Resistance — Why don’t parents follow through? Part 2: Enhancing collaborations

*Please note, we use the word ‘parents’ to encompass primary caregivers in the home and recognize that other relatives and caregivers act as parents in many families. 

Best practices and ethical standards of care require behavior analysts to collaborate with parents in the process of treatment planning. Effective collaboration facilitates the behavior analyst to solicit the parents’ input, and to consider potential cultural or familial rules (e.g., “I shouldn’t have to reinforce my child’s behavior”) that could get in the way of implementation. Collaborative plans maximize implementation success. Here are four meta-strategies from motivational interviewing (Miller & Rollnick, 2023) that organize practical suggestions from applied behavior analysts to enhance collaboration:

Engaging parents: “Can we work together?” – Health service provision is changing. Although the old terms we use still indicate that there is a “provider” and a “recipient” of services, health systems research suggests that a collaborative working relationship is the bedrock upon which all service provision rests. Think of parents as active and involved in all aspects of their child’s wellbeing and thereby an integral partner in treatment planning. Accept and work to understand their perspective.

Suggestion: Be curious. Ask the parent open-ended questions regarding their concrete goals in relation to their child.

Purpose: Find out what the parents are looking for, what their hopes are, and how they have tried to change things in the past. How do the parents understand applied behavior analysis and the services offered? Understand the parents’ short and long-term goals and how they might connect or conflict with common priorities in treatment planning.

Suggestion: Discuss the acceptability and feasibility of available treatment approaches. Listen for indications that parents might feel overwhelmed or judged, or that they have concerns about social stigma. For example, how does the parents’ sociocultural context position people with disabilities, and how do the parents view themselves and their child, as well as the child’s treatment, in that context?

Purpose: Identify the sociocultural demands within which the parents operate. Tweak or modify your plan to increase acceptability and feasibility; help parents solicit social support and bring other people on board if indicated.

Suggestion: Listen closely and acknowledge the parents’ perspective, goals, and concerns.

Purpose: By understanding the parent-child context, you convey respect, compassion, and humility, and you prevent lopsided, expert-driven treatment planning.

Focusing the direction: “Where are you going?” Values serve as a guide in decision-making. Other than concrete goals, values are the overarching themes of people’s lives that characterize what matters in the “big picture.”

Suggestion: Asking the caregiver open-ended questions regarding their long-term values and future expectations in relation to their child.

Purpose: Place the parents’ immediate concerns and goals in the context of their larger life and caregiving trajectory, considering sociocultural themes such as autonomy and dependence. Identify distal concerns that may govern the parents’ responses in the moment.

Suggestion: Explore with the parents how potential treatment approaches are aligned with what matters to the parents in the long run.

Purpose: Distinguish between short-term and long-term effects of treatment approaches, and – if indicated – acknowledge that learning to do something new or different may feel risky, uncertain, and uncomfortable at first. Open a dialogue about focusing on practice to decrease discomfort, with an eye on the long-term outcome.

Evoking change talk: “Why would you go there?” It is not enough if you can make an argument for parental behavior change, or for the selection of one treatment plan over another. Set the occasion for parents to talk about why changing their own patterns of behavior matters, or what the pros and cons are about implementing a given treatment plan. Provide an opportunity for parents to hear themselves argue for change or for a given implementation strategy.

Suggestion: Ask for permission to extend the conversation to potential concrete treatments.

Purpose: Assess whether parents are ready to learn more about details of treatment options. Convey that you are listening to the parent and open to co-constructing pathways and solutions.

Suggestion: Use open-ended questions (such as, “what’s the downside of how things are now?” – “what could be some advantages of …”).

Purpose: Explore the parents’ perspective on what needs to change; have parents observe their own discussions and thereby affirm a commitment to change. Assess parents’ understanding of intervention strategies.

Planning action: “How will you get there?”

Suggestion: Harness and discuss parental strengths.

Purpose: Make sure you acknowledge the parent as competent in many domains; build parents’ confidence to change. Shape the parents’ implementation of the treatment, starting with parental patterns that could be steps toward the target response. Set the occasion for pre-teaching by pointing out effective parental behavior in other contexts.

Suggestion: Invite the parent to role-play potential treatments, alternating roles.

Purpose: Give opportunities to practice, become comfortable, adjust to their own style/words, anticipate potential barriers, and receive feedback. Receive more information on how parents perceive and predict their child’s behavior.

Collaboration is at the heart of successful treatment planning. A treatment plan that is not implemented is useless, regardless of how fantastic it looks on paper. With the parents, identify ways to tailor the treatment to the specific parent-child context. Work on your skills to develop flexibility with the form of the treatment strategy while remaining true to the behavioral functions that must be addressed. Consult if needed; brainstorm with colleagues on potential strategies that might fit a parent-child dyad’s needs.

References and Resources

For parents: Forgatch, M. S., Patterson, G. R., & Friend, T. (2017). Raising cooperative kids: proven practices for a connected, happy family. Conari Press.

To reflect on treatments and brainstorm alternative treatment options:

Goldiamond, I. (1974). Toward a constructional approach to social problems: Ethical and constitutional issues raised by applied behavior analysis. Behaviorism, 2(1), 1–84.

Goldiamond, I. (2022). A programing contingency analysis of mental health. Routledge.

McDowell, J. J. (1988). Matching theory in natural human environments. The Behavior Analyst, 11, 95-109.

Patterson, G. R. (1982). Coercive family process. Castalia.

To learn about motivational interviewing:

Miller, W. R., & Rollnick, S.. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press.

Rosengren, D. B. (2018). Building motivational interviewing skills: A practitioner workbook (2nd ed.). Guilford Press.

To understand coercion:

Goltz, S. M. (2023). An analysis of types and targets of coercive interference. Journal of Theoretical and Philosophical Psychology. Advance online publication.

Sidman, M. (2001). Coercion and its fallout. Authors Cooperative.