A Pilot Study on the Feasility and Efficacy of the Parents Under Pressure

(PuP) Programme in Coolmine Therapeutic Community

Anita Harris, Sharon Dawe, Paul Harnett. Pauline McKeown, Catherine Meleady

www.pupprogram.net.au

08.12.2015

• Established in 1973 as a male only residential centre

Therapeutic Community is

• Highly structured,

• Peer Led

• Self Help

• Community as Method

• Significant changes and modifications over the years

including a women’s only residential treatment

Coolmine Therapeutic Community

Parenting program at COOLMINE

Ashleigh House

• Minimum 5 month residential programme, followed by a 2 month step down programme and 5 months aftercare- Total of 12 month Programme

• Total of 25 Places and upto 10 childrens places

• Provide a safe therapeutic environment

• National Based service

• Dual Diagnosis

• Behavioural Programme- Women address ineffective behaviours causing them issues in their lives

• Women presenting with a wide range of complex issues- addiction only one factor, homelessness, domestic violence, social isolation, stigma, minimal social supports, mental health issues

• Introduction of the mother and child programme in 2008 to its already existing womens’ residential centre –

• Aimed at reducing the barriers experienced by women wishing to enter treatment

• Mothers can access residential treatment accompanied by their children for the duration of their treatment (under 5 years)

• On site creche

• Older children are accomodated at weekends

Mother and Child Programme

Evolution of the Mother and Child Programme

Aim

• Provide childcare whist mother receives treatment

Evolved

• Case management and individualised care plans

Developed

• SLA’S with children services, advocacy groups such as

Barnardos

However something was missing???

Attachment between mother and child •Research has shown that generally, behavioural parent training programmes for substance abusing parents have not led to lasting improvements in parent child relationships or children’s psychological development

•How effective parenting skills programmes are, often depends on the emotional state of the parent

•One reason noted for this is the lack of focus or attention to the emotional state of the parent and the quality of the parent child relationship (Suchman, 2004)

Mother and Child Programme

Introduction of

Parents Under Pressure Programme in July 2014

Introduction of PuP

• 1. The frontline worker will embrace

• 2. Can communicate enthusiastically and optimistically

with parent

• 3. And will make sense to parents

The PuP program takes COMPLEX IDEAS based on attachment theory, developmental psychopathology and neuroscience to DISTIL into a practice framework that

Translating Theory into Practice

PuP Integrated Framework

Emotional Availability

Parental VParenting Values and Expectations

Ecological Context

• 12 modules

• Structured, non-sequential, i.e., order in which modules addresses depends on:-

• Priorities mutually agreed on following assessment

• “Checking out” at the beginning of each session

• Primarily home-based but extensive liaison with other agencies required – school, social services etc

• Include both parents of possible

• Manualised

• Therapists receive regular supervision

PuP Overview

•In February 2014, Coolmine TC introduced PuP to Ashleigh House as its parenting component of it’s already existing programme.

• To date 9 staff members have been trained to deliver PuP and two of these staff members acted as facilitators of the 12 week programme

•Programme was open to both men and women of Coolmine services

•Aim of this study was to evaluate the efficacy and feasibilty of the programme in a residential drug free setting

Introduction of PuP

• To examine any changes in parent/ child functioning

• To explore the extent to which it can improve the parent child relationship

• To investigate the mechanisms by which it may helpful to parents

• To examine the percieved efficacy and feasibilty of the programme in the context of a drug free TC

Objectives

Mixed methods approach employing both quantitative and qualitative methods

Measures included:

•Depression, Anxiety, Stress scale (DASS-21)

•Daily Hassles Scale

•Brief Infant and Toddler Socio Emotional Adjustment Scale (BITSEA)

•Strengths and Difficulties Questionnaire (SDQ)

Carried out prior to intervention, mid way through intervention and immediately following completion of group programme.

7 Semi Structured Individual Interviews were also carried out (5 with PuP participants and 2 with staff members who acted as facilitators of the programme – immediately following completion of PuP

Methodology

Residential facility gives lots of opportunity for integrating PuP into day to day lives of residents and their children – therapuetic opportunities around mindful parenting in particular

In addition there is one to one work that includes working with the Parent Workbook

Use of video is welcomed by many parents and have been a powerful therapeutic tool

This is further consoldated by a PuP group

All staff are trained in the PuP model so even the night time workers are able to help to impliment and consolate PuP principles

How PuP works at Coolmine

• Trauma, attachment history and intergenerational addiction

were key themes:

• Four out of five clients grew up in households where either one or both parents had addiction problems

• Almost all had experienced maltreatment and physical violence by their parents

• Childhood feelings of isolation, abandonment, rejection, humiliation and confusion resonate deeply from the interviews

• A deep distrust of social workers and social services feature strongly

Qualitative findings from 5 clients

• All spoke highly of the PuP programme citing it as a beneficial and valuable programme with real percieved gains

• For all, it was the workshops and knowledge around attachment and detachment that made it different to other parenting programmes and made it a valuable programme

Qualitative findings from five clients

• All stated they are now aware that they were physically there for their children when in addiction but not emotionally

• “I got up and I dressed them, I fed them, I got them to school so I thought I was managing but I wasnt there emotionally, they needed love and attention and I couldn’t give it to them, I just wanted my drugs”

• All state that participation in PuP has helped them realise where their detachment originated from:

“I was detached from a young age, my mother used to leave me alone for days and go to England and I’d have to fend for myself on the streets and I just detached form everyone, I didn’t care about anyone”

• All participants noted that Pups focus on parents emotional state more so than parenting skills and has helped them build on their parent child relationship

Qualitative findings cont.

• It became clear that clients view of themselves at the beginning of the programme was very negative.Low self worth, hopelessness and feelings of failure emerged strongly from the interviews, particularly with regards to parenting

• “ I just felt like a scumbag, a complete scumbag, I wasn’t good enough and my children deserved to be in care”(Lisa)

• I knew I wasn’t a good mother, I chose drugs over my kids, I didn’t try hard enough ( Claire)

• It felt sometimes like there’s just no way out of this pain, it’s like every second of every minute is like a painful hour ( Louise)

Qualitative findings:

Significant reductions in reported levels of depression at end of Pup:

• For many PuP has helped gain an understanding of how to be mindful parents and accept of their limitations whilst in addiction

• Speaking about the guilt and shame they felt with regards to their children appeared to be hugely beneficial/liberating for many clients

• The safety of the group, (it was a closed group), identification with other members of the group and the fact that it was delivered in-house by non-judgemental facilitators that clients were already familiar with, appeared to allow clients to be honest and open about their feelings of shame and guilt and for one client bring issues to the forefront that she had never spoke of before.

Quantatitive findings

To be able to say I am really struggling with feelings towards my child ,I don’t think I have any,was really emotional for me,

I would have never said that before because I’d be afraid they’d be taken off me, and it was making me seriously depressed because I thought there was something wrong with me...something seriously wrong, but then others related to me and (the facilitator) talked about detachment and it clicked for me...

I understood then that I was detached from everyone, not just my child and it went far beyond me drinking as well, I was detached from small.....and straight away I felt so much better about myself and hopeful that I can get it back (louise)

Quantitative findings

Results from COOLMINE

DASS Anxiety score

Sample Questions:-

• I was aware of dryness in my mouth

•I felt I was close to panic

•I felt scared without any good reason

Fear and anxiety surrounding parenting appeared to a be strong theme emerging from the data. For many participants, they had never parented without the use of substances

Difficulties regarding parenting that caused much anxiety included:

•Setting boundaries (particularly with older children)

•Access visits (for those whose children were in care)

•Overcompensating

•Talking to their children, playing with their children, being “fully present” with their children

•Fear of social services removing their child from their care

•“I remember having him that morning after 15 hours in labour and I l just burst into tears, with happiness but also fear that the social worker was going to take him

Quantitative findings

Efficacy of PuP in relation to anxiety:

• Mindful parenting module appeared to be very beneficial, being taught how to be in the moment with their child

• Perhaps one of most noted benefits cited was becoming aware of their own anxiety and how this was impacting on their childs behaviour.

• Setting achievable goals e.g preparing for access visits with a focus on quality of visits as opposed to quantity

Quantitative findings

Results from COOLMINE

DASS Stress

Sample Questions:-

• I tended to over react to situations

•I felt I was rather touchy

•I found myself getting agitated

• Living in a TC can be very intense and stressful, particularly when accompanied by a child

• Clients reported initial high levels of stress trying to participate in their daily structure in addition to managing their own child in the context of other children residing there also

• Awareness of stress appeared to be key in reducing this

• Identifying support networks

• Through learning a number of mindfulness techniques in PuP and another programme (MBRP), becoming aware of when stress is building up has been hugely beneficial in diffusing a number of situations that would otherwise have been hugely stressful

Quantitative findings

Results FROM COOLMINE

SDQ Scores on 5 children

Sample Questions:-

• Considerate of other peoples feelings

• Often loses temper

• Gets along better with adults than children

• Therapeutic comment on good quality caregiving: the little things count

• Helping put structure and routine in place without rigidity, support rather than “rules”

• Mothers said that identifying parents and childs strengths as opposed to weakness or deficits was one of the best parts of PuP

• Data suggests a shift in perception at this point

On receiving feedback from video footage, one mother noted:

“looking at (Son) on video, at first I was waiting on the negative of what I should be doing, but looking at him, I was like ah God, he’s gorgeous and he is actually so good and actually I’m not too bad either, it was lovely

Building parent child relationships

• Goals and skills only appropiate to younger children

• Clients noted that it doesn’t address working with teenage children

• More than 12 weeks desired by a nunber of participants

Limitations of PuP

• Findings suggest PuP fits well within the context of Coolmine’s approach to treatment and relapse prevention

• Parents can be observed in the context of residential treatment

• PuP recognises the extent to which parents are successful depends on external influences such as housing, financial strain etc as well as focusing on the emotional quality of parent child relationships

• Coolmine also recognise that treating addiction in isolation is unlikely to be effective without addressing key context issues- as such CRA attempts to address these key environmental factors

• Findings suggest that the goals of PuP appears to compliment the goals of CRA.

• Mindful parenting is a key component of PuP, which fits well with the mindfulness-based relapse prevention programme already being delivered across the Coolmine services

In the context of Coolmine’s approach