(p. 85) Module 4: Praise and Changing Your Thinking to Feel Better
(Recommended Length: 1 or 2 Sessions)
Materials Needed for the Module
Forms, parent summaries, worksheets, and handouts appear in Appendix A: Client Materials, located at the end of this therapist guide. You may photocopy this material for your clients, or you may download these items from the Treatments ThatWork web site at www.oxfordclinicalpsych.com/ADHDparenting. For an outline of this and all modules, go to Appendix B: Therapist Outlines.
■ Index cards
■ Rubber bands
■ Module 4 Parent Summary
■ Worksheet 4.1: Catch Your Child Being Good
■ Worksheet 4.2: Practice Hot Thoughts and Thinking Errors
■ Worksheet 4.3: Looking at Connections: My Mood/Stress, Caregiving, Activities, and Thoughts
■ Worksheet 4.4: Special Time and Child Behavior Record Form
■ Handout 4.1: Thinking Errors and Strategies for Increasing Helpful and Decreasing Unhelpful Thoughts
Home Practice Review from Module 3
In Module 3, you taught parents about the benefits of maintaining a consistent schedule and routines, how to create a schedule that works for their family, and time management skills, including a prioritized to-do list. If parents did not practice at home, spend time reviewing the rationale for the home practice and help them to troubleshoot any problems they encountered implementing the skills. Some parents will need a lot of support to make these changes. You can use some of the following questions to facilitate the home practice review:
■What adjustments did you make to your schedule after our last session?
■What routine did you choose to break down into steps, and how did that go? What was your child’s reaction? Did any challenges come up?
■What time management strategy did you try? Did you make any modifications to your calendar system or to-do list? How did that go?
If needed during the home practice review, provide reminders that having a daily schedule and daily routines is an “antecedent” that sets the child up for success throughout the day. (You can draw the ABC model [see Module 1] and review the impact of antecedents on the child behavior.)
In earlier modules, you also covered Special Time, mood monitoring, and scheduling pleasant activities. It is important to briefly review the forms (or their calendars) and check in with parents about how their practice is going with all skills covered so far.
■Have you been monitoring your mood and activities? Are you having any difficulty with this—remembering to do it, coming up with the mood rating, and so on?
■What about Special Time practice? Any trouble with this that I can help you with?
Make sure to adjust the home practice review based on what was assigned in the previous session. If topics haven’t been covered yet, omit the questions about that content from the home practice review. Also, if this home practice review does not include content that has been covered and assigned for home practice (e.g., if you are doing modules in a different order), make sure to expand the home practice review to include all assigned items.
Overall Module 4 Goals and Rationale
During Module 4, parents learn to praise their child to increase appropriate and desirable behaviors. They also learn that their own automatic thoughts about their child, parenting, and self can influence how they feel and behave. By learning specific common thinking errors and how to challenge them, parents develop an important skill that can help them with emotion regulation and improved mood, which can in turn affect their parenting. Parents will also be able to increase their sense of control by learning the thoughts-feelings-behaviors connection (refer to Module 2, where the cognitive-behavioral therapy [CBT] model was first introduced). If our reaction to situations is something we can change, then we will feel more capable and in control when challenging situations arise. In other words, although parents cannot always control a situation, they can learn to respond in new ways (in line with the CBT framework). Toward this end, specific strategies for increasing helpful and constructive thinking and decreasing negative or unhelpful thinking (particularly in relation to their parenting and child) will be taught in this module. As parents establish new ways of thinking, different feelings and actions will follow.
Specific goals for this module include
■Goal 1: Teach parents to praise their child’s appropriate behavior and to use praise to increase “positive opposites” in order to influence their child’s behavior.
■Goal 2: Teach parents the situations-thoughts-feelings connection to help them understand the relationship between automatic thoughts and feelings.
(p. 88) ■Goal 3: Describe common thinking errors and practice how to challenge these errors in order to feel better.
■Goal 4: Teach ways to increase helpful thinking and reduce unhelpful thinking.
Module 4 Content (Divided by Goals)
Parental attention is very motivating for children, even if the parent’s interactions with their child are generally more negative than positive. It is easy for children to learn that misbehaving is an effective way to get undivided attention from parents and teachers. This is especially true for behaviors that are attention-seeking, like whining, crying, or interrupting. That is why these are sometimes called “attention-seeking behaviors.” These behaviors continue and grow when you pay attention to them. For example, when a child is in the classroom, they get 1/25th of the teacher’s attention. But, when that child misbehaves, the teacher turns all their attention to the child who is misbehaving. Children may frequently gain adult attention this way. Sometimes parents, just like teachers, get in the habit of not giving attention to positive child behaviors and give more attention to negative behaviors. Parents and teachers may think they should just “let sleeping dogs lie,” but instead, in this module and throughout this program, we will be working with parents to actively notice and praise the child’s positive behaviors.
To begin this discussion, draw the ABC model on a whiteboard or paper (refer to Figure 4.1), and explain that what often happens naturally is that (1) negative behaviors are paired with attention from adults (which is a positive consequence) and (2) positive behaviors are paired with no attention/ignoring (which is a negative consequence). Make sure that parents understand that attention does not have to be positive for it to reinforce behaviors for children. Any attention is better than no attention!
Of course, parents do not intend to ignore their child’s positive behaviors, but this is a common trap to fall into. It is important to normalize this (p. 89) for parents (you don’t want them to feel bad!), but also emphasize that you will be working together to change this pattern.
Some parents may benefit from learning more about the function of attention-seeking behaviors so that they can think more positively about their child. When children do attention-seeking behaviors, they are not being manipulative or “choosing” to bother their parents. Instead, these behaviors often have a history of “working” to engage others (consequence) and so they are likely to keep happening. That is why it is important for parents to actively try to notice when the child demonstrates appropriate behavior, especially when they are upset or are learning a new skill.
We want to change these pairings (i.e., negative behavior with attention; positive behavior with no attention) to make sure we are “growing” the appropriate behaviors. If parents react only to negative behaviors and don’t notice when their child is behaving, their parent-child interactions will become increasingly negative, and it will feel like the parent is mostly criticizing or correcting. Over time, this dynamic diminishes the parent-child relationship, which is an important foundation for all of the other skills included in this treatment program.
On your drawing of the ABC model of child behavior, show that child appropriate behavior (behavior) and caregiver positive attention (consequence) should be paired. When parents do this, they are encouraging their children to behave appropriately in the future while also strengthening their relationship.
The parent has already made important changes with Special Time and pleasant activities. By giving more attention to their child’s positive behavior throughout the day, the scale will be tipped in increasingly positive (p. 90) directions and leave both the parent and child feeling better. Such positive spirals (as opposed to negative spirals) can be created in interactions as both parent and child become more positive. In other words, both parent and child will think, feel, and behave more positively.
How to Praise Effectively
For parents to give their child more attention for positive behavior, they can focus on “catching their child being good.” When the parent sees their child doing something (anything) good—such as following a direction, putting good effort into something (even for a brief time) like homework, or playing nicely with siblings or friends—the parent will praise the child.
Teach parents to be as specific as possible with their praise, telling their child exactly what they did that the parent liked. Specific (or labeled) praises allow children to know exactly what is appreciated, and parents will be more likely to see that exact behavior again. Examples of specific praises can be shared with the parent, such as, “I like the way you asked politely,” “That was really nice of you to share your toy with your sister,” and “You are doing a great job sticking with your homework.” Explain to parents that more vague praise like “Good job!” are not as useful or meaningful because the child will not know exactly what behavior the parent liked. Specific praises also have a bigger impact on the ratio of positive feedback to corrective feedback. Parents would need to give a lot more vague praises to tip the scale to more positive interactions with their child.
An especially important time to practice giving specific praises and to catch the child being good is when children are told to do something. Many parents feel that not following directions (either because of inattention or noncompliance) is one of the biggest problems for their child. Not following directions causes children to have trouble getting along with teachers, caregivers, and their peers. Children often receive negative attention (yelling, nagging, arguing) when they don’t listen to directions. It is therefore important for adults to not miss the chance to give children positive attention whenever they do listen. Instead of moving on, praise can be used to increase this behavior.
It is also important for parents to understand that children with attention and behavior problems have to work harder to do what is expected and deserve credit for this effort.
(p. 91) Some parents are reluctant to praise their child for things that should be done or for expected behaviors. In this case, you can review the information about how their child’s attention-deficit/hyperactivity disorder (ADHD) impacts the ability to perform expected behaviors. Children are supported when they receive more frequent praise for effort and progress, rather than penalized for the challenges that arise due to inattention and/or impulsivity/hyperactivity.
Help parents to understand that their child doesn’t have to do something perfectly or for a long period of time to praise them. It is important to (1) praise effort as well as success and (2) praise progress along the way. Such praise can motivate children to keep going when they are working on a less desirable, challenging, or frustrating task. Praising effort and progress can be especially helpful for behaviors that can be considered “positive opposites.” Positive opposites are the appropriate behaviors that are the opposite of a child’s challenging behaviors. For example:
■ The positive opposite of yelling is playing quietly.
■ The positive opposite of dawdling is getting started on something right away.
■ The positive opposite of bossiness is compromising or going along with someone else’s idea.
■ The positive opposite of demanding behavior is staying calm and being flexible when something does not go as wanted or expected.
If parents begin to give specific praises for effort, progress, and the positive opposite of challenging behaviors, they will be using their attention in a powerful way. They will also train themselves to think more positively about their child(ren).
Some parents may have concerns about praising their child and possible negative effects on child motivation and self-esteem. Genuine praise that focuses on effort and the child’s approach to tasks is recommended and has been shown to have a positive effect on child behavior, self-esteem, and motivation. Praises that are insincere, inflated, or put too high standards on children (perfect, the best, comparing them to others) can be less effective.
(p. 92) Ask parents “What are examples of behaviors you can praise this week?” Encourage them to think of the positive opposites of problem behaviors. If rough play is a problem, praise any gentle behaviors, including efforts or progress that may not be perfect yet. On Worksheet 4.1: Catch Your Child Being Good, there is a section for parents to write in specific behaviors they want to praise their child for this week. Parents should also be sure to incorporate the specific praises during Special Time this week.
You can acknowledge that giving positive attention to your child is harder when you are feeling down or stressed, but remember, by acting in this positive way, parents may think and feel more positively and have a positive impact on their child’s behavior.
Some parents of children with ADHD struggle with deep, ingrained patterns of negative thinking about themselves, others, and/or the world that may require individual CBT. These thought patterns can interfere with the parent’s ability to see the positive aspects of the child’s behavior or the progress the child is making. This may be especially true for parents with a history of recurrent depressive episodes, anger management issues, or trauma. Consider a referral for the parent if the CBT work in this program does not appear to be enough to address the parent’s own interpersonal difficulties.
Culture can also impact a parent’s beliefs about the appropriateness of praise and giving positive attention for expected behaviors. Spend time addressing concerns and identify who else may need to receive information about the intervention so that the parent(s) can feel supported by extended family and community members.
(p. 93) When parents have struggled with their child’s challenging behaviors and impairment related to inattention and hyperactivity/impulsivity, parental patterns of thinking can develop that interfere with their ability to see the positive aspects of their child’s behavior, such as effort and progress that has been made. The history of struggles can lead parents to a “cup-half-empty” mindset and automatic reactions that are more negative, global, and generalized. By helping parents to become aware of their automatic thoughts about their child, their parenting, and themselves, parents will have more success with specific parenting skills like praise.
For this goal, start by reminding parents that there is a strong connection between how we think and how we feel. Difficult things happen; however, what we tell ourselves about what happened can influence how we feel. Challenging situations lead to automatic reactions including thoughts, but the good news is that even if we can’t change a situation (it’s already happened), we CAN change how we think about it. Refer back to Figure 2.1, if needed, and on the whiteboard draw the CBT model to illustrate this concept for the parent.
Now you can provide some examples of the range of situations that can elicit automatic thoughts that lead to unpleasant feelings. Examples include
■ When the parent is criticized by someone (about their parenting, a decision they made)
■ When parents don’t feel appreciated by their family, children, or others
■ When parents don’t get credit for what they are doing (with children, at home, at work)
■ When they don’t meet their expectations for themselves in parenting and other situations (yelled at their child, forgot something important, feel like they aren’t doing enough at home or work)
■ When someone doesn’t say or do something that the parent expected of them (their partner drops the ball or doesn’t agree with them)
■ Having things turn out differently than parents expected (their children’s reaction to something, changes in their health, work, or friendships)
To help parents understand the relationship between situations, thoughts, and feelings even better, you can introduce Albert Ellis’s ABCD model (not to be confused with the ABC model of child behavior discussed throughout this program!) to better understand our reactions to certain situations (see Figure 4.2). Often, people view the situation they are in as causing an emotion (“I felt frustrated because my child had a tantrum”); however, they do not consider that what they tell themselves (i.e., their thoughts or “self-talk”) about what happens also contributes to how they feel. Ellis’s ABCD method can help parents to better understand how they think about difficult situations in their life and how this leads to less healthy emotional functioning. It’s not that unpleasant feelings go away, but the intensity of feelings and the degree of responsibility or control can change significantly. The theory is that feelings of being upset come more from what a person says to themselves about the situation than from the actual events.
Illustrate the model on a whiteboard to help parents follow along as you explain.
Most people assume that the Activating Event causes you to have an emotional reaction or Consequence, C. Rather it is what you believe or say to yourself about the Activating Event that causes the emotional reaction, C.
You can walk through an example, like getting negative feedback from someone about a parenting decision you made. Someone might notice thoughts and beliefs about this situation such as, “I never do the right thing” or “Everyone should agree with my decisions.” These thoughts lead to strong emotions like feeling very down or angry.
(p. 95) Extreme thoughts are called hot thoughts. The parent can consider that, rather than the negative feedback (the situation) making them feel this way, it is also their thinking in response to the negative feedback that leads to their feeling upset.
Explain that in this same situation, if someone else had thoughts like, “It’s okay for that person to disagree with me,” “I made a good decision,” or “I can be open and consider others’ opinions,” this way of thinking would lead to different emotions (such as feeling less stressed, calmer, or more confident).
Make sure to validate that many people feel disappointed or upset when challenging situations happen. Of course we can wish or prefer to have situations go a certain way, and unpleasant feelings are a part of life. However, when we have thoughts like “should” or “must,” we can get stuck in strong and less healthy feelings. The thought “I wish that person agreed with me” leads to different feelings than the thought “That person SHOULD or MUST agree with me.”
Now go through an example that relates to the parent’s child displaying a challenging behavior. You can ask, “What are some hot thoughts that occur when your child is having a tantrum or demanding something or not listening?” [Note: Make sure this example is relevant to the child’s top problems.]
Provide some examples if needed, such as: “My daughter never listens,” “My son won’t have any friends,” “They are doing this to me on purpose,” or “She makes everything harder than it should be.” Validate that when our child is struggling, we can have automatic thoughts that make us very angry or worried (and often both). When kids struggle with following directions and rules, social skills, and managing strong feelings, we can change our thinking to more helpful thoughts. Ask the parent if they sometimes have thoughts that are more balanced when their child’s behavior is challenging and provide some examples of helpful self-talk if needed: “We are working on this,” “This is hard for my child right now,” “Even adults have trouble staying calm when they have intense feelings,” or “There are things I can do to help them deal with this challenge.” These thoughts are more specific and time limited (rather than generalized and global). (p. 96)
The beliefs or thoughts that cause parents to have more intense emotional reactions are also referred to as thinking errors. Thinking errors are automatic ways of thinking that are biased and lead to negative feelings. Specific thinking errors have been identified that lead to people feeling down and stressed/anxious. When people learn these thinking errors, they can notice when they happen and shift to more helpful thinking.
Use Handout 4.1: Thinking Errors and Strategies for Increasing Helpful and Decreasing Unhelpful Thoughts, located in Appendix A at the end of this therapist guide, to introduce four thinking errors common to parents that may occur for them in relation to their child, their parenting, and other situations.
This module also describes six additional thinking errors. If you think the parent would benefit from learning about additional thinking errors or that certain thinking errors are particularly relevant for the parent, you can present some or all of them. We do not want to overwhelm parents with too much information! We recommend that all parents learn about the first four thinking errors, which are included on Handout 4.1 (shoulds, all-or-none, filtering, and labeling).
Our thoughts are automatic (kind of like breathing) so we may not notice that our automatic thoughts are biased or unhelpful. Another way of saying this is that we can have automatic “thinking errors,” but we treat these thoughts as facts. Thoughts are not facts! When we are feeling stressed, anxious, or down, our automatic thoughts can become more negative and extreme, which leads to more upset feelings. Becoming more aware of our (p. 97) thoughts and our most common thinking errors allows us to catch them and challenge them. We are now going to talk about how to do this.
You can next describe the thinking errors and provide examples that are most relevant for the parent and family.
The first thinking error is thinking in SHOULDS: When you have rules about how you or other people should or must act, this often leads to feeling guilty or self-critical (“I should ____ more,”) and becoming angry with others when they don’t follow your expectations (“Others must ______”).
■My child should be able to get ready for school independently at their age!
■My spouse should be helping more with these household chores!
■I should be able to keep my house looking better than this!
■Everyone else’s parents help with their grandchildren!
■Other moms balance everything so much more easily!
Ask the parent to generate some of the “should thoughts” that they have:
These can be thoughts about yourself, your child, or your parenting.
If a parent responds that a “should” thought is true, you can validate and use it as an opportunity to discuss the difference between a “true” or “real” thought and a helpful thought. A thought that includes “should” or “must” may be giving us important information about our values or changes that need to be made. However, helpful thoughts lead to helpful actions. Ruminating (having the same thought over and over) and getting stuck in “shoulds” leads to feeling upset, not feeling better or making a change. A “should” or “must” thought may also keep us from accepting a situation and the aspects of a situation that are out of our control.
(p. 98) All-or-None
The second common thinking error is ALL-OR-NONE THINKING. In all-or-nothing thinking, you think in absolutes like always, never, perfect, or terrible. When we are fighting with someone, we might think in extremes.
■My daughter never does what she is told!
■My son always puts up a fight when I tell him to do something!
■My child always wakes up in a bad mood.
■My spouse never helps with the kids.
■Other people’s houses are always neater than mine.
■Other moms always look better than me.
“Never” and “always” thoughts are rarely 100% true, and, by thinking this way, parents may feel worse and behave in ways that they may later regret.
Ask the parent to think of recent examples of “all-or-none” thoughts.
A third thinking error is FILTERING: We filter out the OK or good things about a situation and we are left only with the negative aspects. The good things “don’t count” and the negative things are magnified. For example, when someone asks how our day was and we say, “My day was awful” because my child got in trouble at school. We filtered out the fact that we had a good conversation with a friend, got something done on our to-do list, or that our child cleaned their room when asked. Your vision of reality becomes darkened like the drop of ink that discolors the entire beaker of water.
■I did not get a thing done today!
■My child had a terrible semester in school!
■That project was a complete failure!
(p. 99) Ask the parent(s) if they notice this type of thinking when something negative happens.
A fourth thinking error is LABELING. When we give labels to ourselves or someone else, we are discounting a lot of information. For example, after making a mistake, you think “I’m a loser” instead of “I made a mistake this time.” Or you think “My child/spouse is selfish” instead of “My child has a hard time sharing sometimes.”
■My child is a lazy student.
■I am not a patient person.
■My child’s teacher is insensitive.
■My child is a mean kid.
■My partner is selfish.
Such thoughts can lead to angry or depressed feelings and behaviors. Ask the parent if they have recently thought in labels when thinking of themselves or others.
Six additional thinking errors are described here. Reviewing ten thinking errors at once may be overwhelming for parents, so we recommend choosing and focusing on the thinking errors you view as most relevant for the parent.
Disqualifying the Positive
A fifth thinking error is DISQUALIFYING THE POSITIVE . You reject positive experiences by insisting that they “don’t count” for some reason or other. In this way, you can maintain a negative belief that is contradicted by your everyday experiences.
(p. 100) For example:
■That was just lucky.
■That only happened because . . .
■I helped the kids with their homework, but the house is a mess and we had fast food for dinner.
■It must have been an easy exam if my child passed.
Ask the parent if they notice a pattern of disqualifying the positive in certain situations, relationships, or areas like productivity.
Jumping to Conclusions
A sixth thinking error is JUMPING TO CONCLUSIONS. You make a negative interpretation even though there are no definite facts that convincingly support your conclusions.
■The teacher called, so something must be wrong.
■If I forget to do something for tomorrow, others will be very upset with me.
■If I invite someone I don’t know that well to a social activity, they will say no.
■No one will come to my child’s birthday party.
Ask the parent if they tend to jump to conclusions and assume a negative outcome will occur.
A seventh thinking error is CATASTROPHIZING . When we catastrophize, we overestimate the likelihood that the worst outcome will occur, which causes us to worry.
■My child won’t have friends (after receiving an email about an incident at school).
■I will lose my job (after making a mistake at work).
■Our relationship will end (after a conflict).
(p. 101) Ask the parent if they notice thinking about “worst case” outcomes that results in feeling very anxious.
An eighth thinking error is MIND READING . You think that someone is reacting negatively to you and don’t check out whether this is true or not.
■Others think I am a bad parent.
■The teacher thinks my child is. . . .
■My partner thinks I am. . . .
Ask the parent if they automatically assume someone is thinking negatively of them when there is no evidence of this.
A ninth thinking error is EMOTIONAL REASONING . You assume that your negative emotions necessarily reflect the way things are: “I feel it, therefore it must be true.”
Ask the parent if they assume their negative emotions are giving them accurate information.
■I feel worried so something must be wrong.
■I feel guilty so I must have done something wrong.
A tenth thinking error is PERSONALIZATION . You see yourself as the cause of some negative external event for which, in fact, you are not primarily responsible.
(p. 102) For example:
■My child’s low grade is because I have not done enough.
■Others aren’t happy because I didn’t have a good plan for the day.
■My child is having a tantrum because of what I did (e.g., taking something away).
Ask the parent if they take responsibility for how others are feeling or for how situations turn out even though there are many things out of their control.
After presenting all (or some) of the thinking errors ask,
“What are the most common thinking errors or ‘hot thoughts’ that occur for you in challenging parenting situations? These can be thoughts about yourself, your child, or your parenting.”
Practice Challenging Thinking Errors to Feel Better
After automatic thoughts and thinking errors are identified, the next important step is to dispute the thinking errors and generate alternative thoughts for the situation (this is the “D” in Ellis’ ABCD model). This is a skill that needs to be practiced! Explain to parents the process of switching from a thinking error to a more balanced thought:
After catching a thinking error, it is helpful to ask yourself challenge questions that will help you to come up with a different (more balanced, more helpful) thought for the situation. When you identify a different thought, you have the opportunity to feel better [refer to CBT model if helpful]. We will go through the thinking errors and some helpful challenge questions.
You can refer to the second column in the table on Handout 4.1 Thinking Errors and Strategies for Increasing Helpful and Decreasing Unhelpful Thoughts to show the parent that each thinking error has challenge questions that can be used to assist in generating more helpful thoughts (i.e., positive self-talk across situations). As you discuss the following challenge questions, focus on the strategies that match up with the thinking errors discussed earlier.
(p. 103) Parents can challenge thinking errors by asking themselves questions like,
■Shoulds: Can you accept yourself and others as you or they are right now? You can wish/prefer something to be the case but not demand it. Be kind to yourself and your child if you or they are not currently performing up to your standards or adjust your standards to be more realistic. (Same goes for others!)
■All-or-None Thinking: Does this really happen for you or your child always or never? Is this really awful? Try to think in shades of gray. Are there examples of times when this did not happen?
■Filtering: What are the positive parts about your parenting or your child’s behavior today? What are some of your partner’s positive qualities? What went OK for your family today? Are you 100% sure that there was nothing positive that happened? (Nothing is too small to count!)
■Labeling: Do you, your co-parent, or someone else really fit the definition of this label (e.g., lazy, loser, selfish, failure)? Are there examples that do not fit that label? Think of things as more temporary (this time, sometimes) and changeable rather than a hard and fast label.
■Disqualifying the Positive: What good things happened for you or your child today that you are forgetting? Are you focusing too much on one detail?
■Jumping to Conclusions: Is your prediction reasonable? How often are you right when you jump to the conclusion that something bad will happen?
■Catastrophizing: How likely is the “worst-case” scenario? What is more likely to happen? If something bad does happen, how would you handle it?
■Mind Reading: How do you know for sure what others are thinking? What are some more likely interpretations of the situation? What would you tell a friend who has this thought?
■Emotional Reasoning: What are the facts in this situation? Is this feeling leading to a helpful action? What would you tell a friend who is feeling this way?
■Personalization: What are you actually responsible for in this situation? What factors are out of your control? What is a fair assessment of your part?”
Therapist Note: Back to Ellis’ ABCD Method
As you are discussing these challenge questions and helping parents come up with more adaptive thoughts, it is important to point out that statements about parent wishes, preferences, and likes or dislikes are perfectly reasonable. With these thoughts, parents may be annoyed or disappointed when the situation occurs, but they are unlikely to feel prolonged anger, hurt, or sadness. When challenging hot thoughts, you can incorporate the ABCD approach and try to get to the core beliefs about themselves (“I am . . . ”), the world (“In a world that is . . . ”), and others (“Where people are . . . ”) (Persons, 1989). Rather than asking parents to immediately dispute negative thoughts, engage the person in exploring these thoughts at a deeper level using standard Beck techniques (e.g., what does it mean if . . . , what would be so bad about . . .). This approach helps get to core dysfunctional beliefs. See Beck (2011) for additional reading about these techniques.
Parents as Models: Helping Children with Thinking Errors
You can also help parents to understand that, just as adults have these automatic thinking errors, so do children. When their child says “We (p. 105) NEVER get to do what I want!” that’s all-or-none thinking. Children have big emotional reactions when they experience thinking errors.
It is very hard for children to change their thinking when experiencing intense emotions. Children learn about emotion regulation by watching their parents manage emotions. Parents can be models by saying out loud what their automatic thought is and then saying a more helpful thought to replace it. They can use opportunities (which are developmentally appropriate) to demonstrate changing from first thought to second thought.
For example, if a parent is disappointed because plans don’t work out, they can say out loud, “I feel so disappointed. My first thought was that our day is ruined because we can’t go on a bike ride like we planned. But then I asked myself, ‘is it really that bad that my whole day is ruined?’ No! My second thought is that we can find something fun to do inside and go on a bike ride tomorrow.” Or “I feel frustrated! My first thought was that we never get a parking spot right away. But then I asked myself, ‘do I really never get a parking spot right away?’ No! My second thought is that we’ll find a parking spot soon, and I can enjoy the music in the car until we find one.” Or “My second thought is sometimes I get a spot right away and sometimes I have to wait.” (See Module 9 for additional information about emotion coaching.)
When children demonstrate flexible thinking, it is an opportunity to praise them and reinforce the fact that when we are flexible we feel better. Noticing successes with flexibility (when a child is not upset) helps to build this skill for children, and it is easier to learn about flexibility when children are calm. When children are very upset, adults often want to challenge unhelpful thinking right away (“Of course that’s not true!” or “This isn’t a big deal!”). When children feel very upset, it is the hardest time for them to learn and practice a skill. Instead, encourage parents to help their child build the skill of flexible and helpful thinking by (1) being a model, (2) catching successes, and (3) talking about thinking errors and helpful thinking after their child has calmed down. If parents focus on being a model—catching their own thinking errors and changing to more flexible thinking—they will be in a better position to help their child.
Parents should become aware of when they may inadvertently model patterns of negative thinking for their children. Learning to counter their negative thoughts, modeling praise, and focusing on the positives (p. 106) can teach the child to do the same. Parents will learn more about helping their child with emotions in Module 9.
After parents become more aware of negative patterns of thinking and specific thinking errors, they can benefit from specific strategies to help them increase flexible and helpful thinking and decrease thinking errors. More information about the strategies listed here can be found in “Control Your Depression” by Peter Lewinsohn.
Four strategies to decrease unhelpful thoughts are:
1. thought interruption,
2. rubber band technique,
3. worry time, and
4. the blow-up technique.
Four strategies to increase helpful thoughts are:
1. writing down positive self-talk statements (priming),
2. using cues,
3. writing down successes at the end of each day, and
4. time projection.
Practicing a variety of strategies will help parents to determine what works best for them, and often they will find that it is a combination of strategies that is most effective in changing thinking patterns.
Strategies to Decrease Unhelpful Thoughts
Strategy One: Thought Interruption
You can teach parents how to gain more control over their thinking by interrupting the patterns of thinking that are most common for them.
One strategy that can help change patterns of thinking is thought interruption. When you notice a thinking error or unhelpful thought, INTERRUPT it with another thought. For example, if you notice you are saying to yourself “Nothing ever works out” after a challenging (p. 107) situation, is this helpful? If it isn’t, yell: STOP! You can do this out loud if you are alone or in your mind if you’re not. Even in your mind, try to yell loudly. Instead of STOP! you can also say to yourself, “I’m not going to think that right now” out loud or silently to yourself.
Strategy Two: Rubber Band Technique
To have a physical reminder, some people find it helpful to wear a rubber band on their wrist and snap it when they notice a negative thought, to help interrupt it. It’s a good idea to have rubber bands available if a parent wants to practice for the remainder of the session.
Strategy Three: Worry Time
Many times, our unhelpful thoughts are worries. Worries about things that are out of our control or imagining “worst-case” outcomes before anything has even happened are unhelpful and lead us to feel anxious and irritable. For example, worrying repeatedly about how a child will behave years from now is not helpful. Worries can be helpful if they lead to an action that keeps someone safe (i.e., worrying about a child running into the street leads to keeping a close eye on the child) or if they help someone to prepare (i.e., worrying about how a meeting will go leads to preparing for it). If worrying does not lead to a helpful action, it is likely a useless or unhelpful worry.
Worry is helpful when it leads to a helpful action. For example, worrying about your child’s friendships can lead to planning a playdate in a way that your child will be most successful (time-limited, structured, etc.). However, many worries are unhelpful because we focus on things out of our control or we catastrophize (you can refer back to this thinking error). To help decrease these unhelpful worries, you can schedule a time to worry— worry time —and limit your worrying to this time. If a worry thought that is not helpful comes up outside of worry time, remind yourself that it is not worry time and move on. You can write the thought in a notebook or in the notes on your mobile phone if you are afraid you won’t remember the worry. Your worry time should be 30 minutes at most. It’s important to ONLY worry during your worry time. If you find yourself distracted and thinking about other things during worry time, make (p. 108) yourself go back to worrying. And when it’s not worry time, make sure you stop yourself from worrying unless it is leading to an immediate, helpful action.
Strategy Four: Blow-up Technique
When we are stressed or anxious, we often imagine negative outcomes that are not likely to happen. To train your brain to recognize this pattern of unhelpful thinking, you can take your thoughts to a ridiculous extreme to gain more control of your thinking. Taking the negative thought to the most ridiculous extreme can often reduce the power of the thought (and even make you laugh) which can change how you feel (you can refer back to CBT model).
[You can give an example like going from the thought “our house is never clean” to imagining your house being extremely filthy and someone very important stops by unexpectedly and everything that could go wrong does.]
Strategies to Increase Helpful Thoughts
Strategy One: Write Down Positive Self-Talk (Priming)
Parents’ thoughts can also be influenced by practicing positive self-talk several times throughout the day. Examples of self-talk include “I am doing the best I can,” “I am a good mother,” “My partner helps as much as they can.” By writing down thoughts that are positive, helpful, and grateful, parents can increase their positive self-talk and feel better. Practicing positive self-talk on a regular basis “primes” thinking and is important in helping the thoughts to become more “automatic.”
Strategy Two: Use Cues
You can remember to read the thoughts throughout the day by cueing, or pairing this with other activities, like brushing your teeth or eating (we (p. 109) also refer to this as “habit stacking”). You can put sticky notes on mirrors and on the refrigerator to remind you or set the timer on your phone to go off several times a day. This will help you to remember.
To practice strategies one and two to increase positive thoughts, hand out index cards and have the parent write one positive thought (or positive self-talk) on each card. They can also write thoughts on sticky notes or in the notepad of their phone. Parents can set the alarm on their phone for multiple times per day to prompt them. Encourage parents to write down thoughts about themselves, their family, and their parenting.
Strategy Three: Pay Attention to Your Successes
When parents feel stressed, down, or anxious, positive aspects of the day can be filtered out (thinking error) and successes can be dismissed or not counted. When expectations for themselves, their child, or their parenting are unreasonable, they need to practice giving themselves credit for what is happening that is positive or a sign of progress.
At the end of every day, write down three things that went well that day. This can be something on your “to-do” list, something you handled well, progress you made on a goal, and so on. The important thing to remember is that nothing is too small! Some people also find it very helpful to keep a gratitude journal and to write down three things they are grateful for every day. For a related exercise, you can also do the “Favorite part of the day” ritual with your children. You can ask children what their favorite part of the day was, and then you can share what your favorite part of the day was. These practices help “train your brain” to not filter out the good parts and to notice how you feel when you change your thinking.
Strategy Four: Time Projection
When we are upset, we often think of things as being permanent rather than temporary. We can remind ourselves that things change (the only (p. 110) constant in life is change!), and imagining a future without a current stressor can help us to feel better now.
When you are in the midst of dealing with a really difficult situation, sometimes it’s useful to think forward to an easier time when the stressor will no longer be there. In using time projection, you try to imagine a time when your current problem will be gone. For example, if you have a deadline at work, it sometimes helps to be able to envision yourself a little down the road, in a better place than where you are right now.
Thoughts About the Likelihood that Parenting or Child Behavior Will Change in Treatment
Changing thoughts is hard, and you want to acknowledge that parents may be having doubts about their ability to feel better or to successfully use the strategies taught in this program.
The skills we talked about today take a lot of practice, so do your best to stick with them. As you practice the strategies, you might have thoughts like, “This isn’t working” or you may predict, “This won’t work for me.” Use this as an opportunity to identify thinking errors (fortune telling, all-or-nothing thinking) and identify helpful thoughts. Examples of helpful thoughts are, “These skills have worked for others and may work for me” or “I will practice the skills regularly and see what happens.” The thought “I can change my thoughts to change how I feel” can be a helpful and important thought to help you remember the reason for using the skills.
You can also introduce the use of mindfulness (refer to Module 5) as parents learn more about challenging and changing thoughts. Mindfulness is being aware of what’s happening in the present moment (with acceptance). This allows for a pause between our initial reactions (intense feelings, extreme thoughts, physiological symptoms of stress) and our response. This program gives parents strategies to strengthen their relationship with their child and increase appropriate behavior. However, the use of these strategies requires the parent to respond in the presence of strong reactions. Parents may experience muscle tension and negative thoughts about their child or parenting (“He doesn’t care if he bothers others” or “Nothing works”) that can prevent them from using (p. 111) praise to help their child. If parents practice mindfulness and improve their ability to notice their experience (and their child’s experience) with acceptance, they will be more likely to respond to their child with praise despite strong reactions. If parents already have a mindfulness practice, encourage them to use this as they work to increase praises. If they have not practiced mindfulness before, there is some mindfulness instruction included in Module 5.
Throughout this program you will acknowledge the parents’ own experience in challenging situations with their child so they can attend to their own needs. It is important to do this in a compassionate and validating way.
At the end of each session, distribute the Parent Module Summary and reinforce the fact that the information discussed today will now be practiced at home. Home practice for this module includes:
■ Completing Worksheet 4.3: Looking at Connections: My Mood/Stress, Caregiving, Activities, and Thoughts
■ Completing Worksheet 4.4: Special Time and Child Behavior Record Form
Discuss with parents that there is a new column on the monitoring form (Worksheet 4.3) so they can begin to track their practice of the thought strategies discussed today. Ask parents which strategies they plan to practice to increase helpful thoughts and decrease unhelpful thoughts and what will support their practice this week.
Also talk with parents about incorporating the specific (labeled) praises during Special Time practice this week. Help parents think of “positive opposites” to praise during this time. There is also an additional column on the Special Time and Child Behavior record form (Worksheet 4.4) for parents to write down their thoughts during Special Time.
This is a lot of home practice to discuss! Some parents may have difficulty keeping up with the home practice assignments. Taking time to help parents set home practice goals is important. For example, if a (p. 112) parent was only able to practice Special Time twice a week for the past 2 weeks, help them set a realistic goal for the next week (e.g., 3 or 4 times) and problem-solve around how to make that happen. Setting a daily phone alarm as a reminder, tying practice to a certain time of day (e.g., right after dinner), or discussing how to have a co-parent or someone else support the parent if possible (e.g., the co-parent can spend time with the sibling while the parent does Special Time) are all possible strategies to discuss.