemed to be bolstered when a parent supported their child through these challenges.
Attending sessions also had benefits that extended beyond session time. Parents learned content that could: a) help them with their own emotion regulation and mental health, and b) equip them to assist their child in emotion regulation tasks and in maintaining therapeutic gains post-treatment. For example, three years after participating in the brief CBT program, one parent (P008) was able to recall specific emotion regulation strategies they continue to use with their child, and described ways they adapted concepts learned in therapy to apply to more complex social situations as their child matured into adolescence. In addition, having a shared experience in therapy, along with a shared vocabulary to communicate about emotions and new tools to cope with strong feelings, can also enhance the parent-child bond. For example, one mother shared about how participating in CBT together helped to deepen her relationship with her son:
“I think it brought my son and I closer together, I think it really did. Being involved with him and walking every step of the way -- there was a deeper sense of trust I think with that. I became his sounding board for a lot of things, and I really credit this program, going through it all together, being involved in all of it. We were [close before] but it just took on a different element.” –P007
Parents may also come away with a deeper understanding of, and compassion for, their child after participating in therapy with them:
“I think sometimes you don’t have the necessary tools to understand what that child is going through because you take for granted that simple things could be difficult. I saw how autism affected him, how challenging simple things were for him, and it made me parent differently. It made me feel stronger as an individual because I had more compassion for what he was going through.” –P011
Section 2: Therapeutic Process Factors
Four therapeutic process factors were seen as important elements of parent involvement (components “in the room” during therapy), including parent therapeutic functions during the intervention (e.g., logistical coordinator, co-facilitator, coach and cheerleader, companion and teammate, complementary helper), parent beliefs and attitudes towards child mental health treatment (e.g., therapy commitment, criticalness, and flexibility), child motivation to participate in therapy, and therapist factors (e.g., characteristics, skill and knowledge, behaviors).
2.1. Parent Therapeutic Functions
Parent-specific therapeutic process factors included five therapeutic functions parents may fulfil during the intervention: logistical coordinator, co-facilitator, coach and cheerleader, companion and teammate, and complementary helper.
2.1.1. Logistical Coordinator: “Let me handle the logistics.” Parents were in charge of planning and organizing the logistics involved with attending sessions. This involved communicating with the therapist to schedule sessions, arranging transportation, ensuring that materials (e.g., handbooks, worksheets, cards) were brought to and from home, coordinating with school staff if session times overlapped with the school day, bringing snacks, and allotting time for traffic to arrive on time. For example, one therapist said:
“I think that it was really nice to have the parents there because they would be better [than the child would be on their own] at organizing all these materials and making sure things are brought to session, not forgetting things. So that management aspect of it was very helpful. Again more logistics stuff but it makes a big difference actually, especially with a CBT program.” – T016
2.1.2. Co-facilitator: “Here is what we need to do.” During sessions, parents assisted therapists with the execution of therapy tasks and were engaged in co-running aspects of the intervention with the therapist. Working as a team, parents brought in expertise on their child (e.g., providing the therapist with relevant clinical information about the child’s history and interests), while the therapist brought in their expertise on the therapy content with the parent helping to facilitate activities (e.g., helping the child understand how to do therapy activities). One therapist (T005) noted: “Just working together, they know their kid better than me, so they know if I word something one way, they might know how to word it differently to make their child understand.” CBT often relies on clients to provide examples of a time when they felt a certain emotion to help guide discussions during therapy, and therapists found it helpful to have parents remind their child of specific examples from the child’s experiences at school or at home.
Parents also provided therapists with insight into the child’s life, articulating recent challenges that may have arisen, and providing therapists with feedback on the implementation of skill practice at home. They also gave therapists an idea of when a particular topic might be difficult for the child. For example, one therapist shared:
“…the parent would lean over and something would be said and they'd [say] ‘Oh this is a tough topic for him, this will be hard today.’ And they give you this little window [into the child’s life] that you wouldn’t probably get without the parent.” – T005
Parents can also provide therapists with helpful information about a child’s strengths and interests, enabling therapists to incorporate those into therapy. In turn, parents’ co-facilitation efforts help to make the material more relatable to a particular child’s context. Over the course of therapy, as parents learned how to help their child identify and rate emotions, and implement coping strategies, some parents spontaneously drew on these skills in-session to support their child during times of emotion dysregulation, with the assistance of the therapist if needed.
Parents were also co-facilitators outside of the session. For example, parents were instrumental in ensuring weekly completion of home practice, orchestrating situations to enable their child to practice the emotion regulation skills, reminding the child to complete home practice, creating an at-home reinforcement system similar to the one used in session, and communicating session content to school staff to help the child practice skills at school. Some parents also found creative ways to complete home practice (e.g., watching the Olympics to practice identifying others’ emotions through facial expressions or body language). Because parents observed how therapists explained concepts in session and learned therapy content first-hand, parents were able to use consistent terminology and language with their child, as well as engage in problem-solving when barriers or challenges arose during skill practice at home or at school.
2.1.3. Cheerleader and Coach: “You can do it and I can help you succeed.” Parents encouraged children in targeted change (i.e., improving their emotion regulation skills), with the goal of increasing the child’s autonomy in coping with their emotions. Parents provided their child with praise and encouragement for completing difficult activities or doing their best to learn new concepts or skills, as well as celebrated and delighted in the child’s successes, such as one parent who said:
“Like when [my son] worked through that anxiety too by himself and I'm just coaching from the sidelines, like giving him extra points, he just—wow! So then [I’d say]… ‘there are times you didn’t realize how big this is that you did this! You did this, right? Yourself! This is huge!’” – P007
If child motivation waned towards the later stages of therapy, parents would also encourage their child to continue. There were times when coping strategies would no longer work, or when families had to go through a period of trial-and-error to identify new strategies, and in those times, parents helped to keep their child moving toward therapy goals. One mother talked about drawing on her personal experiences of the effectiveness of coping strategies to encourage her child to continue practicing these new skills, even when it seemed difficult:
“I think because I could relate and I could see how certain concepts of, for example deep breathing, are so good, I knew that they could work with him as well […] I could encourage him to persevere because if you’ve been through a tunnel you’ve come out the other side, you know there is another side, right? So then you can help him through that as well.” -P007
It was also important to parents that they balance supporting their child with allowing them space to learn how to use coping skills and regulate emotions more independently. Parents felt that providing praise and encouragement also contributed to their child’s confidence and sense of accomplishment. One mother spoke of how rewarding it was to be part of her child’s progress:
“…it was kind of fun, you feel a little bit [like] a mother hen pushing her child out a little bit. But it was so wonderful to see to see him grow, and to be able to pull back and on the sidelines and just kind of push him a little bit out there saying, ‘You can do this, I'm watching you do it.’” – P007
2.1.4. Companion and Teammate: “I am here for you, we are in this together.” Parents were able to act as children’s allies and build a sense of “togetherness.” At the beginning of therapy, a parent’s presence can help them feel more comfortable with the novel environment, making it easier for the child to see therapy as a safe space and enable the therapist to build rapport. Parents were also involved alongside their children in activities, such as role-play to practice coping skills and problem solving, or game-based psychoeducational activities. By being a companion with the child, parents provided a sense of companionship and normalized the experience of receiving help from a mental health professional and allowed the child to feel less alone in the process, knowing that they had someone to trust and rely on. Some parents also found ways to involve other family members in home practice or to teach their other children coping skills to normalize the use of these skills.
Having the parent and child together during sessions allowed them the opportunity to work as a team. One therapist (T016) recounted an example where, “They were on a team and there was a lot of support and a lot of trust, and I think it was a real amazing asset to have them together because it elevated it to another level.” Some parents were enthusiastic about participating to help their child get the most out of their therapy experience, with one therapist (T005) remarking, “I had parents on the ground, making jokes with their kids but keeping the kid comfortable. I had some great examples of parents who would really do anything to get their child engaged and going through the program.”
2.1.5. Complementary Helper: “I can fill in the gaps where you need me to.” This function specifically refers to the acts of helping to bridge the gap between the child’s capacity and what is expected of them within the therapeutic context. By being attuned to the child’s needs, parents could step in to scaffold a child’s participation in session through actions such as: helping the child build a relationship with the therapist, helping the therapist better understand the child, managing the child’s behavioral or attention problems, scribing for a child with fine motor issues, or linking therapy content to the child’s experiences to make abstract concepts more concrete and understandable. For autistic children with social-communication difficulties, developing a relationship with an unfamiliar person can be challenging, and some autistic children may need their parent’s help with building a therapeutic relationship with the therapist. Parents can “bridge the relationship” between the therapist and the child by modelling for the therapist ways to best to relate to the child, especially when a child is less intrinsically motivated to engage with the therapist. Some parents helped their child develop a rapport by prompting them, or by offering information about the therapist that would pique the child’s interest:
“the mom said to [her son], “Did you know that [therapist’s name] has her PhD?” And he like, looked away and then two seconds later, he looked up, he’s like, “Really? What do you have it in?” And all of a sudden he was interested in me… she knew what he would like about me and she tried to develop that relationship.” –T008
Parent complementary helpers also bridge the gap for children by asking therapists to change aspects of sessions to better accommodate specific triggers or needs (e.g., noting how a child can be triggered when hungry can lead to incorporating snack breaks into session agendas). Parents used strategies to help support their child when faced with attentional issues, such as repeating or rewording a question, reminding the child to stay focused, and redirecting the child’s attention back to the goal of the session. In other instances, children experienced negative emotions that could have led to a rupture in the therapeutic alliance and parents functioned as a ‘safety net’ in these situations. One therapist (T008) noted: “I can do my best but [the mother is] the one that gives him a little whisper in the ear. I don’t know what she’s saying but then he starts to actually listen to me.” Children who had fine motor issues benefited from having a parent scribe for them when they needed to complete written activities. CBT also requires a certain level of abstract thinking, as clients are asked to change or bring awareness to maladaptive thoughts. Parents were connecting the dots with their child and helped them understand how to apply a coping strategy by reminding them of a situation in which it might have been useful, or bringing in other personal examples to “bring the material to life for the child” (T017).
2.2. Parent Beliefs About and Attitudes Towards Therapy
In addition to these parent therapeutic functions, three main parent beliefs and attitudes related to therapy emerged as important in influencing parent involvement: therapy commitment, therapy criticalness, and therapy flexibility.
2.2.1. Therapy Commitment: “Therapy is worthwhile,” Positivity, and Persistence. Many parents were committed to therapy, demonstrating an attitude of positivity and persistence, and the belief that participation in therapy is worthwhile. Therapists noticed that some parents seemed particularly committed to prioritizing therapy in their busy schedules, taking an active role in completing therapy tasks (e.g., in-session activities, practicing coping strategies with the child at home), arriving to sessions on time, and a general ‘buy-in’ to the effectiveness of therapy. Parents also understood that helping their child outside of session time and after the CBT program ended would help their family get the most benefit out of therapy: “It’s only as good as the effort you put in after the fact, so [I was] trying to keep drawing on the material and keep it fresh at home” (P005).
Parents also reframed potential barriers to therapy in a positive light. For example, one mother reframed long travel times as an opportunity to bond with her child. Another parent described their commitment to their child’s therapy as a small part of a bigger picture:
“I guess the more you learn about something like autism and how that’s going to affect your child… how it shows in their life, you know, it’s a journey. …this is going to be a journey and [SAS:OR] is then part of the journey.” – P007
Therapists reported that it was helpful to have parents look for positives, even when things were hard in sessions; and to have parents be excited to participate and supportive of the overall process, without expecting every strategy to work flawlessly.
2.2.2. Therapy Criticalness: “Therapy is an added stressor.” The term ‘criticalness’ is sometimes used in a negative tone, but here it is used neutrally to capture a posture of thinking critically about the demands that participating in therapy place on a family and available resources. For example, one parent appreciated how her presence in therapy sessions was helpful for her son, but also felt she could have benefited from an hour’s respite to prevent caregiver burnout:
“I wanted to be a part of [therapy] so I could really capture what they were doing and what was helpful. If I’d been sitting in the waiting room, I wouldn’t have gotten that full effect, which I think is really good. But I did find it, to be honest, exhausting, just because it was a long drive there and because he was a bit resistant to go. We really want to help our kids too but there’s also never time for us either, and then we get burnt out.” –P010
Even if parents think that their involvement in their child’s CBT is helpful, they also benefit from setting realistic expectations of how much their family is able to invest in therapy, understanding that each family is approaching treatment within a different context. Therapists can model this for parents by being flexible and decreasing the pressure to complete prescribed homework.
2.2.3. Therapy Flexibility: Flexibility, Openness, and Letting Things Go. Many involved parents were flexible in their implementation of CBT strategies, were open to trying new ways of coping, and were willing to let things go when situations did not go as planned. Having learned the therapy material alongside their child, parents were empowered to adjust coping strategies as required by different situations, by children’s changing interests, or by different maturity levels:
“It’s like a dial on an instrument and every time his interest or his maturity level [changes], depending on the season, depending if there’s stress factors in his life, you have to turn the dial and adjust the methods that you use. Now I have to use this method a little bit more, this one a little bit less. It’s not working in this situation and so forth. […] And then use the experiences I have from SAS or other strategies from the past and try to merge them and try to come up with a solution.” -P002
Part of flexibility within a therapeutic context is having openness, whether it is trying new things, managing child emotions in a different way, or giving a strategy another chance. Therapy might be a new experience for both the child and the parent, and it was helpful for parents to bring openness to their experiences and those of their child. Having openness does not necessarily mean that all new experiences will be positive; some parents learned to let things go when they encountered difficulties. Some parents had an adaptive response to managing multiple competing demands by prioritizing their focus and by granting themselves compassion to focus on what they could handle in the present moment.
2.3. Child Motivation
Parents and therapists both noted a reciprocal process of child motivation and parent involvement. When children came to their first therapy session with high intrinsic motivation, parents did not need to be as involved because there was less of a need for parents to model positive behaviors to maintain their child’s engagement. When children had low motivation to attend therapy, considerable parental effort was needed:
“He would just move slow[ly] […] when we got to the parking lot, and even just getting out of the parking lot once we got there. So I would do mini-steps, like ‘Well, you know if we just get from here to the elevator then we’ll all talk about it some more.’” – P010
Therapists also noticed that when parents were actively engaged, children also seemed more motivated, had more fun, and were more likely to continue completing therapy homework, even as families faced increasingly difficult challenges as part of the therapy program. For example, a therapist recalled:
“…[when] they would try to use a [coping skill] and it didn’t go so well or [when] they tried something that was really difficult, [the parent] always found a way to be really positive and supportive and find the strengths in those moments. [The parent] was really proud. And the child really picked up on that, and that really motivated him to keep going and trying” –T009
2.4. Therapist Factors
There were also key therapist factors that were associated with parent involvement: therapist characteristics and behaviors, and their level of skill and knowledge. Parents found it helpful when therapists showed compassion and empathy, warmth, eagerness, and flexibility. One mother said:
“…whether it’s SAS or any other therapies I’ve gone to, I always feel like I sit in front of a professional who gives me great advice, but just doesn’t understand the emotional components of how exhausting all this is […] those levels of compassion are so important.” –P003
Therapists appeared to support involvement through specific behaviors. Early in therapy, therapists noted how they clarified what therapy would look like, and expectations during and outside sessions. They also noted that it was helpful to ask parents if there were any barriers to involvement, gauging treatment readiness, and problem solving with parents to set them up for success. Parents and therapists described the importance of therapists making an effort to learn more about families’ previous therapy experiences, asking about what did or did not work from week-to-week, checking-in on parents’ understanding, and aiding parents’ knowledge of how to support their child in therapy.
Many therapists in this study were graduate-level trainees, and those with less experience voiced worries about the possibility of the parent evaluating them negatively, as well as concerns about overstepping parents’ authority or about setting boundaries if parent-child conflict arose. Beginner therapists also appreciated having the parent present for sessions because it helped them with managing child attentional or behavioral problems, and with learning more about the child (e.g., when parents filled complementary helper and co-facilitator functions). Therapists needed to be attuned to both the child and the parent in session and had to build a therapeutic alliance with both, and noted managing two therapeutic relationships by emphasizing collaboration and teamwork among the three parties.